Week 6: Accountability for Clinical Outcomes and Promoting Safety and Quality

Introduction

Throughout your education, patient safety and improving the quality of patient care have been examined. Through numerous readings and media pieces, you have heard about Never Events. These are serious and costly medical errors that are preventable, such as wrong-side surgery, medication errors, and hospital-acquired infections. Each of these types of medical errors is preventable. The consequences of such errors are now financial as well as legal and emotional. The Centers for Medicare & Medicaid Services no longer reimburse for medical errors classified as Never Events.

As a nurse, how can you help to prevent these types of medical errors? What is your accountability for clinical outcomes? There are standards and core measures in place that guide nursing practice. In addition, the National Database of Nursing Quality Indicators (NDNQI) examines those components of clinical care that are specific to nursing. The NDNQI quantifies, or assesses, these nurse-sensitive components and provides specific feedback on how well nursing practice is being executed in those areas related to patient care.

This week, you will consider a series of articles that focus on strategies for ensuring safety and quality care for patients. You will also explore how successful, efficient teamwork between nurses, nursing leaders, physicians, and other medical personnel can help prevent many of the Never Events from occurring and decrease the likelihood of such events in the future.

Learning Objectives

Students will:

• Analyze the core measures and standards for nursing practice that promote patient safety and quality of care outcomes
• Analyze the impact of the nurse’s role in clinical outcomes for organizations
• Analyze nurse-specific challenges for influencing change in quality improvement
• Analyze the role of the nurse in supporting the organization’s strategic agenda in improving clinical outcomes

Photo Credit: PhotoAlto/Odilon Dimier / PhotoAlto Agency RF Collections / Getty Images

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Learning Resources

Prior Knowledge

It is not uncommon for students to be required to complete group projects or to work as part of a team. While obtaining your RN credentials, or at some time in your work career, you have more than likely at some point been part of a unit or a collaborative team. Reflect on that experience of working with others to achieve a common goal. How did the actions of your team members impact your success as a team? Consider how this same philosophy applies within an organization. How might the actions of the individuals influence the success of the organization?

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Amin, A. N., Hofmann, H., Owen, M. M., Tran, H., Tucker, S., & Kaplan, S. H. (2014). Reduce readmissions with service-based care management. Professional Case Management, 19(6), 255–262. doi: 10.1097/NCM.0000000000000051

Note: You will access this article from the Walden Library databases.

Forster, A. J., Dervin, G., Martin, C., & Papp, S. (2012). Improving patient safety through the systematic evaluation of patient outcomes. Canadian Journal of Surgery, 55(6), 419–425. doi: 10.1503/cjs.007811

Note: You will access this article from the Walden Library databases.

Johansen, M. L. (2014). Conflicting priorities: Emergency nurses perceived disconnect between patient satisfaction and the delivery of quality patient care. Journal of Emergency Nursing, 40(1), 13–19. doi: 10.1016/j.jen.2012.04.013

Note: You will access this article from the Walden Library databases.

McDowell, D. S., & McComb, S. A. (2014). Safety checklist briefings: A systematic review of the literature. AORN, 99(1), 125–137. doi: 10.1016/j.orn.2013.11.015

Note: You will access this article from the Walden Library databases.

Payne, D. (2014). Elderly care: Reflecting on that ultimate ‘never event.’ British Journal of Nursing, 23(13), 702. doi: 10.12968/bjon.2014.23.13.702

Note: You will access this article from the Walden Library databases.

Thornlow, D. K., & Merwin, E. (2009). Managing to improve quality: The relationship between accreditation standards, safety practices, and patient outcomes. Health Care Management Review, 34(3), 262–272. doi: 10.1097/HMR.0b013e3181a16bce

Note: You will access this article from the Walden Library databases.

American Hospital Association. (2016). Retrieved from http://www.aha.org/

 

Explore the American Hospital Association’s website. Focus on the information on improving patient safety and quality of care.

 

 

American Organization of Nurse Executives. (2016). Retrieved from http://www.aone.org

 

“Since 1967, the American Organization of Nurse Executives (AONE) has provided leadership, professional development, advocacy and research to advance nursing practice and patient care, promote nursing leadership excellence and shape public policy for health care nationwide. AONE is a subsidiary of the American Hospital Association” (AONE, 2016).

 

 

Centers for Medicare & Medicaid Services. (n.d.). Quality of care center. Retrieved August 11, 2016, from http://www.cms.gov/Center/Special-Topic/Quality-of-Care-Center.html?redirect=/center/quality.asp

 

Most health care organizations receive some amount of reimbursement from the Centers for Medicare & Medicaid Services (CMS). Reimbursement continues to be jeopardized and reduced by pay for performance standards. Health care organizations are being held to higher standards by CMS. Explore the standards set to improve patient safety and the quality of care. Consider how they affect acute care providers and nursing practice.

 

 

The National Academies of Sciences, Engineering, and Medicine. (2016). Health and Medicine Division. Retrieved from http://www.nationalacademies.org/hmd/

 

The Health and Medicine Division (HMD) promotes policies and best practices in an effort to improve patient safety and delivery of quality care. Review a few of the publications available at this site.

 

 

The Joint Commission. (2016). National Quality Forum (NQF) endorsed nursing-sensitive care performance measures. Retrieved from http://www.jointcommission.org/national_quality_forum_nqf_endorsed_nursing-sensitive_care_performance_measures/

 

The Joint Commission (TJC) also accredits health care organizations. Through funding provided by the Robert Wood Johnson Foundation, the Joint Commission developed the Implementation Guide for the National Quality Forum (NQF) Endorsed Nursing-Sensitive Care Performance Measures. Review this guide as you consider how core measures and national guidelines improve nursing practice.

 

Required Media

Laureate Education. (Producer). (2009b). Topics in clinical nursing: Accountability for clinical outcomes and promoting safety and quality [Video file]. Baltimore, MD: Author.

 

Note: The approximate length of this media piece is 15 minutes.

 

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Discussion: Promoting Safety and Quality

In the article “Managing to Improve Quality: The Relationship Between Accreditation Standards, Safety Practices, and Patient Outcomes,” the authors discuss the growing trend by medical insurance companies to eliminate reimbursement for Never Events. As these types of mistakes should be easily preventable, hospitals have developed protocols to lessen or extinguish the occurrence of these events. In addition, The Joint Commission (TJC) and the Centers for Medicare & Medicaid Services (CMS) have developed core measures to guide health care providers’ efforts in improving patient safety and the quality of care delivered.

Health care organizations have developed strategic agendas to help meet these standards and reduce the incidence of Never Events. Nurses significantly influence the overall quality of health care provided and play a pivotal role in improving patient outcomes.

For this Discussion, you will consider the standards that are in place for nurses and how they can be used to improve quality of care.

To prepare for this Discussion:

• Review the information at the Joint Commission and Centers for Medicare & Medicaid Services websites on the core measures and standards presented in this week’s Learning Resources.
• Consider the nurse’s role in supporting the organization’s strategic agenda as it relates to improving clinical outcomes.
• Conduct an Internet search for either a Never Event or a core measure, and select one to address in your post.

By Day 3

Respond to the following:

• How has the emphasis on quality of care, patient safety, and clinical care outcomes been impacted by specific standards emanating from TJC and/or CMS? Cite your selected core measure or Never Event in your response.
• What is the impact of the nurse’s role in clinical outcomes for the organization?
• Discuss nurse-specific challenges in influencing change in quality improvement.
• How does this influence the ability of the organization to achieve its strategic agenda?

Support your response with references from the professional nursing literature.

Note Initial Post: A 3-paragraph (at least 250–350 words) response. Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames. Avoid quotes; paraphrase to incorporate evidence into your own writing. A reference list is required. Use the most current evidence (usually ≤ 5 years old).

Read two or more of your colleagues’ postings from the Discussion question (support with evidence if indicated).

The Assignment

Examine Case Study: An Elderly Iranian Man With Alzheimer’s Disease.

 

You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

 

At each decision point, there will be three decisions. I will choose one out of the three and give the outcome. At each decision point these are the thoughts to ponder:

 

Decision #1

 

Which decision did you select?

 

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

 

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

 

Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

 

Decision #2

 

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

 

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

 

Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

 

Decision #3

 

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

 

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

 

Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

 

***Also include how ethical considerations might impact your treatment plan and communication with clients.***

 

Finally: 1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).

 

 

 

2. Write paper addressing all section listed based on the decision tree.

 

 

 

Case Study: Alzheimer’s Disease

                      (76-Year-old Iranian Male)

 

BACKGROUND

Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.

 

 According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”

 

Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation. SUBJECTIVE During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so the PMHNP performs a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.

 

MENTAL STATUS EXAM

Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When the PMHNP asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.

 

Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)

 

RESOURCES § Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.. 

 

 

Decisions Made and Outcomes (Needed to formulate the paper) (Must use and formulate paper based off of the chosen decision. Then tell why the other two decision were not a good choice with in-text citations noted for each.)

 

 

Choices for Decision 1: Select what the PMHNP should do:

 

Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks

 

: Begin Aricept (donepezil) 5 mg orally at BEDTIME

 

Begin Razadyne (galantamine) 4 mg orally BID

 

Decision Choice Chosen: Begin Exelon (rivastigmine) 1.5 mg orally BID with an           

                                      increase to 3 mg orally BID in 2 weeks

 

***Explain why other two choice were rejected (not adequate choices)***

 

 

RESULTS OF DECISION POINT ONE

·     Client returns to clinic in four weeks

·     The client is accompanied by his son who reports that his father is “no better” from this medication. He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors

·     You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall

Choices for Decision 2: Select what the PMHNP should do:

 

Increase Exelon to 4.5 mg orally BID

 

Increase Exelon to 6 mg orally BID

 

Discontinue Exelon and begin Namenda (memantine) 10 mg orally BID

 

Decision Choice Chosen: Increase Exelon to 4.5 mg orally BID

 

***Explain why other two choice were rejected (not adequate choices)***

 

RESULTS OF DECISION POINT TWO

·     Client returns to clinic in four weeks

·     Client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better

·     He states that his father is attending religious services with the family, which the son and the rest of the family is happy about. He reports that his father is still easily amused by things he once found serious

 

 

Choices for Decision 3: Select what the PMHNP should do:

 

Increase Exelon to 6 mg orally BID

 

Maintain current dose of Exelon

 

Add Namenda (memantine) 5 mg orally per day

 

Decision Choice Chosen: Increase Exelon to 6 mg orally BID

 

***Explain why other two choice were rejected (not adequate choices)***

 

 

Outcome: Guidance to Student
At this point, the client is reporting no side effects and is participating in an important part of family life (religious services). This could speak to the fact that the medication may have improved some symptoms. The PMHNP needs to counsel the client’s son on the trajectory of presumptive Alzheimer’s disease in that it is irreversible, and while cholinesterase inhibitors can stabilize symptoms, this process can take months. Also, these medications are incapable of reversing the degenerative process. Some improvements in problematic behaviors (such as disinhibition) may be seen, but not in all clients.

At this point, the PMHNP could maintain the current dose until the next visit in 4 weeks, or the PMHNP could increase it to 6 mg orally BID and see how the client is doing in 4 more weeks. Augmentation with Namenda is another possibility, but the PMHNP should maximize the dose of the cholinesterase inhibitor before adding augmenting agents. However, some experts argue that combination therapy should be used from the onset of treatment.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern. 

 

***Write on each decision. Make sure that in each decision choice that you explain why the other two decisions were not good choices. Use cited sources to validate points. Make sure that this paper has at least 7 References. Please use in-text citations for each section of each decision. Don’t forget the ethical considerations for this assignment. Make it a section by itself.***

 

***Also please make sure when looking at the ethical consideration for this assignment that you look at how the Caucasian (male) ethnicity and pain medications interact.***

 

Please use the following format when formulating the paragraphs for each section. Don’t forget the intext citations. Remember to use at least 7 references.

 

Introduction

Decision #1

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

Decision #2

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

 

Decision #3

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

Ethical Considerations

Conclusion

References

 

CHECK OUT THE ATTACHMENT FOR MORE INFORMATION

 

 

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Field: Nursing

Posted: A Day AgoDue: 19/09/2017Budget:  $8Report Issue

Week 4: Transformational Nursing Leaders

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Review Appendix A, Sections I–V in Finkelman (2016).

Select one of the sections and share how your chief nurse executive demonstrates expertise in these competencies.  Your comments should be about the “highest nursing leader” in your organization. Typically this is the leader who represents nurses and nursing to the governing board.

In your own words, explain the differences between a transactional nursing leader and a transformational nursing leader. What one is more like your Nurse Executive?

Describe how the Nurse Executive “leads the charge” for transformational leadership in an organization where you work or have done prelicensure clinical experiences.

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Collapse SubdiscussionDesirae Freeze

Desirae Freeze 

Friday Sep 15 at 8:18pm

Manage Discussion Entry

You may begin posting to this discussion on: Sunday, September 17, 2017

Class,

There are several sections in this appendix from which you can choose. Concentrate on one section and discuss competencies you see your Nurse Executive displaying. Keep in mind that they Nurse Executive the individual ultimately responsible for nursing and is at the top of your organization. This is not your director or nursing manager, but your Chief Nurse Executive.

Thanks,

Desirae

Edit question’s body

 

Discussion: Breast Conditions

Throughout a woman’s life, her breasts go through many normal, healthy changes. However, patients do not always understand these changes and often visit health care providers for treatment. When examining these patients, you must be able to identify when a breast condition is the result of a safe and normal physiological change and when it is the result of an abnormal change requiring treatment and management. A diagnosis of a breast condition resulting from an abnormal change can be devastating for women, making emotional support as vital to women’s well-being as proper assessment, diagnosis, and management. For this Discussion, consider how you might diagnose, manage, and support the following two patients presenting with breast conditions:

Case Study 1:

You are seeing a 60-year-old Latina female, Gravida 4 Para 3104, who is concerned about a thick greenish discharge from her left breast for the past month. The discharge is spontaneous and associated with dull pain and burning. Upon questioning, she also tells you that she breastfed all her children and is currently not on any medications except for occasional Tylenol for arthritis. Her last mammogram, 14 months ago, was within normal limits. On exam, her left breast around the areola is slightly reddened and edematous. Upon palpation of the right quadrant, a greenish-black discharge exudes from the nipple. You note an ovoid, smooth, very mobile, non-tender 1 cm nodule in the RUIQ at 11:00 5 cm from the nipple. No adenopathy, dimpling, nipple discharge, or other associated findings. Her right breast is unremarkable. The patient expresses her desire to proactively decrease her risk for developing breast cancer.

 Post an explanation of the differential diagnosis for the patient in the case study you selected. Explain which is the most likely diagnosis for the patient and why. Then, based on the appropriate clinical guidelines, explain a treatment and management plan for the patient, including proper dosages for any recommended treatments. Finally, explain strategies for educating patients on the disorder.