In Week 4, you identified some immediate areas of concern that you were able to effectively address. You must present the final phase of your improvement plan to your staff and upper-level management. You will create a presentation of 15-20 slides. Each slide will have 4-6 bullets and 100-150 words of speakers notes. The presentation will address the following areas:
In preparation for the accreditation visit for AKT, choose 1 health care accrediting and credentialing organization.
- Select a quality improvement focus (QIF) area to improve patient outcomes in beyond the 3 issues that you identified and addressed in Week 4.
- Discuss the selected accreditation agency related to the QIF and why the organization is seeking this particular agency for credentialing.
- As part of the quality improvement initiative, select 3-4 related accrediting standards that the organization will use as the basis for the quality improvement plan.
- Provide a clear mission statement and set of 3-4 specific, measurable, attainable, realistic, and timely (SMART) goals for the QIF initiative.
- Using the online database provided the by the organization you selected conduct an analysis.
- Provide general statistical data related to the QIF.
- Discuss specific health care examples of local, state, and national policies that have been developed to improve this QIF based on evidence-based practice research.
- What internal policies do you plan to implement based on evidence-based practice approaches to ensure your organization meets these standards?
- Develop a plan that includes strategies for your facility to improve patient outcomes regarding the QIF.
- Describe how the QIF initiative can be incorporated to the organization’s overall strategic plan.
- Describe how you plan to evaluate the effectiveness of the initiative.
- Each slide will have 4-6 bullets and 100-150 words of speaker’s notes and pictures.
Expert Solution Preview
In this assignment, we will be presenting a final phase of our improvement plan to the staff and upper-level management for AKT’s accreditation visit. The presentation will address various areas, including selecting a quality improvement focus (QIF) area, discussing the selected accreditation agency related to the QIF, and developing a plan that includes strategies for improving patient outcomes regarding the QIF. With that said, let’s jump into the questions.
1. Which accrediting and credentialing organization did you choose for this assignment, and why?
For this assignment, we have chosen The Joint Commission (TJC) as the accrediting and credentialing organization. The Joint Commission promotes healthcare quality and safety and is known for accrediting the majority of hospitals in the United States. It seeks to continuously improve the quality of health care that patients receive by ensuring that appropriate diagnoses and treatments are provided by healthcare organizations.
2. What quality improvement focus (QIF) area did you select to improve patient outcomes beyond the three issues identified and addressed in Week 4?
We have selected the quality improvement focus (QIF) area of patient safety. Patient safety involves preventing patient harm and ensuring that every patient receives the safest and most effective care possible. By focusing on patient safety, we aim to reduce adverse events, infections, and medical errors, and improve patient outcomes.
3. Which TJC standards will be used as the basis for the quality improvement plan?
As part of the quality improvement initiative, we will be using the following three TJC standards as the basis for our quality improvement plan:
– Standard LD.04.03.09: The organization identifies and manages risks to patients, staff, and others.
– Standard PC.01.02.07: The organization educates staff about their roles in preventing infection.
– Standard NPSG.03.06.01: Maintain and communicate accurate patient medication information.
4. What is the mission statement, and what are the specific, measurable, attainable, realistic, and timely (SMART) goals for the QIF initiative?
Our mission statement for this initiative is to improve patient safety by reducing adverse events, infections, and medical errors in our healthcare organization. Our SMART goals for this initiative are:
– Increase hand hygiene compliance rates among staff by 20% within the next six months.
– Reduce the incidence of catheter-associated urinary tract infections (CAUTIs) by 30% in the next year.
– Improve medication reconciliation processes and reduce medication errors by 50% in the next two years.
5. Using the online database provided by TJC, what statistical data did you find related to the QIF?
According to the TJC database, patient falls are a significant contributor to patient harm and adverse events. Additionally, medication errors and infections are also prevalent causes of harm to patients. It is crucial to focus on reducing these events to improve patient safety.
6. Discuss specific healthcare examples of local, state, and national policies that have been developed to improve patient safety based on evidence-based practice research.
Several healthcare policies have been developed to improve patient safety, including:
– The Institute for Healthcare Improvement’s (IHI) “5 Million Lives Campaign,” which focuses on reducing harm and death from medical errors.
– The Centers for Disease Control and Prevention’s (CDC) “Hand Hygiene in Healthcare Settings” guidelines, which provide recommendations for hand hygiene practices to prevent infections.
– The Agency for Healthcare Research and Quality’s (AHRQ) “Medication Safety: A Patient Safety Threat and a Priority for Action” report, which highlights the importance of medication safety in healthcare organizations.
7. What internal policies do you plan to implement based on evidence-based practice approaches to ensure your organization meets the TJC standards?
To meet the TJC standards, we plan to implement several internal policies, including:
– Providing staff with regular education and training on hand hygiene, infection prevention, and medication safety.
– Implementing a fall prevention program that includes assessments, interventions, and patient education.
– Standardizing medication reconciliation processes to promote accurate medication lists and reduce medication errors.
8. Develop a plan that includes strategies for your facility to improve patient outcomes regarding the QIF.
To improve patient outcomes regarding the QIF, our plan includes the following strategies:
– Implementing evidence-based practices for infection prevention, including hand hygiene, isolation precautions, and environmental cleaning.
– Establishing a patient safety committee to identify and manage risks, conduct root cause analyses, and implement improvement plans.
– Conducting regular patient safety rounds to identify and address potential hazards and risks.
9. Describe how the QIF initiative can be incorporated into the organization’s overall strategic plan.
The QIF initiative to improve patient safety by reducing adverse events, infections, and medical errors can be incorporated into the organization’s overall strategic plan by aligning it with the organization’s mission, vision, and values. It can also be integrated into the organization’s quality improvement and performance improvement programs to ensure that it is a priority and continuously monitored.
10. Describe how you plan to evaluate the effectiveness of the QIF initiative.
We plan to evaluate the effectiveness of the QIF initiative by:
– Tracking patient safety indicator rates, such as falls and infections, to determine if they have decreased as a result of our interventions.
– Conducting periodic audits of hand hygiene, catheter use, and medication reconciliation processes to ensure they are being followed.
– Surveying staff and patients to measure the level of satisfaction with the care provided and their perceptions of safety and quality.