Chat with us, powered by LiveChat Discuss a systems-level safety concern in a healthcare setting by applying the situation, background, assessment, recommendation (SBAR) format by doing the - Writeden

A.  Discuss a systems-level safety concern in a healthcare setting by applying the situation, background, assessment, recommendation (SBAR) format by doing the following: 

1.  Describe a healthcare-related situation (S) prompting a systems-level patient safety concern that has the potential to impact multiple patients.

2.   Analyze background (B) information about the concern by doing the following:

a.  Describe the data that support or would support the need for change.

b.  Explain how one or more national patient safety standards apply to this situation.

3.   Assess (A) the impact of the safety concern on the patient(s), staff, and the organization as situated in the identified healthcare setting.

a.  Explain how the safety concern affects value for the patient(s) and the healthcare setting.

4.   Recommend (R) an evidence-based practice change that addresses the safety concern.

a.  Discuss how this recommendation aligns with the principles of a high-reliability organization.

b.  Describe two potential barriers to the recommended practice change.

c.  Identify two potential interventions to minimize the barriers from part A4b to the recommended practice change.

d.  Discuss the significance of shared decision-making among the healthcare setting’s relevant stakeholders in implementing this recommendation.

e.  Describe an outcome measure that could be used to evaluate the results of the recommendation.

f.   Describe the care delivery model currently being used in the healthcare setting.

  i.  Explain how the current care delivery model in the healthcare setting identified in part A4f would be impacted by the recommended change in part A4.

B.  Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.

C.  Demonstrate professional communication in the content and presentation of your submission.

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Organizational Systems and HealthCare Transformation

D221

Mona Y. Shen

Western Governors University

Dr. Kallie Gatzemeier

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SITUATION: (Healthcare-related situations prompt a systems-level patient safety concern that

could impact multiple patients.)

1. Medication errors remain a major health problem in the healthcare system, medication

errors occur every 22.7 hours, and medication errors that adversely affect patient care

outcomes occurred 0.25% of all patients admitted in hospitals a year (Medication Error

in United States hospitals (2001) pubmed.ncbi.nlm.nih.gov/11560102/). In 2016 John

Hopkins released a longitudinal study between 2000 and 2008 of preventable deaths

caused by medication errors. The John Hopkins study calculated over eight years that

more than 250,000 deaths per year occurred due to medical errors making it a third

leading cause (hub.jhu.edu>2016/05/03>medical-errors-third). Medication errors are

preventable and are considered a never event. A never event according to National

Quality Forum (NQF), are errors in a healthcare setting that are identifiable, preventable,

measurable, and should not have happened in the first place.

BACKGROUND:

2a. (Describe the data support the need for change)

Medication errors cost the healthcare system an estimated 3.5 billion dollars annually due to

adverse drug events (ADE) and the estimated 3.5 billion dollars does not include the loss of

wages and productivity (Institute of Medicine, Committee on Identifying and Preventing

Medication Errors. National Academies Press; 2007:124-25).

The benefits of prevention of ADE promote to improve and facilitating zero patient harm, the

trustworthiness of the healthcare system to perform its due diligence in providing the best quality

care and outcomes for the patients, and the monetary savings can be utilized for improvements or

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upgrades in organizational healthcare technologies, software programming system, medical

durable equipment, streamline healthcare operations, additional resources, and support for staff

training, provide the community with health-related resources such as health education in

chronic disease management, or health prevention measures such as community gardening to

promote healthy nutrition lifestyles and provide low impact exercise activities such as Tai Chi.

2b. (Explain how one or more national patient safety standards apply to the situation)

Quality care and patient safety outcomes are the goals of every healthcare provider. However, the

detrimental impact of a never event occurring in a healthcare organization affects the perception

and places a negative stigma of the organization from the community if not corrected. HCAPS

(Hospital Consumer Assessment of Healthcare Providers and Systems) is the voice of the patient

and the patient’s family review and survey of the care they received at the healthcare facility. The

low HCAHPS score will negatively impact the organization’s reputation and limit the amount of

reimbursement from Medicare/Medicaid to the organization. Healthcare is also evolving from

fee-for-services (FFS) to value-based care payment. The FFS is a payment method based on the

quantity of care and not the value of care. Value-based healthcare is based on the quality of care

and the measuring of patient health outcomes. The center for Medicare/Medicaid service is

moving away from FFS to value-based care payment and private healthcare insurance is

following suit. Quality patient outcomes and financial benefits go hand in hand with the

organization’s success in the healthcare industry. It would be imperative for a healthcare

organization to facilitate medication error prevention, to do no harm, and to align with the

National Patient Safety Goals (NPSGs) under the Joint Commission. Who is the Joint

Commission (TJC)? The TJC is a United States-based nonprofit tax-exempt 501(c) organization

that accredits more than 22,000 US healthcare organizations and programs

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(https://en.wikipedia.org/wiki/Joint Commission). The mission and vision of TJC are to

continuously improve health care for the public, in collaboration with other stakeholders, by

evaluating healthcare organizations and facilitating the provision of safe and effective care of the

highest quality and value. TJC’s vision is that all people always experience the safest, highest

quality, best-value health care across all settings. TJC's main purpose is the assurance of

healthcare organizations meet the criteria to ensure policies and procedures are implemented to

safeguard patients’ safety. TJC annually inspects healthcare facilities and makes

recommendations if necessary. If the healthcare organization is not in compliance with the

patient's safety, the facility can incur penalties and monetary fines. The purpose of the NPSGs is

to assist and collaborate with the healthcare facility to improve patient safety, focusing on the

problem of healthcare safety issues, and how to correct and solve the problem.

ASSESS: (Assess the impact of the safety concern on the patients, staff, and the organization)

3a. We do not live in a perfect world void of human errors and mistakes. We must

acknowledge mistakes do happen and what we can learn from them, prevent them from

happening again, and not look to blame. When a medical staff unintentionally causes an error in

an ADE, there is a tendency to prompt our self-assessment and question our ability to provide

quality care, re-evaluating our judgment, skills, knowledge, and feelings of shame and guilt. One

of the best practices of a healthcare organization is to facilitate and promote a Just Culture. Just

Culture is a concept relating to a system of thinking which emphasizes that mistakes are overall

the product of faulty healthcare organization cultures, rather than solely instituted by the person

or persons directly involved. So, the staff and organization can begin the process of Root Cause

Analysis (RCA). RCA is about what happened, why did it happened, what steps the healthcare

organization can take to prevent it from happening again, and then measure the effectiveness of

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the implemented action. RCA is a systematic approach to assessing the causes of an adverse

event and identifying any system flaws. To pinpoint the area of weakness or root cause of the

problem, to gain a full understanding of the problematic issue or issues it happened, what steps

the healthcare organization can take to prevent it from happening again, and then measure the

effectiveness of the implemented action. To pinpoint the area of weakness or root cause of the

problem, to gain a full understanding of the problematic issue or issues, and take measures to

correct and rectify the problems to prevent them from happening again. The Fishbone diagram

created by Professor Kaoru Ishikawa (please see attached Fishbone diagram) is used as a chart

guide. There are six steps to conducting RCA, first to identify what happened. Second,

determined what should have happened. Third, determine the cause. Fourth, develop statements

about the incident. Fifth, make a list of recommendations. Sixth is the conclusion and

dissemination of the findings and recommendations. The RCA group involves an

interdisciplinary team made up of clinician engagement, eliciting patient involvement upon the

patient’s consent, the patient's family representative that was informed of the medication error,

providing transparency, involvement of risk management, and other stakeholders. The

stakeholders gather documents, assemble timelines, draw out the story from all groups or

individuals that are involved, work together to identify the root causes, identify any gaps in

knowledge, identify any deficiencies in the system’s protocols, standard policies, or technology,

failure of information, identify any environmental sources, such as lack of personnel support or

staffing issues. Once the issues are identified, the process begins in developing a plan of action

for correction that addresses the root causes to improve the quality of the healthcare system and

establish outcome measures. Some findings may be that multi-system level issues have existed.

Such as knowledge gaps, inadequate staff training, work environments such as heavy workloads

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posing a safety risk, distractions, and interruptions. Did the prescriber who ordered the drug

inaccurately express the dosage in the order entry system, did the software program lack warning

alerts for inaccurate dosing, was the dosage and correct medication verified with a second

witness, did the pharmacist who dispensed the medication fail to capture the medication error

due to distractions or was there a software malfunction that dispensed the medication. The main

purpose of conducting the RCA is to find possible near misses that could have harmful effects or

a sentinel event. A sentinel event is defined by TJC as a patient’s safety having been

compromised resulting in death, permanent harm, or severe temporary harm. ADE has a negative

impact and consequences that affect patients’ experience with the healthcare system such as

physical pain, suffering, psychological distress, extended hospitalization, and preventable deaths.

This leads to decreased patient satisfaction and a lack of trust in the healthcare system from the

patients and the patient’s families. The ADE consequences are the extra financial burden for

treatment and rehabilitation expenses from the never event, loss of revenues, and not to mention

the legal ramifications of potential lawsuits.

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Fishbone Diagram Example

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RECOMMENDATION: (Evidence-based practice that changes that addresses safety concerns)

4a. Applying evidence-based practices such as knowledge and performing the 5 Rights.

1st Right patient 2nd Right medication 3rd Right dose 4th Right route 5th Right time. The 5 Rights

are an important integral part of providing patient safety and ensuring patient-centered care.

Taking extra precautions and being proactive to eliminate any potential errors promotes best

practices and promotes patient safety. Healthcare facilities are integrating technology systems to

facilitate protocols and procedures in place to warn and alert staff of look-alike and sound-alike

medications (https://www.nci.nlm.nih.gov/books/NBK2656 / ). Promoting and optimizing the

utilization of best practices throughout the healthcare organization is key for patient safety

outcomes. Most healthcare systems strive to adopt the characteristics of a High-Reliability

Organization (HRO). HRO characteristics involve promoting clinical team training, continuous

learning, and improvement processes, providing a just and safe environment/culture, evaluating

technology, and finding solutions with evidence-based practices, creating innovative partnerships

with stakeholders providing patient safety and value-based care compassionate care. Part of the

HRO has shared decision-making with the patients, and stakeholders. HRO models the focus on

patient-centered care that makes sense to the patients. Including patients to be active in their care

would encourage and motivate the patients to be proactive in implementing the steps they need

to take to enhance their wellness. It leads and initiates patients to offer their valuable input and

suggestions. Patients can provide insights and feedback from their perspective with the

knowledge provided by their care providers. Patients can provide their analysis and assessment

of how effective the healthcare providers’ communication process is perceived by the patients in

comprehending what the healthcare providers are providing. The significance of shared decision-

making encompasses having a conversation between two parties to find common grounds to

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agree on a subject matter. Respecting each other’s differences and valuing each other’s

perspectives.

4b. (Two potential barriers to recommend practice change)

Two potential barriers in implementing plans of intervention are resistance from administration

in support of facilitating change and resistance to change from those who are responsible to

deliver and implement the plan of action. Resistance is natural, it is expected to have some

resistance to change or process, it is the unknown factor resulting the natural occurrence of fight

or flight. Some possible reasonings of resistance from the administration and those who would

be responsible to institute and follow the process of change includes they were not aware of the

never event incident had occurred, so it came as a surprise to the individuals, other possible

reasonings they were not informed or consulted prior to RCA process, they were not prepared to

receive latest information, information was unexpected, conflict with the instability of

leadership, new management’s uncertainty or lack of confidence in the process.

4c. (Identify two potential interventions to minimize barriers)

Some of the following recommendations for intervention to minimize potential barriers;

1) Communicate as early as possible for the rationale of change.

2) Involve and notify the administration, management, team leaders, and the staff early in

the stages of plans for improvement.

3) Provide an opportunity for an open forum that is safe and allows for two-way

communication.

4) Engage staff and stakeholders in the process and change-related activities.

5) Give a clear and concise understanding of the organization’s goals and mission for HRO.

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6) Ensure support and resources are in place to facilitate the activities and are deployable

without hindrance.

7) Provide acknowledgement with positive feedback and reinforcement with support along

the journey

The journey and process to implement change are not void of simplicity, but when an

organization comes in unity and shares the same values for patient-centered care that creates

assurance for patient safety outcomes will allow the process of change to come to fruition

successfully. When we understand that we work together for the greater good and come together

as a team striving for the same mission and goals, we will be able to work cohesively.

4d. (Discuss the significance of shared decision-making among the healthcare setting and

stakeholders in implementing the change)

Everyone has choices and the freedom to choose on how to they go about managing their own

health practices and treatment options. Shared decision-making (SDM) includes the patient,

patient’s family, caregiver, and the patient’s healthcare providers to ensure that patient’s

preferences are acknowledged, respected, and prioritized. Patients who are well-informed and

given reliable, unbiased information can assist the patient to navigate the best options to their

individual preference. A patient’s healthcare provider can provide accurate details of choices,

uncover any myths or assumptions, listen carefully to the patient’s concerns and questions, offer

support, and guide the patient to reach the patient’s anticipated healthcare goals. Patients can also

optimize their pros and cons of treatment options via the utilization of decision aids. Decision

aids are evidence-based medical literature or pamphlets, video, or a website, that can assist the

patients to make informed choices that can lead to better outcomes. The main driver for

stakeholders to implement SDM in the healthcare system is that it is patient centered care. It is

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the right thing to do, acts on behalf of the patient for the individual’s best interest, aid in

preventing health disparities, and can impact the quality, cost, and safety of healthcare delivery

(mghdecisionsciences.org).

4e. (Outcome measure that is utilized to evaluate the results of recommendations)

How does a healthcare facility confirm that the current practice in place is beneficial and

provides positive end results? Answer, perform and compare by benchmarking. The

benchmarking program demonstrates the comparison with other healthcare facilities who are top

notch with high performance ratings of similar processes and applying their tools and processes

for improvement. By applying accurate data to make informed decisions for healthcare practices

can reduce or eliminate mistakes. Healthcare providers gain insights and improve outcomes

through quality measure benchmarking. Benchmarking allows healthcare organizations to

identify best practices in care. By analyzing variation in quality measures, healthcare providers

can identify research opportunities that advance professional knowledge, which informs the

creation of future best practices. Similarly, quality measure benchmarks can be used to

accurately track quality improvement progress.

4f. (Description of current healthcare model being utilized in a healthcare setting)

At the Veteran’s Affairs (VA) ambulatory care clinics (ACC) have a team-based care approach

with integrated care in providing the veterans with all one-stop healthcare needs. The team-based

care at the VA is identified as PACT (Patient Aligned Care Team) that encompasses the MD, RN,

Pharmacist, Nutritionist, LVN (licensed vocational nurse), SW (Social Worker), MSA (Medical

Support Assistant), and PACT working closely with integrated ancillaries such as the specialty

clinics. Specialty clinic providers include Neurologists, Cardiovascular, Pulmonary,

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Gastrointestinal, Endocrinology, Dermatology, Rheumatology, Mental Health, Behavioral

Health, Geriatrics, Orthopedics, Surgeons, Imaging, Laboratory, Physical Medicine, Chaplain,

Education, and in addition with other health-related resources such as the Home Health services,

Telehealth for outpatient monitoring, travel resources, durable medical equipment, and the list

goes on. PACT provides a point of care when a patient comes to the clinic complaining of, for

example, low back pain, the patient is examined, triaged, and given detailed information about

treatment options and preferences. If warranted, the patient may complete imaging, refer to

Physical and Medicine for back brace support, and go to the pharmacy to pick up the medication.

All these healthcare-related activities are done on the same day and completed in the same

building for convenience and accessibility for the patient. The current PACT practice is also

integrated care, and an example of integrated care is when a patient is discharged from the

hospital, the hospital discharge nurse planner notifies the PACT, and the PACT then would

follow up on the patient within 2 days post-discharge. Post-discharge follow-up performance

action from RN includes, but not limited to, is medication reconciliation, which includes

information on any new, discontinued, or held medications from the discharging provider,

reinforcement of discharge instructions understanding, any concerns, issues, or questions patient

may have and address the issues, accordingly, are there any new needs from the patient, such as

dressing supplies, durable medical equipment, ensure there is a scheduled follow-up medical

appointment and if not, we can schedule it at the time of the call. A post-discharge follow-up call

is vital to help facilitate the transition from hospital to home, provide support for recovery and

prevent complications.

4i. (Explain how the current care delivery model identified in A4f would be impacted by

the recommendation change in part A4)

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Teamwork is an essential component of HRO as demonstrated by the VA ACC with PACT

model. The PACT model in which a group of healthcare professionals, led by primary care

providers, work collaboratively with patients to provide all the patient’s healthcare needs. PACT

coordinates care with other qualified healthcare specialists as needed, automated point-of-care

delivery, point-of-care health literacy dissemination. The VA healthcare system puts the patient’s

goals and needs at the center of the treatment decision-making process. The PACT model also

encourages patients to play a more active role in managing their health and healthcare needs. The

PACT model focuses on partnerships with the patients, allowing patients to access care using

diverse methods, coordinated care among team members, and team-based care with patients as

the center of their PACT. Patients’ access to care and the choice of in-person visits with their

healthcare provider (HCP), telephone visits, secure text messaging, or video connection visit.

The study suggests the adoption of PACT reveals significantly associated with a lower risk of

avoidable hospitalization (Yoon J, Rose D, Canelo I, et al.)

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Reference

1. Medication Error in United States hospitals (2001pubmed.ncbi.nlm.nih.gov/11560102)

2. hub.jhu.edu>2016/05/03>medical-errors-third

3. Institute of Medicine, Committee on Identifying and Preventing Medication Errors.

National Academies Press; 2007:124-25

4. https://en.wikipedia.org/wiki/Joint Commission

5. https://www.nci.nlm.nih.gov/books/NBK2656

6. Yoon J, Rose D, Canelo I, et al. Medical home features of VHA primary care clinics and

avoidable hospitalizations. Journal of General Internal Medicine. September

2013;28(9):1188-1194.