01 Aug You will propose how the particular health information system used in your selected case would be applicable in a health care organization of your choice. Refer to your chosen organ
You will propose how the particular health information system used in your selected case would be applicable in a health care organization of your choice. Refer to your chosen organization as System Implementation and Support.
- Evaluate the needs that are present within your selected case study as it applies to your “ABC Health Care” organization.
- Examine the practices from your selected case study that confirm or contradict that data is complete, accurate, consistent, timely, secure, and fit for use.
- Compare and contrast the different types of data and information generated by the health care organization in your case.
**please use the proposal form attached**
QUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL: TYPE YOUR SPECIFIC TITLE HERE
Fill-in the details below between the brackets
Setting: Here, describe the place that you will focus on for this proposal and the specific of that
Health Care Service: In this section, share the specific health care service that you are
proposing a quality improvement for.
Problem: In this section, describe the specific problem you have found. Be sure to include
evidence from sources that support this is a problem.
Barriers to Quality: Here, share any barriers that exist that hinder the quality that is needed.
Be sure to provide evidence from sources to support your claims.
2. THE INTERVENTION
In this section, discuss the intervention or solution you are proposing to improve the quality of
the problem you have identified. Provide evidence from sources to support your suggestions.
Process Defect: Here, include the overall process that will be used to implement the proposed
Aim (Objective): Here, state the objective of the proposed intervention.
3. STRATEGY FOR IMPLEMENTATION
Here, identify and describe the steps or the strategy that will be taken to implement the
Measures : In this space, share what will be used to measure the implementation of the
intervention or how the results of the implementation will be measured.
Barriers to Change : Here, include a discussion of any barriers that could get in the way of the
proposed change. Include any evidence from sources that can support your claims.
Simple Rules: Here, include the rule that will be satisfied by your proposed intervention.
Cost Implications : Here, include any costs associated with the proposed intervention.
QQUALITY IMPROVEMENT STUDENT PROJECT PROPOSAL:
IMPROVING HANDOFFS IN SAN FRANCISCO GENERAL
HOSPTITAL’S EMERGENCY DEPARTMENT
TMIT Student Projects QuickStart Package ™
Setting: Emergency departments are “high-risk” contexts; they are over-crowded and
overburdened, which can lead to treatment delays, patients leaving without being seen by a
clinician, and inadequate patient hand-offs during changing shifts and transfers to different
hospital services (Apker et al., 2007). This project will focus on the Emergency Departments in
county hospitals, specifically San Francisco General Hospital. SFGH has the only Trauma Center
(Level 1) available for the over 1.5 million people living and working in San Francisco County
Health Care Service: This paper will focus on intershift transfers, the process of transferring a
patient between two providers at the end of a shift, which can pose a major challenge in a busy
emergency department setting.
Problem: According to the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO), poor communication between providers is the root cause of most sentinel events,
medical mistakes, and ‘‘near misses.” Furthermore, a recent survey of 264 emergency
department physicians noted that 30% of respondents reported an adverse event or near miss
related to ED handoffs (Horwitz, 2008). A similar survey notes that 73.5% of hand-offs occur in
a common area within the ED, 89.5% of respondents stated that there was no uniform written
policy regarding patient sign-out, and 50.3% of those surveyed reported that physicians sign out
patient details verbally only (Sinha et al., 2007). At SFGH, handoffs occur in the middle of the
ED hallway, usually next to a patient’s gurney. Sign-out is dependent on the Attending and
Residents on a particular shift; thus, it is non-uniform, and hand-offs are strictly verbal.
Barriers to Quality: In a 2005 article in Academic Medicine, four major barriers to effective
handoffs were identified: (1) the physical setting, (2) the social setting, and (3) communication
barriers. Most of these barriers are present during intershift transfers at SFGH. The physical
setting is usually in a hallway, next to a whiteboard, never in private. Presentations are frequently
interrupted, and background noise is intense from the chaos of an overcrowded emergency room.
Attendings frequently communicate with each other and assume that the resident can hear them.
Solet et al. suggests that Residents are unlikely to ask questions during a handoff if the
information is coming from an Attending physician. All transfers are verbal, none are
standardized, and time pressures are well known, since sign-out involves all working physicians
in the ED at one time.
2. THE INTERVENTION
The Institute for Health Care Improvement (IHI) lays out several steps for conducting a quality
improvement project. First, an organization needs to explicitly state what they are trying to
accomplish by setting “time specific and measurable aims” (IHI website). Next, an organization
needs to establish measures that will indicate whether the improvement works. Changes that
result in an improvement need to be identified and then tested in a Plan-Do-Study-Act (PDSA)
cycle. Specifically, the change needs to be planned, tried, studied, and then members must act on
what they have learned (IHI website). PDSA cycles should start out in a small group before
being tried in a large institutional setting. Finally, the changes should be made throughout the
Most projects that use rapid PDSA cycles to address issues with patient handoffs
measured their compliance with a standardized communication method. Programs such as the
Five Ps (Patient, Plan, Purpose, Problems, Precautions), I PASS the BATON, or SBAR, are all
acronyms for a standardized, tested procedure to ensure compliance with the Joint Commission
requirements (Runy, 2008). Such methods may standardize the handoff process, but may not be
considered the most efficient tool by providers; therefore, provider satisfaction is a key
component for compliance and implementation (Wilson, 2007).
Process defect: This project will attempt to address non-uniform patient handoffs at the SFGH
ED by using rapid PDSA cycles to implement the SBAR handoff technique:
– S-ituation: complaint, diagnosis, treatment plan, and patient’s wants and needs
– B-ackground: vital signs, mental and code status, list of medications and lab results
– A-ssessment: current providers assessment of the situation
– R-ecommendation: pending labs, what needs to be done (H&HN, 2008)
Aim (Objective): to improve patient safety, content reliability, and peer satisfaction with SFGH
ED handoffs by having 100% compliance of the SBAR standardized protocol within 18 months
(adapted from Owens et al., 2008)
3. STRATEGY FOR IMPLEMENTATION
The first step of this implementation strategy will be to identify the early adopters and process
owners. A small team, perhaps of one attending and two residents that are passionate about this
project need to be identified and initiate the first PDSA cycle using the SBAR format for patient
handoffs. In this small group, they can work out their pit-falls, and adapt the SBAR technique to
the physical setting and social setting at SFGH. This group may wish to develop an index card
with an SBAR template to improve communication. The first PDSA cycle may look something
– Plan—develop a strategy to reduce noise and distractions, use SBAR (perhaps with an
index card that can be passed on), and have opportunity to ask questions.
– Do—early adopters need to try out the process during two changes of shift.
– Study—evaluate satisfaction, review pitfalls, was it easy to comply?
– Act—Implement changes during next two changes of shift.
Next, this group will need to identify opinion leaders within the organization, perhaps the Chief
Resident, to help convince the early majority that this technique will improve patient safety and
save time and effort during changes of shift. The early adopters may want to hold a training to
convince this larger group. Next, this larger group will initiate its own PDSA cycle, until 100%
compliance with the SBAR protocol is achieved.
Measures: (a) compliance with the SBAR format, via an “all or none” metric, (2) provider
satisfaction via survey, which will include questions on perceptions of time saving.
Barriers to change: The major barriers to change will be from opinion leaders within the SFGH
ED that want to protect the status quo. Some Attending and Resident physicians may be wary of
a new technique for fear that it may add to the amount of time it takes at the change of shift.
Second, most of these physicians have “always signed-out this way and have never had a
problem.” Once the early adopter group has worked out many of the kinks in implementation,
leadership will play a key role for further adoption of this project. Leaders may take note of the
Joint Commission’s recommendation on handoffs (JCAHO, 2006), and support this project, and
help nudge the late adopters along. However, in the long run, provider satisfaction of the
protocol, including provider’s perceptions of saving time, will dictate adherence, so even late
adopters need to have input during PDSA cycles.
Simple Rules: The landmark IOM report Crossing the Quality Chasm identified 10 simple rules
to help redesign health care processes (IOM, 2001). This quality improvement project is in
accordance with rule ten: cooperation among clinicians. Clinicians should “actively collaborate
and communicate to ensure and appropriate exchange of information and coordination of care.”
Standardizing patient handoffs in a busy emergency department setting is crucial to patient safety
and helps place patients needs first; this change manifests this simple rule.
Cost implications: This process change does not require any additional costs.
Apker et al. (2007) Communicating in the “gray zone”: perceptions about emergency physician-
hospitalist handoffs and patient safety. Aca Emerg. Med. 14(10), 884-94
Coleman et al. (2004) Lost in Transition: Challenges and Opportunities for Improving the quality
of Transitional Care, Ann Intern Med. 140:533-36.
Horwitz et al. (2008) Dropping the Baton: A qualitative analysis of failures during the transition
from emergency department to inpatient care. Annals of Emergency Med. Article in press,
accessed April 21, 2009
Horwitz et al. (2009) Evaluation of an Asynchronous Physician Voicemail Sign-out for
Emergency Department Admissions. Annals of Emergency Med. In press, accessed April 21,
IHI website. Improvement methods-PDSA cycle.
April 29, 2009.
Institute of Medicine (IOM). Crossing the Quality Chasm. Washington, DC: National Academy
Joint Commission on Accreditation of Healthcare Organizations. Sentinel event root causes. Jt
Comm Perspect Patient Saf. 2005; 5(7):5–6.
JCAHO. Improving Handoff Communications: Meeting National Patient Safety Goal 2E. Joint
Perspectives on Patient Safety. 2006; 6(8): 9-15.
Owens et al. (2008) Improvement Report: Improving Resident-to-Resident Patient Care
Handoffs, IHI.org, accessed April 29, 2009.
Runy, Lee Ann (2008) Patient Handoffs, the pitfalls and solutions of transferring patients safely
from one caregiver to another. H&HN.com, accessed April 29, 2009.
SFGH website; http://sfghed.ucsf.edu/Index.htm, accessed April 21, 2009.
Sinha et al. (2007) Need for standardized sign-out in the emergency department: a survey of
emergency medicine residency and pediatric emergency medicine fellowship program directors.
Aca Emerg Med.; 14(2) 192-6.
Solet et al. (2005) Lost in Translation: Challenges and Opportunities in Physician-to-Physician
Communication During Patient Handoffs. Academic Medicine; Volume 80 – Issue 12 – pp 1094-
Wilson, Mary Jane (2007) A template for Safe and Concise Handovers, Medsurg Nursing. 16(3);
Chapter 6 System Implementation and Support Learning Objectives To be able to discuss the process that a health care organization typically goes through in implementing a health care information system. To be able to assess the organizational and behavioral factors that can affect system acceptance and use and strategies for managing change. To be able to develop a sample system implementation plan for a health care information system project, including the types of individuals who should be involved. To gain insight into many of the things that can go wrong during system implementations and strategies that health care manager can employ to alleviate potential problems. To be able to discuss the importance of training, technical support, infrastructure, and ongoing maintenance and evaluation of any health care information system project. Once a health care organization has finalized its contract with the vendor to acquire an information system, the system implementation process begins. Selecting the right system does not ensure user acceptance and success; the system must also be incorporated effectively into the day-to-day operations of the health care organization and adequately supported or maintained. Whether the system is built in-house, designed by an outside consultant, or leased or purchased from a vendor, it will take a substantial amount of planning and work to get the system up and running smoothly and integrated into operations.
This chapter focuses on the two final stages of the system development life cycle: implementation and then support and evaluation. It describes the planning and activities that should occur when implementing a new system. Our discussion focuses on a vendor-acquired system; however, many of the activities described also apply to systems designed in-house, by an outside developer, or acquired or leased through cloud-based computing services.
Implementing a new system (or replacing an old system) can be a massive undertaking for a health care organization. Not only are there workstations to install, databases to build, and networks to test but also there are processes to redesign, users to train, data to convert, and procedures to write. There are countless tasks and details that must be appropriately coordinated and completed if the system is to be implemented on time and within budget—and widely accepted by users. Essential to the process is ensuring that the introduction of any new health care information system or workflow change results in improved organizational performance, such as a reduction in medication errors, an improvement in care coordination, and more effective utilization of tests and procedures.
Concerns have been raised about the potential for EHRs to result in risk to patient safety. Health care information systems such as EHRs are enormously complex and involve not only the technology (hardware and software) but also people, processes, workflow, organizational culture, politics, and the external environment (licensure, accreditation, regulatory agencies). The Institute of Medicine published a report that offers health care organizations and vendors suggestions on how to work collaboratively to make health IT safer (IOM, 2011). Poor user-interface designs, ineffective workflow, and lack of interoperability are all considered
threats to patient safety. Several of the suggested strategies for ensuring system safety are discussed in this chapter. Along with attending to the many activities or tasks associated with system implementation, it is equally important to manage change effectively and address organizational and behavioral issues. Studies have shown that over half of all information system projects fail. Numerous political, cultural, behavioral, and ethical factors can affect the successful implementation and use of the new system (Ash, Anderson, & Tarczy-Hornoch, 2008; Ash, Sittig, Poon, Guappone, Campbell, & Dykstra, 2007; McAlearney, Hefner, Sieck, & Huerta, 2015; Sittig & Singh, 2011). We devote a section of this chapter to strategies for managing change and the organizational and behavioral issues that can arise during the system implementation process. The chapter concludes by describing the importance of supporting and maintaining information systems.
System Implementation Process System implementation begins once the organization has acquired the system and continues through the early stages following the go-live date (the date when the system is put into general use for everyone). Similar to the system acquisition process, the system implementation process must have a high degree of support from the senior executive team and be viewed as an organizational priority. Sufficient staff, time, and resources must be devoted to the project. Individuals involved in rolling out the new system should have sufficient resources available to them to ensure a smooth transition.
The time and resources needed to implement a new health care information system can vary considerably depending on the scope of the project, the needs and complexity of the organization, the number of applications being installed, and the number of user groups involved. There are, however, some fundamental activities that should occur during any system implementation, regardless of its size or scope: Organize the implementation team and identify a system champion. Clearly define the project scope and goals. Identify accountability for the successful completion of the project. Establish and institute a project plan. Failing to appropriately plan for and manage these activities can lead to cost overruns, dissatisfied users, project delays, and even system sabotage. In fact, during the industry rush to take advantage of CMS incentive dollars, a flurry of EHR stories hit the news—with everything from CIOs and CEOs losing their jobs as a result of “failed” EHR implementations, to hospital operations screeching to a halt, to significant financial problems arising from glitches in the revenue cycle. These high-profile cases brought national attention to the consequences of a failed implementation. During system implementation, facilities often see their days in accounts receivable and denials increase while cash flow slows. By organizations anticipating risks to the revenue cycle prior to go-live and as part of EHR workflow, they are in a much better position to stay on track and maintain positive financial performance during the transition (Daly, 2016). In today's environment, in which capital is scarce and resources are limited, health care organizations cannot afford to mismanage implementation projects of this magnitude and importance. Examining lessons learned from others can be helpful.
Organize the Implementation Team and Identify a Champion One of the first steps in planning for the implementation of a new system is to organize an implementation team. The primary role and function of the team is to plan, coordinate, budget, and manage all aspects of the new system implementation. Although the exact team composition will depend on the scope and nature of the new system, a team might include a project leader, system champion(s), key individuals from the clinical and administrative areas that are the focus of the system being acquired, vendor representatives, and information technology (IT) professionals. For large or complex projects, it is also a good idea to have someone skilled in project management principles on the team. Likewise, having a strong project leader and the right mix of people is critically important. Implementation teams often include some of the same people involved in selecting the system; however, they may also include other individuals with knowledge and skills important to the successful deployment of the new system. For example, the implementation team will likely need at least one IT professional with technical database and network administration expertise. This person may have had some role in the selection process but is now being called on to assume a larger role in installing the software, setting up the data tables, and customizing the network infrastructure to adequately support the system and the organization's needs.
The implementation team should also include at least one system champion. A system champion is someone who is well respected in the organization, sees the new system as necessary to the organization's achievement of its strategic goals, and is passionate about implementing it. In many health care settings the system champion is a physician, particularly when the organization is implementing a system that will directly or indirectly affect how physicians spend their time. The physician champion serves as an advocate of the system, assumes a leadership role in gaining buy-in from other physicians and user groups, and makes sure that physicians have adequate input into the decision-making process. Other important qualities of system champions are strong communication, interpersonal, and listening skills. The system champion should be willing to assist with pilot testing, to train and coach others, and to build consensus among user groups (Miller & Sim, 2004). Numerous studies have demonstrated the importance of the system champion throughout the implementation process (Ash, Stavri, Dykstra, & Fournier, 2003; Daly, 2016; Miller, Sim, & Newman, 2003; Wager, Lee, White, Ward, & Ornstein, 2000; Yackanicz, Kerr, & Levick, 2010). When implementing clinical applications that span numerous clinical areas, such as nursing, pharmacy, and physicians, having a system champion from each division can be enormously helpful in gaining buy-in and in facilitating communication among staff members. The various system champions can also assume a pivotal role in ensuring that project milestones are achieved and celebrated. Clearly Define the Project Scope and Goals One of the implementation team's first items of business is to determine the scope of the project and develop tactical plans. To set the tone for the project, a senior health care executive should meet with the implementation team to communicate how the project relates to the organization's overall strategic goals and to assure the team of the administration's commitment to the project. The senior executive should also explain what the organization or health system hopes the project will achieve.
The goals of the project and what the organization hopes to achieve by implementing the new system should emerge from early team discussions. The system goals defined during the system selection process (discussed in Chapter Five) should be reviewed by the implementation team. Far too often health care organizations skip this important step and never clearly define the scope of the project or what they hope to gain as a result of the new system. At other times they define the scope of the project too broadly or scope creep occurs. The goals should be specific, mea
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