Carlinville Area Hospital Quality Improvement Plan - Research Paper Example

Carlinville Area Hospital Quality Improvement Plan Executive summary Carlinville Area Hospital planned quality improvement (QI) plan is aimed at improving the medication administration within the hospital. A number of studies have identified that many injuries and death caused by drugs is experienced owing to medication errors and lack of appropriate medication information among the patients. Critical issues relating to medication errors include but not limited to lack of patient education on prescribed medications, similar drug names, prescription illegibility, improper drug labeling, and packaging, error medication reporting plans, and lack of medication safety practices within the organization. Carlinville Area Hospital planned quality improvement (QI) plan will ensure that quality and safety health care service is offered to the patients through proper medication administration. Carlinville Area Hospital plans to engage all its employees in improvement plan irrespective of the level in the organization structure. Carlinville Area Hospital will ensure that its Quality improvement plan is congruent with its key objectives that include but not limited to safety, patient centered, effectiveness, equitable, efficiency, and timely health care service. Carlinville Area Hospital QI plan will cover a wide range of activities that include but not limited to Risk management activities Professional staff credentialing; automated drug-ordering systems; medical record review; prescription legibility; drug labeling and packaging; and patient education on prescribed medications. Carlinville Area Hospital will use six-sigma methodology for its QI implementation plan. The six-sigma methodology will allow the hospital to gather necessary information relating to the present organization’s medication management, which will give clue to management about the processes and activities that require improvement. After implementing the improvement plan the hospital will be forced to undertake annual evaluation of processes and activities to ensure that they are in line with te planned objectives. Introduction The Carlinville Area Hospital is, “a licensed 25-bed acute care clinic that accommodates a wide range of inpatient, outpatient, as well as emergency services” (Carlinville Area Hospital, 2011) Carlinville Area Hospital operates based on the slogan of “excellent care close to home”. Carlinville Area Hospital mission “is to always remain committed to the development of a state-of-the-art rural hospital facility.” Enhancing quality has always been one of the key objectives of the hospital and as such the management is looking forward to a favorable relationship between the staff to provide excellent healthcare close to home. Carlinville Area Hospital various services to patients on inpatient and outpatient basis through the hospital’s cardiopulmonary, imaging, laboratory, and rehabilitative services. Additionally the hospital provides daily primary health care to immediate emergency interventions in the local area. Goals/Objectives Promoting a state of art hospital with quality and safety as its major priority requires a lot of commitment. To ensure that the hospital is on track to fulfill its mission the management of Carlinville Area Hospital has decided to focus on the following objectives: Safe- Carlinville Area Hospital will work tirelessly to ensure that mitigate injuries that patients may suffer from services that are meant to help them (Carlinville Area Hospital, 2011). Patient centered- Carlinville Area Hospital will provide services that recognizes patient’s dignity, worth, respectful and responsive to the needs, expectations, preference and values and above all ensure that medical decisions are based on patients values. Efficient- Carlinville Area Hospital will avoid services that are wasteful in terms of ideas, equipment, energy, and supplies. Timely- Carlinville Area Hospital health care services will emphasis on minimizing potential harmful delays and reducing waits. Effective- Carlinville Area Hospital services will only emphasize on individuals that are likely to benefit rather than those who are not likely to gain to enhance efficiency. Equitable- Carlinville Area Hospital health care services will be offered to everyone within our services area without any restriction or variation base on personal characteristics such as ethnicity, gender, social class, religion, or nationality. The Scope and Quality improvement activities The medication, Nursing and Physician departments are going to be fully involved in the quality improvement effort. Pharmacists, nurses and physicians are highly involved with administration and handling of drugs within the organization (Blegen & Hughes, 2009). Carlinville Area Hospital quality improvement effort will focus on patient medication administration as well as support processes that will ensure that patient are safe and guarded from medication errors. The quality improvement plan demonstrates Carlinville Area Hospital commitment to improve the quality healthcare delivery with respect to effective medication management. Carlinville Area Hospital quality improvement plan will cover the following activities: Risk management activities Professional staff credentialing Automated drug-ordering systems Medical record review Prescription legibility Drug labeling and packaging Patient education on prescribed medications Data Collection Tools The Carlinville Area Hospital is going to gather a wide variety of performance data that are considered important for tracking quality improvement programs and the extent to which organization activities are geared towards attaining the organization’s mission and quality initiative. It is noteworthy that the performance data that will be gathered will exclusively cover medication administration in Carlinville Area Hospital. Medication administration is one of the most sensitive areas in the health care setup and thus the need to continuously improve its quality. Global medical records indicate that most of problems (death and injuries) experience in hospitals relating to medication is realized due to medication errors thus the performance data to be collected will largely relate to medication errors. The data to be gathered include Reported number of illegible prescription Identified cases of improper drug labeling and packaging The number of processes for error recovery instituted in the Hospital The number of educate patients at a given time Effectiveness of the Hospital Information Systems (HIS) employed in the hospital Number of patients with adequate information about dispensed drugs This performance data will be gathered to help the organization establish the exact causes of For data, gathering purpose the researcher will use interviews, self-administered surveys and focus group while the data gathered will be displayed using the control charts. The implementation team settled for self-administered surveys because it provides an opportunity to ask several questions on a given topic and the response to them can be analyzed with flexibility. However, Interview is used to compliment self-administered surveys especially in areas where the respondent is a top executive who is so committed to fill written survey. Focus groups will be used to obtain specific information, which may not be possible using other methods such as self-administered surveys and interviews. Display tools such as control charts will be used because graphical representation enables an easily readable display of the performance results. Processes and Methodology To ensure that no confusion is caused in the implementation process of quality improvement Carlinville Area Hospital has decided to use only Six Sigma methodology. The management has chosen Six-sigma methodology because it will enable the organization to increase efficiency in medication management by reducing errors and wastage (Jay, 2011). The first step in Six sigma involves defining the problem and target goals and it calls for the management not only to focus on the outcome but also process at hand. It is evident that the problem at hand is injuries and death caused by medication errors and lack of patient’s knowledge about medication. The goal of Carlinville Area Hospital with respect to the improvement plan is to enhance safety of patients and increase efficiency in medication management. The next important step in six-sigma involves identifying the customers and their needs. (Jay, 2011) asserts that Jay (2011) the management also needs to map the present medication process in order to identify the areas for improvement. The next stage in six-sigma involves measuring process operation. This should only be done after effective data gathering tools have been put in place. The existing sources should be used to collect the required data for measuring the problem at hand. The already collected data should be analyzed in order to identify the causes of the problem (Hughes, 2008). Carlinville Area Hospital will focus on gathering data relating to medication errors and injuries suffered owing to such errors in order to establish the exact causes of the errors and injuries. In other words identifying the problems in the hospital’s medication administration is the first important step in establishing the processes that require improvement. The next step in six-sigma is to improve the processes in order to avoid causes of errors. The new improvement plan should be tested in small scale to establish if they work or not. According to Hughes (2008), the final step in six-sigma involves putting in place standard measures, which will assist in ensuring that favorable performance is maintained. This means that after improving the processes that cause medication errors Carlinville Area Hospital will institute standard measures that will ensure that the favorable performance is maintained. Comparative Databases, and Benchmarks, What Carlinville Area Hospital needs more are benchmarks and Comparative Databases to map its quality improvement plan. It is noteworthy that Carlinville Area Hospital is not the only operator in the industry and owing to the fact, that other healthcare providers of the same capacity as Carlinville Area Hospital nationwide as well as globally the hospital should use the data provided by those operators to gauge its performance in the industry. Benchmarks are important for comparing organization’s performance against the average industry performance. In this case the Carlinville Area Hospital will compare its performance data relating to the medication administration with that average performance data recorded in the industry. For instance, the data gathered in the hospital about the number of injuries caused as result of improper labeling or packaging of drugs will be compared against the recorded average number of such cases in the entire industry. The average number of reported data relating to medication administration will be used as a standard for measuring organization performance to establish whether further quality improvement should be undertaken or the present processes must be retained (Norton, 2001). Besides the benchmarks, Carlinville Area Hospital will also employ Comparative Databases established by both public and private bodies as a standard measures for measuring its performance. For instance, American Society of Health-System Pharmacists (ASHP) has been instrumental in maintaining a Quality Resource Center, which can be important for organization that intends to improve medication management (AHSP, 2008). Other organization that provides databases with important medication administration information include but not limited to Department of Health, Joint Commission, Centers for Medicare and Medicaid Services [CMS], Food and Drug Administration , and Drug Enforcement Agency. Databases provide an important source of performance measures to organizations that can be used as standards to measure performance. Carlinville Area Hospital will make use of databases of various public and private healthcare organizations to gain important performance measures that will be used as standard measures. Authority structure of the implementation plan It is important to start by noting that every individual in the organization must be involved in the implementation of the quality improvement plan ranging from the board of directors to the lower subordinates. The board of directors will be charged with planning of the improvement plan (Breen et al, 2010). Additionally, the board will be responsible for supporting and guiding implementation activities. Finally, the board will be expected to review, evaluate, and approve the improvement plan an annual basis. Executive leadership will be charged with the responsibility of supporting, guiding and monitoring the implementation processes besides planning team and leadership group (Griffin, 2010). Quality improvement committee which consists of a network of physicians and the psychiatric health workers will charged with the responsibilities of developing, and commenting the quality improvement plan. Other tasks of the committee include indentifying opportunities for enhancement, outlining performance goals, quality evaluation process and guiding quality interventions. Medical staffs that compose of medical clinicians, laboratory technicians, and pharmacists have the responsibilities of ensuring that patients have access to quality services, medical prescriptions, and coordinate quality care by ascertaining availability of the necessary equipment. According to Griffin (2010) middle management plays a significant role of coordinating operations of various divisions as they charged with identifying different operations. Finally, the Department staffs are charged with the responsibilities of outlining type and amount of work to be done. Communication The Quality improvement committee will be responsible for tracking, gathering, compiling, and dissemination of quality improvement of data and information gathered taking into consideration that they will act as the clearinghouse for information. The Committee will prepare the final report for the Board of Directors, participants, staff, and recipients to ensure that they are always up-to-date with the quality improvement initiatives as a means of continually enhancing the performance. Education Carlinville Area Hospital plans to engage all its employees on the Quality Implementation strategy. However before the workforce is oriented in the quality implementation process they will have to be trained, thus making training an important aspect of the improvement process. Training will be done continuously until the project sponsors feel that all the employees are familiar with the improvement process and as such, they incorporate improved activities into the present processes. It is noteworthy that training will be done through, seminars, workshops and field works. All the staff irrespective of the position in the organization structure should be educated regarding the quality improvement plan (McLaughlin & Kaluzny, 2006). In other words Carlinville Area Hospital will train its executive leaders medical clinicians, laboratory technicians, nurses and pharmacists. The training process will take into consideration issues such as description of the improvement plan and how they will be incorporated into the plan based on their job tasks. Additional training will be done on quality improvement methodology put in place by the hospital- Carlinville Area Hospital. It is best interest of the hospital to ensure that properly trained and competent employees are engaged in the implementation process taking into consideration that failure to train the workforce can translates to unsuccessful quality improvement plan. Carlinville Area Hospital will ensure that only well trained employees are involved in full improvement plan, as this is the only guarantee for successful quality and safety implementation measures in medication administration. Annual Evaluation Evaluation forms the last stage of the Quality Improvement implementation plan and it will be paramount that Carlinville Area Hospital conducts an annual evaluation of their processes and activities in order to ascertain that everything is operating as per the plan. Carlinville Area Hospital evaluation process will take into consideration aspects such as outcomes, targeted processes, the performance indicators, data aggregation, and quality initiative interventions taken, assessment and analysis processes relating to medication management. Other areas to be covered by the evaluation process include the Hospital Information Systems of the organization dealing with medication administration. The hospital must evaluate the efficiency and effectiveness of such systems (Council of Europe 1998). The prescription, drug labeling, and packaging processes will also be evaluated to ensure that no errors are reported in future. The hospitals initiative to educate the patient on drug related issues will also be evaluated to establish if patients are well informed about prescribed drugs. References Blegen, M & Hughes, R. (2009). Medication Administration Safety. U.S. National Library of Medicine. http://www.ncbi.nlm.nih.gov/books/NBK2656/ Breen,K., Cordner,M.,Thomson,J., Plueckhahn, V.(2010).Good Medical Practice: Professionalism, Ethics and Law. U.S.A: Cambridge University Press. Carlinville Area Hospital. (2011). Website. Retrieved from http://www.cahcare.com/ Council of Europe . (1998).The development and implementation of quality improvement systems (QIS) in health care: recommendation no. R (97) 17, adopted by the Committee of Ministers of the Council of Europe on 30 September 1997, and explanatory memorandum. Council of Europe Griffin, D. (2010). Hospitals: What They Are and How They Work. Massachusetts: Jones & Bartlett Learning. Hughes, R. (2008). Tools and Strategies for Quality Improvement and Patient Safety. http://www.ahrq.gov/qual/nurseshdbk/docs/HughesR_QMBMP.pdf Jay, A. (2011). Lean Six Sigma for Hospitals: Simple Steps to Fast, Affordable, and Flawless Healthcare. New York: McGraw-Hill Professional McLaughlin, C & Kaluzny, A. (2006). Continuous quality improvement in health care. Massachusetts: Jones & Bartlett Learning Norton, L.(2001). Quality Improvement, Risk Management, and Patient Education: Tools to Reduce Medication Error. Vol. 7, No. 2 Journal of Managed Care Pharmacy. http://www.amcp.org/data/jmcp/Continuing%20Education-156-163.pdf The American Society of Health-System Pharmacists (AHSP). (2008).The Pharmacist’s Role in Quality Improvement. http://www.ashp.org/DocLibrary/Policy/QII/RoleinQI.aspx Read More