IHP 604: Healthcare Quality & Improvement - Project Status Update

This assignment is a reflective journal entry concerning a healthcare quality improvement project, specifically focusing on the IHP 604 course. It includes a discussion on the purpose of implementing a quality plan, the status of quality tools and standards like accreditation and meaningful use of Electronic Health Records, and performance improvement initiatives. The journal reflects on the quality plan at Chesapeake General Hospital, providing process improvement recommendations based on an analysis of the hospital's challenges, such as mortality rates, hygiene maintenance, communication among healthcare facilities, and infection occurrences. The Plan-Do-Study-Act (PDSA) cycle is highlighted as a useful tool for documenting and testing changes, with steps outlined for introducing issues, forming a team, setting aims, establishing measures, selecting and testing changes, implementing improvements, and spreading these changes throughout the healthcare setting. The assignment concludes by emphasizing the importance of patient safety and care, the necessity of maintaining a quality plan, and the role of the PDSA cycle in assessing changes and promoting health in healthcare settings.

Running head: HEALTHCARE QUALITY IMPROVEMENT
HEALTHCARE QUALITY IMPROVEMENT
Name of the student:
Name of the university:
Author note:

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Introduction
Patient safety is the process of nonappearance of the avoidable injury or difficulties to
the individual getting addressed under health care setting (Marx, 2019). It is addressed in
order to reduce the risk factors which may cause excessive harm that are related to the health
care to a satisfactory decrease in the condition (Lynn, & Lynn, 2015). An adequate amount of
decrease is referred to the combined concepts of the present knowledge provided, available
resources and the setting where health care and treatment that has been delivered considered
against the negative effects caused because of the non-treatment or error in the treatment
process (Dekker, 2016). Accreditation is found to result in better and developed quality of
health care and safety for the patients in a health care setting (Shekelle et al., 2016). It guides
the nursing staff to deliver the patients with services focusing on the rights of the patients
which aims towards respect and protection of the patient (Brubakk et al., 2015). The
assignment will focus on the on quality care plan delivery and its effect on patient safety and
better health outcome.
Discussion
Purpose of implementing a quality plan
Patient safety is matter of concern for every county that aims towards delivering
health care services, despite of the fact that they are in private manner commissioned or they
are being funded by the government of the country (Singh & Sittig, 2016). The practice of
prescribing and administering antibiotics without any concern regarding the primary
condition of the patient and also without focusing on the fact that whether the provided
antibiotics will be helpful for the patient, also administering individual with multiple drugs
without attending the side effects or the severity that may cause due to these drugs
administration, altogether have the capability to cause harm to the patient’s safety and

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increase the risk of mortality (Gandhi et al., 2018). Individuals seeking for health care and
treatment are not only effected by the act of misuse of health care technologies, but the health
care delivery can be also hampered because of the deprived communication among the
different health-care staffs (McFadden, Stock & Gowen III, 2015).
The nursing care plans are one of the very essential aspects of the health care services
in providing the patient with quality care (Sowan et al., 2018). They elaborate the nursing
role in the treatment and care process of the patient, also they provide steadiness in the care
given to the patient and helps the nursing staff to develop intervention and care management
focusing on the individual patients needs and requirements (Doenges, Moorhouse & Murr,
2016). Apart from the above mentioned, a quality care plan is observed to promote holistic
care and treatment of the individual and helps in addressing particular goals for these
individuals (Giger, 2016). Thus it makes it essential to develop a quality care plan in order to
provide the individuals with enhanced and appropriate health care and treatment without
causing any error or complication which might lead to increase the risk factors associated
with the patient’s health.
Status of Quality Tools and Standards
Accreditation standards drive an organization’s patient safety and quality initiatives:
Accreditation is one of a voluntary programs conducted by the health care settings
where trained and experienced external health care reviewers assess and inspect a healthcare
setting’s agreements and analyses it to associate with the health care settings pre-established
presentation principles (Saadati et al., 2018) The process has been showing effective result in
encouraging good health care safety practices, error reporting practice and awareness
generation among a community. Accreditation in to a health care setting plays a role as
inspiration to unceasing development and improvement of the setting (Bogh et al., 2016). It

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empowers the health care setting so that they can better validate commitment to the patient’s
quality care (Mohammad Mosadeghrad, Akbari Sari & Yousefinezhadi, 2017). By
performing the accreditation into a health care setting will gain trust and confidence of the
community towards the services that is been provided by the settings to them. It also helps
the healthcare services with the opportunity to target towards the best for the community
(Grepperud, 2015).
The members of the accredited health care organisation are found to be pleased
majorly as these health care organizations accounts for constant learning process, enhanced
and pleasant workplace environment, management and also provides possession of the care
and treatment processes (Vimonvattana, Srisuantang, Songpracha & Supachutikul, 2018).
Meaningful Use is demarcated by the usage of the proficient Electronic Health
Records technology in a significant way such as electronic suggesting (Slight et al., 2015). It
has a purpose of confirming that the proficient Electronic Health Records technology is
associated in a way which is found to provide for the purpose of electronic exchange of the
health care information in order to progress the quality of health care (Birkhead, Klompas &
Shah, 2015). It also states that in the usage process of the proficient Electronic Health
Records technology, the professional must acquiesce to the associated Secretary of Health &
Human Services (HHS) evidence on the quality of health care provided and various other
procedures (Centres for Medicare & Medicaid Services (CMS), HHS 2015).
The implication of the meaningful use in the health care setting is found to be helpful
enough to provide appropriate safety and care to the patients of the health care setting (Meigs
& Solomon, 2016). It keeps a detailed and managed records of the health care setting
regarding such as prescription, medication, patient medical history, update regarding the
treatment process and the recovery process of the patients, in order to avoid any chances of

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error occurrence and negligence which might lead to severe outcomes for the patient
(Jamoom, Yang & Hing, 2016).
Measures and bench marks
Performance Improvement Initiatives
The health care settings are found to routinely conducts the performance improvement
initiatives in order to improve their health care outcomes and individual experiences and
reduce the health care charges. There are few matrices which can be use in a health care
setting to track the performance improvement which are as follows (Sharp, 2017):
 A/R Days Due to Coding: to tract bill and revenue of the health care setting.
 Outlier Average Length of Stay (ALOS): assessment of outlier’s occurrence and
improvements addressing.
 Inventory Turns for High-Cost Items: Evaluation of the usage of high-cost items.
 Inventory Loss Due to Expiration: record the quantity and cost of expired items.
 Registration/Admission Error Rate: error occurrence assessment
 Ticket Resolution Speed: the duration taken to resolve any issues regarding any
techniques (Surroca & Tribó, 2016).
 User Adoption: the data entry and record tracking.
 Service Requests: identify the department having greater number to complaint and
tracking their issues (Harrell, 2015).
The practice provides the tracking of the data related to the health care delivery, error
occurrence and difficulties faced by the patients. By these assessments it will help the health
care setting to develop strategies and interventions to resolve the issues to promote patient
safety and providing quality care (Golden et al., 2017).

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Process improvement
Recommendations based on analysis of Quality Plan at Chesapeake General Hospital
Chesapeake Regional Medical Center has been experiencing average rate of health
care services n few aspects of care delivery. The reason behind these can be the effect of
deprived practices among the health care facilities (Lin et al., 2017). The Chesapeake general
hospital has an average rate of mortality cases from curable serious difficulties which occurs
after surgery. This might be a reason of lack of awareness regarding the complication related
to the aid provided after surgery and also maintaining hygiene plays an important role here
(Estes, Kelemen, Liang & Constanine, 2016). It has also been observed that they have lesser
rate of hand hygiene maintenance in the healthcare setting which might be one of the reasons
behind the growing severity in the patient health. the health care setting also faces difficulty
in delivering better care and safety to their patients as there is a deprived condition of
communication among the health care facilities and the patient, which generates a greater gap
among each other leading to the error occurrence in the treatment and care (Hatef et al.,
2018).
The hospital has also been witnessing greater rise in the rate of infection occurrence
which is massively affecting their patients’ health conditions (Zebrack et al., 2017). In order
to avoid the condition of the Chesapeake general hospital and improve patient care and
treatment delivery, the healthcare setting needs to address the few issues that has been
affecting the system (Sydney, Weinstein & Rucker, 2018). The health care settings need to
focus on the general aspects such as hygiene maintenance and sanitization of the hospitals
along with the instruments and medical technologies used in the treatment process
(Hernández-Gómez et al., 2017). The health care professionals need to develop better
communication among each other in order to understand the condition of the patient and

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avoid any error occurrence in the medication administration, treatment and care provided
(Walls, Hockberger & Gausche-Hill, 2017).
Evaluation and reporting
The Plan-Do-Study-Act (PDSA) Worksheet is one of the useful tools that were proposed
for the documenting purpose of any test of change (Sears et al., 2018). The Plan-Do-Study-
Act (PDSA) cycle is method for analyzing any change that can be operated by evolving a
strategy to check the change (Plan), conducting the assessment (Do), noticing and gaining
knowledge from the different outcomes (Study), and assessing the different modifications
that needs to be addresses to the assessment (Act) (McGowan & Reid, 2018).
 Introduction: introducing the issues related to the health care and treatment delivery
such as maintain hygiene and sanitization, better communication related issues,
infections occurrence after surgery (Murray, 2018).
 Forming the Team: developing a multidisciplinary team which involves the nursing
staff, the doctors, lab technicians, and patients (Muhammed et al., 2018).
 Setting Aims: the aim of the setting is to promote patient safety by insuring decrease
in error and complication in the care and treatment delivery (Spooner, Chaboyer &
Aitken, 2018).
 Establishing Measures: establishment of measures such as sanitizing every tools and
equipment, cleaning the bed sheets and other items on regular basis, promoting hand
hygiene practice, better assessments of the patient after surgery and evaluating any
complications or risks associated after surgery, developing communication skills by
developing interactive sessions (Cartwright et al., 2017).
 Selecting Changes: selecting the changes in the health care settings that needs to be
addressed in order to better evaluate the developing condition.

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 Testing Changes: testing the changes by evaluating the rate of complications or error
recorded and the patient outcomes (Bollegala et al., 2016)
 Implementing Changes: implementation of the changes in the practice after having a
better understanding on their role in better health care promotion and patient safety.
 Spreading Changes: spreading the changes throughout the setting and others as well
to develop the patient safety and care process in the medical field (Reed & Card,
2016).
Conclusion
In order to conclude, it can be stated that, patient safety and care is one of the very
essential factors in ay health care setting. It is necessary of maintain a better quality plan in a
health care service in order to asses better the health condition of the patients and provide
care accordingly without any error or discrimination which may lead to severe difficulties. In
order to better assess any changes and tests, the Plan-Do-Study-Act (PDSA) cycle play a
helpful role, it guides the documentation of the changes made and the development of the
provided interventions and strategies for promoting health in the health care settings. The
Chesapeake general hospital has been witnessing few difficulties and average care delivery
due to hand hygiene, sanitization, communication practise among the health care settings
which was majorly effecting the patient’s health conditions and was increasing the rate of
infection occurrence. Thus developing the practice of quality care plan conduction will help
the the Chesapeake general hospital to deliver a developed and better effective care and
safety to their patients.

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