CAUNTI Outcome Measures Issues Opportunities
Organizational Functions, Processes, and Behaviours at St. Francis Medical Center
Healthcare organizations are constantly under scrutinizing the public, the government, the accrediting bodies, the patients, and patients’ families, among other stakeholders. Advancement in government policies and technology applications in medical settings has empowered patients giving him/her access to vast databases, including customer satisfaction scores, quality scores, and prevalence of harm. Healthcare organizations must demonstrate high-reliability behaviors to ensure they remain competitive in the ever-changing healthcare environment.
There are numerous ways that healthcare organizations could demonstrate behaviors associated with high reliability, including continuous assessment and prevention of failure through continuous quality improvement models and remaining sensitive to frontline operational feedback (Veazie et al., 2020).
St. Francis Medical Center is accredited by DNV-GL, and through their partnership, the organization has built a highly reliable model and customer confidence. The organization uses this accreditation model to drive organizational excellence and performance improvement. The organization’s high reliability has been developed using ISO 9001: 2015, which includes a need to constantly demonstrate our ability to constantly provide services that meet customers’ needs and are consistent with the requirement of the regular constantly enhancing customer satisfaction through effective application of the system. The quality certification model is constantly aimed at assessing the probability errors and non-conforming outputs and then influences processes improvement to prevent such potential adverse events from affecting patients. The model’s primary focus is patients’ safety and satisfaction and constantly engages all the entire team of staff in constants pursuit of patients’ safety and quality of care (LIGARSKI, 2020).
Moreover, ensuring effective communication with our stakeholders is a key component of our high-quality organization journey. Lack of effective communication is one of the leading causes of medical errors and a big contributor to patients’ dissatisfaction (Vermeir et al., 2015). Effective communication between healthcare providers and patients will improve the quality of care and improve patients outcomes. Effective communication between the management and the organizational staff will ensure that organizational goals are met with ease.
Determine how Organizational Functions, Processes, and Behaviours Affect Outcome Measures
To ensure the effective quality improvement of the systems, St. Francis Medical Center’s management needs first to understand its organization’s context. It requires a definite understanding of the influence that various processes have on its healthcare system and its effects on the quality management system. The management also needs to identify various risks and opportunities within the system (Wagner et al., 2006). The quality of care and patient safety will eventually be improved by accurately assessing the system’s risk and opportunities, followed by a quality improvement initiative to mitigate against those risks. Conversely, failure to accurately identify those risks and opportunities will lead to poor patient outcomes and reduced patient satisfaction rates, both of which have significant effects on the organization’s success.
Additionally, accurate data collection is an integral part of the healthcare organization in a highly competitive environment. Healthcare organizations must ensure that the data collected is current and valid to enhance its reliability (Wagner et al., 2006). Its subsequent analysis must be geared towards quality and safety improvement. St. Francis Medical Center has constantly engaged our Electronic Medical Records vendors to ensure the company collects current and valid data. Data accuracy boosts the confidence of our multidisciplinary team regarding quality improvement.
Lastly, for the organization to have a successful process improvement initiative, the organization must maintain an effective communication system. Communication has a huge impact on the overall delivery of quality care and patients safety(Vermeir et al., 2015). Highly reliable healthcare organizations are constantly engaged in quality improvement initiatives and the elimination of non-performing outputs. Quality improvement initiatives mean the healthcare environment is ever-changing, hence the essence of effective communication. Lack of consistent and concise communication may lead to confusion, distrust, and chaos in the organization. St. Francis Medical Center is constantly working to improve its communication through daily updates through newsletters and emails with current and more sensitive information given the priority.
Quality and Safety Outcomes and Associated Measures Relevant to Reduction of CAUTI
CAUTIs outcome measures per the National Healthcare Safety Network (NHSN) are the percentage of infections per 1000 indwelling catheters(Atkins et al., 2020). St. Francis Medical Center can compare its infection rate internally by use if this standard measure. It also compares its infection rate with that in the national database. The management discusses the infections data and trends during the quality oversight meetings where quality improvement initiatives are also discussed. Additionally, the hospital monitors individual patient’s line days at the individual unit level, with the clinician in charge documenting all the clinical indications. The collection of this data provides current process gaps insight. The data is then used in the process improvement at an individual level.
Performance Issues or Opportunities Associated and Quality and Safety Outcomes they Affect.
As per the National Healthcare Safety Network, healthcare organizations are supposed to report CAUTIs infections every month (Atkins et al., 2020). St. Francis Medical Center intends to continue reporting infections per the requirements. The reports are then benchmarked against the national benchmark to determine if organizational care has improved or reduced. However, the organization recognized that it is difficult to drive change using this data alone and therefore identified additional performance elements. These performances are nurse-driven. They include strict documentation of clinical indication during every shift, physician order availability for every 72-hour episode of catheterization and peri care performance documentation in each shift.
Change Model
The healthcare organization intends to use Lewin’s Change Model, which has three steps of execution. The three steps include unfreezing, change, and refreezing(Hussain et al., 2018). The nursing leaders will create awareness for the interdisciplinary team involved in patients’ care about the proposed change. The proposed change will be based on the reported cases of infections in the last month. Currently, the team at St. Francis MedicalmCenter is at stage two after recognizing the need for change. In addition to communication from the nursing leaders, a patient’s data and patients outcomes review was done, which emphasized the need for change. The team has expressed desires to change and improve patients outcomes and quality of care. The team is currently in the second step, where the team is being unfrozen from its previous practices. Fortunately, the hospital is not experiencing any resistance with the patients changing to best practices. However, the unfreeze level will require the investment of time, team support, and resources to succeed fully. Lastly, the team will go through the refreezing level, where the organization can establish stability once the change has been fully established. The level is crucial because it will ensure the team does not fall back to its old practices and maintains its new best practices (Hussain et al., 2018).
During the nursing staff education, the first step towards change will be communicated to the team. The hospital has a monthly clinical education focus on two or three issues. The month of October will see clinical educators pay impromptu visits in all patients to care areas to ensure the team’s competency in performance and documentation of peri care results, insertion of a sterile, and comprehensive understanding of the catheter removal protocol (Atkins et al., 2020). Besides, the unit leadership will focus on improvement opportunities. The team will then be assessed and rated on a scorecard, which will help track their progress over time. It will also help determine their progress towards organizational goals of improved care and patient outcomes.
The process improvement initiative will be re-evaluated after the first quarter of its implementation. The re-evaluation will enable the organization to benchmark its progress against its set expectations. Such goals include reduced infections, improved team knowledge, and improved patients outcomes. Depending on the evaluation process results, the assessment team will engage the management in deciding to either continue with the initiative or abort the project and design a new project. The organization will then move on to the ‘refreezing’ stage once it has achieved and sustained its goals (Hussain et al., 2018).
Conclusion
St. Francis Medical Center has designed its operation to ensure that patient’s safety and quality care our highest priority. The organization is now focused on continuous improvement measures to ensure that it provides patients centered care. The organization hi is conducting its gap analysis through a partnership with our EMR vendors. The interdisciplinary team involved in patient care must be dynamic to embrace change in an ever-changing environment continuously. The organization is confident that the change will lead to a significant decrease in CAUTI infection prevalence.
References
Atkins, L., Sallis, A., Chadborn, T., Shaw, K., Schneider, A., & Hopkins, S. et al. (2020). Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioral analysis of interventions. Implementation Science, 15(1). https://doi.org/10.1186/s13012-020-01001-2
Hussain, S., Lei, S., Akram, T., Haider, M., Hussain, S., & Ali, M. (2018). Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal Of Innovation & Knowledge, 3(3), 123-127. https://doi.org/10.1016/j.jik.2016.07.002
LIGARSKI, M. (2020). Study on disruptions in the quality management system in compliance with ISO 9001:2015. Scientific Papers Of Silesian University Of Technology. Organization And Management Series, 2020(142), 195-203. https://doi.org/10.29119/1641-3466.2020.142.14
Veazie, S., Peterson, K., Bourne, D., Anderson, J., Damschroder, L., & Gunnar, W. (2020). Implementing High-Reliability Organization Principles Into Practice. Journal Of Patient Safety, Publish Ahead of Print. https://doi.org/10.1097/pts.0000000000000768
Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., & Mortier, E. et al. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. International Journal Of Clinical Practice, 69(11), 1257-1267. https://doi.org/10.1111/ijcp.12686
Wagner, C., Gulácsi, L., Takacs, E., & Outinen, M. (2006). The implementation of quality management systems in hospitals: a comparison between three countries. BMC Health Services Research, 6(1). https://doi.org/10.1186/1472-6963-6-50