Quality Improvement in PACU Department, Research Paper Example

Introduction

Quality improvement in the pre-op and PACU unit of a busy hospital should be focused around patients, family and staff in order to improve outcomes and the quality of care. Working in PACU/Pre-op unit within a busy local hospital, it is essential to involve patients, their families and all stakeholders in decision making regarding treatments and improve the quality of care.

Thesis Statement: Improving the quality of care and patient-centered care approaches within the pre-op and PACU unit would have measurable positive impact on patient outcomes, effectiveness and nursing process improvement.

Background-Context

The criteria of assessing quality in nursing and health care are various, and units need to focus on their priorities when carrying out the assessments. According to Donabedian (2005), the assessment of the quality before changes are introduced can be carried out using observation, sampling and the thorough investigation of the care process. The main challenges of the perianasthesia care are: new technologies, medications, procedures, fast turnover time, high-acuity cases and increasing workload, By focusing on process and quality improvement, the challenges mentioned above can be overcome.

The below paper is focusing on two of the assessment criteria: safety of care and the patient-centered approach of the unit including the increased involvement of family members. The two development areas

a. Family -Involve the person and the family in determining the plan of care
b. Safety – developing skills of nursing champions to promote patient safety and quality of care/medication across the nursing unit.

Family involvement has been previously examined by several authors. Davidson et al. (2007) confirm that patient-centered care produces more positive healthcare outcomes than clinical- or disease-centered approaches. The study concluded between 2004 and 2005 has proven the thesis that quality improvement can be achieved by changing the unit’s approach to focus more one relatives and patients’ needs. In the intensive care unit, and especially in the PACU nursing team, the majority of patients are arriving with their relatives and often family members need to make hard decisions regarding the treatment pathway. By improving the communication between family members and staff, patients would be treated more fairly and the quality of care would improve.

Safety of patients is one of the main aspects of nursing leadership development programs. However, benchmarking and setting standards for patient safety does require initial assessment and the evaluation of the team’s, as well as individual employees’ competence level. (Mant, 2001) In order to improve quality, there is a need to identify poor performers on the individual and unit level. When carrying out the assessment, there is also a need to take into consideration patient types, different cases, intervention methods and other variables. (Mant, 2001, p. 477.)

Theoretical Approaches of Change

Managing change should be based on quality evaluation and careful integration of safety and patient communication principles. Identifying the development areas should also be based on the Joint Commission 2012 Patient Safety Goals (2012a). These recommend the introduction of system wide solutions, the identification of problematic areas and the improvement of patient identification, cross-checks process and reporting guidelines. Quality improvement needs to be focused on common goals and outcomes, according to Peden’s publication (2012) and Peden and Rooney (2009) The communication of new procedures, training and the checking of team members’ knowledge, commitment and understanding of the process is also essential in order to reduce the number of errors. Efforts also need to be made to introduce infection-prevention guidelines for staff to reduce the number of complications. Some of the guidelines need to be communicated with family members.

After reviewing the comparison of change models, (Kristonis, 2004) Lewin’s change model seemed to be the most suitable for implementation. Lewin’s change model is based on pushing towards change. (Lewin,1947) According to the model, three steps must be taken:

1. Unfreeze (preparing employees to be ready for the change and gaining commitment)
2. Change (execution of the intended plan for change)
3. Refreeze (making changes “stick” by ensuring they remain permanent.

A force field analysis is needed (Lewin, 1947) and a tool is available online that is to be used in the present case in order to identify the change, analyze the driving and restraining forces. (Change Management Coach tool, 2009, Online)

The most important part of the process would be to identify the area for improvement. In this case, the benchmarks for patient safety and communication need to be measured. The accuracy of patient identification, information included in the record, sample handling, verification of availability, timescales, estimating of procedure, preparation time, safe dosage level determination has to be evaluated. In order to improve communication with patients and family members about treatments, intervention and outcomes, easy to understand process maps, leaflets and information material need to be produced.

 Improvement Tool – Demonstration

In order to evaluate the processes involved in the busy PACU unit, a process man needs to be drawn up highlighting the steps and procedures involved in patient care. Ciesielski et al. (2008) describe how the integration of existing technology, anticipation and preparation time of patients can be described using a flowchart. Milestone timers and quality checks can be placed within the flowchart in order to be able to increase the accuracy of patient identification, proposed time spent under surgical procedure, vital signs and indicators and medical records. The implementation of discussion of procedures with family members can also be added to the demonstration tool, which would be used when communicating change within the unit.

Modeling the change process from the patient safety improvement framework of Peden and Rooney (2012), the communication of goals (what the unit as a whole is trying to accomplish) needs to be the first step. Determining the evaluation benchmarks of assessment in order to prove the positive effects of the change on patient-centered care and safety would also be important. Carrying out audits would need to be completed before the implementation plan is put in place. The change Management Force Field Analysis will also be completed to complement the presentation of proposal. (Change Management Coach, 2009)

Models for Improvement

Campbell (2008), based on the work of Kotter (2007) identifies eight steps for leading change. The implementation model of the eight steps within the PACU unit is detailed below:

1. Establishing a sense of urgency. Nursing team leaders need to communicate the critical areas found during the evaluation process and highlight the importance to make a change.
2. Creating a guiding coalition. Nominating a team to manage and coordinate change and related communication, policy implementation by identifying champions within the nursing team would increase team commitment.
3. Developing a change vision. Providing an end goal and developing strategies as a team would increase engagement.
4. Communicating the vision. Two-way communication (preferably in person during unit meetings) would make the benefits of the change clear for all team members.
5. Empowering broad-based action. Identifying the barriers of change (including policies, workload, staffing) in time would help overcome difficulties during the implementation stage.
6. Short-term wins. Performance complying with the goals and vision of the change should be rewarded in order to gain a higher level of commitment. Pressure to perform might be used. (Kotter, 2007, Campbell, 2008)
7. Consolidating gains. Building on short term achievements, further goals need to be set to involve more nurses, keep urgency high and prove the success of the project constantly.
8. Developing a new culture and implementing the achievements into policies, guidelines.

Resources Needed

Time needs to be allocated for champions of change in order to promote patient safety, communicate guidelines, undergo training and collect data. Staffing needs to be adjusted accordingly, in order to manage the work flow and keep waiting/preparation time at a standard level. There is also a need for involving training departments, evaluation of knowledge among the members of the team regarding the government’s patient safety guidelines. The Core Measure Sets of the Joint Commission (2012b) need to be implemented in the plan of change. Champions for communication between patients, family members and staff also need to be allocated, according to the report published by the Institutes of Health (2012b).

Structural resources also will be needed in order to gain knowledge from other departments’ policies, closely related to the unit. Statistical data of procedures, outcomes and severity of cases needs to be analyzed. The champions need to work together with some of the intensive, surgical and admission unit members in order to gain information about patient profiles, preferences and issues.

The financial resources needed will include funding for overtime, training, evaluation and internal checks. The estimated value of investment the 12- member team unit would need to carry out the change plan within 18 months would be $5000. The majority of the resources would be needed on training and assessment.

Evaluation Methods

During and after the implementation of change within the nursing unit’s processes, safety measures and communication policies, the following data should be assessed and compared to the initial measurements:

1. patient outcomes
2. patient identification
3. family involvement and understanding of procedures
4. Evaluation of patient and family member survey results
5. cross-check of medical records and records of conversation with family members
6. time spent in pre-op department per patient class variables (condition, age, severity)

In order to successfully compare results, the nursing leader would need to create a bar chart that assesses the above process measures (identified by Mant, 2001) on a monthly basis. Expected results would show an improvement in every area as time elapses, using benchmarking. (Hughes, 2008)

Quality and Safety Outcomes. Introducing the use of at least two patient identifiers would increase patient safety and accuracy within the unit. Labeling containers in the presence of the patient is also recommended by the Joint Commission (2012a), as well as the improved communication among caregivers, including safe transfer. Implementing the Universal Protocol in the procedure guidelines would not only increase compliance but also effectiveness and patient safety.

Patient-centered Focus Outcomes. Obtaining information from family members about the patient would not only improve communication and involvement, but also eliminate risks of negative reaction to treatment. As medical records do not always show preferences and allergies, additional information would help health care providers provide the safest possible care. Explaining procedures and timelines for family members would also help selecting the most suitable process, treatment and assist them in making a decision about a particular intervention. Educating patients and families about the prevention measures in place and procedures regarding infections and complications. This would also increase safety and the quality of care.

Conclusion

By implementing changes within the PACU unit of the busy hospital, measurable long term quality improvement can be achieved. Following the guidelines of The Joint Commission (2012a) and implementing policies would increase compliance, patient satisfaction and safety. (Institutes of Health, 2012a) Designating the role of safety and communication champions, on the other hand would increase commitment level of staff and acceptance of change.

References

Campbell, R. (2008) Change Management in Healthcare. The Health Care Manager Volume 27, Number 1, pp. 23–39

Ciesielski, S., Daily, B., Levine, W. (2008) A Dashboard for the PACU. Given a Window into the OR, Recovery Nurses Transform Work Methods. Patient Safety & Quality Healthcare September/October 2008

Davidson, Judy E., Powers, Karen, Hedayat, Kamayar M., et.al: Clinical practice guidelines for the support of the family in the patient-centered intensive care unit. American College of Critical Care Medicine Task Force 2004-2005. Critical Care Medicine 2007;35:605-616.

Donabedian, A. (2005) Evaluating the Quality of Medical Care. The Milbank Quarterly, Vol. 83, No. 4, 2005 (pp. 691–729)

Hughes, R. G. Tools and Strategies for Quality Improvement and Patient Safety.(2008). In Patient Safety and Quality: An Evidence-Based Handbook for Nurses, 3. Retrieved from <http://www.ahrq.gov/qual/nurseshdbk/docs/HughesR_QMBMP.pdf>

Institutes of Health (2012a). Building a quality measurement systems that works. Retrieved: July 12th, 2013 from <http://www.ihi.org/offerings/Training/MeasurementSystem/Pages/default.aspx>

Institutes of Health (2012b). Transforming care at the bedside. Retrieved: July 12th, 2013 from <http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideOptimizingCommunicationTeamwork.aspx>

Kotter, H. (2007) Leading Change. Why Transformation Efforts Fail. Harvard Business Review. January 2007

Kritsonis A. (2004) Comparison of Change Theories. International Journal of Scholarly Academic Intellectual Diversity; 8:1, 2004-2005.

Lewin,K. (1947) Frontiers of Group Dynamics. Human Relations, Volume 1, pp. 5-41

Mant, J. (2001) Process versus outcome indicators in the assessment of quality of health care. International Journal of Quality in Health Care; 2001. Number 13. pp. 475-480

Peden, C. (ed.) (2012) Quality improvement in anaesthesia. Royal College of Anaesthetists |Raising the Standard: a compendium of audit recipes | 3rd Edition 2012

Peden CJ, Rooney KD. (2009)The Science of Improvement as it relates to quality and safety in the ICU. J Intens CareSoc 2009;10(4):260–265

The Change Management Coach, Force-field Analysis. Practical Application Tool. Web. Retrieved: July 12th, 2013 from: <http://www.change-management-coach.com/support-files/force-field-analysis-app.pdf >

The Joint Commission. (2012a) Accountability Measures. Retrieved: July 12th, 2013 from: <http://www.jointcommission.org/accountability_measures.aspx>

The Joint Commission (2012b). Core Measure Sets. Retrieved: July 12th, 2013 from <http://www.jointcommission.org/core_measure_sets.aspx>