Planning for Change: A leader's vision

OUTCOME MEASURES, ISSUES, AND OPPORTUNITIES

Jessica Ramos

Capella University

NURS-FPX6212: Health Care Quality Safety Management

Dr. Mary Ellen Cockerham

Sep 9, 2021

Outcome Measures, Issues, and Opportunities

The undertaken quality and safety study indicated an urgent need to mitigate medication errors in the healthcare institution. As captured in the executive summary, medication errors adversely impact the quality of care advanced to patients. These adverse effects include exposure to new infections such as skin rashes and itching, severe injury, and prolonged hospitalizations. To healthcare organizations, medication errors erode clients' trust, damage the organization's brand equity, and lead to high operational costs due to longer lengths of stays and litigations. Therefore, healthcare organizations need to enact measures to address medication errors. Defining outcome measures is a vital intervention towards providing quality patient care. In this regard, a detailed evaluation of outcome measures, issues, and opportunities are necessary to gain an insightful approach in addressing medication errors. This report describes outcome measures, issues, and opportunities that be considered in mitigating medication errors to improve patient care outcomes and realize effective and efficient healthcare services.

Corporate Processes and Behaviors in Effective Health Care Organizations

The healthcare field deals with human life; hence organizations are mandated to hold the highest possible standards of care. These high standards are realized through organizational excellence. However, high-performing healthcare organizations do not achieve operational efficiency through luck but through deliberate processes and interventions which their leaders have developed. These organizations depict certain functions, processes, and behaviors that enable them to deliver quality healthcare services. These processes and behaviors include effective leadership, strict standardization practices, a favorable error reporting culture, and optimized staffing.

Effective Leadership

In all organizations, leadership is a core determinant in achieving organizational goals. Effective leadership is among the most critical elements that direct an organization to successful outcomes. In high-performing healthcare institutions, effective leadership instills confidence in staff and patients. Additionally, effective leadership in these organizations creates trust, an essential aspect of effective communication in all organizations. Studies indicate a significant correlation between effective leadership styles and high patient satisfaction, reducing the adverse effects experienced by healthcare organizations (Sfantou et al., 2017). Therefore, effective leadership is a crucial element in realizing quality healthcare services in high-performing healthcare organizations.

Strict Standardization Practices

Besides effective leadership, high-performing healthcare institutions depict strict standardization practices. Standardization is a robust solution to various challenges faced in the healthcare sector, including errors. In this regard, standardization plays a significant role in reducing errors (Kriznik et al., 2019). In the healthcare sector, patient pathways, tools of work, and workflows remain localized despite the diverse guidelines implemented in the healthcare sector. However, high-performing healthcare organizations resort to standardization to improve organizational efficiency. Standardization removes variations, creating high certainty in clinical interactions, improving patient care quality.

Favorable Error Reporting Culture

Reporting errors is crucial towards error prevention, and high-performing healthcare organizations have realized the benefits of error reporting. Hence, these organizations create a conducive workplace environment that encourages their employees to report errors rather than hide them. Reporting errors is vital in learning from them and implementing interventions to prevent them, which improves patient safety (Rodziewicz et al., 2021). Due to the significance of reporting medical errors, high-performing institutions have an organizational culture that fosters trust, enabling their professionals to report errors, improving patient experience.

Optimized Staffing

A majority of the medical errors occur due to staff burnout. When an organization is understaffed, its employees are overworked and hence in high chances of experiencing burnout. Employee burnout is directly correlated to medical errors, with research indicating that doctors who experience burnout are twice as likely to make medical errors than their counterparts without burnout. (Motluk, 2018). In this regard, high-performing healthcare organizations have staffing policies that ensure adequate, well-trained, and motivated staff. Optimized staffing reduces medical errors that might results from burnout, hence providing high-quality care.

How Organizational Functions and Behavior Effect Outcome Measures Correlated to Medication Errors

The executive summary describes three outcome measures that can be employed to evaluate the quality of medical care regarding medication errors. These outcomes include the organization's error reporting culture, hospital readmission rates, and medication-related deaths and disabilities. Organizational functions and behaviors have a significant influence on the three outcome measures.

Leadership

A healthcare institution's quality of leadership is a significant element that shapes the error reporting culture. In this regard, effective leadership creates an environment of trust, making employees feel more secure to report their errors. On the other hand, poor leaders develop an atmosphere of mistrust, with the organization perceiving mistakes as undesirable elements that should be punished. Hamilton et al. (2018) assert that many medication errors go unreported due to employee's fear of being punished. In this case, effective leadership creates an error reporting culture that reduces medication errors, consequently reducing medication-related disability and death rates and hospital.

Additionally, the favorable error reporting culture from effective leadership reduces medication-related hospital readmissions. Poor leadership creates a poor error reporting culture, which increases medication errors, consequently increasing medication-related disabilities and deaths, and medication-related readmissions in less than 30 days.

Standardization Practices

As aforementioned, standardization practices are essential in reducing medical errors. Standardization prevents variations, improving communication certainty, hence decreasing medical errors. Therefore, strict standardization guidelines minimize medication errors, reducing medication-related disabilities, deaths, and hospital readmissions in less than 30days.

Staffing

The number of staff in a healthcare institution determines the amount of work they undertake. In understaffed healthcare institutions, the staff is overworked, leading to high burnout. As mentioned earlier, staff burnout is correlated to medical errors. In this regard, employees in understaffed healthcare organizations make more errors, increasing medication relation disabilities, deaths, and hospital readmissions. In healthcare organizations with adequate staffing, their employees perform lesser duties, leading to lesser chances of experiencing burnout. Hence, these organizations register fewer medication-related errors, minimizing medication-related disabilities and death rates, and hospital readmissions.

Quality Outcomes and Measures

In this evaluation, the quality of patient care has been measured in terms of adverse effects. These effects include the medication-related deaths and disability rates and medication-related hospital readmissions in less than 30 days. Using adverse effects is an effective strategy in measuring the quality of patient care since it indicates tangible evidence on the quality of healthcare services administered to the patients. The attached spreadsheet documents the rate of these adverse effects in 1 year. In measuring the quality of care using adverse effects, a high rate of adverse effects indicates patient care that is not safe for the patients. On the other hand, a low rate of adverse effects means safe patient care, representing quality medical care in an organization.

Healthcare institutions use readmission rates within 30 days as a measure of medical care quality. Medication errors indicate the quality of healthcare services received by the patients. Readmissions in less than a month indicate ineffective medical care. Therefore, it indicates higher chances of medication errors in the course of the treatment process. Additionally, medical errors are correlated to deaths and severe disabilities. Therefore, these adverse effects are essential measures of evaluating the quality of medical care. High rates of severe disabilities and deaths indicate high rates of medication errors, hence depicting poor quality medical care. The statistics presented in the attached spreadsheet show 69 medication-related hospital readmissions in a year, which signifies poor quality healthcare services and consequently a high rate of medication errors. Besides that, the data shows eight instances of severe medication-related disabilities and deaths, indicating high rates of medication errors. Therefore, the organization exhibits poor quality healthcare services; hence, it should enact the necessary interventions to improve the quality of its medical care.

Organizational Performance Issues, Opportunities and Quality, and Safety Outcomes

The healthcare organization's quality analysis has exposed various performance issues and opportunities that the organization can exploit to improve its healthcare services. The first organizational performance issue is its error reporting culture. The organization scored an average of 2 out of 5 in its error reporting culture. As aforementioned, healthcare organizations need to develop positive error reporting cultures as it is an evidence-based practice that improves the quality of healthcare services. Jember et al. (2018) assert that 50% of medication errors are preventable. Error reporting is vital in exposing medication errors, which presents chances of learning from mistakes and improving patient care. The organization's poor error reporting culture increases hospital readmissions in less than 30 days of discharge. Additionally, the increased errors due to poor error reporting culture increase severe disabilities and deaths. Hence, the healthcare institution should develop a positive error reporting culture, reducing medication errors and improving the quality of its healthcare services.

Besides that, the organization can exploit strict standardization guidelines to reduce the number of medication errors. As previously mentioned, standardization removes variations in medical processes, tools, and workflow, creating a uniform work context that improves certainty and reduces confusion. In this regard, standardization is vital in reducing medication errors. Hence the organization can employ it to address its high deaths and disability rates and reduce the number of hospital readmissions in less than 30 days of discharge.

A Strategy for Measuring All Patient Care Aspects

There is a need to evaluate all patient care aspects in the healthcare organization. Clinical audit is the strategy that will be employed to assess all the elements of patient care in this organization. In this strategy, aspects of patient care shall be evaluated against the set standards of care. After the evaluation, the project team leader shall prepare a Clinical Audit report and distribute it to all relevant stakeholders via email. Besides that, the healthcare organization shall conduct a re-audit to assess whether there are improvements in all the aspects of patient care.

The Change Management Model

Change management is a challenging task; hence the organization shall employ the ADKAR change management model to guide the implementation of the strategy. In this change management model, the first step will entail creating awareness so that all relevant stakeholders recognize the need for change. After every stakeholder has appreciated the need for change, the second step shall involve strategies to create a desire, to make all stakeholders want the change. When everyone gets the desire for change, the change management team shall provide knowledge on the change, ensuring every member involves in the change management knows which information they need to undertake their part in the change management effort. After providing all the relevant information, the change management team shall train the staff to impart the skills required to accomplish their parts successfully. Lastly, the change management team shall undertake reinforcement, working with all stakeholders and staff to ensure that the change management efforts persist after achieving the change.

In conclusion, the quality of medical care services is an essential element in offering satisfactory healthcare services to patients. High-quality care can be realized through improving the quality outcome measures, achieving safe patient care. In this regard, the healthcare organization should focus on reducing medication errors, which adversely impact patient safety and the quality of healthcare services offered by the firm. Therefore, the organization should implement various interventions such as developing a favorable culture for reporting errors, using standardization in its healthcare practices, and evaluating organizational leadership to assess its efficiency in pursuing organizational objectives of offering quality patient care. Lastly, the firm should implement a Clinical Audit to evaluate all aspects of patient care. The received feedback shall be critical in improving the organization's quality of care.

References

Hamilton, E. C., Pham, D. H., Minzenmayer, A. N., Austin, M. T., Lally, K. P., Tsao, K., & Kawaguchi, A. L. (2018). Are we missing the near misses in the OR?—underreporting of safety incidents in pediatric surgery. Journal of Surgical Research, 221, 336-342. https://doi.org/10.1016/j.jss.2017.08.005

Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). Proportion of medication error reporting and associated factors among nurses: a cross sectional study. BMC Nursing, 17(1), 1-8.

Kriznik, N. M., Lamé, G., & Dixon-Woods, M. (2019). Challenges in making standardisation work in healthcare: lessons from a qualitative interview study of a line-labelling policy in a UK region. BMJ Open, 9(11), e031771.

Motluk, A. (2018). Do doctors experiencing burnout make more errors? Canadian Medical Association Journal, 190(40), E1216–E1217. https://dx.doi.org/10.1503%2Fcmaj.109-5663

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical Error Reduction and Prevention. In StatPearls [Internet]. StatPearls Publishing.

Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou, E. (2017, December). Importance of leadership style towards quality of care measures in healthcare settings: a systematic review. Healthcare (Vol. 5, No. 4, p. 73). Multidisciplinary Digital Publishing Institute.

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Addendum

					OUTCOME MEASURES
					Hospital Adverse Event Data
	January	February	March	April	May	June	July	August	September	October	November	December	Total
HOSPITAL READMISSIONS IN < 30 DAYS	12	7	6	4	4	1	3	10	5	3	12	2	69
MEDICATION RELATED DEATHS AND DISABILITIES	January	February	March	April	May	June	July	August	September	October	November	December	Total	DEATHS & DISABILITIES
	1	0	2	0	1	0	0	2	1	0	0	1	8
	1		1	0	0	0	0	1	0	0	0	0	3	DEATHS
					ERROR REPORTING CULTURE SCORE		2 OUT OF 5