Policy Proposal (Ass 2) (1*)

Policy proposal 1

Policy proposal

Name

Institution

Date

Although St Elizabeth Community Hospital is one of the outstanding health care facilities in California (dignityhealth.org, 2020), several issues need to be addressed to improve patients' safety and improve its transparency reporting score. The facility should employ a Device Associated Module Surveillance system in its monthly reporting plan and link it with the National healthcare safety network as a requirement in California state legislation. This reporting encourages healthcare workers to mitigate medical errors that compromise the safety of patients, increase hospital stays, and report a high mortality and morbidity rate. For improved reported cases of Low-risk Cesarean Rate (Gaieski, Edwards, Kallan, & Carr, 2013), additional resources and more care interventions put in place. Considering the dangers involved in failure for reporting of incidences in any healthcare facility such as St Elizabeth Community hospital needs an organizational policy to address the shortfall in collecting, and recording information for analysis. Further, medical errors should be addressed to improve the scores in Low-risk Cesarean Rate.

Strategies to Ensure Medication events reporting

Medical events analysis

Medical events included in the patient safety component fall into four modules whose focus is on incidences associated with medical devices, multidrug resistant organisms, antimicrobial agents used during healthcare, and surgical procedures. The device associated module focuses on bloodstream infection or CLABSI (Kramer, 2017), central line insertion practice adherence, catheter-associated urinary tract infection, pediatric ventilator-associated events, adult locations ventilator-associated events, and ventilator-associated pneumonia. Procedure associated module include surgical site infection (SSI).

Medical events reporting

The facility should be committed to following the NHSN surveillance protocol in its totality for each particular event as indicated in the NHSN monthly reporting plan. The facility should also ensure off-plan surveillance to track events for its internal purposes. The facility should make a manual follow up to ensure that data that cannot be captured through clinical Document architecture is recorded (Patel, Gupta, & Vaughn, 2018). The NHSN long term care facility component provides long term care facilities with standardized surveillance methods. The modules include multidrug-resistant organisms and lab identified Clostridioides difficile events, urinary tract infection, and prevention process measures. This component can ideally be used by the facility with the surveillance protocols, data collection forms, training materials, instructions, and other helpful materials being provided for by the long term care facility component resource.

Surveillance techniques

Some of the options that the facility can adopt require a well trained Infection Preventionist (IP) to track and record active patient-based prospective surveillance. The IP seeks out infection data from the time the patient is admitted and throughout the hospital stay. Some of the useful data sources that are screened for information include pharmacy, laboratory, imaging/radiography, discharge/admission/transfer, pathology database. Patient charts which include history and physical examination notes, temperature charts, and physician/nurse notes are also important sources of information (Elden & Ismail, 2016). However, the IP is the final determiner since some information cannot stand alone without the rest of the possible criteria for the identification of infection. Retrospective chart reviews are useful in a circumstance where the patient is discharged before all the critical information is gathered (Patel, Gupta, & Vaughn, 2018). However, the facility should train all staff members in data collection points such as central line insertion nurses to collect the denominator information and process care data.

Policy for Managing Medication records

Policy statement

Medical data and information are important aspects of determining whether a facility is following the laid out procedures when executing its mandate. With proper records, it is easy for the auditors and the general public to rate the performance of a health institution, and also help the relevant authorities determine whether the patients' safety and the general public health are at risk. The guidelines and recommendations will provide a framework for improving the practice of the proposed evidence-based strategies.

Scope

The policy applies to members of staff at data entry and collection points such as the PI, nurses, physicians, clinical officers, and the pharmacist. All the concerned individuals are responsible for ensuring that all the relevant data and information is gathered and recorded as the treatment process continues.

Guidelines for implementing evidence-based strategies

The public health committee which comprises of professionals from various disciplines such as the PI, midwives, nurses, pharmacists, local and national health administrators, and lab technicians, should regularly review the quality of the collected and recorded data before any analysis is done. The committee should give an informed opinion on the trajectory that the health facility is taking in ensuring patient safety and reducing the low risk cesarean rates. According to (Elden & Ismail, 2016) the first step towards correcting errors is establishing the sources by critically reviewing the recorded information to establish risky patterns.

Staff education is also necessary to ensure that all members of staff are conversant with the emerging technologies that may be useful for collecting information and improving the facility performance. Proper training help ease the burden of the IP by ensuring that the relevant members of staff can update patient information at every medical event immediately it happens. New members of staff should undergo an induction course that should train them on the importance of collecting and recording information and be made aware of the possible consequences for not following the correct procedure.

The hospital should also ensure that its system is robust in the sense that patient information is secure and cannot be accessed by unauthorized personnel to maintain integrity and privacy. The facility should therefore invest in information technology and ensure that the systems being used are updated and capable of holding a large volume of data. The system should automatically process data and display results on request to minimize the use of manual systems. This will help in reducing errors in data processing and displaying results.

Members of staff who fail to record data in time and following the correct procedure should face disciplinary actions. Also, the management should routinely discuss the results of the analyzed information and come up with strategies for improving the overall performance of the facility. Recording high rates of low risk cesarean rates should not happen since such cases delays the policy-making procedure.

Modules discussed in this report are useful tools for collecting, recording, and monitoring patient information, and also in analyzing data. The process associated module is important in monitoring surgical site infections through the use of pre-discharge and post-discharge surveillance. The device associated module makes records of the medical instrumentation associated infections such as CLABSI, CAUTI, VAE, VAP, and CLIP. The module ensures that device-associated denominator data is collected at the same time it is diagnosed or by the weekly sampling procedure. The antimicrobial use and resistance module allow the facility to collect information regarding the use of antimicrobials in inpatient care and also the prevalence of drug-resistant organisms in both the inpatient and outpatient departments.

Stakeholder Involvement in Implementing Proposed Strategies

The IT department personnel, the PI, lab technicians, clinical officers, physicians, and doctors are useful to staff members who can assist in ensuring that the laid down procedures are followed to the latter. The administrative personnel such as the CEO, chief operations officer, and the director of nursing should assist where necessary. A quality assurance committee can also be formed to incorporate all the stakeholders to establish role accountability and also articulate the quality improvement norms frequently. Nursing staff should be extensively involved since they are at the core of administering medications.

Conclusion

Patient information is the most essential tool that can help the organization makes proper and informed decisions. However, without the correct procedure for collecting, recording, and analyzing this information, it cannot of any use to the organization. Thus the hospital should invest in the appropriate systems for surveillance, collection, and recording of information for further analysis. All stakeholders should work as a team in ensuring that the rates of low risk cesarean cases are reduced while at the same time holding the hospital transparency levels high and also make use of this information to make informed decisions.

References

dignityhealth.org. (2020, October). Dignity Health Quality Transparency Dashboard. Retrieved from dignityhealth.org: https://www.dignityhealth.org/my-home/%E2%80%9C/-/media/cm/media/documents/Quality%20and%20safety/September%202019/St%20Elizabeth%20Community%20Hospital.ashx'

Elden, N. M., & Ismail, A. (2016). The importance of medication errors reporting in improving the quality of clinical care services. Global Journal of Health Science, 243–251.

Gaieski, D. F., Edwards, J. M., Kallan, M. J., & Carr, B. G. (2013). Benchmarking the incidence and mortality of severe sepsis in the United States. Critical Care Medicine, 41(5), 1167–1174.

Kramer, R. D. (2017). Are antimicrobial peripherally inserted central catheters associated with a reduction in central line-associated bloodstream infection? American Journal of Infection Control, 108-114.

Patel, P. K., Gupta, A., & Vaughn, V. M. (2018). Review of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) in Adult ICUs. Journal of Hospital Medicine, 105-116.