Improving Quality and Achieving Equity: A Guide for Hospital Leaders

Outlines the need to address racial/ethnic disparities in health care, highlights model practices, and makes step-by-step recommendations on creating a committee, collecting data, setting quality measures, evaluating, and implementing new strategies

Effects of Multidimensional Vs. Functional Health Literacy Educational Interventions on Standardized Patient-Nurse Interactions: A Feasibility Study

Background. Patients with limited health literacy (HL) are use fewer preventive services, access more emergent care and report poorer health outcomes than those with adequate literacy. Nurse have little consistent preparation to use HL competencies in practice, thus exacerbating risks for miscommunication and harm with patients of diverse literacy levels. Purpose. The purpose was crafting educational interventions to compare effects of two contrasting theoretical approaches on HL practice uptake including initial assessments of a HL competencies tool. Problem/Aims. For nine nurses and nursing faculty, did use of multidimensional versus functional HL educational strategies lead to changes in HL knowledge and HL- related behaviors in recorded standardized patient- nurse interactions? The four aims were to develop the Health Literacy Patient-Nurse Interaction Competencies Evaluation or HLP-NICE tool, craft two contrasting HL curricula and teaching approaches, evaluate intervention effects on HL knowledge and HL-related behaviors of participants, and then identify future research directions. Design/Theoretical Basis. A sequential mixed methods feasibility study design compared effects of the contrasting implementations on HL knowledge and HL-related behavior changes of the nine randomly assigned participants. Zarcadoolas, Pleasant & Greer’s multidimensional HL theoretical framework was integrated through HLP-NICE items and multidimensional teaching activities Procedures. Preliminary qualitative case study methodology shaped standardized patient, teacher and HLP-NICE development through individual cognitive, focus group and expert panel interviews. A quantitative two group between subjects design assessed study feasibility. HL experiences and changes in HL knowledge were based on the Health Literacy Knowledge and Experiences Survey or HLK-ES scores. Kalamazoo Essential Elements Communication Competencies-Adapted or KEECC-A and HLP-NICE ratings evaluated communication and HL-related behavior changes. Findings. HL knowledge did not increase overall for participants, nor was prior HL educational experience associated with HL knowledge gains. Increases in communication and HL-related behaviors were noted for both groups, although functional group gains were greater for KEECC-A communication ratings. Study implementation was feasible for enhancing short-term HL– related behavior changes although challenges existed in recruitment. Conclusions. Improving acceptability for participation, creating additional standardized HL training resources, enhancing educational strategies and strengthening HLP-NICE psychometric support is warranted to advance HL integration in nursing educational and clinical practice

Aligning Forces for Quality: Local Efforts to Transform American Health Care

Profiles RWJF's initiative to raise healthcare quality in targeted communities; reduce racial/ethnic disparities; and offer models for national reform through performance measurement and public reporting, quality improvement, and consumer engagement

Implementation of Teach-Back for Discharge Teaching in a Critical Access Hospital: A Quality Improvement Project

A lack of comprehension of discharge instructions may cause high readmission and emergency room revisit rates for organizations. At the project site, there was no current evidence-based practice to ensure patient comprehension of discharge instructions. The purpose of this quantitative, quasi-experimental quality improvement project was to determine if the implementation of the Institute for Healthcare Improvement (IHI) Always Use Teach-Back Toolkit would impact emergency room revisit rates among adult medical-surgical patients in a critical access hospital in rural Minnesota over four weeks. Afaf Meleis’ transitions theory and the Iowa model for evidence-based practice were the scientific underpinnings of the project. The total sample size was 87, n = 47 in the comparison and n = 40 in the intervention groups. Data was extracted from the facility’s electronic health record. A chi-squared test was used, and results indicated no statistically significant reduction in the ED revisit rates X 2 (1, n=87) =2.00, p=0.157. Clinical significance is found in reducing the ED revisit rates by 1.38% over the four weeks. Therefore, the implementation of the IHI’s Always Use Teach-Back Toolkit may reduce emergency room revisit rates in this population and setting. Recommendations include sustaining the practice, adding teach-back to the discharge planning protocol, and disseminating the project findings

Discharge from Hospital to Home: Implementation and Use of the AHRQ IDEAL CHF Discharge Planning and AHA CHF Discharge Checklist

Section I: Abstract Problem: Hospital readmission rates in the congestive heart failure (CHF) population is a quality concern. As excessive readmissions tend to indicate low quality of care, government and private healthcare payers are increasing their focus on 30-day readmission rates as a new quality measure for hospitals. Context: This was a quality improvement project for a telemetry unit at a medical center in the Central Valley of California. There are 56,551 members in the Central Valley enrolled in the healthcare provider system and 2,567 patients with a primary or secondary diagnosis of CHF. Within the healthcare system, CHF was identified as the third most-admitted diagnosis to the telemetry unit, with an average stay of 5.4 days. Interventions: A multifaceted, evidence-based model was implemented using several interventions: (1) TeamSTEPPS Pre-Training Knowledge Assessment survey to gauge nurse CHF knowledge, (2) Agency for Healthcare Research and Quality IDEAL discharge planning resource, and (3) American Heart Association CHF discharge checklist. Measures: The goal of the project was to reduce the 30-day readmission rates for recently discharged patients from a baseline of 14% to 10% by July 2021, with a focus on the discharge education given to the patients and their family members. Results: Initially, there was a high level of interest and engagement among the nurses in educating the CHF patients and gauging their readiness for discharge. As the project progressed, nurse engagement faltered, with nursing staff reporting burn-out and increased stress from multiple improvement projects being implemented simultaneously. Patient feedback concluded that the discharge education provided by the nursing staff was beneficial and increased their comfort being discharged home to self-care. Due to time constraints with the project deadlines, the patient readmission rates could not be accurately assessed; although, results are expected to improve with the continuation of the education introduced during the project. Conclusion: Staff education on the available resources to assist them with CHF discharge education may increase the readiness of CHF patients to discharge home and reduce the 30-day readmission rates in the CHF patients on the telemetry unit in the Central Valley of California. Keywords: congestive heart failure, readmission, education, best practices, discharge planning, self-managemen

Doctor of Philosophy

DissertationHealth information technology (HIT) in conjunction with quality improvement (QI) methodologies can promote higher quality care at lower costs. Unfortunately, most inpatient hospital settings have been slow to adopt HIT and QI methodologies. Successful adoption requires close attention to workflow. Workflow is the sequence of tasks, processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal. Assessing the impact on workflow is an important component of determining whether a HIT implementation will be successful, but little research has been conducted on the impact of eMeasure (electronic performance measure) implementation on workflow. One solution to addressing implementation challenges such as the lack of attention to workflow is an implementation toolkit. An implementation toolkit is an assembly of instruments such as checklists, forms, and planning documents. We developed an initial eMeasure Implementation Toolkit for the heart failure (HF) eMeasure to allow QI and information technology (IT) professionals and their team to assess the impact of implementation on workflow. During the development phase of the toolkit, we undertook a literature review to determine the components of the toolkit. We conducted stakeholder interviews with HIT and QI key informants and subject matter experts (SMEs) at the US Department of Veteran Affairs (VA). Key informants provided a broad understanding about the context of workflow during eMeasure implementation. Based on snowball sampling, we also interviewed other SMEs based on the recommendations of the key informants who suggested tools and provided information essential to the toolkit development. The second phase involved evaluation of the toolkit for relevance and clarity, by experts in non-VA settings. The experts evaluated the sections of the toolkit that contained the tools, via a survey. The final toolkit provides a distinct set of resources and tools, which were iteratively developed during the research and available to users in a single source document. The research methodology provided a strong unified overarching implementation framework in the form of the Promoting Action on Research Implementation in Health Services (PARIHS) model in combination with a sociotechnical model of HIT that strengthened the overall design of the study

From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke

Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group’s Movement Interventions Task Force offer these 5 recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes; (2) using transition specialists; (3) implementing a patient-centered discharge checklist; (4) using standardized outcome measures; and (5) establishing partnerships with community wellness programs. Because of changes in health care policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during poststroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (Early Supported Discharge, planned predischarge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community

Identifying ICU patient safety priorities within a Northern Ontario setting : a delphi study

The purpose of this study was to explore patient safety priorities as perceived by clinical experts working in a northern Ontario adult ICU. A modified Delphi was used to elicit consensus regarding patient safety priorities from the perspective of an expert panel of registered nurses and intensivists. At the onset of the study, the consensus level was set at 70%. Data was collected through serials rounds with researcher-developed questionnaires. Descriptive statistical analysis was completed. No consensus was reached at Round 1. Three points of consensus regarding patient safety priorities were reached at Round 2: improving pain and agitation management; incorporating a checklist into the bullet round reporting tool; and implementing use of visual cues for high-risk lines. These strategies support the need for anticipation, recognition, and management of at risk situations. The results have the potential to guide the advancement of the patient safety mandate within an ICU setting.Master of Science (MSc) in Nursin