Process Improvement Plan

Once an area of evidence-based practice has been chosen for investigation, the reviewer must locate current evidence sources and, using a structured approach, assess each for applicability to the issue being investigated. The aim of this paper is to use a Rapid Critical Appraisal Checklist (Melnyk and Fineout-Overholt, 2011) to support these sources of evidence into a review that discusses the importance of daily, high-level, multidisciplinary communication and patient safety. The summaries of these evaluations will be provided as an appraisal of each study.

Assess the hazards identified in the health and social care setting. And make recommendations in relation to identified hazards to minimise the risks to the service user group. M2 and D1

The issues that are prone to high risks can be surveyed by this process as a detailed survey would help overcome many hazards which can threaten the safety of patients. Examples of these issues would be disinfection, diagnostic imaging, cleaning, sterilization etc (Joint, 2007).

The submission of the Initial Self Study Report (ISSR) begins the process. CoAEMSP Executive Director will review the study report and pass along to establish a site visit with the site review team. After the site visit occurs, the review team completes their findings and holds an exit interview with our staff. Formal recommendations will be written and forwarded to the Board of Directors for recommendation of approval or for deficiencies that need to be corrected. If in the event there are deficiencies, we need to reply immediately because we will only have 14 days to respond to their findings, with failure to respond leading to probation and possible

1. Look for factors that may lead to patients, staff and others, including yourself, being in danger of harm and

The final identified recommendation is the use of a standardized action plan format that will provide the framework for change. Defined expectations and deadlines will ensure that progress is maintained amongst the numerous and diverse clinical settings. My role-modeling of this step will teach my management team how to utilize this tool as well as assist with setting the expectation that they utilize the tool with their staff members as well.

Some advantages of the self-administered survey are: Low cost. Extensive training is not required to administer the survey. Processing and analysis are usually simpler and cheaper than for other methods. The reduction in bias error. The questionnaire reduces the bias that might result from personal characteristics of interviewers and/or their interviewing skills. Greater anonymity, absence of an interviewer provides greater anonymity for the respondent. This is especially helpful when the survey deals with sensitive issues such as questions about involvement in a gang, because respondents are more likely to respond to sensitive questions when they are not face to face with an interviewer.

I have chosen two SMART goals to research and put into action by the end of week six of class. SMART Goal 1 is the leadership development goal and will standardize the surgical time-out procedure to include all required elements as recommended by the World Health Organization (WHO) and meet the requirements of the Joint Commission Universal Protocol. I chose this goal for myself to ensure that all nurses are consistently including all required information each and every time in the surgical time-out procedure and as a result

The Utilization Review Plan for Chestatee Regional Hospital is sufficiently organized and detailed. The first section of the plan identifies the purpose, objectives, and scope of the UR plan. The plan states that the Board, through the Administration, and Medical staff, has established a comprehensive utilization process (Chestatee, 2014). The goal of the UR plan is to appropriate allocation of resources through identification, and elimination of over-utilization, under-utilization, and the inefficient delivery of health care services (Chestatee, 2014). This section of the plan includes several objectives to implement an effective process to achieve the highest quality of care in a cost-effective manner. The objectives include:

“We will find our baseline measurement using nurse surveys, audits and observation timings. We will track what steps are covered and how long each step takes and the number of occurrences of near misses due to inefficient handoffs relating to patient safety. We will also measure our patient baseline data from current patient satisfaction surveys” N. Guyse (personal communication, February 22, 2014). Currently we are inefficient and unsafe with handoff practices due to missing or incomplete information, multiple processes used between the nursing staff, and multiple report out processes being practiced on the floor. Multiple processes are causing confusion and incidental overtime. With multiple processes, information is being missed between nursing staff, which is a safety concern due to the increased errors. Our organization is working on the creation of one standardized process used between all employees to ensure that all handoffs are efficient and safe. “We have implemented a group report out for nursing staff in conjunction with the beside report outs” N. Guyse (personal communication, February 22, 2014).

An action plan to help reduce a risk for healthy and safety using the 5 stage process (Obeng, 2007).

Implementing a project for a change requires patience and time. Presenting the issue to the staffs is not an easy task. There will be resistance and disagreement that the issue persists. According to Stevens, even though the evidence-based practices are embraced in the microsystem by nurses, there will be impediments in employing it into practice (2013). Showing the evidences and explaining the reason why the change is urgent ensure cooperation. Teaching the health care providers of the organization’s policy regarding restraint and the recommendation of the Center for Medicare and Medicaid Services (CMS) as well as The Joint Commission (TJC) will enhance compliance and improve patient outcome by providing a safe environment for the patients,

Ardizonne’s presentation. Programs such as MedTeams and TeamStepps provide strategies to create teams which are high functioning, resourceful, aware and ultimately achieve desired outcomes. Dr. Ardizzone shared an event which triggered the implementation of checklists in the operating rooms at Memorial Sloan Kettering Cancer Center(MSKCC). These checklists were implemented after multiple scholarly articles recommended such measures, with substantial positive outcomes. She also mentioned the challenges faced by enacting such measures, i.e. training, buy-in, interdisciplinary education. All this information gave me a better understanding of the different tools available in healthcare and the constant struggles to implement such measures to fundamentally enhance patient safety.

Protocols and guidelines have been used for many years and has many advantages in ensuring unacceptable care is kept to a low if followed .One of the main advantages is patient saftey if protocols are put in place there is little room for error which is just as ressuring for the care giver to know

employee. This is part of day to day management and is intended to ensure that