NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Name

Capella university

NURS-FPX 6212 Health Care Quality and Safety Management

Prof. Name

Date

Outcome Measures, Issues, and Opportunities

Communication failures in nursing handover are a significant issue in (mention your organization). This report is for executive leaders and concerned stakeholders to identify the quality and safety issues and opportunities within the organization that can be leveraged to improve outcomes. This report further elaborates on the plan for change, highlighting the importance of effective hands-off communication. 

Analysis of High-Performing Settings

High-performing healthcare organizations often excel in quality and safety through well-defined functions, processes, and team behaviors, particularly in mitigating hands-off communication failures. These organizations prioritize clear communication, effective teamwork, and a culture of continuous improvement (Sinnaiah et al., 2023). For instance, high-performing healthcare settings have robust standardized handoff protocols, which they continuously monitor to understand the effectiveness of these protocols. This monitoring helps in making relevant changes to improve organizational performance. Furthermore, the leadership in these organizations fosters a culture of accountability and blame-free reporting, encouraging staff to follow best practices and report adverse incidents without any fear of repercussions (van Baarle et al., 2022). 

Additionally, the organizations prioritize regular training and interdisciplinary collaboration. Regular training sessions help staff maintain high competency levels, while interdisciplinary team meetings promote cooperation and problem-solving, address communication gaps, and enhance coordination (Leykum et al., 2023). Despite these best practices, knowledge gaps and areas of uncertainty remain. The optimal frequency and format for training sessions on handoff communication are still unclear. There is also limited data on the long-term sustainability of improvements achieved through initial interventions. Further research and data collection in these areas could significantly enhance the understanding and implementation of effective handoff communication practices.

Organizational Functions, Processes, and Behaviors and Outcome Measures

These organizational functions, procedures, and team actions significantly impact quality and safety outcome measures such as adverse events, patient satisfaction, and staff compliance with protocols related to handoff communication. Organizations that promote clear communication, prioritize team coordination, and foster a continuous improvement environment are able to reduce adverse events and improve patient satisfaction (Sinnaiah et al., 2023). Therefore, (mention your organization) can promote effective communication through standardized protocols to decrease the occurrence of preventable incidents, directly improving patient safety. Moreover, fostering a culture of continuous quality improvement can help identify practice loopholes and enhance organizational performance.

Additionally, encouraging accountability and blame-free reporting motivates staff to adhere to best practices and report incidents, leading to continuous quality improvement. This environment can enhance staff compliance with protocols, as employees feel supported to follow standardized procedures without fear of punitive consequences (Abuosi et al., 2022). Regular training and interdisciplinary collaboration further supports these outcomes by maintaining high competency levels and promoting teamwork.

In (mention your organization), regular training sessions would ensure that staff are well-versed in handoff procedures and capable of executing them effectively. Interdisciplinary meetings can address communication gaps and enhance coordination, leading to a more seamless patient care experience (Leykum et al., 2023). These improvements are likely to boost patient satisfaction, as patients receive consistent and reliable care. This determination is based on several assumptions, including the belief that standardized protocols and training will be equally effective in our healthcare setting and that leadership will support these initiatives. It is also assumed that staff will engage positively with these changes and that adequate resources will be available for implementation.

Identification of Quality and Safety Outcomes and Measures

Identifying the quality and safety outcomes in our practice setting is essential to improve current practices and achieve desired targets. (Mention your organization) has developed several safety and quality outcome metrics to assess communication failures in nursing handover and the effectiveness of preventive measures. These include the number of adverse events, patient satisfaction score, and staff compliance rate. Currently, the organization has reported 25 adverse events per 1000 patient days, 70% patient satisfaction rate, and 65% staff adherence to communication protocols. However, through various preventive measures, we aim to improve these numbers to 15 adverse events, 85% patient satisfaction, and 90% staff compliance. The spreadsheet in the appendices elaborates these numbers. 

The proposal for (mention your organization) is to implement standardized communication protocols (90%) to provide a consistent and accurate method for staff hands-off. Chien et al. (2022) elaborate on the effectiveness of SBAR (Situation, Background, Assessment, and Recommendation) as an efficient method to minimize communication failures and conduct seamless information transfer. Similarly, integrating electronic health record (EHR) systems with dedicated handoff checklists (90%) can ensure that all patient information is accurately conveyed and stored in one system for re-checking at the time of need (Panda, 2020).

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Finally, it is vital to provide an interruption-free environment for nurses while performing hands-off communication (90%), ensuring they can communicate all essential patient information without distractions (Teigné et al., 2023). Other preventive measures for our organization include standardizing communication and improving patient education (100%), implementing regular staff training,  conducting compliance audits, and using standard communication checklists (85%) to achieve the desired results of quality and safety outcome measures. 

The evaluation of the data used to create a spreadsheet is positive as data is collected from the performance dashboards within (mention your organization). This data provides insights into the safety and quality outcome measures for our organization, highlighting the need for improvements. The data is reliable because our practice setting conducts regular audits and ensures data integrity by cross-referencing with quality assurance teams. This reliable data is essential for informed decision-making and developing targeted measures. 

Performance Issues or Opportunities

Ineffective hands-off communication among nurses in our organization is a critical performance issue that impacts various systemic functions, procedures, and behaviors, ultimately affecting quality and safety outcomes. In our system, this problem arises from the lack of standardized protocols and inconsistent communication practices, such as the lack of an interruption-free environment during shift changes. Nurses follow different procedures, leading to incomplete or inaccurate information transfer, which increases the risk of adverse events (Chien et al., 2022). Additionally, the absence of a structured environment for handoffs, such as designated times and places free from interruptions, exacerbates communication breakdowns. These deficiencies compromise patient safety, affect staff compliance with care protocols, and decline patient satisfaction with care (Teigné et al., 2023). 

Yet, several opportunities within the organization can be leveraged to improve these safety and quality outcomes. For instance, using leadership support for implementing standardized handoff protocols and regular training can strengthen staff communication skills and foster a culture of accountability and continuous improvement. Moreover, the organization can leverage existing EHRs to streamline and ensure consistency in information transfer. Through interdisciplinary collaboration, the teams can create dedicated, interruption-free times and spaces for handoffs, which can enhance nurses’ focus and uphold accurate communication. However, there are knowledge gaps and uncertainties, such as the availability of resources, resistance from staff, and organizational culture that may hinder seamless implementation. Information about these organizational aspects may improve implementation plans and produce more effective results for the practice settings. 

Strategy for Outcome Measurement and Knowledge Sharing

To enhance patient care measurement and knowledge sharing within our organization, the team will utilize the Plan-Do-Study-Act (PDSA) change model. According to the literature, this change model is efficacious in improving communication failures among healthcare teams by implementing standardized protocols using the change management process (Kay et al., 2022). This iterative approach ensures systematic improvements and effective dissemination of information among staff. 

• Plan: The organization should identify critical aspects of patient care that require measurement. Moreover, it should develop standardized protocols and checklists for handoffs, incorporating evidence-based best practices. Establish metrics to evaluate patient care. This step also includes developing a detailed implementation plan outlining roles, responsibilities, and timelines. 
• Do: Implement the standardized protocols and tools in a controlled setting, such as a pilot unit. Provide comprehensive training sessions for staff, emphasizing the importance of accurate handoff communication and the use of new tools. Encourage interprofessional collaboration during training and implementation to ensure all team members are aligned and competent in the new processes.
• Study: Monitor the implementation process closely, collecting data on the predefined metrics. Conduct regular reviews and feedback sessions with the interprofessional teams to assess the effectiveness of the new protocols and identify any challenges or areas for improvement. 
• Act: Based on the findings from the study phase, adjust the protocols and tools as necessary. Expand the implementation to other units within the organization, ensuring all staff receive updated training and resources. Establish a continuous feedback loop where staff can share their experiences and suggest improvements. 

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

To ensure effective knowledge sharing with staff, the organization should establish regular interprofessional meetings and workshops where team members can discuss best practices, challenges, and solutions (Leykum et al., 2023). Moreover, it is crucial to create a centralized digital platform for sharing updates, protocols, and training materials to keep all staff on the same platform. Furthermore, the organization can encourage collaboration through cross-departmental projects and committees focused on quality improvement to promote a culture of continuous learning. Additionally, implementing mentorship programs and peer review sessions will facilitate the exchange of expertise and experiences among staff, enhancing overall communication and patient care practices (Hookmani et al., 2021). This strategy will foster a cohesive, well-informed, and collaborative work environment.

References

Abuosi, A. A., Poku, C. A., Attafuah, P. Y. A., Anaba, E. A., Abor, P. A., Setordji, A., & Nketiah-Amponsah, E. (2022). Safety culture and adverse event reporting in Ghanaian healthcare facilities: Implications for patient safety. PLOS ONE, 17(10), e0275606. https://doi.org/10.1371/journal.pone.0275606 

Chien, L. J., Slade, D., Dahm, M. R., Brady, B., Roberts, E., Goncharov, L., Taylor, J., Eggins, S., & Thornton, A. (2022). Improving patient‐centred care through a tailored intervention addressing nursing clinical handover communication in its organizational and cultural context. Journal of Advanced Nursing, 78(5), 1413–1430. https://doi.org/10.1111/jan.15110

Hookmani, A. A., Lalani, N., Sultan, N., Zubairi, A., Hussain, A., Hasan, B. S., & Rasheed, M. A. (2021). Development of an on-job mentorship programme to improve nursing experience for enhanced patient experience of compassionate care. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00682-4 

Kay, S., Unroe, K. T., Lieb, K. M., Kaehr, E. W., Blackburn, J., Stump, T. E., Evans, R., Klepfer, S., & Carnahan, J. L. (2022). Improving communication in nursing homes using Plan-Do-Study-Act cycles of an SBAR training program. Journal of Applied Gerontology: The Official Journal of the Southern Gerontological Society, 42(2), 7334648221131469. https://doi.org/10.1177/07334648221131469 

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

Leykum, L. K., Noël, P. H., Penney, L. S., Mader, M., Lanham, H. J., Finley, E. P., & Pugh, J. A. (2023). Interdisciplinary team meetings in practice: An observational study of IDTs, sense-making around care transitions, and readmission rates. Journal of General Internal Medicine, 38(2), 324–331. https://doi.org/10.1007/s11606-022-07744-6 

Panda, S. (2020). Nursing shift handoff process: Using an electronic health record tool to improve quality. Clinical Journal of Oncology Nursing, 24(5), 583–585. https://doi.org/10.1188/20.cjon.583-585

Sinnaiah, T., Adam, S., & Mahadi, B. (2023). A strategic management process: The role of decision-making style and organisational performance. Journal of Work-Applied Management, 15(1), 37–50. Emerald. https://doi.org/10.1108/jwam-10-2022-0074

Teigné, D., Cazet, L., Birgand, G., Moret, L., Jean-Claude Maupetit, Guillaume Mabileau, & Terrien, N. (2023). Improving care safety by characterizing task interruptions during interactions between healthcare professionals: An observational study. International Journal for Quality in Health Care, 35(3). https://doi.org/10.1093/intqhc/mzad069 

NURS FPX 6212 Assessment 3 Outcome Measures, Issues, and Opportunities

van Baarle, E., Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R., & Widdershoven, G. (2022). Fostering a just culture in healthcare organizations: Experiences in practice. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-08418-z