NSG 601 Module 5 Discussion Rivier University

Please assess the requirements on the discussion board in the rubric.  For the discussion boards each week, please answer the questions in light of your future role according to your program track.  For example if you are a nurse practitioner student, consider answering the questions from the perspective of a provider in a primary care setting.

Think of some graphs or charts you have seen posted in your workplace or online. Provide examples of a structural measure, a process measure, and an outcome measure. Explain each one and what associated goals are for each.  Who sets the goals and why? Do the goals have benchmarks for comparison? How is this data used for improvements in your workplace? How do you see informatics used as part of process improvement initiatives in your workplace? Be creative with this assignment and feel free to post examples of charts and graphs either hypothetical or available publicly.

Please upload the images of charts and graphs directly into the discussion text box to facilitate viewing.  The directions to insert an image into the discussion board are here: How to embed images from the web  (Links to an external site.)

Canvas help on adding images to discussions

No peer responses this week. Posts are due Sunday by 11:59 PM EST.

The majority of charts/graphs at my workplace, an inpatient unit, fall into the category of outcome measures. Outcome measures represent the impact of the care being provided. For example, our graphs are often reporting to the nursing staff how we are doing in terms of hospital acquired infections, falls, etc. according to NSG 601 Module 5 Discussion Rivier University, this data is collected during our press ganey surveys and posted in a visual graph form in our break room to keep us up to date with where we fall compared to other units in these areas. The hospital wide data is combined to set the benchmark for where we are expected to be in terms of CAUTIs, CLAPSIs, HAPIs, etc. Of course the goal is zero, but the benchmark tells us how we are doing compared to the rest of the hospital, which sets realistic goals for us. This can also be compared to national data collected through the NDNQI. We use this data for improvement by working together as a unit to implement changes where need be. For example, one year we were higher on CAUTIs than the rest of the hospital and we had the foley catheter reps come in and do multiple inservices on indwelling catheter insertion and daily peri care methods to prevent infection. The next quarter, our CAUTI rates went down. I have attached an image of some of these outcome measurement graphs from my workplace.

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A structural measure is oftentimes used to provide insight on the level of care a hospital is able to provide. While we do not have any posted data around our unit on this, an example can be my hospital’s number of registered nurses who have their bachelors of science in nursing degree (BSN), a number that we advertise as we are a magnet certified hospital.

 

as stated in NSG 601 Module 5 Discussion Rivier University, a process measure represents our ability to maintain or improve health quality in the hospital. Once again this data is not as easily accessible as outcome measure data at my hospital but it can be hypothetically applied to an inpatient setting. A process measure could be the percentage of follow up appointments made on discharge

 

Ogrinc, G. S., Headrick, L. A., Barton, A. L., Dolansky, M. A., Madigosky, W. S., Miltner, R. S. (2018). Fundamentals of health care improvement: A guide to improving your patients’ care (3rd ed., pp. 55-95). Joint Commission Resources and Institute for Healthcare Improvement.

 

Institute for Healthcare Improvement. (n.d.). Science of improvement: Establishing measures. IHI. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx.

Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP)

At Melrose-Wakefield Hospital, an interprofessional team reviewed the current oral care practices in practice and determined a baseline non-ventilator hospital-acquired pneumonia (NV-HAP) rate. Opportunities for quality improvement were identified. One in four patients who develop a hospital-acquired infection will be diagnosed with pneumonia, with 60% attributed to NV-HAP. NV-HAP can lead to harm, due to the possible following outcomes: broad-spectrum antibiotics, greater risk of sepsis, transfer to a higher level of care, longer length-of-stay, discharge to a skilled nursing facility instead of home, and loss of function. More importantly, NV-HAP can affect any patient, regardless of age.  according to NSG 601 Module 5 Discussion Rivier University, most hospital-acquired pneumonia is due to bacteria associated with the oral cavity. The habitat within the oral microbiome can change within 48 hours of hospitalization. Factors that influence the microbiome balance may include the effect of illness, immunological condition, mental status, medications, change in nutrition, and lack of mobility. This disruption can cause the risk of pathogens aspirating into the lung. Oral care is a simple, yet critical intervention found to decrease NV-HAP risk.

Hospital-acquired pneumonia (HAP) is among the most common hospital-acquired infections (HAI), with NV-HAP comprising 60% of all HAPs (Baker et al., 2019). The literature shows that NV-HAP is harmful to patient safety and quality of care because NV-HAP:

• Is one of the most frequent hospital-acquired infections (McNally et al., 2019).
• May lead to sepsis (Giuliano & Baker, 2020).
• Can increase length of stay by 7-9 days.
• Causes large financial burden of at least $40K/case.
• Can affect any patient (Quinn & Baker, 2015).

The oral flora within the oral cavity changes due to hospitalization (Quinn & Baker, 2015). Disruption to the oral microbiome combined with other factors, such as a weakened immune system, leads to the risk of pathogens to aspirate into the lung. Emerging research demonstrates that oral care is linked to decreasing NV-HAP incidence. Oral care is an imperative clinical intervention because:

• The balance of the oral microbiome can be disrupted due to illness, immunological condition, mobility, nutrition, medications, and mental status (Jia et al., 2018).

• Oral hygiene is frequently missed among hospitalized patients (Baker et al., 2019).
• Oral care is a modifiable risk factor that affects every patient (Quinn & Baker, 2015).

The Centers for Disease Control and Prevention National Health Safety Network (CDC-NHSN) NVHAP surveillance protocol was used to determine if a comprehensive oral care protocol reduced non-ventilator hospital-acquired pneumonia (NV-HAP) among inpatients in an acute care hospital setting. The 28-month study showed a 58% decrease in NV-HAP among patients in the medical-surgical units. Informatics played a significant role throughout this entire process and the adjustment to the protocol was measured with data from the CDC-NHSN. Informatics was applied to perform a gap analysis of current oral care practices with literature and model oral care protocol after Quinn and Baker (2015). according to NSG 601 Module 5 Discussion Rivier University,  informatics was utilized to design an oral care algorithm to assess and compile the oral care needs of patients, educate staff and produce patient teaching material.

References

Baker, D., Quinn, B., Ewan, V., & Giuliano, K.K. (2019). Sustaining quality improvement: Long-term reduction of nonventilator hospital-acquired pneumonia. Journal of Nursing Care Quality, 34(3), 223- 229. https://doi.org/10.1097/NCQ.0000000000000359

Giuliano, K. K., & Baker, D. (2020). Sepsis in the context of nonventilator hospital-acquired pneumonia. American Journal of Critical Care, 29(1), 9 – 14. doi:10.4037/ajcc2020402

Jia, G., Zhi, A., Lai, P.F.H., Wang, G., Xia, Y., Xiong, Z., . . . Ai, L. (2018). The oral microbiota– a mechanistic role for systemic diseases. British Dental Journal, 224(6), 447 – 455. doi:10.1038/s.j.bdj.2018.217

McNally, E., Krisciunas, G. P., Langmore, S. E., Crimlisk, J. T., Pisegna, J. M., Massaro, J. (2019). Oral care clinical trial to reduce non-intensive care unit, hospital-acquired pneumonia: Lessons for future research. Journal for Healthcare Quality, 41(1), 1-9.             doi:10.1097/JHQ.00000000000131

Quinn, B., & Baker, D. L. (2015). Comprehensive oral care helps prevent hospital-acquired non- ventilator pneumonia. American Nurse Today, 10(3), 18-2

In November 2020, after four years of planning, a new primary care office opened for business, however due to the COVID-19 Pandemic the initial planned measures of nurse practitioner performance required updating due to the unexpected alterations and decline in people accessing healthcare.  Specifically, the measure of billing was unrealistic due to the slower than expected increase in new clinic patients.  The above document, albeit low sophistication, was generated in collaboration with the Chief Operating Officer to identify measures of performance during the first year of operations.

NSG 601 Module 5 Discussion Rivier University lists Five of these areas of measurements  established in conjunction with the recommendations set forth by the United States Preventative Task Force (USPSTF), which is one of our key leaders in identifying evidence based preventative services in primary care – with the goal of improving our nation’s health (United Preventative Task Force, 2021).  The USPSTF publishes the recommendations with the evidence/rationale and their assigned letter, identified as A-D.  This lettering system allows for easy identification of those recommendations that are considered “must-do’s” – defined as “A” and “B”, and those recommendations that have little or no value for the overall population – defined as “C” and beyond.

In NSG 601 Module 5 Discussion Rivier University, one of these measurements, annual Pulmonary Function Test (PFT) or Asthma-Control Test (ACT) is included for ongoing evaluation to assess the asthmatics lung function, efficacy in pharmacological treatment, prevention of reduced lung capacity, and permanent loss of lung function.  New Hampshire has over 100,000 people diagnosed with asthma, and asthma accounts for an approximate 4,000 emergency room visits per year (State of New Hampshire, Department of Health and Human Services, Division of Public Health Services, Bureau of Public Health Protection, Healthy Homes and Environments Section, Asthma Control Program, 2019).

Tracking these six measures and meeting or achieving the stated goal(s) aligns with providing quality healthcare – and the goal is to improve outcomes, reduce healthcare costs, and promote overall longevity and quality of life.

The six metrics (above) that have been identified by NSG 601 Module 5 Discussion Rivier University for use in nurse practitioner performance evaluation include:

1. Obesity
   1. Current weight & BMI
   2. Goal: 90% of all face-to-face visit notes
   3. USPSTF Screening Recommendation: B
2. Blood Pressure
   1. Elevations in blood pressure above 140/90 are to be rechecked in the same visit
   2. Goal: 80%
   3. USPSTF Screening Recommendation: A
3. Tobacco/Vaping Screen
   1. Every positive screen to be addressed in the Assessment & Planning, to include cessation documentation
   2. Goal: 80%
   3. USPSTF Screening Recommendation: A
4. Mammograms
   1. Documentation of screening and/or discussion to all women 40 years old and older
   2. Goal: 80%
   3. USPSTF Screening Recommendation: B
5. Colorectal Screening
   1. Documentation of screening and/or discussion to all people 50 years old and older; or pending risk factors/family history at 45 years old and older
   2. Goal: 80%
   3. USPSTF Screening Recommendation: A, B, C
6. Asthma Diagnosis
   1. Annual PFTs or ACT Test (Questionnaire)
   2. Goal: 80%

Informatics in the current workplace, specifically through the Electronic Health Record (EHR), and when designed correctly, allows users to pool data across many fields, many of which can be used in identifying goal attainment (Ogrinc, MD, MS, Headrick, MD, MS, FACP, Barton, PhD, RN, FAAN, ANEF, Dolansky, PhD, RN, FAAN, & Miltner, PhD, RN, CNL, NEA-BC, 2018, p. 71) as stated in NSG 601 Module 5 Discussion Rivier University.  For example, in the identified measures data can be accessed through the EHR to identify documented blood pressures greater than 140/90, and then further filtered to identify how many of those patients had a repeat blood pressure during the same visit.

The structural measures that are utilized here for evaluating the identified measures are through the EHR system currently in use.  Because there are many systems available for outpatient clinics, adopting a specific EHR system must take into consideration security of data, customer support, and the available features that the clinic will utilize and/or develop for customization.

According to NSG 601 Module 5 Discussion Rivier University, the process measures outlined above are the steps that the clinician will take to obtain the data.  For example, obtaining a person’s weight and calculating their BMI allows the clinician to identify their weight class as “normal” or within a range of obesity classes.  However, what is not depicted here is the expectation that the clinician understands the health risks associated with obesity and not just identifies the risk but addresses the risk with the patient and collaborates on a plan to reduce their weight and therefore their risk factors for negative health outcomes.  There would be no value here if the only goal is to capture the data and postpone interventions (Ogrinc, MD, MS, Headrick, MD, MS, FACP, Barton, PhD, RN, FAAN, ANEF, Dolansky, PhD, RN, FAAN, & Miltner, PhD, RN, CNL, NEA-BC, 2018, p. 71).

The outcome measures are defined as meeting the stated goals identified above, and again not depicted here is the expectation of implementing an intervention to improve outcomes.  For example, identifying a patient as one who could benefit from Colorectal Screening is not enough – documenting the discussion should follow with a referral for a colonoscopy or provide the answer to why a referral is not generated, (i.e., the patient already had the screening, or the patient declines the screening).

References

Ogrinc, MD, MS, G. S., Headrick, MD, MS, FACP, L. A., Barton, PhD, RN, FAAN, ANEF, A. J., Dolansky, PhD, RN, FAAN, M. A., & Miltner, PhD, RN, CNL, NEA-BC, R. S. (2018). Fundamentals of health care improvements: a gued to improving your patient’s care (3rd ed.). Joint Commission Recources.

State of New Hampshire, Department of Health and Human Services, Division of Public Health Services, Bureau of Public Health Protection, Healthy Homes and Environments Section, Asthma Control Program. (2019). New Hampshire Asthma Burden Report.

United Preventative Task Force. (2021, October 06). Published Recommendations. Retrieved from U.S. Preventative Task Force: https://uspreventiveservicestaskforce.org/uspstf/