Explore Health Quality Catalyst Insights

Explore Health Quality Catalyst Insights

Analysis and Quality Improvement Initiative Proposal

Hospital systems are facing a number of pressing problems to include dwindling cash flows, delays in patient discharge, hospital acquired infections, preventable medical errors, clinical variation and so on. The hospital systems need to constantly innovative in order to address these problems with a focus on ensuring that there is a return on investment. While many definitions can be offered for the concept of quality improvement in health care systems, an underlying definition is that it concerned continuous and systematic actions that result in measurable improvements in the delivery of medical care as well as health status of targeted patient populations. For a quality improvement initiative to be successful even as it moves forward, it must have a roadmap to act as a guide in its application (Schmidt & Brown, 2019). The present paper focuses on helping a health system in evaluating, identifying, prioritizing and succeeding in tackling a quality improvement project. It presents the combination of methods, analytics and evidence to help the improvement team to transform health care while improving the bottom line and quality of care delivered to the patients being served. As a result, the present proposal seeks to offer a roadmap to use analytics, adoption and best practice to drive outcomes improvement.Explore Health Quality  Catalyst Insights

Data analysis to identify area of concern

Bethesda Hospital is an acute long-term care and teaching hospital facility that is located in Saint Paul, Minnesota. It provides medical care to patients whose injuries and illnesses have long term effects. In fact, it prides itself in being a specialty, family-focused medical facility that offers services specifically designed to treat patients with complex care needs who require hospital level, long-term care with daily involvement by nurses and physicians. It offers 24-hour physician services alongside an extensive range of inpatient recreational, respiratory, speech, occupational and physical therapies. The facility focuses on supporting patients and their families in the recovery process with respect to the attention and respect they deserve. Every year, the facility handles more than 1,000 patients who are subjected to customized therapy programs intended to promote independence (Fairview Health Services, 2019).

A review of medical records for Bethesda Hospital reveals patient care quality concerns. Data on patient falls with major injuries for long-staying patients at the facility reveals some worrying trends. In 2013, the facility reported a fall percentage rate at 0.88%. The data moved to 0.9% in 2014, 0.85% in 2015, 0.88% in 2016, and 0.86% in 2017. A review of the data reveals that while the facility’s performance has remained consistent, the figures are high thereby indicating low quality nursing care that exposes the patients to high fall rates. Further analysis of the presented data reveals that the State of Minnesota performs better than the facility while the national figures have better performance than the state figures (see Table 1). The presented data offers opportunities for improving performance through making quality changes in nursing care delivery (Agency for Healthcare Research and Quality, 2020).

Table 1. Long-stay patients experiencing one or more falls with major injury for Bethesda Hospital, Minnesota State and National for falls with major injury, 2013-2017


  2013 2014 2015 2016 2017 Average
Bethesda Hospital (%) 0.88 0.9 0.85 0.88 0.86 0.874
Minnesota State (%) 0.85 0.88 0.81 0.85 0.84 0.846
National/Federal (%) 0.6 0.62 0.61 0.66 0.6 0.618


Quality improvement initiative supporting data analysis

As earlier indicated, Bethesda Hospital performed worse than the state and national average for falls with major injury among long-stay patients. For the five years under review (from 2013 to 2017), the average performance of Bethesda Hospital was 0.874%, while Minnesota State average was 0.846% and national average was 0.618% (see Figure 1).Explore Health Quality  Catalyst Insights

Bethesda Hospital is aware of the patient falls concerns and has implemented a falls management program targeted at reducing the falls incidences. The program adopts an interdisciplinary quality improvement initiative that is designed to provide person-centered, individualized care while improving fall care processes and outcomes. The program is presented in four sections. The first section presents a protocol concerned with fall responses, noting that previous history of a fall is the best individual of a future fall incidence. A review of the facility data revealed that 35% of the patients who experience falls are likely to have a fall reoccurring at a future data. This awareness helps the medical personnel to respond effectively and quickly after the fall. This section also presents an eight-step fall response plan (Helming, Shields & Avino, 2020). The second section presents a data collection and analysis plan that leverages informatics tools to facilitate tracking of fall incidences and indicators while identifying opportunities for improving performance. The measurement system helps the facility to determine the specific changes in care that lead to improvements. Some of the key indicators that act as best markers of improvement include the number of fall incidences, the number of patients who fall, the number of patients who fall multiple times, circumstances of the falls, and number of falls that result in serious injuries. The third section is concerned with long-term management to include managing the different levels of risk, grouping the patients based on fall risks, screening processes, falls assessment, fall interventions plan, and falls intervention monitor. The final section is concerned with environment and equipment safety, which is concerned with equipment inspections, engineer inspections, nursing inspections, and living space inspections. This also includes inspection of the patients’ footwear and feet, wheelchairs, walkers, canes, bathrooms, and resident rooms (Helming, Shields & Avino, 2020).

Although the patient falls management program helps in keeping the fall incidences low by allowing for improvements, it is faulted for adopting reactive strategies. The reactive strategies are in response to identifiable sets of circumstances/conditions. They bring about immediate behavioral changes to establish control over the health care situation so that the risks associated with falls are eradicated or minimized. Given this awareness, the quality improvement proposal is made for a proactive strategy to be incorporated into the reactive program (Raingruber, 2017). The proposal is for the inclusion of a section on information and training for patients, families and medical personnel. This would involve training the medical personnel, offering information to medical personnel, and offering information to patients and their families. Training medical personnel would provide training sessions for all medical personnel to understand why falls over, importance of reducing falls, and reducing fall incidences. This would allow the medical personnel to develop an awareness of specific strategies for reducing fall risks and how they can be applied to individual patients. Also, this would enable nurses to coordinate fall prevention and responses. Providing information for medical personnel would identifying what information medical personnel would need with regards to patient falls to include the key indicators and benchmarks. Providing information to patients and families would be targeted at describing the program for reducing fall risks, informing them about fall risks and causes of falls, and allowing them to participate in fall intervention and prevention (Helming, Shields & Avino, 2020). Unlike the reactive strategies applied by the facility, the proactive approach would be appreciated for avoiding and preventing falls from occurring as they are introduced before falls occur and help to reduce the chances of falls occurring (Raingruber, 2017).

Integrating interprofessional perspectives

The proposed quality improvement project is intended to reduce fall incidences while improving recovery after falls thereby taking on an implementer perspective with the tools at the foreground and placing stakeholders in the background. While the quality improvement project would be expected as a core work, it would traditionally have been based on technical and medical innovations, and mainly driven by nurses based on nursing care logic. However, this would increase the project complexity and not allow the project to be facility-related thereby reducing the chances of the project succeeding as intended. The reality is that the project involves different and often competing logics as perceived by the different medical professions. Taking on an implementer perspective that ignores the other medical professions would result in their perspectives missing from the project while they take on a passive role or act as resisters. This would in turn result in their capacity being misunderstood thus increasing opportunities for failure. The inability of the proposed project to be adequate, owing to its dynamics and complexity, implies that the perspectives of other medical professions becomes even more important (Fawcett, 2016).

Understanding the perspectives of other medical personnel on the project involves developing an understanding of what influences their actions concerning the project. Applying professional logics as manifested through the different medical professions shows that the diverse professional knowledge and judgments that different medical professions present help to guide and steer the project towards the desired outcome. The perspectives of the different professions imply taking the many health professions at the facility into consideration since they have greater professional belonging than facility belonging. Also, it would ensure that the different professions do not feel threatened, and feel that their identities are understood and appreciated. Failing to integrate interprofessional perspectives into the project would result in the different medical professions causing problems, challenges and resistance in the project (McEwen & Wills, 2018).Explore Health Quality  Catalyst Insights

The present project will ensure that interprofessional perspectives are integrated into the project by first collecting interprofessional perspectives through interviews, surveys and comments from key persons. The collected information would then be synthesized for themes that would then be incorporated into the strategies adopted by the project. Overall, there is an expectation that integrating interprofessional perspectives will be a significant catalyst to positive advancement in the research, as it allows access to resources so that more meaningful and complex solutions are presented (Renpinning, Gebhardt-Taylor & Pickens, 2016).


Effective communication strategies

Care quality is best improvement when the different medical professions work in collaboration to share their unique perspectives on patient care. Each medical profession enters into practice with different professional identifies, knowledge and skill sets to enhance patient care. Through incorporating the different professional perspectives, a team-based approach can be adopted. For the proposed project, SBAR (an acronym for Situation, Background, Assessment and Recommendation) has been presented as an appropriate communication strategy. This is a structured communication tools that clarifies communications with written information on recommended actions and urgency of the action. SBAR is a standard handoff communication structure that acts as a framework for structuring interprofessional communications about situations that require attention. The SBAR format offers a structured format for presenting information in a succinct and logical sequence that is concise and easy to use. In addition, the format helps in creating a shared mental model around a situation so that every person has the same understanding of the situation even as the different communication styles are bridged. SBAR is considered appropriate since it is a widely applied communication tool thereby ensuring that there would be good uptake and consistent use of the tool in the project (Truglio-Londrigan & Lewenson, 2018).

Besides that, the facility has adopted the use of electronic medical records (EMR) and SBAR leverages this capability. EMR focuses on improving patient care through transparent and accurate documentation. Integrating SBAR with the EMR will be associated with complete documentation of critical patient fall events and an increase in documentation of notification from attending medical personnel. In addition, the use of SBAR would support efforts to improve patient safety as intended by the proposed quality improvement project. That is because its integration significantly improves working conditions, job satisfaction, safety climate and teamwork climate (Black, 2016).

The reality is that Bethesda Hospital receives patient with complex needs that are managed by an interprofessional team. Communication among members of the team should be concise, clear and consistent to ensure that they all have a good awareness of each case information. In using SBAR, common language among the team members would be supported while promoting shared conflict resolution and decision making among the team members, which would likely improve care outcomes and patient satisfaction. Also, it results in shorter review times for cases during interprofessional rounds since it organization clinical information while providing cues on what needs to be communicated to the team members (Stanley, 2017).Explore Health Quality  Catalyst Insights


One must accept that quality improvement projects present important opprotunities for addressing clinical problems facing a health care system through innovative practices. In addition, one must acknowledge that as an acute long-term care and teaching hospital facility, Bethesda Hospital faces concerns about patient falls thereby acting as a quality improvement opportunity. The facility has a higher falls rate (0.874%) than Minnesota State (0.846%) and the nation (0.618%). A significant aspect of the concern at the facility is that it has adopted a reactive falls management program that includes protocols for fall responses, a data collection and analysis plan, long-term management, and environment and equipment safety. The quality improvement project proposes that a proactive approach be adopted by including a section on information and training for patients, families and medical personnel. Besides that, SBAR tool should be adopted to support interprofessional communication efforts for the project.


Agency for Healthcare Research and Quality (2020). Table 3_7_1_4_1.2 Long-stay nursing home patients experiencing one or more falls with major injury, by State, 2013-2017. https://nhqrnet.ahrq.gov/inhqrdr/data/submit

Black, B. (2016). Professional Nursing: Concepts & Challenges. Elsevier Health Sciences.

Fairview Health Services (2019). About Bethesda Hospital. https://www.fairview.org/locations/bethesda-hospital/about-us

Fawcett, J. (2016). Applying Conceptual Models of Nursing: Quality Improvement, Research, and Practice. Springer Publishing Company.

Helming, M., Shields, D., & Avino, K. (2020). Dossey & Keegan’s Holistic Nursing: A Handbook for Practice (8th ed.). Jones & Bartlett Learning, LLC.

McEwen, M., & Wills, E. (2018). Theoretical Basis for Nursing (5th ed.). Wolters Kluwer.

Raingruber, B. (2017). Contemporary Health Promotion in Nursing Practice (2nd ed.). Jones & Bartlett Learning, LLC.

Renpinning, K., Gebhardt-Taylor, S., & Pickens, J. (2016). Foundations of Professional Nursing: Care of Self and Others. Springer Publishing Company.

Schmidt, N., & Brown, J. (2019). Evidence-Based Practice for Nurses: Appraisal and Application of Research (4th ed.). Jones & Bartlett Learning, LLC.

Stanley, D. (2017). Clinical Leadership in Nursing and Healthcare: Values into Action (2nd ed.). John Wiley & Sons, Ltd.

Truglio-Londrigan, M., & Lewenson, S. (Eds.) (2018). Public Health Nursing: Practicing Population-Based Care (3rd ed.). Jones & Bartlett Learning, LLC. Explore Health Quality  Catalyst Insights