A Quality Framework for Improving System Performance in Health Care - Essay Example

Running Header: QUALITY ISSUES Student’s name: Instructor’s name: Course title: Date of Submission: Quality issues Introduction The process of health service delivery requires a guaranteed quality engagement. Quality assurance and customer satisfaction is an important and integral part of any sector more so the health sector since it deals with human life. Human life is valuable and can not be subject to unproven medical practices. A positive response in regards to patients’ hospital experience is an important index for rating the level of service offered which can allow prospective patient to make informed and objective comparison. Health delivery is a critical sector for the overall development of a nation. In the past years, there has been a silent concern by the Australian public about access to treatment in the public hospitals. The turning point was on that fateful evening of 25th September 2009 which affirmed the not uncommon occurrence. The occurrence highlighted the harrowing experience the public undergo while seeking medical treatment. Specifically was the touching story of Jana Horska and further confirmation by NSW health. Lastly, the needs for reforms were necessitated by the Vanessa Anderson case of 24th January 2008 and the parliamentary inquiry according to (Garling, 2008a). The approach This paper examines how to develop a quality framework for improving system performance in health care by identifying the key improvement activities within health care. This paper is divided in to two sections, section A and B. It goes deeper to discuss how the quality issue of concern was identified and why improvement is required. The first section deals with how to identify and provide an outline of an issue of concern in author’s workplace (Bankstown- lidcombe hospital) that requires a quality improvement (QI) initiative to be implemented. The section will provide evidence to support the choice of this issue for a quality improvement initiative. Lastly, the last section entails developing a proposal for a small pilot quality improvement project. This is achieved through describing in detail the process to be used to design, implement and evaluate the effectiveness of this quality initiative The work place/ Hospital and its clinical services Bankstown-Lidcombe Hospital (often referred to as Bankstown hospital) is a 433 bed principal referral hospital. The hospital has been designed to offer quality care in modern, purpose-built facilities. They aim to provide quality services to our consumers by being keen to work with clients and their families to achieve the best possible outcomes. The Hospital offers great opportunities for professional development and advancement. They attempt to foster improvement and innovation by seeking to attract clinicians (nursing, allied health and medical) who share on their vision and values and believe that they can participate in advancing their objectives. The hospital has teaching and research links to the University of New South Wales, University of Sydney and University of Western Sydney, offering supervised undergraduate placements and encouraging recruitment of motivated new graduates (nsw.gov.au). Lastly, the Hospital is accredited with the Australian Council on Healthcare Standards (myhospitals.gov.au). The hospital has 433 beds. It offers a range of admitted patient and outpatient services. The hospital has eight operating rooms and two procedure rooms, six birthing rooms as well as a family-centered birthing room. The hospital offers the following services: aged care assessment, aged care psychiatry, physical rehabilitation for the aged, stroke unit, nutrition & dietetics, occupational therapy, orthoptics (eye clinic), podiatry , physiotherapy, social work, speech pathology, cancer centre, intensive care / high dependency unit, emergency services, rapid response service, medical assessment unit (MAU), diagnostic services, drug & alcohol services, ambulatory care, mental health, outpatient (clinic) services, surgical services, day surgery, maternity services, baby photographic services and pediatric services (nsw.gov.au). Part A: concern in Bankstown- lidcombe Hospital This section identifies and provides an outline of an issue of concern in (Bankstown- lidcombe Hospital) that requires a quality improvement (QI) initiative to be implemented. It further discusses how the quality issue of concern was identified and why improvement is required by providing evidence to support the choice of this issue for a quality improvement initiative. Aged health care Current situation at the hospital The hospital has a number of services for aged care clients. There is a 20 bed ward for elderly patients who have acute medical conditions (ward 2c) and a 20 bed unit specializing in aged psychiatry (ward 2d). The aged psychiatry service also provides community based services. The aged care assessment team provides assessment, information advice and assistance to older people who want to remain at home or who are thinking about moving into a hostel or nursing home (nsw.gov.au). The first service offered is the aged care assessment service by team which is located in the aged care / allied health building. The team supports carers, general practitioners and other primary care providers in looking after the frail and disabled aged people. The services include: assessment of clients in their homes by health professionals, organization of community support services, rehabilitation (this may be in the hospital, home or residential facility), assistance with continence problems, long term loan of equipment to pensioners, low income people and war veterans, assistance with home modifications when necessary, frail aged day care – social activities for frail and disabled aged who are socially isolated, information on nursing homes and hostels, arrangement of respite care for aged and disabled people, aged care psychiatry (nsw.gov.au). The second service offered relates to the aged care psychiatry. The service has four components: inpatient service – ward 2d consists of 12 aged care psychiatry beds and 8 medical beds. The unit is specifically designed to accommodate cognitively impaired elderly or frail patients who require intervention for their behavior or who require psychiatric assessment and management in general. The unit is also suitable for managing on a voluntary basis; frail and or elderly people who have a psychiatric disorder, but are not cognitively impaired. In addition to the above, the other services offered include: aged care psychiatry consultation liaison service, outpatient service, community team outreach service (nsw.gov.au). The third service related to aged health care is rehabilitation. The rehabilitation unit (ward 2a) aims to assist patients to achieve the highest possible level of independence physically, psychologically and socially after loss of function or ability due to disease or injury. The rehabilitation team includes a range of staff including, medical, physiotherapy, nursing, social work, dietetics, occupational therapy, speech pathology and community services. Lastly, is the stroke unit, the stroke unit is located in ward 2b of the hospital. In partnership with community staff, local government agencies and other organizations, the unit strives to provide quality care to stroke affected people and their families. Staffs in the unit use the latest techniques and treatments to enable patients to achieve optimal health and quality of life within their own environment. Stroke rehabilitation commences on the day of admission and involves a continuum of care from the acute to post-discharge stage (nsw.gov.au). The projected situation The hospital in a great deal tried to enhance medical services related to aged health care, but more effort is still required to spruce up the perfection to match current dynamics in aged health care. With ageing, majority of senior citizens are prone to opportunistic and chronic infections. This is affirmed by the fact that 3% of Australian populations have complex chronic disease and that one-third of total hospital visits are by those above 65 years (Garling 2008) and that there will be a 50% increase in over 5 years in the number of persons aged 85 presenting to an emergency department (Garling 2008). This calls for proper planning, co-ordination and management, through better co-ordination and treatment of these patients within the hospital system or treating them outside the hospital environment. The various issues pertaining to aged care includes; cognitive impairment, malnutrition of older adults in hospital, adverse events and morbidity in older adults in hospital, advocacy in the acute care setting for vulnerable and frail older adults and chronic, complex and elderly patients and coordination of care as stated by Garling (2008). In this section, I will particularly focus on cognitive impairment and malnutrition of older adults in hospital. Cognitive impairment of older adults With advancement in age people become more vulnerable to cognitive impairment with a doubling of prevalence every 5 years (Rait et al, 2004). Dementia forms the most common cause of cognitive impairment that is defined as significant memory impairment and loss of intellectual functions; it interferes with patients’ work, normal social activities and relationship with others. (Gonzalez-Gross, Marcos and Pietrzik, 2001). The disease is costly and can represent a greater health problem to an ageing nation or society (Laurin et al, 2009). As noted by Garling (2008a) being in the hospital and leading a sedentary life leads to muscle wasting and loss of cognition power, this is affirmed by Ohayon and Vecchierini (2002) that there is a relationship between excessive daytime sleeping and cognitive deficits. Garling commission reported that, elderly sicknesses were related to co-morbidity, complexity, lack of physiological and functional reserve and a propensity for illness to be manifest in characteristic ways. Such include immobility, incontinency, instability and impaired intellect or memory. The disease can be controlled by engaging the elderly in physical activities which has been found to be productive in reducing the level of impairment. Lautenschlager (2008), notes that a six month program of physical activity provided a significant improvement. Further to help alleviate pain for those elderly people with cognition impairment; early and proper pain detection should be applied through pain awareness, pain inquiry, pain description and location (Royal College of Physicians, 2007). Finally reducing the days of admission at hospital is significant since there are no organized social activities as compared to home. This can be achieved through implementation of hospital at home concept (Garling, 2008a). The above fear is attested and affirmed by Laurin (2007), Ohayon and Vecchierini (2002) that regular physical activity can form protective front for cognitive decline. Malnutrition of older adults in hospital While everyone is vulnerable to malnutrition, certain fractions of the population are more prone including the elderly. The major cause of malnutrition to the elderly can be noted as social economic and clinical (European nutrition for health alliance, 2005). The prevalence in geriatric hospital has been proved to have a prevalence rate of 30% to 60 %. The most contributing factors are depression, infections, sarcopaenia, falls, fractures, reduced autonomy and increased mortality (Gazzotti et al, 2011). Nutritional requirements changes with increase in age, energy requirements slow down with advancement in age thus this should be compensated with sufficient intake of other nutrients (Beck et al, 2009). The most prevalent under nutrition for the hospitalized geriatric populations is the protein – energy cases (Gazzotti et al, 2011). Patients who are malnourished usual take longer to recover, requires more medication and usually suffers. In addition it is reported that that people with gastrointestinal, respiratory and neurological disease related malnutrition have a 6% higher general practitioner consultation rate, are written 9% more prescriptions, and have a 26% higher hospital admission rate than people who are well nourished (Visvanathan, Newbury & Chapman, 2007). Malnutrition in hospitals can be stopped through listening to aged, carers and the relatives; making all ward staff food aware; staff should follow their professions’ assessing malnutrition ethics and lastly having protected mealtime (Age concern, 2006). Parameters for concern identification It is reported that there is a 20 bed ward for elderly patients who have acute medical conditions (Ward 2C) and a 20 bed unit specializing in Aged Psychiatry (Ward 2D). The Aged Psychiatry Service also provides community based services. The Aged Care Assessment Team (ACAT) provides assessment, information advice and assistance to older people who want to remain at home or who are thinking about moving into a hostel or nursing home (nsw.gov.au). The above noted facility can be deemed to be inadequate in relation to the Garling report (2008a) which noted that with ageing, majority of senior citizens are prone to opportunistic and chronic infections. This is affirmed by the fact that 3% of Australian populations have complex chronic disease and that one-third of total hospital visits are by those above 65 years (Garling 2008a) and that there will be a 50% increase in over 5 years in the number of persons aged 85 presenting to an emergency department. Part B This section tries to develop a proposal for a small pilot quality improvement project. It describes in detail the process used to design, implement and evaluate the effectiveness of this quality initiative Proposal for a small pilot quality improvement project It has been noted that there is overwhelming of public hospitals by the population dynamics. An increase in number of elderly patients with chronic diseases that requires specialized treatments and longer stay at hospital has been noted with their visit standing at one-third of total visits. As a solution, wide ranging improvements like; patients’ need being paramount, review of doctors and nurses role by abolishing the rigidity as a measure to improving team work should be embraced (Garling, 2008). The need to improve team is necessitated by the need to improve clinical innovation and emergency agency, improving database management (Garling, 2008b). Lastly there is need to adopt new concepts like ‘model of care’, which is a consensus by professionals on best way approach (Garling, 2008b). The tools and indicator/ performance measures that will be used Competency and capability development A person or organization can acquire or instil leadership capability respectively through educational training in technical skills, interpersonal development and through personal reflection. Technical skills are ‘competencies’ associated with nursing. For example, these may include the ability to effectively plan and control operational activities, design processes, forecast, and monitor and achieve targets, determine appropriate layout and flow of operations, develop / deploy quality systems and apply appropriate tools, techniques and mechanisms for continuous improvement / performance excellence. Soft skills generally relate to the interpersonal skills such as cultural intelligence / awareness, engaging effectively with others in diverse teams, ‘active listening’, being able to conduct productive meetings, good time management, qualities associated with ‘deep and strategic’ thinking, leadership attributes including emotional intelligence, empathy, being able to influence others, being able to build networks and communicate effectively with others (Anderson et al, 2009). Personal reflection gives an insight into particular skills and competencies that a nurse perceive necessary for tackling operational challenges in today’s work environment and lessons learned from it (Ward, Barrat & Aston, 2009). Initiative to be implemented The steps to achieve them would be through; embracing information technology to develop health information system, improved training of clinical officers, bottom driven innovation & research and proper supervision of junior doctors (Garling, 2008b). Secondly improvement in ward handling to avoid further infections, note taking and concerted teamwork approach to treatment where there is an overall who is in charge (Garling, 2008b). Desires like shifting the discharge time and work force reforms by senior nurses relinquishing administrative functions to focus on their core functions, imparting the concept of being multidisciplinary, improving on clinical rosters and ward reorganization (Garling, 2008b). It is noted that the elderly faces unnecessary delays in discharge due their complex needs as noted by Garling (2008a). This should be hastened since having a sedentary life leads to muscle tone loss thus it can worsen rather than attain the intended benefits. To curtail this, the aged should be booked at nursing home or aged care facility (Garling, 2008). To support the above, investment in hospital in home programs should be paramount. The lack of aged care bed further contributes to longer waiting time and blocked access. This should be improved on (Garling, 2008a,). The finding which relates to special need exposed the fact that most nursing homes do not accept them leading to overstay in acute hospital bed thus12-week transitional placements in absence of aged care program is highly recommended. The other observation and recommendation relates to guardianship tribunal who viewed hospital as the safe environment and thus do not treat applications with urgency, thus the need to prioritize hearing for patients on urgent need. On the treating the elderly patient more smartly, better models of care need to be enshrined by pursuing clinical innovation and enhancement agency to identify patients who are likely to be impacted negatively by overstay in hospital. Apart from this, early planning should be commenced by aged care assessment team so as to hasten discharge (Garling, 2008a). In addition there is need to invest more in terms of training remuneration in geriatricians to help address workforce issues while not forgetting the nursing staff as noted that at some hospitals shortage is worse that they employ guards to nurse the elderly. Lastly, they noted there is need to increase the number of psycho geriatric bed and implementation of an electronic medical record to ease data management (Garling, 2008a). How the effectiveness of the project will be evaluated and communicated Adoption of survey of patients’ hospital experiences from HHS A positive response in regards to patients’ hospital experience is an important index for rating the level of service offered which can allow prospective patient to make informed and objective comparison. In order to formulate the design and initiative to be implemented, the process adopted US department of health and human services human health survey parameters such as: well communication by nurses, well communication by doctors, advancing of help when required by patients, proper control of pain, cleanliness in room and other service areas like bathroom and giving information on what to do during recovery at home (Department of health & human services, 2011). Conclusion Quality issues in human health service delivery are a paramount requirement especially in public hospitals in Australia who saw their ratings and trust in the public drop. All hospitals should encourage holistic quality improvement in their core functions and other related services. Quality improvement starts from the review of legal framework nationally, improvement in working for various medical staffs such as doctors, nurses and pharmacists. One critical observation is that with the growing of an ageing population and the need for redefined health care access and delivery this report was timely. As noted there has been disconnect especially relating to aged health care whereby little attention has been given. On the other hand the critical health stakeholders such as nurses have largely been neglected through understaffing and work overload, underpay, low morale amongst others yet they are integral part in the process of health service delivery. To try and correct and improve the problems, proper pay, increase in enrolment opportunities at training institutions, and improving working conditions are needed. Also, re absorption of those out of practice back to the profession should be given a priority. Lastly, the hospitals should strive to domesticate the Garling recommendations in order to help in realization of quality health care for all. The challenges noted that needed improvement were; the ever increasing medical costs, work force concerns such as doctors shortage, nursing demographical composition that noted 22% of the workforce are supposed to be retiring by 2011, in addition to majority being junior and thus lacking senior ones to mentor and supervise them (Garling, 2008). As a solution, wide ranging improvements like; patients’ need being paramount, review of doctors and nurses role by abolishing the rigidity as a measure to improving team work and clinical innovation (Garling, 2008b). References Age concern 2006, Hungry to be heard: the scandal of malnourished older people in hospital, Age concern, London. Amella EJ 2007, Assessing nutrition in older adults, issue No. 9. Anderson, D., Gardner, G., Ramsbotham, J., & Tones, M. 2009, E-portfolios: Developing nurse practitioner competence and capability. Australian Journal of Advanced Nursing, 26(4), 70-76, viewed on 21th October from: http://www.ajan.com.au/Vol26/26-4_Anderson.pdf. Australian Institute of Health and Welfare 2011, viewed on 22th October from: www.myhospitals.gov.au/hospital/bankstown-lidcombe-hospital/profile Beck et al 2009, appropriate use of oral nutritional supplements in older people: good practice examples and recommendations for practical implementation, SCC 945-01/09 Department of health & human services 2011, Hospital care: survey of patients’ hospital experiences. Viewed on 22th October from: http://www.hospitalcompare.hhs.gov/hospital- compare.aspx?hid=100128,100206&lat=27.950575&lng=- 82.45717760000002&stype=GENERAL&&stateSearched=FL Department of health, metropolitan NSW 2009, South Western Sydney local health district, Bankstown-Lidcombe Hospital 2009, viewed on 22nd October 2011from: http://www.sswahs.nsw.gov.au/bankstown/ European Nutrition for Health Alliance, August 2005, Malnutrition within an Ageing Population: A Call to Action. Garling P 2008a, Special commission of inquiry: acute care services in NSW public hospitals Volume 1, Sydney. Viewed on 22nd October 2011from: http://www.lawlink.nsw.gov.au/acsinquiry Garling P 2008b, Special commission of inquiry: acute care services in NSW public hospitals overview, Sydney, viewed on 22nd October 2011from: http://www.lawlink.nsw.gov.au/acsinquiry Gazzotti et al, 2003, Prevention of malnutrition in older people during and after hospitalization: results from a randomized control led clinical trial, Age and Ageing, Vol. 32 No. 3, pp. 45-67. Gonzalez-Gross M, Marcos A and Pietrzik K 2001, Nutritional and cognitive impairment in the elderly, British Journal of Nutrition (2001), Vol. 86, pp. 313–321. Herr K and Decker S 2004, older adults with severe cognitive impairment: assessment of pain, Annals of Long-Term Care: Clinical Care and Aging, Vol. 12, no. 4, pp. 46-52. Laurin D et al 2001, physical activity and risk of cognitive impairment and dementia in elderly persons, Arch Neurol, Vol 58, pp. 89. Lautenschlager et al 2008, Effect of physical activity on cognitive function in older adults in risk for Alzheimer disease. JAMA, September 3, 2008—Vol 300, No. 9 Lea j & Cruickshank MT, 2007, Rural and remote health, international electronic journal of rural and remote health research, education practice policy. Ohayon, M & Vecchierini, M 2002, daytime sleepiness and cognitive impairment in the elderly population, Arch Intern Med, Vol. 162, pp. 34-56. Rait et al 2005, Prevalence of cognitive impairment: results from the MRC trial of assessment and management of older people in the community, Age and Ageing, Vol. 34, pp. 242– 248 doi:10.1093/ageing/afi039 Royal college of physicians 2007, The assessment of pain in older people, viewed on 22th October from: http://www.britishpainsociety.org/book_pain_older_people.pdf Vishvanathan R, Newbury JW & Chapman I, 2004, Malnutrition in older people: screening and management strategies, Australian Family Physician, Vol. 33, No. 10, pp. 23-56. Ward H, Barrat J & Aston J 2009, Passing your advanced nursing OSCE: A guide to success in advanced clinical skills assessment, Oxon, Radclife publishing. Read More