Executive Summary on Inpatient Fall Healthcare Gap Analysis

Executive Summary on Inpatient Fall Healthcare Gap Analysis

Executive Summary

Healthcare professionals constantly try to enhance patient safety and quality of care in their organizations. Healthcare is founded on EBPs, and when a care gap is recognized in the facility, a multidisciplinary team must propose evidence-based transformation and execute an enhancement strategy (Braithwaite, 2018). This executive summary submits evidence-based interventions to tackle a healthcare gap that has affected inpatient fall aversion results.

Quality and Safety Outcomes

The fall rate is critical since it computes falls per unit period or patient population. The incident rate per 1000 PDs is the yardstick for assessing inpatient falls (Cuttler et al., 2017). These falls are costly, and the yardstick helps healthcare institutions evaluate the fall results. Further, fall-linked hospitalizations occur when these fall cause significant injuries that need hospitalization. When the tally of fall-associated healthcare facility admissions is trailed, intuitions on the effects of falls on client morbidity are discerned.

Strategic Value to the Institution

The inpatient fall rate is indicated in this metric as the perceived ratio of falls. For instance, 1.0 may demonstrate that falls are consistent with projections, while a figure greater than 1 demonstrates that the fall rate was adverse to the projections.

Moreover, these fall mirror system breakdowns in institutional procedures, frameworks, quality enhancement interventions, and procedures, and assessing them may enhance the facility’s safety culture. The facility’s safety culture is associated with patient outcomes, safety, and quality (Montejano-Lozoya et al., 2020).

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Healthcare organizations failing to measure fall rates can affect patient care. Some instant consequences of falls comprise pain and psychological and physical agony. In addition, prolonged hospital stays and loss of trust in healthcare are long-term impacts of falls. Notably, the multidisciplinary hospital team tackling this adverse occurrence may suffer from low quality of life and mental-related issues (Winning et al., 2018). Further, litigation, decreased professional belief, and social segregation affect these healthcare providers. Moreover, the health organization may suffer costs related to these falls. The falls have been clustered as non-reimbursement hospital-acquired situations by the Centers for Medicare and Medicaid Services. Thus, the hospital is compelled to encompass these costs in its cumulative loss. Also, the healthcare organization may experience a decrease in worker morale, causing personnel loss. Current outcome metrics offer data that guarantee the facility can fix the issue, enhance patient and worker welfare, and decrease expenses.

Relationship Between Care Delivery and Quality and Safety Results

According to my facility’s fall yardsticks, existing fall prevention and patient safety interventions are unsuccessful. Additionally, many components impact care delivery leading to negative results. For example, the coronavirus brought problems to the facility, leading to the overworking of scarce hospital personnel. This means there is a direct link between inpatient falls and nurse staffing. Further, burnout because of overworking may lead to a decline in the quality of care and patient safety. Due to this staff strain, the assessment procedure for quality and client safety interventions may have deteriorated. Also, adding specific metrics may help my facility create a complete image of fall results and reduce the rate and impact Executive Summary on Inpatient Fall Healthcare Gap Analysis.

Fall Rates Help Fall Interventions Linked to Safety and Quality Culture

The fall ratios presented in 2020 reaffirm the gains of my facility’s fall aversion interventions linked to the safety and quality culture of the institution. Further, my facility adopted Fall TIPS, a client-focused fall prevention tool kit, in mid-2019, and an all-inclusive training started in September (Dykes et al., 2017). Fall TIPS was executed in all facility divisions at the beginning of 2020, with fall metrics being trailed for consistency and progression. The QI intervention led to a 35% decrease in documented inpatient falls by mid-2020. Further, the remaining half of 2020 was plagued by increased falls due to the pandemic strains. Additional evaluation of the existing fall intervention recognized initiatives that improve patient quality and safety. Further, among the appropriate results is the instigation of a committee that will coordinate backdated assessments of existing fall rates. Evaluating near-miss events, guaranteeing the steadiness of fall evaluation components, and encompassing multidisciplinary lineups in Fall TIPS will help to enhance client safety and fall rate quality.

Additionally, client-centred metrics positioned with healthcare professionals’ goals may promote a quality and safety culture. The capability to give safe, high-quality care needs a healthy work-life balance. Further, embracing evidence-based safety initiatives can positively impact client outcomes, worker confidence, and workplace morale. People and institutions are appreciated for their role to fall interventions, strengthening the common duty for client safety.

Notably, my facility’s strategic plan may become irrelevant because of the existing nurse shortage and burnout. The hospital must observe the positive results recorded during the first half of 2020 before the pandemic and use them to close this gap. The existing intervention to tackle these falls is sufficient and may be amplified and transformed later. However, the facility must ensure that it has adequate staff members to avoid issues related to burnout and staff turnover. Employing more nurses means that there will be a massive pool of individuals who will assist each other in minimizing the issue of inpatient falls. Even though nurses will get help from IT department personnel regarding video monitoring, it is prudent for the facility to work on the nurse shortage.

Leadership Function in Executing and Sustaining the Proposed Transformations

Video monitoring and evidence-based educational program will aid in reducing inpatient fall in the facility. This education will encompass non-hospital personnel like family members, meaning leadership is needed. Every team must have a leader who will coordinate training and education. The leadership will offer coaching and guidance to the multidisciplinary team encompassed in the execution. By providing direction and help, the leaders assist these people in learning about the issue, building their expertise in handling it and feeling certified to embrace the changes. Further, implementing the changes requires resources, and the leadership will secure critical resources. Ensuring that the execution team has these resources means embracing the transformation becomes easy. The leadership will also supervise and assess outcomes frequently. This means the facility leadership must possess data collection mechanisms that will assist in recognizing areas of enhancement. Furthermore, having a nurse-led committee conducting weekly examinations of fall rates will help give updated and pertinent data to all facility employees. Lastly, leadership will assist in communicating the rationale and goal of change. Without articulating the goal, the transformation may fail (Men et al., 2020). Thus, leaders must ensure everyone on the multidisciplinary team comprehends the significance and aim of the transformation Executive Summary on Inpatient Fall Healthcare Gap Analysis.

In conclusion, facilities must embrace strategies that improve safety and quality. Employees and patients must be safeguarded from any dangers that may lead to reduced quality of life or even mortality. Any current gaps, like inpatient gaps, must be tackled using evidence-based practice. Using a multidisciplinary team can improve safety and quality outcomes, leading to an improved facility culture.

References

Braithwaite, J. (2018). Changing how we think about healthcare improvement. 
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Cuttler, S. J., Barr-Walker, J., & Cuttler, L. (2017). Reducing medical-surgical inpatient falls and injuries with videos, icons and alarms. 
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(2), e000119.

Dykes, P. C., Duckworth, M., Cunningham, S., Dubois, S., Driscoll, M., Feliciano, Z., … & Scanlan, M. (2017). Pilot testing fall TIPS (tailoring interventions for patient safety): a patient-centered fall prevention toolkit. 
The Joint Commission Journal on Quality and Patient Safety
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43
(8), 403-413.

Men, L. R., Yue, C. A., & Liu, Y. (2020). “Vision, passion, and care:” The impact of charismatic executive leadership communication on employee trust and support for organizational change. 
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(3), 101927 Executive Summary on Inpatient Fall Healthcare Gap Analysis.

Montejano-Lozoya, R., Miguel-Montoya, I., Gea-Caballero, V., Mármol-López, M. I., Ruíz-Hontangas, A., & Ortí-Lucas, R. (2020). Impact of nurses’ intervention in the prevention of falls in hospitalized patients. 
International Journal of Environmental Research and Public Health
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(17), 6048.

Winning, A. M., Merandi, J. M., Lewe, D., Stepney, L. M., Liao, N. N., Fortney, C. A., & Gerhardt, C. A. (2018). The emotional impact of errors or adverse events on healthcare providers in the NICU: the protective role of coworker support. 
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Executive Summary on Inpatient Fall Healthcare Gap Analysis

Write an executive summary, 4-5 pages in length, of existing outcome measures related to a performance issue uncovered in your gap analysis that you intend to address.

Introduction

Note: Each assessment in this course builds on the work you completed in the previous assessment. Therefore, you must complete the assessments in this course in the order in which they are presented.

As a nurse leader, you must be able to access, identify, and describe outcome measures as they relate to safety and quality problems in your organization.

This assessment provides an opportunity to examine existing outcome measures, assess their strategic value, and present your findings to executive leaders in a manner that will help you gain their support.

Quality and safety are everyone’s responsibility as a team of interprofessional care delivery partners. Together we develop policies that support quality and safe care delivery. As part of the interprofessional team, nurses are leaders in care and thus are responsible and accountable for leading and providing safe quality care.

Health care delivery is structured around evidenced-based information. Quality is defined by exploring proven, evidenced-based information. After reviewing and defining evidenced-based information, the interprofessional team applies this knowledge to assess the organization’s or the practice setting’s ability to provide evidenced-based care delivery. When a gap in care is identified, it is important to propose an evidenced-based change and to execute a plan for improved care.

Your summary of relevant outcome measures is based on your findings from the quality and safety gap analysis you completed in the previous assessment.

Preparation

Your analysis of the gap between current and desired performance was the first step toward improving outcomes. You now have the information you need to move forward with proposed changes. Your next step is to focus on existing outcome measures and their relationship to the systemic problem you are addressing. For this assessment, you have been asked to draft a summary of existing outcome measures for your organization’s executive team to raise awareness of the problem and the strategic value of existing measures.

Note: As you revise your Executive Summary on Inpatient Fall Healthcare Gap Analysis writing, check out the resources listed on the Writing Center’s Writing Support page.

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

Building stakeholder support is crucial to fostering and sustaining change. Therefore, as you approach this assessment, think about the stakeholders whose support you will need for the change you want to bring about.

What information is most essential for both the formal and informal stakeholders to understand about the proposed change?

How might you communicate the need for change using just a few sentences (this is often referred to as an “elevator speech”).

The following resources are required to complete the assessment.

APA Style Paper Tutorial [DOCX]. Use this for your executive summary.

Requirements

Note: The requirements outlined below correspond to the grading criteria in the Executive Summary Scoring Guide. Be sure that your written analysis addresses each point, at a minimum. You may also want to read the Executive Summary Scoring Guide and Guiding Questions: Executive Summary [DOCX] to better understand how each criterion will be assessed.

Composing the Executive Summary

Explain key quality and safety outcomes.

Determine the strategic value to an organization of specific outcome measures.

Analyze the relationships between a systemic problem in your organization or practice setting and specific quality and safety outcomes.

Determine how specific outcome measures support strategic initiatives related to a quality and safety culture.

Determine how the leadership team would support the implementation and adoption of proposed practice changes affecting specific outcomes.

Writing and Supporting Evidence

Write clearly and concisely, using correct grammar and mechanics.

Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style.

Additional Requirements

Format your document using APA style.

Use the APA Style Paper Tutorial [DOCX]. Be sure to include:

A title page and reference page. An abstract is not required.

A running head on all pages.

Appropriate section headings.

Properly-formatted citations and references.

Your Executive Summary on Inpatient Fall Healthcare Gap Analysis should be 4- 5 pages in length, not including the title page and reference page.

Portfolio Prompt: You may choose to save your executive summary to your ePortfolio.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

Competency 1: Analyze quality and safety outcomes from an administrative and systems perspective.

Explain key quality and safety outcomes.

Analyze the relationships between a systemic problem in an organization and specific quality and safety outcomes.

Competency 2: Determine how outcome measures promote quality and safety processes within an organization.

Determine how specific outcome measures support strategic initiatives related to a quality and safety culture.

Competency 3: Determine how specific organizational functions, policies, processes, procedures, norms, and behaviors can be used to build reliability and high-performing organizations.

Determine the strategic value to an organization of specific outcome measures.

Competency 4: Synthesize the various aspects of the nurse leader’s role in developing, promoting, and sustaining a culture of quality and safety.

Determine how a leadership team would support the implementation and adoption of proposed practice changes affecting specific outcomes.

Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.

Write Executive Summary on Inpatient Fall Healthcare Gap Analysis clearly and concisely, using correct grammar and mechanics.

Integrate relevant and credible sources of evidence to support assertions, correctly formatting citations and references using APA style