Performance Improvement Theory And Models NUR630
Topic 3 DQ 1
Your unit data reflect an upward trend in blood administration errors. Is this likely an individual failure or a system failure? Which performance improvement theory or model would you use to address it?
Sample Topic 3 DQ 1
In the healthcare industry, blood transfusions are a common practice that can save lives. However, administering blood products to patients is not without risks. Blood administration errors are a serious issue that can lead to adverse outcomes for patients. Despite strict protocols and guidelines in place, if I saw an upward trend in blood administration errors I would do an investigation. It’s hard to say if I think it would be an individual failure or a systems failure right off the bat.
The distinction between individual failure and system failure is crucial when considering performance improvement theories and models. Individual failure refers to instances where an individual’s actions or decisions lead to a negative outcome, while system failure refers to flaws in the larger system that lead to negative outcomes regardless of the actions of individual members. It is important to note that these two types of failures are not mutually exclusive; often, individual failures can be symptomatic of systemic issues.
There are many factors that contribute to individual failures such as lack of training, distractions, or fatigue. To investigate I would use performance improvement tools starting off with a root cause analysis (RCA). An RCA is a framework to discover any systemic issues to prevent another adverse event from happening (Percarpio et al., 2008).
The steps to a root cause analysis are: defining the problem, gathering data, identifying any factors that may have contributed, determining the root cause of the issue, and lastly recommending and adopting solutions. I would also employ a plan, do, study, act cycle to make sure the changes were implemented and upheld.
Percarpio, K. B., Watts, B. V., & Weeks, W. B. (2008). The effectiveness of root cause analysis: what does the literature tell us?. The Joint Commission Journal on Quality and Patient Safety, 34(7), 391-398. https://doi.org/10.1016/s1553-7250(08)34049-5
Topic 3 DQ 2
Select a problem that you have experienced or identified within your workplace or in a health care setting. What steps would you take to address the problem?
Topic 3 CLC – CLC Agreement
Assessment Description
This is a Collaborative Learning Community (CLC) assignment.
Meet with your instructor-assigned group to review the Topic 4 assignment and familiarize yourselves with the expectations for the project.
Fill out the attached “CLC Agreement” form and submit it to the instructor
Resources
Review Chapter 4 in Continuous Quality Improvement in Health Care.
2. Washington Manual of Patient Safety and Quality Improvement
Read Chapter 6 in Washington Manual of Patient Safety and Quality Improvement.
3. Performance Improvement: Stages, Steps and Tools
Explore the Performance Improvement: Stages, Steps and Tools page of the IntraHealth International website.
https://www.intrahealth.org/
4. Serious Reportable Events
Explore the Serious Reportable Events page located on the National Quality Forum website.
https://www.qualityforum.org/
5. Talking Quality: Reporting to Consumers on Health Care Quality
Explore the Talking Quality: Reporting to Consumers on Health Care Quality page of the Agency for Healthcare Research and Quality (AHRQ) website.
https://www.ahrq.gov/
6. Medicare Initiatives Improve Hospital Care, Patient Safety
Read “Medicare Initiatives Improve Hospital Care, Patient Safety,” by Conway, from The Hospitalist (2015).
7. Optimize Data Visualization to Improve Communication About Quality Improvement
Read “Optimize Data Visualization to Improve Communication About Quality Improvement,” by AHC Media, from Case Management Advisor (2019).
8. The Effectiveness of Continuous Quality Improvement for Developing Professional Practice and Improving Health Care Outcomes: A Systematic Review
Read “The Effectiveness of Continuous Quality Improvement for Developing Professional Practice and Improving Health Care Outcomes: A Systematic Review,” by Hill, Stephani, Sapple, and Clegg, from Implementation Science (2020).
9. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future)
Read “Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future)” by Classen, Munier, Verzier, Eldridge, Hunt, Metersky, Richards, Wang, Brady, Helwig, and Battles, from Journal of Patient Safety (2021).
10. A Primer on Data Visualization in Infection Prevention and Antimicrobial Stewardship
Read “A Primer on Data Visualization in Infection Prevention and Antimicrobial Stewardship,” by Salinas, Kritzman, Kobayashi, Edmond, Ince, and Diekema, from Infection Control and Hospital Epidemiology (2020).