Discussion
Purpose
The purpose of this discussion is for you to evaluate a National Practice Problem within the context of your practice problem idea and technology expansion within your healthcare setting.
Instructions
Select one leading National Practice Problem that is prevalent in your patient population or healthcare setting and address the following:
- Describe an issue related to the National Practice Problem you selected that is impacting quality, safety, or financial outcomes at your practice setting.
- Elaborate how technology such as the electronic medical record might assist in implementing, evaluating, or sustaining an evidence-based intervention to address the identified problem.
Please click on the following link to review the DNP Discussion Guidelines on the Student Resource Center program page:
Rubric
| Professionalism in Communication | Presents information using clear, concise language in organized manner (0-1 error patterns in English grammar, spelling, syntax, and punctuation). | Presents information using clear, concise language in organized manner (2-3 error patterns in English grammar, spelling, syntax, and punctuation). | Presents information using understandable language; information is not organized 4-5 error patterns in English grammar, spelling, syntax, and punctuation). | Presents information that is not clear, logical, professional, or organized; reader has difficulty understanding the post; 6 or more error patterns in English grammar, spelling, syntax, punctuation). |
Course Outcomes
This discussion enables the student to meet the following course outcomes:
- Use information technology to collect and analyze data to generate evidence-based nursing practice across healthcare settings. (PO 7)
- Design programs that monitor and evaluate outcomes of care, care systems, and quality improvement. (PO7)
- Evaluate the types of healthcare information systems, knowledge-based systems, and patient care technology and the impact on patient safety, quality of care, and outcome measurement. (PO 7)
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Please read the question carefully to understand all the components. Then respond in a scholarly manner following the Graduate Discussion Grading Guidelines and Rubric. Our interactive discussion addresses the following course outcomes:
CO 2: Use information technology to collect and analyze data to generate evidence-based nursing practice across healthcare settings. (PO7)
CO 3: Design programs that monitor and evaluate outcomes of care, care systems, and quality improvement. (PO7)
CO 4: Evaluate the types of healthcare information systems, knowledge-based systems, and patient care technology and the impact on patient safety, quality of care and outcome measurement. (PO 7)
Consider your own experiences as well as the literature.
I am looking forward to your discussions
Dr Herlihy
Lesson 1
Evidence-Based Practice: Improving Practice
Knowledge Access and Dissemination through Information Technology
Evidence-based practice (EBP) is widely endorsed by all health professions as essential to improving healthcare outcomes. Information technology plays a fundamental role in EBP by enabling healthcare providers to access and evaluate clinical evidence to inform patient care. Using information technology to support EBP is critical to improving the quality of care while maximizing patient safety and cost savings. With increasing demands to adhere to established clinical evidence and practice guidelines, healthcare organizations and providers, including the DNP-prepared nurse, must utilize information technology to ensure reliable evidence is translated into practice. Informatics structures, tools, and resources provide this information to practitioners at the point of clinical decision-making (Reed et al., 2018). As the leader of quality improvement, the DNP-prepared nurse must gather, critically analyze, and synthesize evidence at the point of care.
Explore the following scenario to investigate the location, evaluation, and synthesis of electronic evidence-based sources of information.
Application: Case Study
Janice is a new manager on an orthopedic unit at Care Optimization Medical Center. Janice notes that there has been an increase in falls and pressure ulcers in the geriatric patient population. After reviewing the agency policies regarding pressure ulcer and fall prevention, she decides to search for an evidence-based intervention to decrease the incidence of falls and pressure ulcer development. She shares the evidence-based interventions with the nurses, empowering them in the decision-making process on which current and reliable intervention to implement on the unit. As a DNP-prepared nurse, Janice understands the importance of promoting evidence-based practice readiness. Creating a workplace culture that fosters evidence-based practice is foundational to improving patient outcomes while decreasing healthcare costs and increasing performance and satisfaction among nurses (Schaefer & Welton, 2018).
Now, explore the electronic resources Janice used to support knowledge access and dissemination to improve outcomes on her unit.
Click on the plus sign for more information about each resource.
Electronic Resources Interactive Transcript
Information Technology in Evidence Translation: Improvements at the Point of Care
By harnessing the power of information technology, the DNP-prepared nurse and other healthcare providers are empowered to apply evidence at the point of care, while generating new knowledge from clinical practice. The complex healthcare system and the inherent challenges of translating evidence to practice require the use of information technology to advance patient care outcomes. Gone are the days when healthcare providers retreated to the brick-and-mortar library to search through archives of historical information. Intricate technological systems and processes are required to enact sustainable improvements in today’s healthcare landscape through real-time knowledge creation, synthesis, implementation, and evaluation (Harris et al., 2018).
View the following activity to explore the use of health informatics in evidence-based practice and knowledge translation.
Health Informatics Interactive Transcript
Lesson 2
Evidence-Based Practice: Improving Outcomes
Quality Improvement through Workflow Redesign
Leveraging informatics to bridge the quality chasm in the U.S. healthcare system is a strategic approach to improve quality, efficiency, and lower the costs of healthcare. Health information technology (HIT) holds promise to facilitate access to patient data, improve guideline adherence through computerized decision-support, and enhance workflow and process redesign (McBride & Tietze, 2019). Workflow redesign encompasses making changes in existing clinical practices to improve efficiency and outcomes, as well as addressing unintentional errors in the design and/or implementation of new HIT, such as poor software usability.
Workflow redesign uses process mapping or graphical representation of workflow elements, sequences, and actions to improve processes (McBride & Tietze, 2019). Workflow mapping diagrams include several types, from Simple Linear Workflow Diagrams to the popular Swimlane or Cross-Functional Diagrams and Flowcharts.
View the following diagram to consider how the Swimlane Diagram maximizes efficiencies and care coordination while enhancing healthcare quality and safety in a patient care visit. Click on the image for a PDF version.
Electronic Resources Interactive Transcript
Quality Improvement through Failure Mode and Effects Analysis
Systems and processes can fail or break through various methods or modes for several reasons and create potential negative consequences called failure effects. One method to examine for potential failure effects is known as the failure mode and effects analysis (FMEA). This tool assists the DNP-prepared nurse in determining if real or potential failures (errors) might occur, as well as the likelihood and severity of the failures. Warnick et al., (2020) conducted a risk analysis using the FMEA and the scoring guidelines from the Institute for Healthcare Improvement. Once the risks for failure are identified, solutions can be developed to mitigate or reduce the potential risks. The goal is to ensure that potential failures do not create harm to patients or staff.
Review the following scenario to explore the use of FMEA to address a practice problem.
Application: Practice Problem Analysis
At a local facility, a new information system with computerized order sets for heart failure patients provides the best practice guidelines; yet the 30-day readmission rate remains high for direct admission patients. As the DNP-prepared nurse, your goal is to determine if these computerized order sets are consistently used and are improving patient care.
Through your investigation, you identify that your organization’s heart failure patients’ readmission rate is well above the national average. Evidence indicates that the use of computerized order sets improves compliance with best-practice guidelines and results in lowered readmission rates, improved outcomes, and lowered mortality rates.
- What is going wrong (failure mode)?
- Why is it happening (failure cause)?
- What is the consequence of the error (failure effect)?
To answer these questions, the DNP-prepared nurse utilized the FMEA tool.
Examine the FMEA diagram below developed to address the scenario.
Heart Failure Computerized Order Set Usage for Direct Admit Patients
| Step in Process | Failure Mode | Failure Cause | Failure Effect | Occurrence Likelihood | Detection Likelihood | Severity | Risk Profile Number | Actions to Mitigate Risk |
| Patient Arrives on Inpatient Unit | No orders | Physician did not enter orders in the EMR His office did not check for orders | Delay in care while try to contact physician for orders | 3 | 1 | 10 | 30 | Evaluate cause Medical staff to develop protocol for general admission set initiation on arrival for all patients |
| RN Assesses patient and documents admission history | Misses history elements that initiate HF Plan of care | Time of day Staffing Workload Patient unable to provide accurate history | Task to notify Social Service HF admission not sent and general admission plan of care initiated instead of HF plan of care | 5 | 3 | 6 | 90 | Report to determine compliance with admission history by nurse Charge nurse check to see if social services notified Reeducate nursing staff admission history screens |
| Physician initiates order set | General admission set used instead of HF order set | Not aware MED Hospital Admit order set has HF sub-phase Poor internet connection | Requires manual initiation of HF measures | 7 | 2 | 6 | 84 | Report developed to identify physicians not using HF order set – work with physician champion to educate and answer any concerns about HF order set |
| Physician identifies diagnosis and problems | Misses BNP and Echocardiogram orders as well as cardiology consult | Orders not in the general admission order set | Delay in care to determine appropriate medications or order cardiology consult | 4 | 6 | 8 | 192 | Work with informatics team to have HF diagnosis initiate an alert for physician to consider ordering BNP/consult/or echocardiogram if HF order set not used |
- Occurrence Likelihood rate 1-10 (10 means most likely to occur)
- Detection Likelihood rate 1-10 (10 means least likely to be detected)
- Severity rate 1-10 (10 means most likely to cause severe harm)
Using your judgment and reasoning about the practice problem situation, assign the occurrence, detection, and severity likelihood scores. Then, calculate the Risk Profile Number by multiplying the occurrence likelihood score by the detection likelihood score by the likelihood for severity score.
- Example: The mathematical formula would be (occurrence likelihood score X detection likelihood score X severity likelihood score=risk profile number).
Note: The step in the process with the higher risk profile number is more likely to have a negative impact with potential for harm. The risk profile number assists to prioritize improvement initiatives.
Quality Improvement using the Ishikawa (Fishbone) Cause and Effect Diagram
Another tool to assist in analyzing a practice problem is the Ishikawa or Fishbone Cause and Effect Diagram. This diagram is a continuous quality improvement tool that provides a methodology to categorize the cause of problems into a visual display. This visual display assists in determining the root cause of the practice problem (Otitigbe, 2017).
Through the completion of the failure mode and effects analysis tool, the DNP-prepared nurse has determined the failure mode, failure cause, and failure effect related to the admission of a direct heart failure patient without the use of a heart failure computerized order set. It was identified that the physician’s office failed to send orders with the direct admission patient and the office staff failed to check on orders before sending the patient to the hospital. After the patient arrived, the nurse had difficulty obtaining an accurate health history partly because the patient was unable to provide a complete health history.
The DNP-prepared nurse’s next step is to evaluate the problem more specifically in five areas regarding people, environment, materials, methods, and equipment impacting the problem. Further investigation determined that both the admitting physician and registered nurse had information literacy issues extracting data from the information system, requiring retraining. Poor preparation along with a patient who was a poor health historian added to the problem complexity. Interviews with the physician and office staff identified internet connectivity problems, slow response rate, and interoperability issues negatively impacting the exchange of information between systems. Mapping this information on an Ishikawa or Fishbone Cause and Effect Diagram provides a visual display of the problem under analysis.
Now, examine the Ishikawa (Fishbone) Cause and Effect Diagram below to address the scenario.
Fishbone Diagram Image Description
References
Harris, C., Garrubba, M., Melder, A., Voutier, C., Waller, C., King, R., & Ramsey, W. (2018). Sustainability in healthcare by allocating resources effectively (SHARE) 8: Developing, implementing and evaluating an evidence dissemination service in a local healthcare setting. BMC Health Services Research, 18(1), 151. https://doi.org/10.1186/s12913-018-2932-1
McBride, S., & Tietze, M. (2019). Nursing informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism (2nd ed.). Springer Publishing Company.
Otitigbe, J. (2017). Fishbone facilitation reflection: Team-based cause-and-effect study can point the way to the real problem. ISE: Industrial & Systems Engineering at Work, 49(7), 48-51.
Reed, J. E., Howe, C., Doyle, C., & Bell, D. (2018). Simple rules for evidence translation in complex systems: A qualitative study. BMC Medicine, 16(1) 92. https://doi.org/10.1186/s12916-018-1076-9
Schaefer, J. D., & Welton, J. M. (2018). Evidence-based practice readiness: A concept analysis. Journal of Nursing Management, 26(6), 621-629. https://doi.org/10.1111/jonm.12599
Warnick, R. E., Lusk, A. R., Thaman, J. L., Levick, A. H., & Seitz, A. D. (2020). Failure mode and effect analysis (FMEA) to enhance safety and efficiency of Gamma Knife radiosurgery. Journal of Radiosurgery and SBRT, 7(2), 115-125.
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