DDHA 8103 Week 8 Improvement Proposal Example

No Patient on Top of the Pack: An Improvement Proposal for Twelve Therapy Clinics, With Outcome, Process and Balancing Measures and the Baseline Each Is Judged Against

Student Name

Walden University

DDHA 8103: Advanced Healthcare Quality and Risk Management

Instructor Name

Month Day, Year

No Patient on Top of the Pack: An Improvement Proposal for Twelve Therapy Clinics, With Outcome, Process and Balancing Measures and the Baseline Each Is Judged Against

The Request

This proposal asks the vice president of ambulatory operations to approve one change across the twelve outpatient therapy clinics of Hollins Ford Health, a composite regional system: from the first of next quarter, no patient receives moist heat while lying on the pack. Heat will be applied with the patient face down, on the side or seated, with the pack on top of the body, and a patient who cannot use any of those positions will not receive moist heat that day. The change costs about $9,400 to start, mostly for positioning wedges and fitted covers, and it will be judged against three measures with baselines and decision rules set out below.

Why This Change

The root cause analysis of last spring's partial-thickness burn found that the injury followed from a positioning practice that had spread across several clinics: patients who could not lie face down were placed face up on the pack, with an added towel standing in for correct positioning. Body weight compresses towel layers, and the analysis team's probe testing found surface temperatures under load well above those of a free-lying pack. Of the actions the analysis recommended, this one removes the mechanism of injury most directly. It is also the action staff can begin soonest. Hettinger et al. (2013) rank actions that remove a hazard or change the physical setup above actions that ask people to try harder, and a rule backed by fitted covers that cannot take extra towels sits higher on that ladder than a reminder to watch the skin more closely.

The Change in Practice

At the start of every moist heat application, the clinician chooses one of three positions with the pack on top: face down with a pillow under the abdomen, side-lying with a wedge behind the back, or seated with the pack held in place by a strap. For a patient who cannot use any of the three, the clinician records the reason and offers another approach that day, such as a warm-up period of gentle movement, or no heat. Fitted covers sized for each pack replace loose towels, so no extra layers can be slipped beneath a patient. Two clinics, Millbrook and one other chosen by the clinic managers, will test the change for four weeks using small plan-do-study-act cycles as described by Langley et al. (2009), adjusting the wedge sizes and the wording of the flowsheet prompt before the change spreads to the other ten.

Outcome Measure

For the outcome, the proposal adopts the injury rate the division specified earlier in the year, which counts heat injuries found within a week of treatment from three reconciled sources and expresses them per 1,000 recorded pack uses. The baseline is the rolling twelve-month rate before the change, 0.61 per 1,000 applications, or about 11 injuries a year across roughly 18,000 applications. Because injuries are rare, a fall in the monthly rate will not show quickly. The proposal therefore also tracks the number of applications between injuries, which will lengthen if the change works. Success is defined in advance as at least 6,000 applications without a qualifying injury, about four months of division volume, within the first year.

Process Measure

The process measure is the share of observed moist heat set-ups in which the pack is on top of the patient in one of the three approved positions. Each clinic will be observed at 20 random set-ups a month by a staff member from another clinic, so that the observation reflects ordinary work. The baseline, from four weeks of observation before the change, is 69 percent: 31 percent of observed set-ups had the patient lying on the pack. The target is 95 percent or higher at every clinic by the end of the second month after spread. This measure will move first and will tell leaders whether the change is happening at all, which the rare outcome cannot do.

Balancing Measures

Two balancing measures look sideways, at what the rule could quietly cost patients. The first is the share of visits that include moist heat. If clinicians respond to the new rule by quietly dropping heat for patients who would benefit from it, that share will fall. The baseline is 22 percent of visits. A fall below 17 percent at any clinic will prompt a conversation with that clinic's therapists about which patients are going without heat and why. The second is patient comfort, measured with a single question added to the visit survey for six months: how comfortable were you during your heat treatment today? The baseline mean on a five-point scale, from a two-week pilot of the question before the change, is 4.4. A sustained fall below 4.0 will prompt a review of the positioning options. Langley et al. (2009) note that a change can improve the measure it targets while making the system worse in ways no one is watching, and these two measures are there to catch that.

Display and Decision Rules

Monthly run charts will show each measure over time, read with the rules described by Perla et al. (2011) for distinguishing a real shift from the month-to-month noise of small samples. The process measure will be shown for each clinic separately, so that one slow clinic cannot hide behind eleven fast ones.

Table 1

Measures, Baselines, Targets and Decision Rules

The division's quality committee owns these rules and applies them when each month's charts are reviewed.

Cost and Resources

The startup cost is about $9,400: positioning wedges and straps for each clinic, fitted covers for each pack, printing for the revised procedure card and four hours of a clinical educator's time per clinic for a short in-service. Ongoing cost is mainly the observation time, about two hours a month per clinic, which the clinic managers have agreed to absorb by swapping observers between clinics. No additional staff are requested.

Risks and Limits

Three risks are acknowledged. Observers may become lenient over time, which the swap between clinics is designed to slow. Some patients may refuse the new positions and leave unhappy, which the comfort measure will show. And a fall in injuries may reflect other changes, such as the revised skin check, which are being introduced at the same time; the proposal does not claim that this change alone will produce any improvement in the outcome.

Conclusion

One change, no patient on top of the pack, is proposed for twelve clinics after a four-week test at two. It will be judged by an outcome measure with a prespecified success line, a process measure that will move first, and two balancing measures that will reveal whether heat is being withheld or comfort lost. Each measure has a baseline and a rule for what happens if it is missed.

References

Hettinger, A. Z., Fairbanks, R. J., Hegde, S., Rackoff, A. S., Wreathall, J., Lewis, V. L., Bisantz, A. M., & Wears, R. L. (2013). An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions. Journal of Healthcare Risk Management, 33(2), 11-20. https://doi.org/10.1002/jhrm.21122

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality and Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895