MMHA 6050 Week 6 Quality Aims Application Paper Example

The Six Quality Aims Applied to a Skilled Nursing Facility: Which Its Design Makes Easy and Which It Makes Hard

Student Name

Walden University

MMHA 6050: Delivery of Healthcare

Instructor Name

Month Day, Year

The Six Quality Aims Applied to a Skilled Nursing Facility: Which Its Design Makes Easy and Which It Makes Hard

Introduction

The Institute of Medicine's report Crossing the Quality Chasm named six aims for care (Institute of Medicine, 2001), and this paper applies those aims to one composite setting, Brookside Rehabilitation and Nursing, an invented 120-bed skilled nursing facility that takes most of its admissions from two nearby hospitals for short-term rehabilitation after surgery or illness. The question is not whether Brookside is good or bad, but which aims its design makes easy to meet and which it makes structurally hard. Each aim is tied to a specific feature of how the facility operates.

The Setting

Brookside admits about eight patients a week, most arriving in the afternoon or evening after hospital discharge. Discharge information arrives by fax or through a shared portal from one of the two hospitals; the other hospital sends a printed packet with the patient. A physician visits three days a week, and a nurse practitioner covers the other weekdays; evenings and weekends are covered by phone. Licensed nurses staff each unit around the clock, with fewer on evenings and nights. Therapy is scheduled on weekdays, with limited weekend sessions. About one resident in five prefers a language other than English, and the facility uses a telephone interpreter service.

Safety

Safety centers on medication reconciliation at admission. Patients often arrive in the evening, when the physician is not on site, with discharge medication lists that may differ from what they took before the hospital stay. Nurses reconciling those lists depend on the hospital's discharge information, which research describes as often incomplete: nurses receiving patients from hospitals report missing or incorrect medication orders, including missing pain prescriptions, and repeated calls to clarify them (King et al., 2013). Brookside's design makes safety hard at exactly this moment: an evening admission, a paper packet and a physician available only by phone. A safer design would admit before 3 p.m. where possible, require the electronic portal from both hospitals and have a pharmacist review every admission's medications the next morning.

Timeliness

Timeliness is hindered by the weekday therapy schedule. A patient admitted on a Friday evening may not begin full therapy until Monday, losing two days of a short rehabilitation stay. The design is efficient for staff scheduling but slows recovery. Adding weekend therapy for new admissions would support timeliness at a modest cost.

Effectiveness

Effectiveness, providing care based on evidence to those who will benefit, depends on recognizing changes in condition. Brookside's evening and night staffing, with fewer nurses and no on-site clinician, makes early recognition harder. Rehospitalization from skilled nursing facilities is common: an analysis of Medicare data found that almost a quarter of beneficiaries discharged from the hospital to a skilled nursing facility were readmitted within thirty days (Mor et al., 2010). A structured tool for recognizing early warning signs, used on every shift, would support effectiveness where staffing cannot easily be increased.

Efficiency

Brookside's design supports efficiency in several ways. Concentrating physician visits on three days reduces cost; weekday therapy concentrates therapists' time. But some efficiencies shift cost elsewhere. A readmission that better evening recognition might have prevented costs Medicare far more than the staffing that might have prevented it; the same analysis estimated that readmissions from skilled nursing facilities cost Medicare $4.34 billion in 2006 (Mor et al., 2010). The facility's design is efficient for the facility, but not necessarily for the system.

Equity

Equity, care that does not vary in quality by personal characteristics, is tested by language services. Residents who speak a language other than English depend on a telephone interpreter, which works for scheduled conversations but is often skipped in quick exchanges, such as a nurse checking pain at night. Discharge teaching delivered through an interpreter may also be shorter. The design makes equitable care harder for a fifth of Brookside's residents, at the moments, evenings and discharge, when communication matters most.

Patient-Centeredness

Patient-centeredness, care that respects patients' preferences and values, is supported by Brookside's admission care conference, held within a week, where the patient and family set goals with the team. It is hindered by the admission timing: patients arriving in the evening, tired after discharge, may not be able to say what matters to them until days later, after the care plan has been written.

Where to Start

If Brookside's leaders could change only a few features in the next year, the analysis suggests ranking candidate changes by how many aims each would help. Moving admissions earlier in the day, by agreement with the two hospitals, would help safety, because reconciliation could happen while the physician or nurse practitioner is on site; timeliness, because therapy evaluation could start the same day; and patient-centeredness, because patients would arrive less exhausted. Requiring both hospitals to send discharge information through the shared portal would help safety and effectiveness. Adding video interpretation, which supports quick bedside exchanges better than a telephone line, would help equity and patient-centeredness. Weekend therapy for new admissions would help timeliness and, by shortening stays, efficiency. Each change has a cost, but the first two depend mainly on agreements with the hospitals rather than new staff, which makes them the most practical place to start. Progress could be tracked through the share of admissions arriving before 3 p.m., the share of medication lists reconciled without a clarification call and thirty-day readmissions.

Summary

Brookside's design makes efficiency and parts of patient-centeredness relatively easy. It makes safety, timeliness, effectiveness and equity structurally hard, and the same few features explain most of the difficulty: evening admissions with incomplete information, thin evening clinical coverage, a weekday therapy schedule and telephone-only interpretation. The aims are linked: improving how discharge information arrives would help safety, effectiveness and equity at once. A facility leader using this analysis would start with the handoff from the hospitals, because that is where the most aims are lost together, and because the fix depends on partners who also benefit when fewer patients bounce back.

References

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.

King, B. J., Gilmore-Bykovskyi, A. L., Roiland, R. A., Polnaszek, B. E., Bowers, B. J., & Kind, A. J. H. (2013). The consequences of poor communication during transitions from hospital to skilled nursing facility: A qualitative study. Journal of the American Geriatrics Society, 61(7), 1095-1102. https://doi.org/10.1111/jgs.12328

Mor, V., Intrator, O., Feng, Z., & Grabowski, D. C. (2010). The revolving door of rehospitalization from skilled nursing facilities. Health Affairs, 29(1), 57-64. https://doi.org/10.1377/hlthaff.2009.0629