Post a brief explanation of how you would identify a quality improvement practice gap in your practice or organization. Describe a potential quality improvement practice gap you might use for your DNP project, and explain why. Then, explain at least two types of tools and/or methods you might use to address this quality improvement practice gap, and explain why. Be specific and provide examples.

Post a brief explanation of how you would identify a quality improvement practice gap in your practice or organization. Describe a potential quality improvement practice gap you might use for your DNP project, and explain why. Then, explain at least two types of tools and/or methods you might use to address this quality improvement practice gap, and explain why. Be specific and provide examples.

Quality Improvement Practice Gap

Quality practice gaps in an outpatient setting can be identified from a variety of sources.  Much of the data utilized for quality improvement practice purpose in my organization comes from EHR software, quality measurement tools such as Tableau, patient satisfaction surveys, and from the annual employee engagement surveys.  In the ambulatory setting, many quality indicators like patient falls, depression and violence screenings, pain assessments, risk assessments (BMI & hypertension) can be assessed through the EHR.  This retrospective data collection is utilized by many data collection projects including several national quality improvement database projects (Nash et al., 2019).  As a nurse manager, I have access to reporting analytics that determine the percent of compliance to these quality indicators.  Additionally, my organization utilizes a program called Tableau that also analyzes date from each clinical site in comparison with the organizational standards to produce a weekly report identifying strengths and weaknesses in the organizational quality indicators.  Another resource for identifying quality practice gaps in with our annual employee engagement survey which includes questions about culture of safety, morale, and work-life balance.  Utilizing the data from the various tools provided by my organization allows for in-depth data analysis for identifying practice gaps.

Potential Quality Improvement Gap

A quality improvement gap that has been identified at my organization is access to care.  Access to care is a critical component in providing quality care in that lack of access delays care and preventable services, excessive financial burdens, and increased hospitalizations or length of stays (“Measures Management System”, 2021).  My organization focuses on a 14-day access new patients quality measure, in which all new patient referrals should be scheduled with an appointment within 14 days. This quality indicator has been attainable for all but one provider in our clinic, with current new patient access running about 16-20 days. Provider clinic schedule changes could be made to help alleviate this burden with results tracked using a run chart to help identify improvement or setbacks, as well as the ability to annotate changes along the way

Access of care is also currently affecting my organization in another way.  Due to our extensive Covid surge taking place in our state currently, my organization’s children’s hospital is at 110% capacity with backup in the pediatric emergency department, which has led to several diverting emergency patients at several different instances.  Being one of just a few children’s hospitals in the state and the only one taking care of most of the central and eastern areas of the state, this has been a critical emergent crisis for our area.  The lack of pediatric inpatient beds affects many patients who require frequently scheduled hospitalizations, such as our scheduled admits for pediatric chemotherapy patients.  To help offset this crisis, I have been asked to assist in leading the creation of a new monoclonal antibody infusion clinic for pediatrics age 12-17 years.  This emergency request for assistance to relieve inpatient volumes was announced two days ago with a one-week deadline to open to the new clinic and is hopeful to help alleviate the strain currently being faced by the overwhelming number of pediatric Covid patients.  This will be the only pediatric monoclonal antibody infusion site in the state of Kentucky. This quality improvement gap was identified quickly, and data will be analyzed throughout the development process.

References:

Measures Management System. Cms.gov. (2021). Retrieved 17 September 2021, from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Access-Measures.pdf.

Nash, D., Joshi, M., Ransom, E., & Ransom, S. (2019). The Healthcare Quality Book: Vision, Strategy, and Tools (4th ed.). Healthcare Administration Press.