The purpose of this assignment is to examine how publicly reported data influences internal quality improvement initiatives.
Identify a specific health care organization of your choice. Review its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and Hospital Acquired Infections (HAIs) reports.
In a 1,250-1,500 word paper, discuss your findings on the HCAHPS scores and HAIs for the health care organization you selected. Include the following in your paper:
1.Describe the health care organization you have selected.
2.Discuss the role of HCAHPS and HAIs in creating quality indicators and how they contribute to the quality improvement process.
3.Discuss how the HCAHPS and HAIs data of your selected organization compare to national benchmarks.
4.Discuss the role of consumer satisfaction in quality improvement.
5.Describe the intent and outcomes of public reporting.
6.Discuss what actions leadership could take at your selected organization based on the reported HCAHPS and HAIs data.
This assignment requires four to six scholarly resources.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
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The Importance of Public Reporting
Quality improvement in the hospital is an ongoing process. It involves the collection of data on the quality of care delivered as well as the patient perception on the care they have received. There are outcome measures that are used to assess whether the hospital or healthcare facility is conforming to the required standards of quality as prescribed by regulatory authorities. Two of the most notable regulatory authorities that supervise quality and offer certification are the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Agency for Healthcare Research and Quality (AHRQ). Various quality outcome measures are use to evaluate the success of a healthcare organization in conforming to quality standards. One of these is the survey instrument known as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). It is a questionnaire survey that is used to gauge the perception of discharged patients about the services offered at the healthcare facility. Another quality outcome measure is the rate of hospital acquired infections in a given facility. The purpose of this paper is to discuss the role of the HCAHPS and the HAI rates in healthcare quality improvement.
The Healthcare Organization Selected
The healthcare organization that has been selected for this discussion is a mid-level suburban 45-bed hospital that offers primary healthcare services and a few specialty services such as oncology and reproductive health. The hospital has an organizational culture that is friendly to change and is gold certified by the JCAHO as a center of excellence. It thrives on the exclusive use of evidence-based practice (EBP) and frequently has its staff carry out clinical inquiry into clinical problems that are identified within the institution (Melnyk & Fineout-Overholt, 2019). This normally leads to change recommendations that are implemented with the support of the top leadership (directors) who provide the resources. Despite its high quality rating, the hospital is however not immune to quality lapses here and there. For instance, there have been some instances where a number of patients on mechanical ventilation in the ICU for more than 48 hours have contracted ventilator-associated pneumonia or VAP (Papazian et al., 2020). This was however quickly dealt with through clinical inquiry that found scholarly peer-reviewed evidence in support of the use of chlorhexidine mouthwash in effectively preventing VAP in the ICU (Rabello et al., 2018; Enwere et al., 2016). The recommendation was successfully implemented using the transtheoretical model (TTM) of change as the conceptual framework (Prochaska et al., 2015).
The Role of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey and Hospital Acquired Infections (HAIs) in Quality Improvement
The HCAHPS is a survey that is carried out continuously on patients who have been discharged and who are going home from a healthcare facility. The objective is to get their views on the quality of the services they received and therefore their satisfaction or otherwise with the same. It is currently the national standard for collecting and reporting publicly the information collected regarding satisfaction of patients or otherwise with the services they received in the healthcare facility. This is data that is also used by the JCAHO to rate hospitals for quality of services. The HCAHPS survey instrument has 29 questions in total, 19 of which are core one about critical areas of service in the facility in question. These include communication by staff, cleanliness of the facility, responsiveness of staff when called by patients, health education about medications and about treatment, comprehensiveness of discharge information, and whether the patient would recommend the hospital to other persons (CMS, 2020).
The sampling of the patients to whom this survey is administered is random and the survey is supposed to be administered within 48 hours to six weeks after the patient has been discharged. If it happens outside the stated time-frame then the validity of the results will be called into question. The survey can be carried out either by telephone or mail. The development and testing of the HCAHPS survey instrument was carried out by the Centers for Medicare and Medicaid Services (CMS) in partnership with the AHRQ that conducted the scientific testing and endorsement of the instrument
Hospital-acquired infections (HAIs) as stated in the introduction are infections that are acquired in the hospital after the patient is admitted. Importantly, these are infections that the patient did not have at the time that they were being admitted to the healthcare facility. It therefore follows that the patients contract these infections as a result of lapses in the quality of care given by the nurse and other healthcare team members. In short, HAIs are a quality improvement issue of great concern. They include VAP, catheter-associated urinary tract infections (CAUTIs), and central line-associated bloodstream infections (CLABSIs). The role of HAIs and HCAHPS in creating quality indicators is therefore in the fact that they enable the hospital authorities to determine where there are lapses in quality. This enables them to take targeted quality improvement action that then restores patient satisfaction and improves patient outcomes. The two therefore contribute to the quality improvement process by offering measurable parameters that can be turned into outcome measures used to gauge success of QI initiatives. The Importance of Public Reporting Essay Example
Comparison to National Benchmarks and Role of Consumer Satisfaction in the Quality Improvement Process
The HCAHPS and HAIs data for the organization discussed here compare favorably with national benchmarks. CAUTI and CLABSI rates are below the national averages. Only the VAP rate had matched the national average but after the QI initiative targeting it the rate has now fallen substantially below the national benchmark. As for the HCAHPS survey data, patients overwhelmingly view the hospital in good light and are generally satisfied with the services offered there. The information obtained after data coding and analysis of the monthly survey results is in line with the national benchmark. The hospital is therefore not an outlier with regard to this tool.
Consumer satisfaction in quality improvement is a very important element in the provision of services that are timely, efficient, effective, safe, equitable, and patient-centered. These are the six domains of healthcare quality as proposed by the Institute of Medicine (AHRQ, 2018; Tzelepis et al., 2015). Consumer satisfaction surveys are the only way that the healthcare facility can accurately gauge how the patients feel about the services that they offer. It is a measure of the patient outcomes from the perspective of the patient and is therefore objective as an assessment of the reality. This is very important for quality improvement as initiatives will be based on the actual problems the patients see rather than on the whims and arbitrary decisions by nurse leaders and hospital managers. It is the patients who are consumers of the healthcare services. It follows that it is their opinion that counts when it comes to improving aspects of the care that is given to them. It may not be possible for the hospital management to know what is not right if the patients themselves are not asked whether they are satisfied or not.
Intent and Outcomes of Public Reporting and the Actions Leadership Can Take
Public reporting in healthcare is the process of collecting data on the structure of healthcare, the processes and outcomes (Moore et al., 2015). This information is then made publicly available to everyone, usually free of charge or at a nominal cost of access. The intention of public reporting is therefore to inform and t assist in decision making about where to consume services. In the case of healthcare services, getting information on the best facilities to visit for care is crucial to quick recovery and saving costs. This is because contracting a HAI for instance will mean that one stays for a longer period in the hospital than they would have done if they had not. This directly translates to higher hospitalization costs and poor patient outcomes. With poor patient outcomes the patient satisfaction levels drop significantly. The outcomes of public reporting are therefore a better informed public and better quality healthcare in healthcare facilities. When the facilities know that their performance is being monitored both by the regulatory agencies such as the JCAHO and the public, they will strive to offer the best quality of services they can.
The actions that the leadership at the organization in question can take based on the reported HCAHPS and HAIs data include:
• Initiating change initiatives
• Providing resources for the change process
• Inspiring the staff to embrace the change through transformational leadership
• Ensuring the change becomes part of the organizational culture.
Quality care in healthcare is a right of every patient. Delivering evidence-based care is one of the ways that can assure patients of quality care. To do this, there must be a movement towards continuous quality improvement. This is not possible without quality outcome measures such as the HCAHPS and HAI rates.
Agency for Healthcare Research and Quality [AHRQ] (2018). Six domains of health care quality. Retrieved 20 January 2020 from https://www.ahrq.gov/talkingquality/measures/six-domains.html
Centers for Medicare and Medicaid Services [CMS] (2020). HCAHPS overview. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS
Enwere, E.N., Elofson, K.A., Forbes, R.C., & Gerlach, A.T. (2016). Impact of chlorhexidine mouthwash prophylaxis on probable ventilator-associated pneumonia in a surgical intensive care unit. International Journal of Critical Illness & Injury Science, 6(1), 3-8. https://doi.org/10.4103/2229-5151.177368
Melnyk, B.M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice, 4th ed. Wolters Kluwer.
Moore, L., Lavoie, A., Bourgeois, G., & Lapointe, J. (2015). Donabedian’s structure-process-outcome quality of care model. Journal of Trauma and Acute Care Surgery, 78(6), 1168–1175. https://doi.org/10.1097/TA.0000000000000663
Papazian, L., Klompas, M., & Luyt, C-E. (2020). Ventilator-associated pneumonia in adults: A narrative review. Intensive Care Medicine, 1-19. https://doi.org/10.1007/s00134-020-05980-0
Prochaska, J.O., Redding, C.A., & Evers, K.E. (2015). The transtheoretical model and stages of change. Health behavior: Theory, research, and practice, 97. https://psycnet.apa.org/record/2015-35837-007
Rabello, F., Araújo, V., & Magalhães, S. (2018). Effectiveness of oral chlorhexidine for the prevention of nosocomial pneumonia and ventilator-associated pneumonia in intensive care units: Overview of systematic reviews. International Journal of Dental Hygiene. https://doi.org/10.1111/idh.12336
Tzelepis, F., Sanson-Fisher, R., Zucca, A., & Fradgley, E. (2015). Measuring the quality of patient-centered care: Why patient-reported measures are critical to reliable assessment. Patient Preference and Adherence, 9, 831-835. https://doi.org/10.2147/ppa.s81975 . The Importance of Public Reporting Essay Example