Quality Improvement In Gastroenterology

Quality Improvement In Gastroenterology

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Quality Improvement In Gastroenterology

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Quality Improvement In Gastroenterology

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Question:
Discuss about the hand hygiene based on PDSA Model Quality Improvement in Gastroenterology Health Care Centre.
 
 
Answer:

Introduction
Quality and safety management is crucial in the context of prevention of infections within an acute healthcare setup. The quality management here refers to taking care of the overall aspects of healthcare which are pivotal in maintaining an aseptic condition within the care setting. For the current study we have taken into consideration hand hygiene which helps in reducing the chances of infection within a hospital framework. The focus has been narrowed down to the application of the project initiative within the Gastroenterology Healthcare centre, Toronto upon the Plan DO Study Act (PDSA) model. The paper discusses the issue in more detail focussing upon the importance of hand hygiene and relation of the same in ensuring health improvements within the concerned department. The study further elaborates the role of the nurses in ensuring the efficiency of the aforementioned processes.
Description of issue
Hand hygiene has been described as the single most effective method of infection prevention (CDC, 2002; World Health Organization [WHO], 2009). The cleaning of hands before, after and during surgical processes is crucial in the prevention of infection through the spread of microorganisms.  As commented by Septimus et al. (2014), increased use of hand hygiene equipments have been seen to reduce the incidents of infection spread within healthcare centres. Some of the disinfectants which could be used over here are –soap dispensers, alcohol based foam dispensers, paper towel dispensers. The statistical figures showed a 24 % reduction in the healthcare associated infections after the implementation of the disinfection process on a regular basis. This resulted in saving approximately 27 % of the cost of antibiotics (Moraros, Lemstra, & Nwankwo, 2016).
In the present context, precautionary measures must be taken in dealing with patients suffering from gastrointestinal issues. The staff may encounter exposure to pathogens such as Clostridium difficile, vancomycin resistant enterococci (VRE), carbapenam resistant enterobacteriaceae (CRE). In this respect, rigorous cleaning of the environment with EPA-registered hospital disinfectant has been seen to eliminate some of the microbial agents such as C. difficile which have been known to result in acute gastric infection in individuals (Jones et al., 2016).The aspects of hand hygiene have been further discussed with respect to the PDSA model. The model has four active components such as ‘Plan, Do, Study and Act’. The application of the model helps in evaluation of the different steps which could be taken for improvement of quality within the Gastroenterology health care centre. The different steps of the model have been represented with the help of flowchart as follows:

What are we trying to accomplish?
How will we know that change is an improvement?
What changes can we make that will result in improvement?

Evaluation of the current scenario through the PDSA model helps in the identification of the problem situation. The goal is to improve quality of services delivered within the Gastroenterology healthcare units through implementation of hand hygiene methods. In this respect, the   hand hygiene practices have been promulgated as the cornerstone of preventing infection by IPAC Canada. The improvements brought about by the implementation of such methods can be measured using survey analysis. The reduction in the rate of infection after the application of the cleaning methods could be compared with that of situation before the application of the control methods.  The figures so obtained provide an overview about the various loopholes and gaps within the delivery of the care services.  The gaps could be further improved with the application of stricter control measures which enhances the quality of the care services.
 
Application of hand hygiene based on PDSA
The PDSA model is based upon the objectives of learning through planning, executing the plan, study the gaps in the processes and act accordingly for the mitigation of the gaps. The models have been discussed in more details below:
Plan (P):

Will implementing sufficient standards of hand hygiene enhance quality care within the gastroenterology wards of the hospital?
Will sufficient staff education about the disinfection process help in reducing the rate of infection?
What are the necessary standards and guidelines which have to be implemented for achieving success in the above outcome?

Do (D):
The healthcare team need to do planned activities for bringing about the change
Study (S)

Did the planning go right?
Was optimum education regarding the disinfection process given to the staffs?
Were adequate policies and programs followed for the implementation of the objectives within the gastroenterology healthcare centres?

Act (A):
Based on the results obtained from above interrogation, the gaps or the loopholes are identified which the team could further work upon.
Strength of the model
There are a number of strengths of the PDSA model such as collective problem and solution ownership. As commented by Smiddy, O’Connell & Creedon (2015), the collaborative mode of working helps in building positive relationship between team members. The PDSA model helps in empowerment of team members through common goal synthesis for achieving better clinical outcomes. The PDSA provides a structured environment for the realization of the clinical outcomes (Dai, Milkman, Hofmann & Staats, 2015). The PDSA cycles allow the staff to better understand the organizational processes. It promotes a gradual shift in accountability for problems from management to the frontline staff.
Limitations of the PDSA model
There are a number of limitations of the application of the PDSA model such as loss of momentum due to the removal of a team member. The jumping of the steps of the PDCA cycle may result in adequate learning which fails to address the root cause of the problem (Smiddy et al., 2015). The analysis of the problem situation through PDSA requires unit specific and time sensitive data and is dependent upon human labour for sufficient collection of data. In order to work through individual steps of the PDSA cycle sufficiently longer time is required.
Role of the nurse
The nurses play a critical role in reducing the rate of infection within a clinical setup by the implementation of sufficient policies and procedures. The influences excised by the nurses within the control of infection can be divided into a number of factors such as – intrapersonal, interpersonal and organizational factors. The intrapersonal factors here refer to the level of knowledge, skills along with perceptions or values possessed by the nurses which influence their set of practices. The interpersonal factors refer to the relation of the nurses with their friends, peers and patients which further govern the success of the implementation objectives. The organizational factors refer to the policies norms and culture, which helps in the establishment of the IPAC standards of clinical hygiene and safety. Additionally, inter facility collaboration can promote organizational learning regarding techniques and procedures such as alcohol rub for cleansing hands before, after and during patient handling, which can prevent spread of infection (Ellingson et al., 2014).The attending nurses need to maintain proper quarantine in dealing with highly infectious cases. They should wash their hands during each step of attending to the patient such as making the bed of the patient along with handing and management of the contaminated soils and articles of the patients.
Strength
In his respect skill building, peer –to –peer role modelling have been seen to positively influence the implementation of infection control procedures. As commented by Allegranzi, Sax & Pittet (2013), the old and experienced nurses can preceptor the newly enrolled nurses about the disinfection methods and control. The nurses also play a significant role in educating the patients and the respective family members of the patient about the disinfection process.
 
Limitations
In a care set up dealing with patients who have been kept in under quarantine, the nurses have to monitor that the family members of the patient are allowed restricted entry. There are similar situations where the nurse has to persuade the family members of the visiting patients to rub their hand with alcohol before they could meet or touch their loved ones (Al-Tawfiq & Pittet, 2013). The application of such restrictions often results in heated exchange of words between the nursing professionals and the visitors to the hospitals. Therefore, such ethical barriers limit the potential contributions of the nursing professionals within a care setup.
Physician’s role
In this respect, the physicians attending to the patient can act as a go-to person by the family members of the patient being admitted to the hospital with serious infections. Therefore, they need to practice effective communication skills, where they need to be empathetic in their approach. As commented by Abdella et al. (2014), values and compassion serves as the core factors for ensuring less ethical dilemmas are faced by the practising physicians as per the IPAC hygiene standards. The physicians need to look upon the hygiene standards implied by the nursing professionals and educate the same. They also need to be careful with the equipments for treating patients in the gastroenterological wards.  The instruments should be dipped in ethanol after every use.
Critical solution by managers
In this respect, the managers of the healthcare centres can act as volunteers for the promotion of programs such as antimicrobial stewardship. The   antimicrobial stewardship is an excellent tool for improving the clinical outcomes of patients with severe microbial infections by analysing each step from infection contraction to recovery, through constant research into the clinical data and active record keeping (Al-Tawfiq & Pittet, 2013). The programs can be also used for educating the staffs for coping with future recurrence of such infections. The implementation of the program can be used for meeting with the loopholes of hand hygiene techniques implemented within the medical wards. The institution wide programs for guideline compliance should be followed by the responsible management for reporting of the cases of infection to the higher authorities, which can help in controlling the rate of infection.
Application of PDSA model by managers for controlling the rate of infection in gastroenterology wards

 
Factors

Attributes

Plan (P)

·         Will implementing antimicrobial stewardship address the loopholes of hand hygiene alone?
·         Will education of the staff in the relevant fields address the issue?
·         What necessary steps need to be taken for the implementation of the program?

Do (D)

The managers of the institution need to negotiate with the higher authorities for bringing about the change

Study (S)

·         Does the clinic possess sufficient infrastructure for supporting the implementation of the program?
·         Did the staff possess sufficient knowledge about the antimicrobial stewardship program?

Act(A)

The management needs to  organise sufficient workshops and training programs for educating the staff in the  alternate methods of hygiene implementation

Table 1: PDSA model applied by the managers for controlling infection rate in hospitals and clinics
(Source: Author)

Figure1: Antimicrobial stewardship program
(Source:  Davey et al., 2015)
Strengths and limitations of the managers in healthcare wards
The managers can influence positive organizational processes along with guaranteeing swift flow of funds through active engagement with stakeholders, for implementation of the some of the hygiene maintenance protocols and devices.  As commented by Smolowitz et al. (2015), the negotiations skills of the mangers are particularly important in generating organizational change by focussing more upon the outcomes. The managers can act as preceptors by training the newly recruited staff about ways to improve organizational performance by employing active engagement policies.
However, the lack of trained staff and additional funds often delimit the role of the managers. Additionally, organizational disputes often hinder the application of the said objectives and programs.
Effectiveness of Registered nurse in establishment of quality improvement initiative
The registered nurse can play an effective role in controlling the spread of infection within a clinical set up. Some of the methods which could be applied by the registered nurse are maintaining active documentation entailing the patient record and history (Unroe et al., 2015). The time of recurrence of chronic infections can be noted down by the nurse. As commented by Grol  et al. ( 2013), the relapse of chronic infection can often be related to breach of hygiene practices. The registered nurse can prepare a screening chart detailing the steps that needs to be followed for dealing with a patient suffering from highly contagious infection.
The registered nurse can take appropriate action to ensure the protection of the patients. The RN can brief the attending physician regarding the immunization of the patient based upon which referral and isolation strategies could be applied. As asserted by Blot, Vogelaers & Blot (2015), advocating an aseptic environment and transmission control processes can prevent the spread of infection.  In this respect, some of the recommended nursing standards prescribed by NANB play a crucial role in the prevention of infection through transmission.
 
The NANB standards could be discussed in details for understanding the role played by the registered nurses in infection control. The nursing standards have been four types such as:
Standard1:  Application of evidence informed measures for control and prevention of infection through microorganisms.
The nurse can follow a systematic approach to care by adhering to the guidelines of Public Health Agency Canada. Here, the nurse can track the immunization status of the clients based upon which appropriate quarantine measures could be implemented. This also helps in planning the hygiene standards to be implemented and practised for particular patient population.
Standard 2: Application of professional judgement
The nursing professional is supposed to take adequate measures for the prevention of chance contamination of the skin and the mucous membranes with microorganisms. Additionally, modification of the practise methods stressing upon the use of personal protective equipments for infection prevention and control can restrict the spread of infection. The use of personal protective equipments such as gloves can reduce the chances of contamination and transmission of contamination (Smolowitz et al., 2015).
Standard 3:  reduction of risk to self and others through appropriate handling, cleaning, and disposal of materials and equipments.
The use of safety devices such as sharp disposal containers, needleless IV systems along with safe disposal can reduce the risk of accidents by checking the spread of microbial agents.  In this respect, marking some of the items as single use only can prevent the usage of such articles again. As commented by Murphy (2013), failure in implying with the hygiene standards can be a serious breach of policies and procedures.
 
Standard 4: Use of timely communication strategies with clients and significant others
Effective communication of health information to the clients explaining the use of isolation and masks to the patients and the respective family members of the patients can be helpful. As commented by Davey et al. (2015), open communication with the healthcare team can help in the establishment of the safety and hygiene measures.
Recommendations for hand hygiene initiative
A number of steps could be taken for the implementation of the hand hygiene practices within a care set up. In this response maintaining an aseptic condition is pivotal within the context of an acute health care set up.  During the process of handling and management of the patients affected with infectious disease, the nursing professionals need to rub their hands with alcohol everytime after handling such patient population. This helps in the prevention and control of disease through microbial contamination. Additionally, some of the measures which could be implemented over here are provision of sufficient education and training to the health staff regarding the aseptic conditions and methods which could be implemented by them within the care setup. Moreover, evidence based measures along with implementation of the nursing standards (NANB) can reduce the recurrence or breach of protocols of hygiene within an acute hospital and care setup (Melnyk et al., 2014).
Conclusion
The assignment uses the PDSA model for evaluating the different intervention and approaches implemented within a care set up for establishing sufficient standards of hand hygiene. The application of the model analyses the affectivity of different steps and measures such as team planning of activities along with role-modelling of significant practice methods which prevents future recurrence of such accidents. In this respect, some of the standards of nursing practices can be applied along with promulgation of antimicrobial stewardship can also facilitate in meeting with the demands of health and hygiene standards.
 
References
Abdella, N. M., Tefera, M. A., Eredie, A. E., Landers, T. F., Malefia, Y. D., & Alene, K. A. (2014). Hand hygiene compliance and associated factors among health care providers in Gondar University Hospital, Gondar, North West Ethiopia. BMC Public Health, 14(1), 96.
Allegranzi, B., Sax, H., & Pittet, D. (2013). Hand hygiene and healthcare system change within multi-modal promotion: a narrative review. Journal of Hospital Infection, 83, S3-S10.
Al-Tawfiq, J. A., & Pittet, D. (2013). Improving hand hygiene compliance in healthcare settings using behavior change theories: reflections. Teaching and learning in medicine, 25(4), 374-382.
Blot, K., Vogelaers, D., & Blot, S. (2015). Central line-associated bloodstream infections: a critical look at the role and research of quality improvement interventions and strategies. In Annual Update in Intensive Care and Emergency Medicine 2015 (pp. 15-24). Berlin: Springer International Publishing, pp.105-369.
Dai, H., Milkman, K. L., Hofmann, D. A., & Staats, B. R. (2015). The impact of time at work and time off from work on rule compliance: The case of hand hygiene in health care. Journal of Applied Psychology, 100(3), 846.
Davey, P., Peden, C., Charani, E., Marwick, C., & Michie, S. (2015). Time for action—Improving the design and reporting of behaviour change interventions for antimicrobial stewardship in hospitals: Early findings from a systematic review. International journal of antimicrobial agents, 45(3), 203-212.
Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N., … & VanAmringe, M. (2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control & Hospital Epidemiology, 35(8), 937-960.
Grol, R., Wensing, M., Eccles, M., & Davis, D. (Eds.). (2013). Improving patient care: the implementation of change in health care. New Jersey: John Wiley & Sons, pp.15-25..
Jones, E. L., Lees, N., Martin, G., & Dixon-Woods, M. (2016). How well is quality improvement described in the perioperative care literature? A systematic review. The Joint Commission Journal on Quality and Patient Safety, 42(5), 196-AP10.
Kamdar, B. B., Yang, J., King, L. M., Neufeld, K. J., Bienvenu, O. J., Rowden, A. M., … & Needham, D. M. (2014). Developing, implementing, and evaluating a multifaceted quality improvement intervention to promote sleep in an ICU. American Journal of Medical Quality, 29(6), 546-554.
Lavin, M., Harper, E., & Barr, N. (2015). Health information technology, patient safety, and professional nursing care documentation in acute care settings. OJIN: The Online Journal of Issues in Nursing, 20(2).
Melnyk, B. M., Gallagher?Ford, L., Long, L. E., & Fineout?Overholt, E. (2014). The establishment of evidence?based practice competencies for practicing registered nurses and advanced practice nurses in real?world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence?Based Nursing, 11(1), 5-15.
Moraros, J., Lemstra, M., & Nwankwo, C. (2016). Lean interventions in healthcare: do they actually work? A systematic literature review. International Journal for Quality in Health Care, 28(2), 150-165.
Murphy, J. I. (2013). Using plan do study act to transform a simulation center. Clinical simulation in Nursing, 9(7), e257-e264.
Ouslander, J. G., Bonner, A., Herndon, L., & Shutes, J. (2014). The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: An overview for medical directors and primary care clinicians in long term care. Journal of the American Medical Directors Association, 15(3), 162-170.
Septimus, E., Weinstein, R. A., Perl, T. M., Goldmann, D. A., & Yokoe, D. S. (2014). Approaches for preventing healthcare-associated infections: go long or go wide?. Infection Control & Hospital Epidemiology, 35(7), 797-801.
Smiddy, M. P., O’Connell, R., & Creedon, S. A. (2015). Systematic qualitative literature review of health care workers’ compliance with hand hygiene guidelines. American journal of infection control, 43(3), 269-274.
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