Download Heart Failure Quality Improvement Process

Running head: QUALITY IMPROVEMENT PROCESS
Heart Failure Quality Improvement Process
Trevor Mattarella
Ferris State University
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Abstract
The purpose of this paper is to focus on leadership strategy analysis to improve current
documentation methods in heart failure patients regarding their intake, output, and daily weights.
The analysis is supported by current evidence-based nursing practice in order to promote new
documentation methods and useful interventions to improve current plan of care in heart failure
patients through improved documentation techniques. The analysis will elaborate and explain the
validity of the research based on the clinical need, data collection method, outcomes,
implementation strategies, and evaluation of new techniques.
Keywords: heart failure, documentation, interdisciplinary team, data collection
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Heart Failure Quality Improvement Process
The patient population has recently experienced an increase in the incidence and
occurrence of heart failure (HF). According to A.D.A.M. Medical Encyclopedia (2012), heart
failure is defined as the following, "A condition in which the heart cannot pump enough blood to
the rest of the body". This medical condition is classified as chronic and involves extensive
management of medications, intake, output, and monitoring body weights daily. The quality and
safety initiatives in the following improvement process focus on improved documentation of
intake, output and daily weights regarding HF patients. It has been discovered on the cardiac
nursing unit in which I currently work as a registered nurse that the documentation of intake,
output and daily weights has been considered well below the expected documentation
requirements. These problems with documentation accuracy must be improved immediately to
assist patients with safety and overall quality of care of heart failure patients. The leadership
strategy that will be elaborated upon involve measures to improve documentation methods to
ensure better results in the cardiac unit. The changes in documentation methods will be
performed under the supervision of a specialized health care team to ensure improved accuracy
of intake, output, and daily weights in heart failure patients.
Clinical Need
Heart failure patients require significant medical management on behalf of the patients
and the health care professionals providing care for the individual. While under hospitalized care,
it is necessary to improve on the accuracy of the intake, output and daily weights of each patient
to assess the effectiveness of diuretic therapy and diagnostic testing. Congestive heart failure is a
chronic problem but with efficient home management of heart failure, readmissions rates related
to heart failure exacerbation should decline. According to DeFelice, et al. (2010), "Chronic
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illness consumes 82% of the health care dollars in the United States. Despite this, patients with
chronic illness receive only 56% of recommended care" (p. 390). Chronic illnesses, such as
congestive heart failure should be taken more seriously in the hospital by nursing staff to prevent
future readmissions or extended hospitalization due to poor documentation. DeFilice et al. (2010),
states, "Disease management programs have been shown to help patients with chronic illnesses
achieve optimum health and to control costs through an integrative care approach" (p. 390). The
management programs are primarily nursing driven; therefore, redefining health care in the
United States which will have a dramatic impact on the role of nursing in patient care (DeFilice,
et al., 2010). The author of this paper works in a cardiac telemetry unit that specializes in
providing care to cardiac patients and is currently advocating for the improvement of
documentation methods to accurately record intake, output, and daily weights for heart failure
patients.
Interdisciplinary Team
The goal of making changes to improve the documentation of intake, output and daily
weights in heart failure patients will require an interdisciplinary team. An interdisciplinary team
will be formed to review standard documentation methods as compared to news method of
collecting patient data regarding intake, output and daily weights. The interdisciplinary team to
be formed will include registered nurses, nursing care assistants, cardiologists, physicians, a
clinical nurse educator and hospitality ambassadors. The registered nurses and the nursing care
assistants whom are providing direct patient care will be responsible to actively document the
intake, output and daily weights of all heart failure patients within the cardiac unit. The
hospitality ambassadors who take meal orders and deliver trays to patients will also be
responsible to assist with data collection. They have been removing trays from the room at times
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without notifying a nurse or nursing care assistant, and they should be responsible to make note
of the amount of intake prior to discarding the tray to allow staff to document accurately. The
clinical nurse educator will be responsible to implement and provide education for staff about the
new documentation methods, which will ensure quality care and patient safety. The physicians
and cardiologists within the interdisciplinary team will be responsible to oversee the accuracy of
documentation trends to verify if the new methods are improving the medical management of
their patients.
Data Collection Method
The type of data collection method is very important to successfully implement change
within nursing practice. According to Yoder-Wise (2011), "After the multidisciplinary teams
forms, the group collects data to measure the current status of the activity, service, or procedure
under review" (p. 396). The most accurate form of data collection would be the use of a Pareto
chart to assess the lack of documentation and missing areas of intake, output and daily weights in
heart failure patients. Yoder-Wise (2011) states, "A bar chart that identifies the major causes or
components of a particular quality control problem is called a Pareto chart" (p.396). The Pareto
chart is influential to this topic because it involves leadership strategy. According to Yoder-Wise
(2011), "Used often in quality improvement, the Pareto chart helps the quality improvement team
determine priorities, allowing the most significant problems to be addressed first" (p.398). The
leadership of physicians and cardiologists to supervise the quality improvement implementation
of new standards of care regarding documentation of intake, output and daily weights is essential
to success. Application of the Pareto chart will support the use of the current leadership strategy
and data collection methods to assess need for change. Proper data collection methods will help
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to ensure successful documentation methods and positive patient outcomes of heart failure
patients.
Outcomes
The goal after implementation of the new strategies would be accurate and consistent
documentation of HF patient’s intake, output and daily weights necessary to assess and monitor
heart failure therapy effectiveness. Yoder-Wise (2011) states, "This goal can be established in a
number of ways but always involves a standard of practice and a measurable patient-care
outcome or nursing-sensitive outcome" (p.399). The diet, fluid intake and daily weights are
essential to properly treating heart failure and providing patients with the best results. According
to Ignatavicius and Workman (2010), "In heart failure, nutrition therapy is aimed at reducing
sodium and water retention" (p.772). At times patients may experience a craving for water in
excess, which means that a fluid restriction would be necessary to monitor for improvement or
worsening of their condition. The accurate documentation of fluid intake, output and daily
weights cannot be overlooked, to determine the effectiveness of heart failure management and
therapy. Ignatavicius and Workman's (2010) strategy stated, "Their fluid intake may be limited to
a more normal 2 liters daily. Adherence to these simple strategies varies. Supervise unlicensed
assistive personnel (UAP) to ensure that they limit the prescribed intake and accurately record
intake and output" (p. 772).
Evidence-based practice and nursing theory have proven the importance of properly
documenting intake, output and daily weights of patients with heart failure. The expected patient
outcomes would be decreased length of hospitalization and better effectiveness with diuretic
therapy when using these important management principles. According to Georgiopoulou,
Kalogeropoulos and Butler from Emory Clinical Cardiovascular Research Institute (2012),
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"Unfortunately, most participants return to their baseline dietary habits or regain the weight lost.
The effectiveness of major lifestyle changes for the general population can be challenged,
especially when supplementary measures to increase adherence to these changes, including
population-based strategies" (p. 1382). The evidence based practice examples support the need
for accurate documentation to achieve positive patient outcomes for heart failure management
and ensure quality health care.
Implementation Strategies
The process for implementing change to increase accuracy of documenting intake, output
and daily weights will be presented using a Pareto chart. The main changes that will need to
occur to increase patient success is accountability of the nursing care assistant’s documentation,
just as the registered nurse is responsible to chart accurately. However, the nurse is not always
the person removing the tray from the room. It will be required by the staff member removing
the tray to write the intake, amount of fluids and the time consumed. If the trays are removed by
the nursing care assistant, they will chart the amount before the end of their shift. A hospitality
ambassador removing a tray will be required to give the paper with the amount of intake on it to
the nurse or the nursing care assistant responsible for that particular patient. Heart failure
management as stated by Ignatavicius and Workman through evidence based practice (2010),
"Weigh the patient daily, or delegate this activity to UAP and supervise that it is done. Keep in
mind that 1 kg of weight gain or loss equals 1 liter of retained or lost fluid" (p. 772). The other
issue with measuring daily weights is that the scale used from day to day is not the same scale
and they are not calibrated as frequently as needed. The current calibration protocol is only to
ensure proper calibration every year. Calibration of the scales will occur every two months to
ensure accurate weights, to manage heart failure and assess for trends in weight. The same scale
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must be used to weight patients. There will be a number assigned to each scale so it will be
known which scale was used to compare weights from day to day.
The clinical nurse educator is responsible to ensure the nursing staff, both registered
nurses and nursing care assistants, is providing quality documentation. The clinical nurse
educator will also be responsible to provide further education regarding implementation
strategies and future changes regarding documentation. They will be responsible to meet with
physicians and cardiologists to focus on the improvement of documentation regarding intake,
output and daily weights in heart failure patients. The meetings between the educator and the
physicians will assist in analysis of current implementation strategies and to assess areas of
improvement. Ultimately the registered nurse will be responsible for the documentation of these
important aspects of heart failure patients, however the nursing care assistants will be held
accountable and have chart checks done periodically. According to Yoder-Wise (2011),
"Hospitals whose practice environment includes investment in staff development, quality
management, frontline managerial ability, and good nurse-physician relations are associated
with better nurse and patient outcomes" (p. 407). The improved relations among staff sharing the
documentation workload will ultimately help patients to achieve better results and shortened
hospitalization.
Evaluation
The evaluations of proposed changes are important to assess if the implementation
strategies are working well. The process of evaluating the implementation strategies will involve
all members of the discipline including physicians, clinical nurse educator, staff nurses, nursing
care assistants, and hospitality ambassadors. The inclusion of all staff members will allow the
process to be communicated to everyone. This will assist with creating better documentation
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collection and more accurate intake, output and daily weights. The method of evaluating success
with the new implemented strategies will begin with monthly meetings to analyze the
documentation. The meetings will involve all members of the discipline to help keep everyone
working collaboratively to achieve common goals. Physicians will be assessing the quality of
documentation as they are tracking intake, output and daily weights of heart failure patients. The
interdisciplinary team of physicians, cardiologists, and clinical nurse educators will meet every
three months to discuss how the implementation strategies are working. After they meet, they
will bring the statistics to the meeting with all staff members to assess whether the
implementation strategies are working or if adjustments need to be initiated.
The plan of care will be determined based on the improved accuracy of documentation
methods. This will hopefully bring positive change to the cardiac unit and promote improved
patient outcomes. According to Yoder-Wise (2011), "Creating and leading change rather than
merely reacting can promote overall organizational effectiveness" (p. 341). The change of
documentation requirements will ultimately increase the success rates pertaining to the medical
management of heart failure patients. Once all staff members are accepting of the change, they
will be able to provide better, more competent care to heart failure patients, thus decreasing the
length of hospitalization. Documentation of intake, output and daily weights is essential to
proper management of heart failure patients and ensuring proper interventions in the treatment
plan.
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References
Chen, M.M. (2012). Heart failure: Overview. A.D.A.M. Medical Encyclopedia. Retrieved March
16, 2013 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001211/
Defilice, P., Masucci, M., McLoughlin, J., Salvatore, S., Shane, M., & Wong, D., (2010).
Congestive heart failure: Redefining health care and nursing. Journal of Continuing
Education Nursing, 41(9), 390-391. Retrieved March 16, 2013 from http://0web.ebscohost.com.libcat.ferris.edu/ehost/pdfviewer/pdfviewer?vid=5&sid=54f75f9c2587-4d4f-b5e8-89a6d82434a8%40sessionmgr113&hid=117
Georgiopoulou, V.V., Kalogeropoulos A.P., & Butler, J. (2012). Heart failure and hypertension:
Prevention and treatment. Emory Clinical Cardiovascular Research Institute. 72(10),
1373-1398. Retrieved March 18, 2013 from http://0web.ebscohost.com.libcat.ferris.edu/ehost/detail?sid=46bc69ce-1c39-4a70-9f55acfacb705fdf%40sessionmgr114&vid=11&bk=1&hid=118&bdata=JnNpdGU9ZWhvc3Q
tbGl2ZQ%3d%3d#db=cin20&AN=2011632001
Yoder-Wise, P. S. (2011). Leading and managing in nursing (5th ed.). St. Louis, MO: Mosby