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Running head: QUALITY IMPROVEMENT PROCESS Heart Failure Quality Improvement Process Trevor Mattarella Ferris State University 1 QUALITY IMPROVEMENT PROCESS 2 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 QUALITY IMPROVEMENT PROCESS 3 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 QUALITY IMPROVEMENT PROCESS 4 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 QUALITY IMPROVEMENT PROCESS 5 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 QUALITY IMPROVEMENT PROCESS 6 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), QUALITY IMPROVEMENT PROCESS 7 "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 QUALITY IMPROVEMENT PROCESS 8 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 QUALITY IMPROVEMENT PROCESS 9 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. QUALITY IMPROVEMENT PROCESS 10 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