Problem Description
The case at hand points out that the risk for readmission and occurrence of preventable complications as high in the home care settings upon discharge from ambulatory surgery centers. This problem implies that upon discharge, the patient’s risk of complication was much higher than their counterparts in full-time clinical settings. In a bid to address this problem, it is vital to organize an effort to reduce chances of complication and readmission rates due to lack of poor service delivery in homecare settings.
The ambulatory surgery settings, otherwise named ambulatory surgery centers (ASCs), represent a type of facilities that provide patients with surgical services and procedures outside the clinical setting. They work with homes as a viable care environment for the entire treatment process. The homecare environment represents a system of care offered by skilled physicians to patients in home environments. According to Rhinehart (2001), some of the services under this system include physical therapy, nursing care, occupational, and medical-related social services. The primary objective of the system in ASCs capacity is to improve health outcomes for post-operative patients. Other goals include helping them live with enhanced autonomy, promoting their optimal well-being, and assisting them to remain in homecare environments.
The other vital characteristic of homecare systems is that clinicians offer care to each of their patients in a tailored setting. However, there are situational variables under this setting that present infection risks to patients that are out of the clinicians’ control. For instance, unlike hospitals, homecare environments lack the clinical service delivery aspects that monitor the quality of care and inhibit the occurrence of preventable complications. Contrarily, caregivers in home care environments may lack the resources and training required to assess and eliminate such risks. Such instances call for QI practices to help improve homecare patient management techniques to prevent the occurrence of preventable complications and readmission into hospitals (Ellenbecker, Samia, Cushman, & Alster, 2008).
Background
The past decade has witnessed a gradual progress towards the integration of healthcare settings. Such models serve as critical structures aimed at improving the quality of life, solving inefficiencies, and improving outcomes. The case at hand calls for the integration of ambulatory surgery and home care settings. There is a notable difference between homecare environments and ambulatory surgery centers. According to Rhinehart (2001), unlike ASCs, homecare environments direct that nurses work alone with limited or no assistance from their parent organization. Therefore, there is less direct patient-physician contact. Ideally, physicians depend on nurses and family members to continue with the treatment plan and help communicate findings where appropriate.
That said, it is vital to note that numerous studies have been done on the home care setting as a challenging healing environment for post-surgery patients. For instance, Rhinehart (2001) notes that though homecare continues to expand in scope and intensity, infection surveillance, control, and prevention efforts lag behind. The author describes the environment as a situation where patients are under the care of family members with occasional visits from a trained practitioner. The condition means that patients have limited access to appropriate services and may experience a number of risk factors such as immunosuppression and chronic illnesses leading to readmission. Also absent is the basic principle of controlling and preventing infection such as proper sanitation and ventilation. Rhinehart (2001) concludes by stating the need for patient-centered and scientific-based practices to help reduce such risks.
Gershon et al. (2008) explored some of the safety hazards leading to infection available to patients in homecare settings. The authors began by identifying home care settings as a vigorously growing system in the US health care sector. However, the issue presents itself in the increase of risk factors that affect health outcomes and safety in such uncontrolled settings. Gershon et al. (2008) used a convenience sample comprised of home care aides, personal care workers, and untrained attendants to conduct the survey. The results revealed an exposure to a variety of health hazards that could result in reinfection, all touching on an unsafe healing environment. They concluded that homecare patients are at a greater risk of infection hence readmission.
Key Themes for Improvement Efforts
Two themes for improvement efforts emerge from this case. First, ASCs have improved care delivery, but their coordination with home care settings remain modest. Homecare nurses usually work alone with limited or no support from both the lead physician and informal caregivers. Proper coordination during home visits may enhance communication and data collection. Both parties rely on the visiting nurse to communicate findings as well as make assessments concerning patient progress. The relationship in question here shows the existence of the nurse’s less direct contact with physicians and family members, hence negatively affecting health outcomes.
Second, there is a need to educate home care aides on ideal practices that control the occurrence of preventable complications. Most home-bound patients are either on self-care or receive health-associated assistance from informal caregivers such as nannies, family, and friends. In such environments, clinicians have limited or no authority over these individuals. Furthermore, in home environments, the absence of a practitioner would limit the caregivers’ ability to observe care quality, thus leading to complications.
The reason for these choices is that to become truly successful, the homecare setting requires the support of ASC physicians among other important caregivers within the healthcare system. Both themes call for inclusiveness of all people involved to help manage the entire service delivery process. They all identify as respectable persons to that liaise in between settings to improve service delivery.
Improvement Process (PDSA)
The improvement process best suited for this project is the Plan-Do-Study-Act (PDSA) model (see diagram 1). The PDSA cycle is useful in testing change through the development of QI plan given four major stages, namely planning, doing, studying and acting. The planning stage describes the change to be implemented or tested upon analysis. Next, the team then perform the change or test process. The third stage includes the collection of data before and after the given change as a reflection of any visible issues. Finally, the team either prepares the organization for full change implementation or plans for the next change process (Taylor, et al., 2013).
This process acknowledges the fact that cycles may happen simultaneously given complex changes, usually hooked to different departments. Therefore, teams that follow this process should find it vital to identify the interactions existing between such cycles. For instance, making changes regarding nurse visits to one home care setting could alter the change of another setting within the same ASC. There is vitality in changing the whole process so that the nurse focuses on each homecare setting at different times (Taylor, et al., 2013).
The cycle is applicable to this situation because it offers a framework suitable for establishing, testing, and implementing progressive changes for QI in the ASC. This model relies on the scientific technique and helps moderate the impulse required to take immediate action. As stated, the primary goal of this plan is to reduce the chance of complication occurrence in homecare settings upon discharge from ambulatory surgery settings to prevent subsequent readmissions. Thus, there are three major justifications to this QI method. First, the PDSA technique is effective in terms of money, time, and risk. Second, the tool is powerful in a way that it uses teamwork to enhance learning from various workable ideas. Third, the tool is safe and will be less disruptive for both patients of staff.
Alternative Approaches
First, the Fishbone diagram and “Five Whys” approach will be useful in brainstorming and mapping out generalized potential causes of the problem earmarked for improvement. The diagram acts as an important initial step to help in listing all possible causes. This paper uses a fishbone diagram (see diagram 2) that comprises of four major groupings, namely environment, method, equipment, and people. The next step would involve giving the team an opportunity to identify different causes to the central effect on the far right. Finally, the successful completion of this process would allow for a cause-effect analysis as outlined below.
As a simple brainstorming QI tool, the Five Whys works with perfectly with the PDSA to get to the root causes of a problem. For a problem identified using the Fishbone diagram, one would ask the “why” questions as a drill-down to the root cause. In this case, the following questions are applicable. Why could be the patients at risk of preventable complications? They cannot find appropriate care within the home. Why can they not find appropriate care? They may lack proper education and resources that teach on quality service delivery. Why don’t they have access to proper education and resources on quality service delivery? ASCs personnel does not mention it during the discharge process or when they visit during routine check-ups. Why don’t they let them know now? Let’s test it.
Second, seeking external support to provide solutions through feedback and benchmarking. According to Michel, Levif, and Ettorchi-Tardy (2012), feedback offers the QI team information on the primary indicators that facilitate or inhibit proper service delivery in the home. Some of the processes would include the service in usage, patient experience, and the cost of operating homecare services. Contrarily, benchmarking would encourage teams to compare performance with other health settings and the national target to test for compliance. This alternative would offer the direction and motivation needed to reduce the risk of readmission. Furthermore, it will help in identifying the gaps evident during service delivery for improvement. Finally, it allows for teams to track the required changes in patient performance given time (Michel et al., 2012).
Third, another alternative approach would involve the use of shared learning as a way of solving the ASC-homecare dilemma. In this case, practitioners collaborate to train share experiences and evaluate performance in their respective healthcare settings. They then work on a team basis to implement changes that would help improve the health outcomes of patients in the home environment. This alternative offers inspiration and motivation through the creation of a multidisciplinary community that shares peer-to-peer experiences. The alternative also creates the pressure needed to enhance change within the respective environment.
Faced with this problem, I would have assembled a QI team comprising of physicians, nurses, and informal representatives from the home setting. My team would look into the risk factors that drive infection occurrence and consider which of these risks appeared as first priority. I would then allow a week for the team to study the problem, brainstorm, and rank interventions based on past research and experience. The team would then discuss their findings, including coordination, communication, home care visits, and education as some of the possible intervention. They would then, maybe, settle for the PDSA model as part of the process that makes the change more consistent. The first idea could include amending the communication process to allow for feedback and change management. The nurses would take responsibility for liaising between the ASC and the home. After a month or so, the team would study the change process and explore for any changes in readmission rates 24 hours upon discharge. The results would direct whether we require another trial or stick to communication as the ultimate solution.
References
Ellenbecker, H., Samia, L., Cushman, M., & Alster, K. (2008). Patient Safety and Quality in Home Health Care. Retrieved from NCBI: http://www.ncbi.nlm.nih.gov/books/NBK2631/
Gershon, R., Pogorzelska, M., Qureshi, K., Stone, P., Canton, A., Samar, S., . . . Sherman, M. (2008). Home Health Care Patients and Safety Hazards in the Home: Preliminary Findings. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK43619/
Michel, P., Levif, M., & Ettorchi-Tardy, A. (2012). Benchmarking: A Method for Continuous Quality Improvement in Health. Journal of Healthcare Policy, 7 (4), 101-119.
Phillips, J., & Simmonds, L. (2013). Change management tools part 1: using fishbone analysis to investigate problems. Nursing Times,109 (15), 18-20.
Rhinehart, E. (2001, March-April). Prevention is Primary: Infection Control in Home Care. Retrieved from Centers for Disease Control and Prevention : http://wwwnc.cdc.gov/eid/article/7/2/70-0208
Taylor, M., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. (2013). Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Quality and Safety. doi:10.1136/bmjqs-2013-001862
PDSA (Diagram 1)
Fishbone Diagram (diagram 2)
