D912 Task 1 Quality Improvement Project Design Example

What Is This Pill For? A Quality Improvement Project Design to Raise a Composite Hospital's Patient Experience Scores on Communication About Medicines

Student Name

Leavitt School of Health, Western Governors University

D912: Healthcare Quality, Task 1

Course Instructor

Month Day, Year

What Is This Pill For? A Quality Improvement Project Design to Raise a Composite Hospital's Patient Experience Scores on Communication About Medicines

The Quality Gap and Why It Matters

Riverside Medical Center is a composite 240-bed hospital. On the national HCAHPS patient experience survey, its score for communication about medicines, the share of patients giving the most favorable answers when asked whether staff told them the purpose of each new medicine and explained its possible side effects understandably, has been 55% for four quarters, about seven points below the national average. Side effects are the weaker of the two questions: only 44% of Riverside's patients said staff always described them understandably.

The gap matters for patients, because a patient who does not know why a new medicine was started or what side effects to watch for is less able to take it safely after discharge. It also matters financially. Under Medicare's Hospital Value-Based Purchasing program, a portion of hospital payments is withheld and redistributed according to performance, and patient experience measured by HCAHPS forms one of the program's scoring domains. An analysis of the program found that hospitals earn patient experience points for achievement, improvement and consistency, and that points for improvement were especially valuable for lower-performing hospitals (Elliott et al., 2016). Riverside can therefore gain from improvement even before it reaches the national average.

Aim

Within 12 months, raise Riverside's HCAHPS communication about medicines score on its four medical-surgical units from 55% to 65%, and the side effects question from 44% to 55%.

Root Causes

A project team observed medication passes on two units, reviewed 30 patient comments and held huddles with nurses and pharmacists, then organized the causes in a fishbone diagram. Four causes stood out. New medications are often given during a busy medication pass with no signal to the nurse that the drug is new to the patient. The printed drug information sheets are long and pitched at a reading level many patients cannot manage. Nurses report being less confident describing side effects for some drug classes, especially new anticoagulants and antibiotics. And medication teaching is concentrated at discharge, when patients are tired and distracted.

Improvement Method and Interventions

The project will use Plan-Do-Study-Act cycles, testing each change on one unit before spreading it. Three interventions answer the root causes.

First, a new medicine prompt. The electronic medication administration record will flag the first dose of any medication new to the patient. The flag prompts the nurse to use a short script covering what the medicine is for and its two most common side effects, followed by teach-back, in which the patient explains the information in his or her own words.

Second, plain-language side effect cards. The pharmacy will write one-page cards for the 40 medications most often started on the units, at a sixth-grade reading level, and nurses will leave the card at the bedside after the first dose. Pairing a simple reminder with teaching has worked before: at one hospital, pairing medication information labels with briefing and teach-back raised unit HCAHPS scores for medication communication from 55% to 79%, a change that persisted for three quarters (Gillam et al., 2016).

Third, a unit-based pharmacist pilot. A clinical pharmacist will be assigned to two of the four units for six months to review new medications with patients each weekday. At an orthopedic hospital, units with a unit-based clinical pharmacist saw significant increases in the percentage of patients who reported receiving and understanding medication information (Guerin et al., 2020). The pilot will show whether the benefit justifies the cost of expanding to all units.

Stakeholders and Roles

The chief nursing officer sponsors the project and removes barriers. The director of patient experience leads it and manages the data. Nurse managers on the four units own implementation on their units, supported by one staff nurse champion per unit. The pharmacy director is responsible for the side effect cards and the pharmacist pilot. The EHR team builds the new medicine prompt. Hospitalists are consulted because they order the new medications and can reinforce the teaching on rounds. A pair of patient and family advisors from the hospital's council review the cards and the nurse script before they are tested, and the finance department estimates the project's effect on value-based payment.

Measures

The outcome measures are the HCAHPS communication about medicines composite and its side effects question, reported by unit each month, with baselines of 55% and 44% and targets of 65% and 55%. The process measures are the percentage of first doses with documented teach-back, from the EHR (baseline not recorded; target 85%), and the percentage of patients on the pilot units seen by the pharmacist (target 70%). The balancing measures are average medication pass time and nurse overtime hours, to make sure the added teaching does not delay other care or burn out staff.

Timeline

Months 1 and 2: baseline data, fishbone analysis, script and cards drafted and reviewed by the patient advisors. Months 3 and 4: first PDSA cycle on one unit with the prompt, script and cards. Month 5: revise and spread to all four units; begin the pharmacist pilot on two units. Months 6 to 11: monitor, run further cycles as needed. Month 12: evaluate the pilot and decide on expansion.

Two risks could slow the timeline. HCAHPS results arrive in small monthly samples, so a single unit's score can swing by several points by chance; the team will judge progress on three-month rolling results and on the process measures, which respond faster. And the pharmacist pilot depends on filling a position; if hiring takes longer than two months, the pilot will start with pharmacy residents on one unit rather than wait.

Communicating Results

Results will reach each audience in a form it can use. Frontline nurses will see a run chart of their unit's teach-back rate and monthly scores at weekly huddles. Unit leaders will review a one-page dashboard monthly. The hospital's quality committee will receive a quarterly report on all measures, including the balancing measures, and the board will receive a summary at mid-year and at the end of the project with the estimated effect on value-based payment. Patients will hear about the project through the patient and family advisory council, and staff whose teaching is praised in patient comments will be recognized by name at huddles.

References

Elliott, M. N., Beckett, M. K., Lehrman, W. G., Cleary, P., Cohea, C. W., Giordano, L. A., Goldstein, E. H., & Damberg, C. L. (2016). Understanding the role played by Medicare's patient experience points system in hospital reimbursement. Health Affairs, 35(9), 1673-1680. https://doi.org/10.1377/hlthaff.2015.0691

Gillam, S. W., Gillam, A. R., Casler, T. L., & Curcio, K. (2016). Education for medications and side effects: A two part mechanism for improving the patient experience. Applied Nursing Research, 31, 72-78. https://doi.org/10.1016/j.apnr.2015.11.017

Guerin, K., Quinlan, P., Wessolock, R., Goldberg, S., Nguyen, J. T., & Stone, P. W. (2020). Impact of a unit-based clinical pharmacist on communication of medication information in an orthopedic hospital. HSS Journal, 16(Suppl. 2), 333-338. https://doi.org/10.1007/s11420-019-09739-2