Research and describe at least 2 measures that you plan to use in your facility that are currently used to gauge quality in health care.

Sample Solution

Quality Measures for Week 5

This section explores two quality measures I plan to implement in my facility to gauge healthcare quality:

1. Hospital Readmission Rate (HWRR):

The HWRR reflects the percentage of patients readmitted to the hospital within a specific timeframe (typically 30 days) after discharge for the same or related condition [1].

• Data Collection: Data can be collected from electronic health records (EHR) by tracking readmissions within 30 days of discharge for specific diagnoses, such as heart failure, pneumonia, and chronic obstructive pulmonary disease (COPD).

• Analysis: We will calculate the HWRR quarterly and compare it to national benchmarks. We can also analyze readmissions by department, physician, and diagnosis to identify areas for improvement.

• Benchmark and Rationale: A national target of less than 18% readmissions for Medicare patients has been set by various healthcare organizations [2]. Our initial benchmark will be 20%, aiming for a gradual reduction towards the national target within a year. This allows for initial improvement and time to implement interventions to address potential causes of readmissions, such as inadequate discharge planning or lack of follow-up care.

2. Hand Hygiene Compliance Rate:

Hand hygiene is a crucial factor in preventing healthcare-associated infections (HAIs) [3]. This measure tracks the percentage of hand hygiene opportunities where healthcare personnel correctly perform handwashing or use alcohol-based hand rub.

• Data Collection: Direct observation by trained personnel is the gold standard for monitoring hand hygiene compliance. Trained observers will randomly select healthcare workers throughout the day and different units to observe hand hygiene practices at designated moments (e.g., before patient contact).

• Analysis: We will calculate the hand hygiene compliance rate monthly and compare it to national benchmarks. We can also analyze compliance by department, shift, and type of healthcare worker.

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Full Answer Section

• Benchmark and Rationale: The World Health Organization (WHO) recommends a hand hygiene compliance rate of at least 80% [4]. Our initial benchmark will be 70%, aiming to reach 80% within six months. This allows for focused training and education programs to improve hand hygiene practices among staff.

By monitoring these quality measures, we can identify areas for improvement, implement targeted interventions, and ultimately enhance patient safety and quality of care.

References:

[1] Centers for Medicare & Medicaid Services (CMS). (n.d.) Hospital readmission reduction program. Retrieved from https://www.cms.gov/medicare/quality/value-based-programs/hospital-readmissions (accessed June 7, 2024) [2] American Hospital Association (AHA). (2019). AHA advocacy priorities: Reducing hospital readmissions. Retrieved from https://www.aha.org/topics/readmissions-0 (accessed June 7, 2024) [3] World Health Organization (WHO). (2019). Guidelines on hand hygiene in healthcare. Retrieved from https://www.who.int/teams/integrated-health-services/infection-prevention-control/hand-hygiene (accessed June 7, 2024) [4] World Health Organization (WHO). (2015). Clean hands save lives: A global campaign to improve hand hygiene. Retrieved from https://www.who.int/campaigns/world-hand-hygiene-day (accessed June 7, 2024)