Section 3: Quality Measurement and Assessment

Pneumonia 30 day readmission is the quality improvement issue

Think about the quality improvement issue that you are addressing and the associated plan that you are developing. Consider the following:

· What is the overall purpose, or aim, of doing this work?

· What would you hope to achieve for the organization by undertaking this project? What are the objectives of this initiative?

· What value would this work add to the organization?

· How would this work improve practice and create outcomes with impact?

Consider how addressing this quality improvement issue would align with the organization’s mission, vision, values, and strategic goals and objectives. How does it relate to regulatory issues, and other matters that are significant for the organization? If you notice a misalignment, use this as an opportunity to refine your focus.

With this in mind, continue to hone your development of this Assignment, integrating the concepts addressed here into Section 3.

To complete:

Write a 3- to 5-page paper that includes:

· An introduction to your quality improvement plan, including the overarching aim of this initiative and an explanation of how it aligns with the mission, vision, values, and strategic goals and objectives of the organization, as well as regulatory issues and other matters that are significant for the organization

· An overview of the current situation with regard to this quality improvement issue in the organization

· A description of measures and indicators

· A presentation on data related to this issue, including:

· Actual historical and current data and/or a description of the methods that you would use to collect and analyze the data

· Methods for collecting and analyzing data in the future, including when you would do this

· A description of realistic, evidence-based targets

Be sure to cite evidence from the literature to justify your selection of the measures and indicators, as well as the performance targets. 

Section 4: Quality Improvement Strategies

Through your work on Section 3 of the Course Project, you have examined the gap between current performance and evidence-based targets and considered how addressing this gap relates to organizational priorities and large-scale aims for quality improvement.

In this section of the Course Project, you begin to think about quality improvement strategies that could help to bridge this gap. As noted in the Sadeghi, Barzi, Mikhail, and Shabot text, this is referred to as performance-driven planning.

Since the publication of the Institute of Medicine’s report “Crossing the Quality Chasm,” a good deal of attention has been paid to the need to examine processes that contribute to outcomes (Ernst, Wooldridge, Conway, Dressman, Weiland, Tucker, and Seid). As the USAID has noted, interventions “will not create the desired outcome to improve the quality of care unless the overall process of care delivery is also improved.” Therefore, attention to process redesign is a central aspect of cultivating strategies for improvement.

To prepare:

· Refer to the modified Donabedian model (access, structure, process, outcome, and patient experience) presented in Chapter 9 of the Sadeghi, Barzi, Mikhail, and Shabot text.

· Recall the performance targets that you identified for Section 3 (in Week 6). What does the recommendation that performance-driven planning should “begin with the end in mind” suggest given your established goals?

· Review the information presented in Chapter 9 of the Sadeghi, Barzi, Mikhail, and Shabot text, and think about how you would assess the organization’s strengths and weaknesses related to the performance gaps you identified in Section 3 (Week 6).

· Based on the above, start to think of specific evidence-based strategies that could be implemented to close/minimize the performance gaps you have identified. Consider both interventions (what) and processes (how). Focus on strategies that are supported by the latest research and could create systems-level change. These may be tentative for now, but be sure to identify at least one that specifically lends itself to a change in process (i.e., practice, protocol, pathway, activity).

Throughout this course you have been considering the relationship between structure, process, and outcomes as it relates to health care quality. Looking at outcomes, alone, may not tell the “whole story.” For instance, if you are concerned with improving fall rates, evaluating the process—related activities or practices—can help you identify factors that contribute to outcomes and develop strategies for improving them.

For this section of your Course Project, you create a process map to examine a current process related to your quality improvement issue. You will use the results of the process mapping to redesign a process to help minimize or close the performance gap(s). As you proceed, keep in mind the importance of maintaining a patient-centered focus so the patient experience is not negatively affected by any changes in process.

To prepare:

· Review the instructions provided in the Learning Resources for creating a process map.

· With your quality improvement issue in mind, as well as the other work you have completed on your Course Project thus far, think about how creating a process map could help you to better understand your quality improvement issue and redesign an associated process.

· Create a process map using Microsoft Word or PowerPoint.

· Refine the strategies for promoting systems-level change to minimize or close the performance gap(s) that you began to think about in Week 7. As part of this, identify a way to redesign at least one process based on your analysis of the process map that you have created.

To complete:

· Write a 2- to 3-page paper in which you describe quality improvement strategies that you selected related to your quality improvement issue.

· Finalize your process map, which will be submitted along with the paper.

Process map help

https://www.isixsigma.com/tools-templates/process-mapping/practical-guide-creating-better-looking-process-maps/

Provides detailed description of how to create a process map

http://www.miltonkeynesccg.nhs.uk/resources/uploads/files/NHS%20III%20Handbook%20serviceimprove.pdf

 

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In preparation for this hypothetical coaching exercise, identify one individual, staff member, or employee (from your current organization or a past setting) who could benefit from coaching. Create a pseudonym for him or her.

Use the six-step coaching process to develop a coaching and development plan

   

Submit a 5- to 7-page paper in which you do the following:

Step One: Determine your intention.

· Describe your intention and purpose for coaching this specific individual.

· Explain the goals, skills, and/or competencies you have in mind, and define your primary focus.

· Explain how you would engage this individual in identifying these and other development opportunities.

Step Two: Assess the performer.

· Identify the individual’s strengths and level of development.

· Explain the leadership style and interventions that would be most appropriate to help this individual achieve his or her identified goals, skills, and/or competencies.

Step Three: Clarify expectations and parameters.

· Describe the roles and expectations of both you and the individual.

· Outline the learning opportunities you could provide and the order in which they should be approached.

· Identify the specific objectives to be achieved for each learning opportunity.

· Explain the coaching best practices you would apply and why.

Step Four: Carry out the coaching intervention.

· List the coaching questions you might develop to ensure that learning opportunities and interventions are applied as needed, and explain how any additional development opportunities might help to address your intended coaching goals.

Step Five: Observe performance.

· Explain the observation method you will use to assess whether or not your coaching has been effective.

Step Six: Give feedback.

· Describe how you will administer feedback to this individual.

 

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Post an explanation of how competing needs, such as the needs of the workforce, resources, and patients, may impact the development of policy. Then, describe any specific competing needs that may impact the national healthcare issue/stressor you selected. What are the impacts, and how might policy address these competing needs? Be specific and provide examples.

 

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 Volume 2, Case #21: Hindsight is always 20/20, or attention deficit hyperactivity disorder 

 

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Question 20

A patient recovering from shingles presents with tenderness and sensitivity to the upper back. He states it is bothersome to put a shirt on most days. This patient has end stage renal disease (ESRD) and is scheduled to have hemodialysis tomorrow but states that he does not know how he can lie in a recliner for 3 hours feeling this uncomfortable. What will be the PMHNP’s priority?

a) order herpes simplex virus (HSV) antibody testing

b) Order a blood urea nitrogen (BUN) and creatinine STAT

c) Prescribe lidocaine 5%

d) Prescribe hydromorphone (dilaudid) 2mg

Question 21

The PMHNP prescribed a patient lamotrigine (Lamictal), 25 mg by mouth daily, for nerve pain 6 months ago. The patient suddenly presents to the office with the complaint that the medication is no longer working and complains of increased pain. What action will the PMHNP most likely take? 

a) Increase the dose of lamotrigine (Lamictal) to 25mg twice daily

b) Ask if the pt has been taking the medication as prescribed

c) Order gabapentin, 100mg TID because lamotrigine is no longer working for this patient

d) Order a CBC to assess for an infection

Question 22

An elderly woman with a hx of alzheimer’s disease, coronary artery disease, and myocardial infarction had a fall at home 3 months ago that resulted in her receiving an open reduction internal fixation. While assessing this patient, the pmhnp is made aware that the patient continues to experience mild to moderate pain. What is the pmhnp most likely to do?

a) order an X-ray because it is possible that she dislocated her hip

b) order ibuprofen because she mayneed long term treatment and chronic pain is not uncommon

c) Order naproxen because she may havarthritis and chronic pain is not uncommon

d) Order morphine and physical therapy

Question 23

The PMHNP is assessing a 49-year-old male with a history of depression, post-traumatic stress disorder (PTSD), alcoholism with malnutrition, diabetes mellitus type 2, and hypertension. His physical assessment is unremarkable with the exception of peripheral edema bilaterally to his lower extremities and a chief complaint of pain with numbness and tingling to each leg 5/10. The PMHNP starts this patient on a low dose of doxepin (Sinequan). What is the next action that must be taken by the PMHNP? 

a) Orders liver function tests

b) Educate the patient on avoiding grapefruits when taking this medication

c) Encourage this patient to keep fluids to 1500ml/day until the swelling subside

d) Order BUN/Creatinine test

Question 24

The PMHNP is evaluating a 30-year-old female patient who states that she notices pain and a drastic change in mood before the start of her menstrual cycle. The patient states that she has tried diet and lifestyle changes but nothing has worked. What will the PMHNP most likely do?

a) Prescribe estrin FE 24 birth control

b) Prescribe Ibuprofen 800mg every 8 hours as needed for pain

c) Prescribe desvenlafaxine (Pristiq) 50mg daily

d) Prescribe Risperdal 2mg TID

Question 25

A patient with chronic back pain has been prescribed a serotonin-norepinephrine reuptake inhibitor (SNRI). How does the PMHNP describe the action of SNRIs on the inhibition of pain to the patient? 

a) “the SNRI can increase noradrenergic neurotransmission in the descending spinal pathway to the dorsal horn”

b) “the SNRI can decrease noradrenergic neurotransmission in the descending spinal pathway to the dorsal horn”

c) “the SNRI can reduce brain atrophy by slowing the gray matter loss in the dorsolateral prefrontal cortex”

d) “the SNRI can increase neurotransmission to descending neurons”

Question 26

A patient with fibromyalgia and major depression needs to be treated for symptoms of pain. Which is the PMHNP most likely to prescribe for this patient? 

a) Venlafaxine (Effexor)

b) Duloxetine (Cymbalta)

c) Clozapine (Clozaril)

d) Phenytoin (Dilantin)

Question 27

The PMHNP prescribes gabapentin (Neurontin) for a patient’s chronic pain. How does the PMHNP anticipate the drug to work? 

a) It will bind to the alpha-2-delta ligand subunit of voltage-sensitive calcium channels

b) It will induce synaptic changes, including sprouting

c) It will act on the presynaptic neuron to trigger sodium influx

d) It will Inhibit activity of dorsal horn neurons to suppress body input from reaching the brain

Question 28

Mrs. Rosen is a 49-year-old patient who is experiencing fibro-fog. What does the PMHNP prescribe for Mrs. Rosen to improve this condition? 

a) Venlafaxine (Effexor)

b) Armodafinil (Nuvigil)

c) Bupropion (Wellbutrin)

d) All of the above

Question 29

The PMHNP is caring for a patient with fibromyalgia. Which second-line treatment does the PMHNP select that may be effective for managing this patient’s pain?

a) Methylphenidate (Ritalin)

b) Viloxazine (Vivalan)

c) Imipramine (Tofranil)

d) Bupropion (Wellbutrin)

Question 30

The PMHNP is attempting to treat a patient’s chronic pain by having the agent bind the open channel conformation of VSCCs to block those channels with a “use-dependent” form of inhibition. Which agent will the PMHNP most likely select? 

a) Pregabalin (Lyrica)

b) Duloxetine (Cymbalta)

c) Modafinil (Provigil)

d) Atomoxetine (Strattera)

Question 31

A patient with irritable bowel syndrome reports chronic stomach pain. The PMHNP wants to prescribe the patient an agent that will cause irrelevant nociceptive inputs from the pain to be ignored and no longer perceived as painful. Which drug will the PMHNP prescribe?

a) Pregabalin (Lyrica)

b) Gabapentin (Neurontin)

c) Duloxetine (Cymbalta)

d) B and C 

Question 32

The PMHNP wants to use a symptom-based approach to treating a patient with fibromyalgia. How does the PMHNP go about treating this patient?

a) Prescribing the patient an agent that ignores the painful symptoms by initiating a reaction known as “fibro-fog”

b) Targeting the patient’s symptoms with anticonvulsants that inhibits gray matter loss in the dorsolateral prefrontal cortex

c) Mzatching the patient’s symptoms with the malfunctioning brain circuits and neurotransimitters that might mediate those symptoms

d) None of the above

Question 33

The PMHNP is working with the student to care for a patient with diabetic peripheral neuropathic pain. The student asks the PMHNP why SSRIs are not consistently useful in treating this particular patient’s pain. What is the best response by the PMHNP? 

a) “SSRIs only increase norepinephrine levels” 

b) “SSRIs only increase serotonin levels”

c) “SSRIs only increase serotonin and norepinephrine levels”

d) “SSRIs do not increase serotonin or norepinephrine levels”

Question 34

A patient with gambling disorder and no other psychiatric comorbidities is being treated with pharmacological agents. Which drug is the PMHNP most likely to prescribe? 

a) Antipsychotics

b) Lithium

c) SSRI

d) Naltrexone

Question 35

Kevin is an adolescent who has been diagnosed with kleptomania. His parents are interested in seeking pharmacological treatment. What does the PMHNP tell the parents regarding his treatment options? 

a) “Naltrexone may be an appropriate option to discuss”

b) “there are many medicine options that treat Kleptomania”

c) “Kevin may need to be prescribed antipsychotics to treat this illness”

d) “Lithium has proven effective for treating kleptomania”

Question 36

Which statement best describes a pharmacological approach to treating patients for impulsive aggression?

a) Anticonvulsant mood stabilizers can eradicate limbic irritability

b) Atypical antipsychotics can increase subcortical dopaminergic stimulation

c) Stimulants can be used to decrease frontal inhibition

d) Opioid antagonists can be used to reduce drive

Question 37

A patient with hypersexual disorder is being assessed for possible pharmacologic treatment. Why does the PMHNP prescribe an antiandrogen for this patient?

a) It will prevent feelings of euphoria

b) It will amplify impulse control

c) It will block testosterone

d) It will redirect the patient to think about other things

Question 38

Mrs. Kenner is concerned that her teenage daughter spends too much time on the Internet. She inquires about possible treatments for her daughter’s addiction. Which response by the PMHNP demonstrates understanding of pharmacologic approaches for compulsive disorders?

a) “Compulsive internet use can be treated similarly to how we treat people with substance use disorders”

b) “internet addiction is treated with drugs that help block the tension/arousal state your daughter experiences”

c) “When it comes to internet addiction, we prefer to treat patients with pharmaceuticals rather than psychosocial methods”

d) “there are no evidence-based treatments for internet addiction, but there are behavioral therapies your daughter can try”

Question 39

Mr. Peterson is meeting with the PMHNP to discuss healthier dietary habits. With a BMI of 33, Mr. Peterson is obese and needs to modify his food intake. “Sometimes I think I’m addicted to food the way some people are addicted to drugs”, he says. Which statement best describes the neurobiological parallels between food and drug addiction?

a) There is decreased activation of the prefrontal cortex

b) There is increased sensation of the reactive reward system

c) There is reduced activation of regions that process palatability

d) There are amplified reward circuits that activate upon consumption

Question 40

The PMHNP is caring for a patient who reports excessive arousal at nighttime. What could the PMHNP use for a time-limited duration to shift the patient’s brain from a hyperactive state to a sleep state?

a) Histamine 2 receptor antagonist

b) Benzodiazepines

c) Stimulants

d) Caffeine 

Question 41

The PMHNP is caring for a patient who experiences too much overstimulation and anxiety during daytime hours. The patient agrees to a pharmacological treatment but states, “I don’t want to feel sedated or drowsy from the medicine.” Which decision made by the PMHNP demonstrates proper knowledge of this patient’s symptoms and appropriate treatment options?

a) Avoiding prescribing the patient a drug that blocks H1 receptors

b) Prescribing the patient a drug that acts on H2 receptors

c) Stopping the patient from taking medicine that unblocks H1 receptors

d) None of the above

 

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