PDSA Practice Improvement Plan PDSA Practice Improvement Plan The assignment will be divided into four phases.
The PDSA project will give students the experience to initiate and coordinate planned changes in a healthcare organization. This assignment aims to engage the student in identifying a clinical problem or process, undertaking a literature review, and implementing an evidence-based intervention to improve patient, nurse/staff, or clinical outcomes and/or processes.
Students will use the Agency for Healthcare Research and Quality's (2020) Plan-Do-Study-Act (PDSA) Directions and Examples as a guideline for this assignment (Web link Available in Modules)
Part I: Plan
1. Problem Identification
· Problem Identification:
· Students will identify a clinical issue or process by:
· Reviewing clinical site's electronic health records.
· Nurses can leverage Electronic Health Records (EHRs) to identify clinical issues and improve system processes in several impactful ways:
2.
1. Data Aggregation and Analysis: EHRs compile comprehensive patient data, allowing nurses to analyze trends and patterns. This can help identify common clinical issues, such as frequent infections or medication errors, and address them proactively
1. Clinical Alerts and Reminders: EHRs can generate alerts for potential clinical issues, such as abnormal lab results or missed medications. These alerts help nurses intervene promptly, improving patient safety and care quality
1. Support for Diagnostic and Therapeutic Decisions: EHRs provide decision support tools that assist nurses in making informed clinical decisions. These tools can suggest potential diagnoses or treatment options based on patient data, enhancing the accuracy and efficiency of care
1. Improving Communication: EHRs facilitate better communication among healthcare team members by providing a centralized platform for patient information. This ensures that all team members are aware of the patient's status and any clinical issues, leading to more coordinated and effective care
1. Identifying Systemic Issues: By analyzing data from EHRs, nurses can identify systemic issues within the healthcare facility, such as workflow inefficiencies or resource shortages. Addressing these issues can lead to improved processes and better patient outcomes
1. Quality Improvement Initiatives: EHRs enable the tracking of key performance indicators and outcomes. Nurses can use this data to participate in quality improvement initiatives, aiming to enhance care standards and patient satisfaction
1. Documentation and Compliance: Accurate and thorough documentation in EHRs helps ensure compliance with regulatory requirements and standards. This not only improves patient care but also protects the healthcare facility from legal and financial risks
2. Review of Literature
· Review of literature:
· What level of knowledge is out there to address the clinical problem or process you identified at your clinical site?
· Currently, what evidence-based guidelines are published on the clinical problem or process?
· The literature reviewed should consist of systematic reviews, meta-analyses, peer-reviewed studies, or clinical guidelines.
· Expert opinion articles and clinical articles can be used as supportive literature for clinical issues with limited research.
Clinical Alerts and Reminders: While the EHR provides Clinical Alerts for HRLRs, the system lacks a sophisticated, automated mechanism to escalate alerts after the initial clinician acknowledges the result, especially if the patient has been discharged. This creates a safety gap, relying purely on manual hand-off or memory.
Identifying Systemic Issues: The EHR data indicates a workflow inefficiency where the responsibility for HRLR follow-up is not clearly assigned or tracked across different departments, leading to the HRLR potentially falling into a communication void.
Target for Improvement: To reduce the number of high-risk abnormal lab results that do not receive documented, time-stamped patient follow-up communication within 24 hours of result finalization.
2. Review of Literature
What level of knowledge is out there to address the clinical problem?
The knowledge base regarding critical lab result management is extensive and well-established but often focuses on technology and policy adherence rather than human factors and workflow design. There is a high level of research interest in this area because missed follow-up on critical test results is a leading cause of medical error and malpractice litigation.
Currently, what evidence-based guidelines are published on the clinical problem or process?
The literature provides several established, evidence-based guidelines that directly address the management of critical and high-risk abnormal results:
Joint Commission National Patient Safety Goals (NPSGs): The Joint Commission requires healthcare organizations to implement a standardized approach to improve the effectiveness of communication among caregivers. This specifically mandates that organizations develop and implement policies for communicating critical test results to the responsible licensed caregiver in a timely manner. (The Joint Commission, National Patient Safety Goals, Goal 2)
Agency for Healthcare Research and Quality (AHRQ) Safe Practices: AHRQ strongly endorses practices that ensure timely and reliable follow-up of critical and unexpected test results. The evidence supports the use of structured, closed-loop communication systems (ensuring the recipient acknowledges the information) rather than relying on passive communication (like simple EHR alerts).
Sample Answer
This is the first part of a comprehensive PDSA practice improvement plan, focusing on identifying a clinical problem using Electronic Health Records (EHRs) and then establishing the evidence base through a literature review.
PDSA Practice Improvement Plan: Part I - Plan
1. Problem Identification: Reduction of Missed or Delayed Follow-up for High-Risk Abnormal Lab Results (HRLRs)
Clinical Issue Identified through EHR Analysis
The clinical issue identified through EHR analysis is the inconsistent and delayed follow-up on High-Risk Abnormal Lab Results (HRLRs), particularly in the Emergency Department (ED) and during transitions of care (e.g., patient discharge with outstanding critical results).
Data Aggregation and Analysis: An audit of the EHR's lab module revealed a pattern where HRLRs (defined by the laboratory as results requiring immediate clinician review and action, such as critically elevated troponin, severe hyperkalemia, or positive blood cultures) are frequently marked as "read" by the ordering clinician but lack documented evidence of a patient-specific follow-up plan (e.g., communication to the primary care provider (PCP), a scheduled follow-up appointment, or a discharge notification phone call).