Investigate your organization’s compliance rate with one specific core measure of your choice and write a 2-3-page (maximum) executive summary analyzing the financial and regulatory impact of organizational compliance with your chosen measure. Include recommendations for improving performance on the measure.
In order to promote safe, caring, patient-centered environments, nurse leaders must both conceptually understand and be proficient at performing a wide variety of leadership skills. Effective nursing leaders develop and maintain awareness of issues that emerge at many levels within and outside of their organizations. In addition to developing self-assessing competencies necessary for their roles, nurse leaders must also acquire organizational and systems leadership skill sets.
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By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
Competency 4: Policy, Finance, and Regulations – Understand the scope and role of policy, finance, and regulatory environments in relationship to individual and population outcomes.
Compare the compliance rates of a specific measure for different organizations.
Identify the financial implications associated with compliance.
Explain the importance of compliance in terms of policy, regulation, and finance.
Competency 5: Communication – Communicate effectively with all members of the health care team, including interdepartmental and interdisciplinary collaboration for quality outcomes.
Write coherently to support a central idea in appropriate APA format, with correct grammar, usage, and mechanics as expected of a nursing professional.
Competency 6: Organizational and Systems Management – Apply knowledge of organizational behavior, nursing theory, and systems (micro- and macro-) as appropriate for the scope and role of one’s own practice.
Identify the people affected by changes to a specific compliance measure.
Outline a plan to implement changes to a specific compliance measure.
Identify organizational barriers to change.
Explain strategies to overcome organizational barriers to change.
Competency 9: Professional Role – Incorporate the qualities, skills, behaviors, and knowledge required to function as a patient advocate, practice high-quality care, assess and evaluate patient outcomes, and provide leadership in improving care.
Describe changes that would improve compliance of a specific measure.
Focus:
My facility’s as a whole falls short on the core measure of sepsis. However, the emergency department is the focus here. Especially since most of these patients present to ER 1st.
As a facility we are about 70% compliant on sepsis protocol.
Reasons why:
1) Old guard nurses routinely under triage patients, the attitude is I’ve been around forever and I know whats best.
2) Physicians and nurses both try to avoid the label sepsis because it activates a time clock. Several measures must be completed in a certain time frame. This is seen as extra work and also it is a form of “If we ignore the issue it’s not an issue.”
3) Failure to recognize the early vital signs related to possible sepsis and taking the appropriate actions.
4) Even in light of lab values and vital signs providers will sometimes not use the sepsis protocol. It is well known we are below an appropriate level of compliance so “If we don’t call it sepsis we don’t have to worry about compliance”
Possible solutions:
1) Our charting system EPIC can be programed to flag lab results and vital signs as an early warning for sepsis. 2 or more vital signs indicating sepsis as a possible concern can be set to notify the nurse or provider that sepsis is a concern and to take appropriate 1st line measures. This would have the added benefits of checking behind the triage nurse and catching it that much sooner along with forcing the old guard nurses performing triage to acknowledge the vitals as being important and thereby assigning an appropriate ESI level to the patient or justify in the triage notes as to why they are not a candidate for further sepsis screening.
2) Better training in recognizing the early signs of sepsis and the follow on protocols.
3) We have a sepsis screening tool posted in triage rooms but does not seem to be used.
This should become a regular part of every patient intake done in the ER.