NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal ​​​​​​​Data Analysis and Quality Improvement Initiative Proposal

NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initative Proposal

Data Analysis and Quality Improvement Initiative Proposal

Good morning, everybody. I am ………… Today, we are going to analyze the critical concern of patient falls at Springfield General Hospital in detail; specifically, we will look into adverse events such as John’s fall, which unveiled areas for lapses in communication, failure to follow set safety protocols, and monitoring of patients. Statistics show that these accidents result in avoidable harm, decreased patient satisfaction, and increased hospital readmission. Thus, our quality improvement initiative has drawn on the PDSA framework to identify these challenges and address them through enhanced fall-risk assessments, training for staff members, and appropriate use of certain technologies such as bed alarms and EHR alerts. We can and will create safer environments supportive of both the patients and staff while significantly reducing the rates of falls.

Analysis of Health Care Issues

Data reveals that the patient falls issue in Springfield General Hospital is a persistent health concern: it reveals fall rates within the healthcare facility exceed the set national benchmark standards. Though the national benchmark for fall rates reported was 3.44 falls per 1,000 patient bed days (Venema et al., 2019), the health facility reported 6.2 fall rates in 2021, 6.4 in 2022, and 6.7 in 2023. These indicate an exceptional deviation from the expected performance. Moreover, patient satisfaction scores decreased from 85% in 2021 to 70% in 2023, suggesting that safety concerns could be related to the perceived quality of care by the patients. Also, the average hospital stay length increased from 4.2 days in 2021 to 5.1 days in 2023, indicating possible fall-related injuries complications.

The quality of the data is reliable, as it derives from hospital performance records and validated reporting systems. Nevertheless, additional insights are required to identify cause-and-effect factors. Relying on a greater measure of quantification will limit understanding without complementary qualitative data, such as interviews with staff, feedback from patients, or direct observational audits. Such inclusions may contribute to a more holistic assessment of the causes and opportunities for improvement.

Recommendations for Quality Improvement

1. General Hospital will standardize using the Morse Fall Scale (MFS) for fall-risk assessments in all patient units. This standardized tool helps a health care professional to assess the risk of falls in patients based upon a set of criteria that includes having had falls in the past, mobility problems, and mental status. The hospital seeks to enhance the identification of fall risks in patients. At the same time, interventions are promptly conducted to help prevent falls by encouraging its utilization through general training of its staff and frequent assessments (Baumann et al., 2022).
2. Springfield General Hospital should ensure a better understanding of what has been achieved in fall prevention by undertaking patient satisfaction surveys on fall prevention and safety measures. These surveys will collect important feedback from patients regarding their perception of the hospital’s fall prevention policies, the effectiveness of personnel communication, and overall safety and security. This will allow for better refining of the strategy, keeping in view the patient’s perspectives while implementing fall prevention strategies in the future (Dykes et al., 2020).

Quality Improvement Initiative Proposal

The fall-prevention quality improvement initiative at Springfield General Hospital will be conducted during a designed PDSA cycle toward continuous improvement. During the Plan phase, the hospital will standardize MFS to assess the fall risk for all patient units. This scale will rate how likely a patient is to experience an unintentional fall due to factors like a history of falls, mobility problems, and mental status. In addition, the hospital will emphasize training staff members on t