Draft a 6-page report on outcome measures, issues, and opportunities for the executive leadership team or applicable stakeholder group.

Outcome Measures, Issues, and Opportunities Report

Introduction

The purpose of this report is to address outcome measures and performance issues or opportunities related to a systemic problem identified in the previous executive summary. The focus is on improving patient outcomes by analyzing organizational functions, processes, and behaviors in high-performing healthcare organizations or practice settings, and identifying the quality and safety outcomes associated with the performance gap.

Analysis of Organizational Functions, Processes, and Behaviors

High-performing healthcare organizations or practice settings are characterized by a commitment to quality and safety, and an emphasis on patient-centered care. These organizations have effective communication systems that ensure that patients receive appropriate care and that any concerns or issues are addressed promptly. They also have a culture of continuous improvement, with a focus on identifying and addressing performance gaps.

In contrast, organizations that struggle with quality and safety issues may have a fragmented communication system, inadequate resources, and a culture of blame rather than improvement. These organizations may lack the necessary infrastructure to ensure that all aspects of patient care are measured, and that staff have access to the knowledge they need to deliver effective care.

Effects of Organizational Functions, Processes, and Behaviors on Outcome Measures

The systemic problem identified in the previous executive summary is a high rate of hospital-acquired pressure injuries (HAPIs). HAPIs are a preventable adverse event that can have serious consequences for patients, including pain, infection, and prolonged hospital stays. HAPIs are associated with a range of quality and safety outcomes, including increased morbidity and mortality, decreased patient satisfaction, and increased healthcare costs.

The high rate of HAPIs in the organization can be attributed to a range of organizational functions, processes, and behaviors. These include inadequate staffing levels, inadequate education and training for staff, inadequate resources for pressure injury prevention, and a lack of a standardized approach to pressure injury prevention.

Quality and Safety Outcomes and Associated Measures

The quality and safety outcomes associated with HAPIs are well established. The National Pressure Ulcer Advisory Panel (NPUAP) has identified the following outcomes and associated measures:

• Incidence and prevalence of HAPIs
• Severity of HAPIs
• Time to HAPI resolution
• Cost of HAPI care
• Patient and family satisfaction with care

Creating a Spreadsheet of Outcome Measures

To effectively measure these outcomes, a spreadsheet can be created to track the incidence and prevalence of HAPIs, severity of HAPIs, time to HAPI resolution, cost of HAPI care, and patient and family satisfaction with care. The spreadsheet should be regularly updated with data on these measures, and the data should be used to inform continuous improvement efforts.

Performance Issues and Opportunities

The performance issues and opportunities associated with HAPIs include inadequate staffing levels, inadequate education and training for staff, inadequate resources for pressure injury prevention, and a lack of a standardized approach to pressure injury prevention. These issues can be addressed by developing a comprehensive pressure injury prevention program that includes the following:

• Staff education and training on pressure injury prevention
• Adequate staffing levels to ensure that patients receive appropriate care
• The use of appropriate pressure-relieving devices and support surfaces
• A standardized approach to pressure injury assessment and prevention

Strategy for Ensuring All Aspects of Patient Care are Measured

To ensure that all aspects of patient care are measured, a change model can be used to develop and implement a comprehensive pressure injury prevention program. The Plan-Do-Study-Act (PDSA) cycle can be used to test and refine the program, and the Lean Six Sigma approach can be used to identify and eliminate waste and inefficiencies in the program.