This essay examines a Quality Improvement (QI) initiative that utilized nursing education and skill evaluation to lower rehospitalization rates in an acute/long-term rehabilitation institution. The facility’s dedication to delivering high-quality care is consistent with the project’s focus on improving patient outcomes and maximizing resource usage. The essay draws on a conversation with Susan Baker, MSN, the facility’s clinical coordinator and critical contact for quality improvement, while maintaining the privacy of all mentioned people and data. The essay sets the context for debating the issue, defending the need for intervention, and presenting the possible project’s description and anticipated results by summarizing the setting as an acute/long-term rehabilitation institution. The project’s incorporation of crucial areas further emphasizes the comprehensive approach used to solve the rehospitalization problem. The essay’s main point is how vital the QI project is for lowering readmission rates and improving patient care at acute/long-term rehabilitation institutions.
Background of the Problem:
The high rate of rehospitalization in the acute/long-term rehabilitation facility is the issue that this QI study seeks to address. Patients who are readmitted to the hospital soon after being initially discharged are referred to as being rehospitalized. This issue is serious since it affects patient outcomes and raises healthcare expenses. Rehospitalization might jeopardize the continuity of care, increase complication risk factors, and impede patients’ recovery.
Several academic sources support the rehospitalization problem’s existence and importance. Rehospitalization rates within 30 days of discharge from a rehabilitation facility were frighteningly high, reaching 20% in their sample, according to a study by Hughes and Witham (2018). Anderson et al. (2020) other study emphasized the link between rehospitalization, higher medical expenses, and lower patient satisfaction. These references emphasize how crucial it is for the acute/long-term rehabilitation center to address the issue of rehospitalization.
The high rehospitalization rate strongly impacts the acute/long-term rehabilitation facility. First, it has a detrimental effect on the general standard of patient care. Recurrent hospital stays can interfere with rehabilitation, resulting in drawn-out recovery times and less-than-ideal results. Rehospitalization also strains the facility’s resources, such as the number of beds available, the workload of the staff, and the financial resources (Kumar et al., 2019). If the facility cannot correctly address rehospitalization, it may face reputational problems. Rehospitalization must be reduced to enhance patient outcomes, maximize resource usage, and preserve the facility’s reputation as a provider of high-quality treatment.
Numerous criteria support the need for intervention and the suitability of the DNP QI project. First, lowering the number of readmissions is consistent with improving patient outcomes and raising the standard of care offered at the acute/long-term rehabilitation center (Hoyer et al., 2017). The project intends to address the underlying reasons for readmission and enhance care coordination by adopting focused treatments, such as nurse education and skills evaluation. Second, the significant expenses of rehospitalization highlight the problem’s economic significance. Rehospitalization rates can be decreased, which may result in financial savings and more effective resource allocation for the facility. Lastly, the QI project offers a chance to put evidence-based practice into practice, support the nursing profession, and highlight the significance of advanced practice nurses in leading quality improvement initiatives because it is being led by a DNP (Doctor of Nursing Practice) student.
The history of the issue at the acute/long-term rehabilitation center emphasizes the relevance of the rehospitalization problem and its impact on patient outcomes, resource use, and overall quality of treatment. The body of available literature supports measures to lower readmission rates. The DNP QI project’s potential to enhance patient outcomes, optimize resource allocation, and advance evidence-based nursing practice justifies its emphasis on nursing education and skills evaluation (Hoyer et al., 2017). The Acute/Long Term Rehabilitation Facility can improve the continuity of treatment, lower healthcare costs, and preserve its standing as a provider of high-quality rehabilitation services by addressing the rehospitalization issue.
The Potential QI Project’s Description:
The proposed QI project calls for routine nursing training and skill evaluation to lower readmissions to the acute/long-term rehabilitation institution. Nursing education is essential for giving nurses the knowledge and abilities to give patients complete care. By emphasizing education, nurses can better grasp the typical illnesses that result in readmission, discover evidence-based methods for avoiding complications, and develop communication and care coordination abilities (Karam et al., 2021). Additionally, skill evaluation confirms that nurses have the knowledge and abilities to provide high-quality care. Any knowledge or skill deficiencies can be found through regular evaluation and filled through specialized training and professional development opportunities.
The QI project will include additional crucial elements to improve patient care and lower rehospitalization rates, nursing education, and skills assessment. Implementing care transition interventions is one of these elements. In order to provide a smooth transition from the rehabilitation facility to the home or community environment, nurses will work closely with patients, families, and other healthcare professionals. Organizing follow-up appointments, giving thorough discharge instructions, and facilitating communication across various care locations may all be part of this (Bajorek & McElroy, 2020). The project aims to prevent interruptions and the risk of complications or readmission by enhancing the continuity of care during the transition period.
Implementing a thorough discharge planning procedure is another crucial component of the QI project. Nurses will work with interdisciplinary teams to determine patients’ needs and create individualized discharge plans. This may entail arranging medical equipment or supplies, scheduling home health care services, and addressing any social or psychosocial issues hindering the patient’s rehabilitation. Nurses may ensure that patients are actively involved in their care and have the essential support systems upon discharge by incorporating them into the discharge planning. This patient-centered strategy for discharge planning may help patients have better outcomes and experience fewer readmissions.
Integrating community services and resources to help patients after they leave the acute/long-term rehabilitation center is another critical component of the possible QI project (Dowla & Chan, 2017). The project will create partnerships and collaborations with neighborhood organizations, home healthcare agencies, and outpatient rehabilitation facilities to recognize how difficult it may be to move from a facility to a home or community setting. Through these partnerships, a smooth continuum of care will be ensured, and access to essential resources, including follow-up appointments, assistance with medication management, home health services, and rehabilitation programs, will be made more accessible. The project seeks to give patients lasting gifts and monitoring, lowering the risk of readmission and fostering successful recovery and reintegration into their everyday lives by fortifying ties between the facility and the community.
The possible QI study at the acute/long-term rehabilitation hospital combines extra elements, including care transition interventions, thorough discharge planning, nursing education, and skills assessment. These components are designed to improve continuity of care, encourage patient involvement, and address the various reasons that lead to rehospitalization. The project aims to maximize resource use inside the hospital, enhance patient outcomes, and save healthcare costs by combining multiple treatments.
Application of Essential Domains to Project:
The Essential Domains that will be addressed in the QI project are as follows:
Patient-Centered Care:
In an acute or long-term rehabilitation institution, decreasing rehospitalization is crucial. With an emphasis on comprehending each patient’s particular requirements and preferences, nurses will participate in educational activities and skills evaluations. Nurses can promote a sense of empowerment in patients and enhance patient outcomes by offering tailored care, addressing patient concerns, and integrating patients and their families in the care planning process (Flaubert et al., 2021). The chance of rehospitalization will be decreased by encouraging self-management and adherence to discharge guidelines through patient education.
Evidence-based practice
QI project will give nursing education and skill evaluation a high priority. The most recent findings and recommendations for care coordination, preventive interventions, and joint conditions contributing to readmission will be available to nurses. Nurses can improve patient outcomes and lower rehospitalization rates by implementing evidence-based practices because they can give care based on the best available information and make educated decisions.
Quality Improvement
The QI project itself is a part of this discipline. The project’s objectives include locating potential improvement areas, putting interventions into place, and assessing the success of the chosen tactics. Continuous progress will be possible with regular evaluations of nursing knowledge and abilities since gaps or inadequacies can be filled with the proper training and professional development opportunities. The facility can reduce rehospitalization rates by implementing sustainable improvements and making data-driven decisions by regularly monitoring and analyzing the project’s results.
Essential Domain: Informatics
By enhancing nursing education and skill assessments using technology and data, informatics plays a crucial part in the QI initiative. Electronic health records (EHRs) can spot patterns, trends, and risk factors linked to readmission to the hospital (Ehrenstein et al., 2019). Nurses can pinpoint areas for improvement, customize educational activities, and monitor the project’s effects on rehospitalization rates by evaluating these data. Informatics also makes it easier for healthcare professionals to communicate and work together, ensuring that crucial patient data is shared and accessible throughout various care settings.
Collaboration and Interprofessional Communication
Reduction of rehospitalization rates requires collaboration and interprofessional communication. Nurses will form a collaborative healthcare team with doctors, therapists, social workers, and case managers. Nurses can guarantee a smooth transition of care, facilitate prompt interventions, and address the complex needs of patients through excellent communication and coordination. Shared decision-making, collaborative rounds, and interdisciplinary discussions will increase care continuity and encourage a comprehensive strategy to lower rehospitalization rates.
Leadership
The QI project needs strong leadership to move further. The clinical coordinator and the DNP student are just two examples of nurse leaders who will mentor, encourage, and guide the nursing team. They will establish an atmosphere that promotes career advancement, supports a culture of ongoing learning, and gives nurses the freedom to run their practices. Effective leadership will encourage integrating nursing education and skills assessment into everyday practice to ensure that all nurses are actively contributing to the decrease in rehospitalization rates.
Professionalism
Professionalism is essential to the QI project’s success. The most significant standards of professionalism, ethics, and responsibility will be upheld by nurses. When interacting with patients and their families, they show respect, empathy, and cultural understanding. Professionalism also requires continual self-reflection and self-evaluation to find opportunities for personal and professional development (Cattaneo & Motta, 2020). Nurses that exhibit professionalism will improve the working atmosphere, the patient experience, and the overall standard of care provided.
Systems Thinking
Understanding the intricate causes of readmission and creating thorough therapies depend heavily on systems thinking. Nurses will consider the interaction between patient characteristics, medical procedures, and the healthcare system. To improve care coordination and avoid readmission to the hospital, they will look at workflows, spot any obstacles or bottlenecks, and suggest system-level adjustments. By taking a holistic approach and taking into account the larger environment in which rehospitalization happens, systems thinking enables nurses to strive towards long-lasting solutions.
Improvement in safety and quality
The QI project must prioritize safety and quality improvement. Nurses will emphasize patient safety by using evidence-based techniques and treatments to avoid complications and lower the chance of rehospitalization. This involves procedures to prevent falls, review prescriptions, prevent infections, identify potential adverse effects early, and treat them. By putting safety first, nurses can establish a safe setting that encourages the best possible patient outcomes and reduces the need for readmission (Vaismoradi et al., 2020). The initiative will also incorporate mechanisms for quality improvement, such as gathering and analyzing information on patient satisfaction, rehospitalization rates, and adherence to best practices. Nurses can find areas for improvement, make changes, and guarantee continual improvement of care quality by constant monitoring and evaluation.
Ethical and Legal Considerations:
In the QI project, ethical and legal considerations are crucial. Nurses shall follow the professional standards of ethics and laws governing patient care and privacy. They will ensure that patients and their families have given their informed permission for educational interventions and skill evaluations. Patient privacy and confidentiality will be upheld throughout the initiative, and data will be managed securely and without identifying information. When discussing treatment alternatives and discharge planning, nurses will also consider potential ethical problems, such as balancing autonomy and beneficence. Nurses can build trust, encourage patient autonomy, and provide care that complies with legal obligations and professional standards by maintaining ethical and legal principles.\
To address the issue of rehospitalization in the acute/long-term rehabilitation institution, the QI project integrates several required fields. Individualized techniques that empower patients and enhance outcomes are guaranteed by patient-centered care. Nursing education and skill evaluation are guided by evidence-based practice to provide the best care possible. The project’s continual evaluation and improvement activities are driven by quality improvement. Utilizing technology and data, informatics improves treatment and decision-making. Smooth transitions and comprehensive treatment are supported by collaboration and interprofessional communication. Leadership offers direction and encouragement to promote a culture of ongoing learning. Nursing practice that is ethical and accountable is ensured by professionalism. Systems thinking enables the development of long-lasting solutions and a thorough knowledge of rehospitalization. The QI project hopes to have a good effect on lowering rehospitalization rates and raising the general standard of care in the acute/long-term rehabilitation center by implementing three binding domains.
Conclusion:
The potential QI project to decrease readmissions in acute/long-term rehabilitation facilities through nurse education and skills evaluation shows excellent promise. The project aims to enhance patient outcomes, maximize resource use, and keep the hospital’s reputation for providing top-notch treatment by addressing the high rehospitalization rates. A thorough and integrated approach to solving the rehospitalization problem is ensured by applying key domains such as patient-centered care, evidence-based practice, quality improvement, informatics, collaboration and interprofessional communication, leadership, professionalism, and systems thinking. The Acute/Long Term Rehabilitation Facility can improve patient care by implementing the treatments indicated in this QI study, which will help lower rehospitalization rates.
References
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