D156 Updated HIP Paper Template for Nursing Weekly Assessment

D156 Updated HIP Paper Template for Nursing Weekly Assessment

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Western Governors University

D156 Business Case Analysis for Healthcare Improvement

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Date

D156 Updated HIP Paper Template for Nursing Weekly Assessment

Healthcare Improvement Project: Introduction and Project Initiation

Organizational Problem

The healthcare improvement initiative focuses on developing a unified weekly nursing assessment document for acute psychiatric patients. This document will allow nursing staff to consolidate interdisciplinary information and provide comprehensive updates on patients’ progress toward discharge and treatment objectives. Currently, documentation practices are fragmented, with licensed nurses and mental health technicians charting separately according to patient status. Licensed nurses document 1:1 care and 15-minute observation statuses, while non-licensed staff handle 60-minute observational documentation. Weekly, registered nurses (RNs) conduct head-to-toe assessments and document findings, but information relayed to social workers for community placement referrals is primarily based on non-licensed staff notes, which inadequately reflect the patient’s treatment progress.

The proposed single assessment document aims to satisfy Centers for Medicare & Medicaid Services (CMS) standards and enhance interdisciplinary communication by providing weekly summaries of patient engagement, medication usage, behaviors, and medical concerns. This will enable timely adjustments in treatment plans and improve discharge planning by accurately depicting patients’ clinical progress.

Stakeholders

Key stakeholders involved in this project are:

These stakeholders bring a wealth of knowledge and hold organizational authority to influence policy, training, and compliance. Their commitment ensures that the documentation improvements align with clinical standards and hospital objectives.

Project Team Roles and Responsibilities

The project manager’s responsibilities span multiple critical areas:

• Process Management: Identify issues, organize stakeholders, and guide implementation efforts to ensure success.

• Coaching: Facilitate team development, promoting a culture of continuous improvement and patient-centered care.

• Communication: Maintain open dialogue among team members, listen actively, and collaboratively steer the project.

• Accountability: Monitor task completion and hold team members responsible to avoid delays and maintain momentum.

Two essential skills the project manager brings are active listening and analytical thinking, enabling the identification of departmental needs and ensuring accurate, meaningful documentation that supports clinical and discharge decisions.

Susan Lynch, Director of Nursing Education, plays a pivotal role in:

• Designing the nursing assessment template informed by clinical experience.

• Leading education efforts for both new hires and current staff.

• Updating policies to integrate the new documentation process.

Needs Assessment

The team employed the “5 Whys” technique to diagnose the root causes of inadequate nursing documentation. It was found that current records lacked consistent reporting on patient behaviors linked to treatment plans, primarily because non-licensed staff documented daily progress notes. This disparity complicated discharge planning, as referral packets to community placements were incomplete or inaccurate. The assessment identified that a weekly document including a head-to-toe exam, medication compliance, PRN usage, behavioral observations, and activities of daily living (ADL) support would meet clinical and administrative needs effectively.

SWOT Analysis

The SWOT analysis yielded the following insights:

This comprehensive analysis informed the approach to implement the assessment tool efficiently while addressing organizational challenges.

Impact Analysis

An impact analysis was performed with a total benefit score of 11 and risk score of 7, yielding an impact ratio of 1.57. The primary focus areas included medication monitoring and enhanced nursing documentation.

• Medication Monitoring Risks:

  • Potential increase in medication error reports.

  • Possible decline in staff morale due to education or disciplinary measures.

• Medication Monitoring Benefits:

  • Enables timely medication adjustments based on patient response.

  • Enhances provider oversight of medication adherence and patient progress.

• Nursing Documentation Risks:

  • Reduced nurse-patient interaction during documentation.

  • Risk of documentation falsification under high workload stress.

• Nursing Documentation Benefits:

  • Improves communication across disciplines.

  • Ensures compliance with CMS standards and quality of care.

The benefits of improved documentation and medication monitoring are projected to outweigh the identified risks.

Justification and Project Purpose

The project’s goal is to implement a consolidated weekly nursing assessment to enhance treatment tracking and documentation quality for acute psychiatric patients. This tool will:

• Facilitate comprehensive tracking of patient engagement, medication use, and medical concerns.

• Provide accurate data to multidisciplinary teams to guide treatment and discharge planning.

• Meet CMS and The Joint Commission documentation standards, enhancing regulatory compliance and patient care quality.

Available organizational resources such as nurse supervisors and the education department, coupled with adherence to established healthcare standards, justify the feasibility and necessity of this project.

Review of Relevant Scholarly Sources

Several peer-reviewed studies reinforce the need for this project:

1. PRN Medication Use: Wong and Muller (2023) highlight the overuse of PRN medications and the importance of non-pharmacological interventions and improved documentation of PRN usage and patient behaviors, which supports the weekly assessment design.

2. Nursing Documentation Quality: Moldskred, Snibsøer, and Espehaug (2021) emphasize the role of nursing documentation in patient outcomes and discharge readiness, validating the need for structured templates and education.

3. Nursing Interventions in Psychiatry: Ameel, Kontio, and Valimake (2019) discuss common nursing interventions, such as coping skill support and education, underpinning the importance of scheduled therapeutic engagement and documentation.

4. Laboratory Monitoring: Schoretsanitis et al. (2020) focus on the clinical necessity of monitoring antipsychotic drug levels and lab compliance, supporting the integration of lab tracking in the assessment.

5. Environmental and Rapport Factors: Barr et al. (2019) illustrate the impact of nurse-patient rapport and organizational support on treatment outcomes, underscoring the need for consistent documentation of physical interventions and environmental assessments.

These studies collectively advocate for a systematic, comprehensive weekly nursing assessment to optimize treatment and discharge planning.

Project Environment

CMS guidelines require weekly documentation of patient progress in acute psychiatric settings (Centers for Medicare & Medicaid Services [CMS], 2024). The proposed assessment merges clinical evaluation (head-to-toe) with summaries of medication adherence, behavioral observations, lab monitoring, and discharge planning, ensuring holistic patient care documentation.

SMART Goal

Specific: Develop and implement a weekly nursing assessment form that includes head-to-toe evaluation, treatment engagement, and medication compliance documentation.

Measurable: Achieve 95% completion rate of the assessment form by nursing staff for all patients by May 29, 2024.

Achievable: Utilize organizational support from nursing leadership, education departments, and nurse supervisors to train staff and monitor compliance.

Relevant: Improve documentation quality to enhance patient care, regulatory compliance, and discharge planning effectiveness.

Time-bound: Project start date February 14, 2024, with full implementation by May 29, 2024.

SMART Goal Summary Table

Project Management Lifecycle

The project follows a structured lifecycle:

• Initiation: Identify stakeholders and define the problem.

• Planning: Develop a detailed plan, timeline, and assign responsibilities.

• Implementation: Educate staff, deploy the assessment, and begin usage.

• Evaluation and Closure: Assess outcomes against goals and decide on project continuation or adjustments.

Each phase builds on the previous one, ensuring the project progresses toward sustainable improvements.

References

Ameel, M., Kontio, R., & Valimake, M. (2019). Interventions delivered by nurses in adult outpatient psychiatric care: An integrative review. Journal of Psychiatric and Mental Health Nursing, 26(9-10), 301–322. https://doi.org/10.1111/jpm.12543

American Nurses Association. (2010). ANA’s Principles for Nursing Documentation: Guidance for Registered Nurses. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf

Barr, L., Wynaden, D., & Heslop, K. (2019). Promoting positive and safe care in forensic mental health inpatient settings: Evaluating critical factors that assist nurses to reduce the use of restrictive practices. International Journal of Mental Health Nursing, 28(4), 793–1014. https://doi.org/10.1111/inm.12588

Centers for Medicare & Medicaid Services (CMS). (2024, July 21). State operations manual Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_a_hospitals.pdf

Hansmann, M. L. (2018, March 30). The top 8 skills every healthcare process improvement leader must have. HealthCatalyst. https://www.healthcatalyst.com/8-skills-needed-healthcare-process-improvement

Moldskred, P. S., Snibsøer, A. K., & Espehaug, B. (2021). Improving the quality of nursing documentation. BMC Nursing. https://doi.org/10.1186/s12912-021-00629-9

Schoretsanitis, G., Kane, J. M., Correll, C. U., Marder, S. R., Citrome, L., Newcomer, J. W., … Gründer, G. (2020). Blood levels to optimize antipsychotic treatment in clinical practice: A joint consensus statement. The Journal of Clinical Psychiatry, 81(3), e1–e12. https://legacy.psychiatrist.com/jcp/delivery/consensus-on-monitoringblood-antipsychotic-levels/

The Joint Commission. (2018). Behavioral Health Care Standards Sampler.

Wong, S., & Muller, A. (2023). Nurses’ use of pro re nata medication in adult acute mental healthcare settings: An integrative review. International Journal of Mental Health Nursing. https://doi.org/10.1111/inm.13148