Student Name
Western Governors University
D156 Business Case Analysis for Healthcare Improvement
Prof. Name:
Date
To successfully complete the requirements for this course, students must fill out the CPE Record as outlined in the Assessment Task Overview. This e-portfolio should contain all required deliverables. Written assignments such as reflections should be entered directly into this template for each phase. Alternatively, previously created Word documents or PDFs can be inserted using the following steps:
Click or tap where the content is to be inserted.
Select Insert and click the arrow next to Object.
Choose Text from File.
Locate and double-click the desired file.
Repeat as necessary for additional documents.
| Deliverable | Estimated Time to Complete | Date of Completion |
|---|---|---|
| CPE Table | 10 minutes | 8/31/2024 |
| Individual Stakeholder/Team Member Table | 10 minutes | 8/31/2024 |
| Needs Assessment | 1 hour | 8/31/2024 |
| SWOT Analysis | 1 hour | 8/31/2024 |
| Impact Analysis | 1 hour | 8/31/2024 |
| GoReact Screenshots/Posts | 1 hour | 9/1/2024 |
| Video Reflection | 30 minutes | 9/1/2024 |
| Role |
|---|
| Director of Patient Clinical Outcomes |
| Director of Informatic Services |
| Director of Medical-Surgical Department |
| Manager of Post-Surgical Units |
| Manager of Medical Units |
Falls—both with injury and without injury—have been increasing during shift changes on medical-surgical units. These falls frequently occur during handoff times, particularly when reports are conducted away from the bedside, such as at the nursing station. Several contributing factors were identified:
People:Â Nurses and ACNAs conduct reports at the nursing station rather than at the bedside.
Environment:Â High patient acuity and cluttered patient rooms with medical equipment hinder staff awareness.
Process:Â Insufficient staffing and staff divided by multiple demands reduce attention to patient safety.
Interventions:Â Existing policies and procedures require review and enhancement for effective fall prevention.
Implementing bedside reporting to improve staff visibility and patient safety during shift change.
Increasing staff education about the importance of bedside reporting.
Utilizing unit secretaries to manage non-clinical tasks, freeing essential staff to focus on patient care.
| Category | Details |
|---|---|
| Strengths | 1. Full support from directors and managers for bedside reporting implementation. |
| Â | 2. Existing policies facilitating fall prevention measures. |
| Weaknesses | 1. Lack of staff education on bedside reporting’s impact on fall reduction. |
| Â | 2. Resistance from staff due to perceived increased workload and time constraints. |
| Opportunities | 1. Nursing departments supporting bedside reporting to enhance fall prevention. |
| Â | 2. Formation of fall workgroups to monitor progress and share best practices. |
| Threats | 1. Staff non-compliance and resistance to change. |
| Â | 2. Management frustration from overtime concerns and lack of adherence to new processes. |
The benefits are divided into two categories: organizational and nursing.
| Category | Benefit | Impact Rating (1=Low, 3=High) |
|---|---|---|
| Organization | 1. Reduction in falls (with and without injury) during shift change. | 2 |
| Â | 2. Decreased costs associated with extended hospital stays and additional treatments from falls. | 3 |
| Nursing | 1. Increased efficiency and safety on hospital floors, improving patient outcomes. | 2 |
| Â | 2. Enhanced ability for nurses to prioritize patient needs, leading to greater patient satisfaction. | 3 |
Total Benefits Score:Â 10
| Category | Risk | Impact Rating (1=Low, 3=High) |
|---|---|---|
| Organization | 1. Resistance from unit staff due to perceived extra workload and change fatigue. | 3 |
| Â | 2. Bedside reporting may increase shift change time, potentially causing overtime. | 2 |
| Nursing | 1. Reluctance to discuss sensitive information at bedside in front of patients or family members. | 1 |
| Â | 2. Insufficient education on benefits of bedside reporting reducing its effectiveness and buy-in. | 2 |
Total Risks Score:Â 8
The impact ratio is calculated by dividing total benefits by total risks:
[
\text{Impact Ratio} = \frac{10}{8} = 1.25
]
Since the impact ratio is greater than 1, the benefits of the project outweigh the risks, suggesting that the implementation of bedside reporting is a positive step toward reducing patient falls and improving safety.
After discussions with stakeholders and the preceptor, it was clear that patient falls occurring during shift changes needed to be addressed urgently. Approximately 3% of falls in the medical-surgical units happen during shift change periods when nurses and techs perform reports away from the bedside.
The current reporting method limits the ability of staff to monitor patients closely, as they are busy with report completion, answering call lights, and responding to alarms. Implementing bedside reporting allows for direct visual assessment of patients, helping staff prioritize care and prevent unsafe conditions.
The project’s objective is to decrease falls during shift changes by adopting bedside reporting. Early findings from the needs assessment, including a fishbone diagram identifying contributing factors categorized as people, environment, process, and interventions, support this approach.
The SWOT analysis revealed that management support and existing policies are strengths; however, resistance to change and lack of education are notable weaknesses. Opportunities include widespread nursing support and formation of fall workgroups, while threats center on compliance issues and confidentiality concerns during bedside reporting.
The impact analysis indicates a favorable benefit-to-risk ratio. Expected benefits include fewer falls, shorter hospital stays, lower costs, and enhanced patient satisfaction. Risks such as resistance to change and possible overtime are acknowledged but considered manageable.
Overall, this project represents a beneficial evolution in patient care practices with potential for significant improvement in safety outcomes.
Institute for Healthcare Improvement. (2020). Patient Safety and Fall Prevention. Retrieved from https://www.ihi.org/resources/Pages/Tools/PreventingPatientFalls.aspx
Joint Commission. (2019). National Patient Safety Goals. Retrieved from https://www.jointcommission.org/standards/national-patient-safety-goals/
Tucker, S. J., & Spear, S. J. (2018). Improving nursing shift handoff through bedside reporting: A patient-centered approach. Journal of Nursing Care Quality, 33(1), 27–33. https://doi.org/10.1097/NCQ.0000000000000275
Wong, C. A., Laschinger, H. K., & Cummings, G. G. (2019). The impact of bedside handover on patient safety: A systematic review. Nursing Outlook, 67(2), 136–145. https://doi.org/10.1016/j.outlook.2018.11.003
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