Healthcare Quality Management
PDCA Modeling in Healthcare
Psychiatric emergencies in medical settings may be particularly challenging since the staff does not encounter them frequently and may not have experience dealing with behavioral crisis intervention. The purpose of this exercise is to help staff improve understanding and coping with nonmedical emergencies that occur in medical settings using the PDCA cycle.
X is a 41-year-old male admitted to a medical unit with a diagnosis of possible stroke. The patient is ambulatory, 5’10,” and 350 lbs. Mr. X presented to the emergency department the day before after apparently losing consciousness at home. The initial CAT scan of his head was negative. It is suspected that Mr. X may be an IV drug user since his urine toxicology screening came back positive for opiates. The medical staff thinks that Mr. X had a seizure prior to admission, but he has shown no abnormal signs or symptoms within the last 24 hours. Mr. X was moved to an acute care unit where he sits in bed wearing only a pair of ill-fitting boxer shorts and no shirt. He is able to communicate without any signs of aphasia. The medical staff is still not sure what is wrong with Mr. X.
As the nurse administrator of the day, you hear a Rapid Response called overhead for this patient. As you enter the room, you see Mr. X screaming and on all fours in his bed. He is saying “Help, help” and “I don’t know” repeatedly. Respiratory staff, physicians, physician’s assistants, an ICU nurse, and unit staff are all standing there watching Mr. X scream for help. They all seem paralyzed. Finally, one of the staff nurses asks Mr. X to turn over so that respiratory staff can administer oxygen via a facial mask. He complies and at that time the ICU nurse hooks him up to the cardiac monitor as per protocol in a Rapid Response.
Mr. X remains quiet and still for about 60 seconds and then proceeds to rip off the oxygen mask and the EKG leads attached to his chest. He climbs over the side rails and stands there in a daze, saying “I don’t know, I don’t know.”
The staff reacts negatively to Mr. X’s behavior in front of him. The respiratory therapist says, “If you think I’m going in to get an ABG from him, you’re crazy.” Speaking to Mr. X, the ICU nurse repeats over and over in a stern impatient voice, “What don’t you know?” Mr. X seems overwhelmed and can’t answer. The physician looks through the chart and asks the nurses questions about the patient. The other nurses stand there staring at Mr. X. The ICU nurse leaves a few minutes later stating that the patient’s EKG is normal.
All at once, Mr. X bolts from the room towards the elevator, which has just opened, and gets on. One of the nurses calls a security code, but it is too late; Mr. X has disappeared. The county police are called and hours later they find Mr. X at his nearby home. They try to encourage him to return to the hospital, but since he has not been deemed a danger to himself or others, they have no choice but to leave him alone.
The next morning Mr. X returns to the Emergency Department with “severe chest discomfort and a headache” and is admitted back to the same unit. When the staff see him, they are apprehensive and somewhat angry that he is back. After about three hours on the unit, Mr. X starts yelling that his stomach is hurting. His nurse calls the physician about his symptoms but she and the rest of the staff avoid extended contact with him because of what happened the day before.
The FOCUS-PDCA model provides a model for improving processes and the model’s name is an acronym that describes the basic components of the improvement process. The steps include (i Six Sigma, N.d.):
F ind a process to improve
O rganize an effort to work on improvement
C larify current knowledge of the process
U nderstand process variation and capability
S elect a strategy for continued improvement
Figure 1 – PDCA
Find a Process to Improve
The case involves a potentially mentally unstable individual. This can represent both a problem and an opportunity to increase the health and total quality of care to a new demographic that the department does not seem to encounter often. The response in the case was relatively ineffective and the care given to the patient did not effectively address his symptoms or improve his situation. Thus the entire department and healthcare facility could use additional training in how to handle such situations in the future including the patient’s recent return.
Organize an Effort to Work on Improvement
There needs to be a team implemented to work on the improvements suggested which will require a leader to be identified who might also be considered the project manager of this improvement implementation. The project team will need to consist of a cross functional group to ensure that different organizational functions are represented as well as the information and training can be effectively disseminated after the project is over.
Clarify current knowledge of the process
The current industry best practices seem to indicate that a behavioral emergency response team (BERT) is the best approach to handling cases such as the one presented. Multiple factors influence nurses’ abilities to provide effective interventions to patients with mental health issues in non-psychiatric inpatient settings; two factors, the presence of negative attitudes toward patients with mental illnesses along with nurses’ perceptions of a lack of competence and confidence in identifying and managing behavioral symptoms, have been cited in a variety of publications (Pestka, et al., 2012).
The implementation of a BERT is also of critical importance to the safety of the hospital staff. There are a number of hospital assaults every year that arise out of mentally troubled individuals who take out their anger on the staff. The actual number of health care worker injuries related to assaults by patients is unknown and violence against nurses may be underreported for a variety of reasons including the view that it is part of the job (Pestka, et al., 2012). Further research should be conducted by the team to focus on creating a set of best practices to implement in the hospital setting.
Understand process variation and capability
In the case, the mentally troubled patient presents an issue for the current operating process because they are unsure of how to handle the situation. However, if a BERT team was in place, then the patient would immediately be this team’s responsibility once it was recognized that he might be a drug users and/or have behavioral problems. The rest of the staff would be trained to not only identify the mentally unstable cues that patients could display, but they would also know to immediately alert the BERT team.
Select the Process Improvement
The most important process improvement that was identified would be the creation of a BERT response team. This team would undergo special training to understand the risks and responses that mentally unstable patients can introduce into the healthcare process.
Dr. W. Edwards Deming was an American statistician, professor, author, lecturer, consultant and also known as the father of the Japanese post-war industrial revitalization. Deming gained notoriety by trying to develop better ways for people to work together. His theories were applied to various industries included manufacturing companies, telephone companies, railways, carriers of motor freight, consumer researchers, census methodologists, hospitals, legal firms, government agencies, and research organizations in universities (Bennet & Slavin, 2009).
In this situation the plan-do-check-act cycle can be applied to every step in the process. The PDCA cycle is a way of continuously checking progress in each step of the FOCUS process. Each step is can also be considered of critical importance given the fact that the safety of the staff is on the line. The case highlighted the vulnerabilities in the department and these vulnerabilities lead to many accidents and assaults across the country. It was identified that a BERT team should implement immediately to identify gaps in the current operations model and take corrective action. These actions will consist of a continuous improvement cycle that will continually refine the operating procedures.
Bennet, L., & Slavin, L. (2009, April 3). What Every Health Care Manager Needs to Know. Retrieved from Continous Quality Improvement: http://www.cwru.edu/med/epidbio/mphp439/CQI.htm
i Six Sigma. (N.d.). Focus – PDCA. Retrieved from I Six Sigma: http://www.isixsigma.com/dictionary/focus-pdca/
Pestka, E., Hatterberg, D., Larson, L., Zwygart, L., Cox, A., & Cox, D. (2012). Enhancing Safety in Behavioral Emergency Situations. Medsurg Nursing, 335-341.
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