Introduction

In the provision of childcare or healthcare services to children and families, organizations should ensure consisted commitment to quality for this fundamental service is the foundation on which the future of any country lies. Consisted quality in healthcare or childcare can never be achieved or even maintained if organizations do not come up with quality improvement initiatives that are designed to ensure that the organization delivers nothing but quality to its patients (Finlay, 2017). Quality initiatives are activities and processes that are put in place to check on quality and ensure that there are quality improvement initiatives in place so that quality is revised and always improved. Healthcare does not only involve treating and ensuring that the sick but also providing their comfort and managing symptoms. This assessment will study and propose quality improvement initiatives for hospice healthcare at Villa healthcare. Hospice care is a type of care that that is designed to give supportive care to those with chronic illness or in final phases of terminal illness providing focus on the quality of life and comfort rather than cure (Harrison, 2016). The primary reason for this care is to ensure that the patients leave every day o their remaining time entirely and free of pain.

The type of data that am analyzing is from media piece; Monthly adverse event report from Hospice Unit, Villa Healthcare. The data presents the number of adverse events for two consecutive years (2015 and 2014), which includes the Length Of Stay (LOS) for each month, In-Patient Unit, Pain level 7-10 more than 24 hours, and Inadequate symptom relieves more than 25 hours.

From the analysis of the data, the total number of patients who received the services for less than seven days were 50 in the years 2014. This number dropped in the following year to a total of 46. The year with the highest count in 2014 was March (11) while the year which received the highest number of such cases was in January (10). The data also reveals that the number of In-Patient admissions dropped from  47 to 27 from the year 2014 to the year 2015 which was a drop of 20.the number cases of inadequate symptom relief moiré than 24 hours increased 13 to 22. Also, the data also shows an increase in the affairs of patients with pain level between 7-10  in more than 24 hours from 13 to 17.

Data interpretation and issues

Analysis of the data revealed some issues that indicated a lapse in the quality of services offered by the institution, showing a need for quality improvement initiatives to ensure that the patients receive the highest comfort possible at the end of life. First,  an increase in the number of patients with a pain level of 7-10 more than 24 hours indicates not only does the organization have poor pain management services but also that it fails to live to its mission, which according to Roger Goldenberg, is to provide end of life comfort care. There can never be a comforting end of life if the pain level is at level 7-10, which according to pain scale is a high and critical level of pain which indicates that the patient is severely suffering. An increase in the number of these cases in the two consecutive cases is a clear indication that the organization does not have quality initiatives to monitor and manage the level of pain for the patients. Though the organization currently utilizes a holistic approach in achieving comfort and pain management, there is a need for this to be incorporated with a more active approach to pain management to ensure that the quality of services is improved.

One of the goals of any hospice service providers is to ensure that the symptoms of the diseases are treated (McMillan & Mahon, 2016). According to David Broose, Quality assurance Director of the organization, the goals of the organization is to ensure high quality of life for the patients, and in doing this, the organization ensures that it meets the physical, psychological, spiritual and emotional needs. To access the quality of life the nurses and other healthcare providers approach this by asking questions to monitor the symptoms and pain level of the patients and asking the family members too. But from the data, the number of case of short symptom relief more than 24 hours increased from 2014 to 2015 by 69.20%. This is a high increase and indicates that there is a lapse in the treatment of the symptoms by the organization. It’s either the organization is not giving the issue of symptom treatment the weight it deserves or the measures that the organization is applying are faulty. From an interview with the officials, it was discovered that nurses and other health professionals mostly relied on questioning the families and the patients to monitor the symptoms and the level of pain. There is a need for improvement of this or a new approach to ensure that quality is improved in symptom relief for the quality end of life care.

The drop of the number of In-Patient admissions from 47 to 27 indicates a decrease in the name of patients who received quality services and comfort life especially the ones who required aggressive management that the one provided by home care. Not all functions can be obtained from home care, especially towards the death of the patient where he /she is at despair and requires more care and attention than the one provided by the home care services. For increased comfort for the patients, there is a need for quality improvement initiatives that will ensure increased in In-Patient admissions in the hospital.

Even though there was a drop of LOS less than seven days from 50 in the year 2014 to 46 in the year 2015, the number is still high. Patients are deemed to have benefited from hospice services is they receive the comfort for a more extended period before their death. Hospice services that are provided just before or a few days and hour before death are not much or at all effective as the patient is in the mood of death and has suffered enough. In totality, the patient is said to have lived a low-quality life even though a few minutes before death he or she was provided with quality hospice service (Teno, 2015). s.Therefore, the hospital does not achieve its mission of providing comfort and quality end of life care if most of the patients receive its hospice services for less than a week. The minimum recommended number of days that patients should be receiving hospice services to be said to have benefited from them is 18  days (Harrison, 2016). This period or more ensures that the patient understands and enjoys his or her end of life, through man and symptom management. Though it might be argued that they are not liable for late admissions and since most of the patients are referred to the few days before death, its still the duty of the organization as a health service provider to ensure that it gets customers to receive their services early stages of death –time to provide full benefit. To increase the length of stay, there is a need for quality improvement initiatives that will ensure that patients consume the hospice services for a more extended period before their death. This is through proposals that will provide that the start receiving hospice services many days before their death as the goal of thor organization is not to save a life or to extend life but to provide comfort and quality end of life.

Important of the data and missing figures

Generally, the data is essential as it provides fundamental information that can be used to come up with quality improvement initiatives that can be used to improve quality in the organization’s quality delivery. However, it has some missing figures. To evaluate how the effectiveness of the hospice services and effectively decide on the quality improvement initiatives that can work best for the organization, it’s important to have data on the how organization performed on hospice services provided to the family members. This is because hospice services do not only involve the sick but also comfort the family members. This missing information could relate to the evaluation of Grief Support services, Family Outcomes and Measure(POM) as well as Family evaluation of Palliative care(FEHC)

Quality improvement initiatives

The Benchmarks

There are various quality improvement initiatives are requirements that have been set by state and federal laws and health policies. One of such is  by Hospice Law and Regulations (The uniform standards of care for federal and state laws) that indicates that organizations that are registered and permitted to provide hospice services should dedicate their efforts and ensure that they abide by the core purpose of provision of hospice services; quality and comfort end of life care (Teno, 2015). Also, organizations must ensure that the p[atient receives minimum or no suffering and in doing this, the organization should not act in a way that leads to the death of the patient.

According to Social Security Act (section 1395d(a)(1))  on the rights of hospice care patients, the act indicates that hospice patients have right to receive effective pain and symptom management to end suffering and promote comfortable life. The policy suggests that all the licensed hospice providers should abide by this to void revocation of the licenses.

The proposed quality improvement initiatives

To help achieve adequate pain management, the organization should adopt a policy of training its nurses and other hospice services providers for at least once every month, to ensure that they are equipped with necessary skills of monitoring and rating the pain levels of patients to that they can decide to the action to take. Different medications are used for varying levels of pain hence ability to evaluate and rate the level of patients pain is necessary. The monthly training will ensure that the healthcare professional is equipped and updated on the changes in the health sector that concern hospice service provision, and develop an altitude of continuous learning for continuous quality improvement. The organization should also test the effectiveness and quality of pain management drugs such as uploads to ensure that they acquire medications that can relieve pain as required and without any side effects to the patient.

Training the hospice professionals like nurses monthly will also be essential to equip them with skills for monitoring and evaluating the patients’ symptoms to decide the type of treatment to give to manage the symptoms. This training should not only be theoretical but a simulation that provides the nurses with a  better practical understanding of how to deal with actual situations (Meier, 2014). The organization should also employ experts on temporary or permanent basis whose work will be to audit the work done by the nurses and another professional, and provide an insight on the areas that need improvements or changes to conform to standards and quality.

The organization should develop and marketing team whose role will be to market the services provided by the hospital. This will ensure that the patients get to receive the hospice services early enough that they can obtain maximum comfort.

On IPU admission, the first initiative would expand the admission unit so that it can be able to admit more patients. It was discovered that the hospital had stringent policies on admission as a way of singling out some people due to limited space. Admitting all qualifying and terminally ill patients especially those in situations that require aggressive management would lead to improvement in quality. Modern types of equipment such as beds and art-work should be maintained in the admission unit for improved quality.

In order to improve quality on support services given to family members, the organization should come up with metric and scale which the family members will be evaluating and rating the services and level of consolation they receive from the hospital at the end of service to indicate satisfaction and dissatisfaction. This will be crucial too for the organization to identify improvement areas hence leading to continuous quality improvement.

Inter-professional perspectives and roles

For the above initiatives to be implemented, both the management as well as the staff have a role to play which are equally significant. The purpose of the administration including the Director, Chief Nursing Officer, Quality Assurance Director and Chief Finance Officers to ensure that the initiatives are financed, implemented and their effectiveness evaluated while the staff such as the nurses and caregivers do the practical implementations under the instructions of the management. Quality Assurance Officer will have a significant role in ensuring that these quality improvement initiatives are appropriately implemented and doing supervisory and audit work to monitor the improvement in the quality of the services.

Non-nursing concept

For the implementation of these initiatives, it would require nursing and non-nursing concepts. An example of a nursing concept that I would use is Ibraham Maslow’s theory of the hierarchy of need. This theory states that human act towards a goal and divide the needs to 5 levels including physiological needs, safety, self-esteem and self-actualization (Meier, 2014). Psychological needs relate to basic needs, and this would be met by proper nutrition and sheltering the patients that would bring satisfaction. Oxygen is also a basic need for the patient; hence it will be maintained. Safety of the patient is paramount, and this will bring great focus to the security of the hospital and the protection of the patient at home in cases of home care. For self-esteem need, the concept would involve respecting the patients all the time. Self-actualization would involve motivating the patients and teaching them to take control and care of their illness.

Impact and outcomes

The proposed initiatives would lead to excellent pain management that will increase the quality end of life for the patients due to reduced suffering and greater comfort.

Adequate symptom relief will ensure reduced suffering for patients. Extension of the thenadmision unit will ensure that more patients are admitted while availing hospice services to patients at an early stage or illness will ensure they receive maximum comfort.

To the nursing staff and interprofessional team, the initiatives will improve the work-life quality due to extensive knowledge on how to perform tasks as a result of continuous training. The audit and evaluation of the work done by experts will improve effectiveness and efficiency, making working lively and enjoyable due to expertise. This will lead to more job satisfaction and work-quality life.

To ensure cost effectiveness in implementing the quality initiatives, the monthly training would be done by the management rather than hiring such services. The organization would only incur the cost of buying education manuals and materials.

These suggestions are based on assumptions that the organization has adequate financial muscles to implement them effectively. Its also assumed that the current admission unit is small and thus needs expansion to accommodate more In-Patients.

proposed communication strategies

For effective implementation of the above quality improvement initiatives, the interprofessional communication strategies that will be implemented include listening-listening strategy where the leaders listen to subjects more than they talk,use of non-threatening communication, method of motivating and encouraging language,communication that recognizes and accepts diversity as well as communication that is directed to person rather than describing person to others (McMillan, & Mahon, 2016). This proposal will also incorporate communication using the SBAR  model.

Conclusion

Hospice healthcare services are necessary just like any other healthcare. It’s important that those terminally ill are provided with quality life and comfort that will ensure death which is accompanied by little or no pain. One doesn’t have to suffer and experience a painful death. To provide this, it’s essential that organizations train their nurses and another professional on how to identify, evaluate and manage patients levels of pain and symptom. Quality hospice service should not only be provided to patients but also families to relieve their suffering.

References

Finlay, I., (2017). Palliative care in hospital, hospice, at home: results from a systematic review. Annals of Oncology, 13(suppl_4), 257-264.

Harrison, R. (2016). First Medicare demonstration of the concurrent provision of curative and hospice services for end-of-life care. American journal of public health, 106(8), 1405-1408. Cornell Law School. (2016, August 14). 42 CFR Subpart D – Conditions of participation: Organizational Environment. Retrieved from https://www.law.cornell.edu/cfr/text/42/part-418/subpart-D

McMillan, S. & Mahon, M. (2016, August). The impact of hospice services on the quality of life of primary caregivers. In Oncology Nursing Forum (Vol. 21, No. 7, pp. 1189-1195).

Meier, D. E. (2014). Increased access to palliative care and hospice services: opportunities to improve value in health care. The Milbank Quarterly, 89(3), 343-380.

Teno, J. (2015). Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. Jama, 309(5), 470-477.

US Legal, Inc. (2017). Hospice Law and Legal Definition. Retrieved from https://definitions.uslegal.com/h/hospice/