HI230 Unit 10 Quality Improvement Report Example

Nine of Eleven Misses Arrived Overnight: A Unit 10 Quality Improvement Report Taking a Fall Risk Screening Rate of 63.3 Percent From Audit Finding to One Handoff Change, Three Measures and a First Test on One Unit

[Student Name]

Purdue University Global

HI230: Quality Assurance and Statistics in Health Information 1

Unit 10 Quality Improvement Report

[Instructor Name]

[Date]

The hospital, its units, its staff roles and every figure are composite; the improvement method and the sources cited are real.

Summary

Problem: fall risk screening on the adult medical units is documented within eight hours of arrival in 63.3 percent of records, against a policy threshold of 90 percent. Cause: most misses are patients admitted from the emergency department overnight, when the screen is deferred to day shift. Change: make the fall risk screen a required field in the emergency department's handoff note to the inpatient unit. Measure: monthly review of 20 overnight admissions, with a target of 90 percent within three months.

The Problem

The quarterly records audit reviewed a systematic sample of 30 adult medical discharges against four documentation criteria. Fall risk screening within eight hours of arrival on the unit was met in 19 of 30 records, 63.3 percent, the largest gap of the four. With 30 records the true rate could plausibly lie anywhere from the mid-forties to the high seventies, but even the top of that range falls well short of the threshold, so the shortfall is real even if its exact size is uncertain. The criterion matters for two reasons. The first is clinical: the screen is meant to start prevention before the patient's first night, and a screen completed the next afternoon guides nothing during the hours when a confused, newly admitted older patient is most likely to try to walk alone. The second is the reliability of the record itself. A policy the record shows being met only two times in three gives a surveyor, a risk manager or a court little reason to trust the rest of the documentation, and hospital rules require record entries to be timed so that the sequence of care can be reconstructed (42 C.F.R. § 482.24, 2024).

Cause, From the Audit's Own Data

The cause analysis uses only what the audit found. No fishbone diagram was filled with possibilities nobody checked.

1. Overnight arrivals from the emergency department, 11 p.m. to 7 a.m.: 9 of 11 misses.

2. Daytime arrivals from the emergency department: 1 of 11 misses.

3. Direct admissions from clinics: 1 of 11 misses.

In every one of the eleven records, a screen was eventually documented, at a median of about fourteen hours after arrival. The screen was not being skipped. It was being postponed. Interviews with four night-shift nurses on the two medical units gave the same account: an overnight admission arrives with a full emergency department record, the admitting nurse completes the safety essentials and vital signs, and the full admission database, which contains the fall screen, is left for the day nurse, who has a new set of morning priorities. The emergency department already performs a brief fall risk check for older patients but records it in a section of its own note that does not cross over to the inpatient record. The hospital was already screening most of these patients for fall risk. It was doing so in the emergency department and then losing the result at the door of the unit.

The Change

One recommendation: the fall risk screen becomes a required field in the emergency department's handoff note to the inpatient unit for every admitted adult. The emergency nurse completes the screen, using the same scale the inpatient units use, before the transfer can be finalized in the record system. On arrival the inpatient nurse confirms or updates the score and signs it, which takes a minute rather than the twenty the full admission database requires. The score then shows on the unit's whiteboard and in the care plan from the first hour. The scale itself stays the same. The Morse Fall Scale already in use was designed to be scored quickly from a few observable items, which suits a busy handoff (Morse et al., 1989). No scale predicts falls well on its own, and reviews of hospital fall research advise that universal precautions continue for every patient whatever the number says (Oliver et al., 2004). The aim of this change is narrower than predicting falls better. It is to have the screen and its prevention steps in place before the first night instead of the next afternoon. The national toolkit for preventing falls in hospitals treats screening on admission as one of the core practices that should happen reliably, which is what this change targets (Agency for Healthcare Research and Quality, 2013). Only one change is proposed. If the outcome measure moves too little after the first month, the next candidate for the council is a short admission checklist for night shift that puts the fall screen first; it is held back for now. Adding a second change, such as extra night staffing, at the same time would make it impossible to know which one moved the rate. Owner: the nurse manager of the 4 West medical unit, with the emergency department's clinical educator and the health information department's record systems analyst, who will build the required field.

How the Change Will Be Tested

The change follows a plan-do-study-act cycle, a method that works best when cycles are small, measured with data collected over time and repeated rather than run once (Taylor et al., 2014). The first cycle tests the required field for admissions to 4 West only, for one month. If the measures improve and the balancing measure holds, the second cycle extends the change to 5 West. If the field causes delays or workarounds, the second cycle adjusts it before any spread. The sequence borrows its three opening questions from the model for improvement: what the unit wants, how a gain would be recognized and which single adjustment to try, all settled before the first admission is affected (Langley et al., 2009).

Measures

1. Outcome measure. Numerator: overnight admissions from the emergency department with a fall risk screen documented within eight hours of arrival on the unit. Denominator: overnight admissions from the emergency department to 4 West, sampled as the first 20 each month. Target: 90 percent within three months.

2. Process measure. Numerator: handoff notes with the fall risk field completed. Denominator: all emergency department handoff notes for admissions to 4 West. This shows whether the change is being used.

3. Balancing measure. Median minutes from the inpatient bed assignment to the patient's arrival on the unit. The required field could slow transfers from a crowded emergency department, and that cost has to be visible.

Every month, each measure gets one new point on its own run chart, with the audit baseline of 63.3 percent drawn as the first point and the 90 percent threshold as a horizontal line. Six months of points will be needed before anyone calls the change a success.

Risks to Watch During the Test

The main risk is a screen completed in haste to clear a required field, which would raise the outcome measure without improving care. The monthly review will therefore check five records for agreement between the emergency score and the inpatient confirmation; large disagreements will be discussed with both departments. A second risk is that emergency nurses come to see the field as one more task from another department. The emergency department's educator will present the audit results at their staff meeting so the nurses hear the case for the field as numbers from their own patients rather than as a memo.

Review Date

Results from the first cycle will go to the quality council in its April meeting with a decision requested: adopt, adapt or abandon.

References

Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals: A toolkit for improving quality of care (AHRQ Publication No. 13-0015-EF). Agency for Healthcare Research and Quality.

42 C.F.R. § 482.24 (2024). https://www.ecfr.gov/current/title-42/section-482.24

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Morse, J. M., Morse, R. M., & Tylko, S. J. (1989). Development of a scale to identify the fall-prone patient. Canadian Journal on Aging, 8(4), 366-377. https://doi.org/10.1017/S0714980800008576

Oliver, D., Daly, F., Martin, F. C., & McMurdo, M. E. T. (2004). Risk factors and risk assessment tools for falls in hospital in-patients: A systematic review. Age and Ageing, 33(2), 122-130. https://doi.org/10.1093/ageing/afh017

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862