What is the main issue for your organization in addressing a solution to evidence-based nursing practice? Discuss what might be the first step in addressing and resolving this issue.
One reference in last 5 years
In this chapter from slide 26-30 there’s an example of use cases and there’s is also template. the required is two template cases example to fill the template. Please read before you start your bit.
Why is the concept of family health important? Consider the variousstrategies for health promotion. How does a nurse determine whichstrategy would best enable the targeted individuals to gain morecontrol over, and improve, their health?
Beverly,
You presented relevant information regarding economic and accounting profits. You stated, “Economic profits are determined by economic principles, whereas accounting is determined by GAAPS.” What is GAAPS? How would you describe GAAPS to your colleagues?
Read the three articles that are listed below (scroll down after the questions) and answer the questions in paragraph form:
The Yamas and Niyamas by Emma-Louise Newman
Eight Limbs, Pantanjali’s eight-fold path by Mara Carrico
Pratyahara, Yoga’s Forgotten Limb by David Frawley
Which of the Yamas and Nyamas do you relate to and why?
What is the purpose and/or benefit of each of the eight limbs of Yoga and how you experience each limb on and/or off your mat?
How do the limbs relate to each other? Do you feel one is more important than the other and why?
The Yamas and Niyamas
by Emma-Louise Newlyn
The word ‘yoga’ is understood differently by many of us; for some it’s purely a physical exercise, a way to get stronger, healthier and more flexible; for others it’s meditating each day, and for others still, it might mean chanting mantras or worshipping a deity.
If there’s one thing to be sure of though, it’s that yoga meaning ‘unity’, offers us a way of life that can be much more transformational than a 60-minute yoga class once a week….
Beyond asana
While all the stretching, twisting, balancing and occasionally falling over (or a lot of falling over) is very beneficial, and certainly opens the gateways to a healthier, more vibrant and ‘alive’ sense of being, it is just one branch on a very big tree of yoga. Ancient texts such as the Hatha Yoga Pradipika and The Yoga Sutras focus very little on physical yoga postures (asana), and in fact when Patanjali speaks of ‘asana’ he is in no way at all referring to Headstand or Warrior II; he’s talking about the position you choose to sit in while meditating your ‘seat’. It’s the tantric traditions that focussed more on what the body could do, and these texts show more evidence of where the postures come from…
The Yoga Sutras
The Yamas and Niyamas originate from the very well known text ‘The Yoga Sutras of Patanjali’, which many yoga teachers or teachers-in-training will have attempted to decipher at some point. Patanjali is known as a sage, but it’s very unlikely that one man wrote these texts and far more likely that the texts are the
culmination of what a group of Patanjali’s disciples wrote over a period of time.
Without going into too much detail the Yoga Sutras are essentially less of a deep and philosophical book like many may think, and more like a guide or instruction manual on how to live in order to advance along a spiritual path towards enlightenment.
The Eight Limbs of Yoga
The Yoga Sutras contain a set of observances and practices referred to as “limbs”; each describing a different aspect of the yoga practice, and a different step on the ladder to realization. These are commonly known as the ‘Eight Limbs of Yoga’:
come to class for the physical benefits, but the reason so many of us stay is because there’s an inkling that there’s some other sort of magic at work here….
The Yamas and Niyamas are often seen as ‘moral codes’, or ways of ‘right living’. They really form the foundation of our whole practice, and honoring these ethics as we progress along ‘the path’ means we’re always being mindful of each action, and therefore cultivating a more present and aware state of being. It’s interesting to note that these five Yamas and five Niyamas resemble the ten commandments, and the ten virtues of Buddhism, so we’re all ‘different’ yet ‘united’ at the same time….
The idea of a yoga practice is really not just to focus and be aware and mindful and calm for the time that we’re on the mat, but to carry this state of being with us when we leave class
The Yamas
The word ‘yama’ is often translated as ‘restraint’, ‘moral discipline’ or ‘moral vow’, and Patanjali states that these vows are completely universal, no matter who you are or where you come from, your current situation or where you’re heading. To be ‘moral’ can be difficult at times, which is why this is considered a very important practice of yoga. Remember that the word ‘yoga’ means ‘unity’, ‘wholeness’ or ‘connectedness’; of course it’s important to be mindful, gentle and present in class, but if this doesn’t translate off the mat and connect into what we do in our day-to-day lives, we will never feel the real benefits of yoga.
The Yamas traditionally guide us towards practices concerned with the world around us, but often we can take them as a guide
of how to act towards ourselves too. There are five Yamas in total listed in Patanjali’s Sutras:
The Eight Limbs
Patanjali’s eight-fold path offers guidelines for a meaningful and purposeful life.
By Mara Carrico
In Patanjali’s Yoga Sutra, the eightfold path is called ashtanga, which literally means “eight limbs” (ashta=eight,anga=limb). These eight steps basically act as guidelines on how to live a meaningful and purposeful life. They serve as a prescription for moral and ethical conduct and self- discipline; they direct attention toward one’s health; and they help us to acknowledge the spiritual aspects of our nature.
1. Yama
The first limb, yama, deals with one’s ethical standards and sense of integrity, focusing on our behavior and how we conduct ourselves in life. Yamas are universal practices that relate best to what we know as the Golden Rule, “Do unto others as you would have them do unto you.”
2. Niyama
Niyama, the second limb, has to do with self-discipline and spiritual observances. Regularly attending temple or church services, saying grace before meals, developing your own personal meditation practices, or making a habit of taking contemplative walks alone are all examples of niyamas in practice.
3. Asana
Asanas, the postures practiced in yoga, comprise the third limb. In the yogic view, the body is a temple of spirit, the care of which is an important stage of our spiritual growth. Through the practice of asanas, we develop the habit of discipline and the ability to concentrate, both of which are necessary for meditation.
4. Pranayama
Generally translated as breath control, this fourth stage consists of
techniques designed to gain mastery over the respiratory process while recognizing the connection between the breath, the mind, and the emotions. As implied by the literal translation ofpranayama, “life force extension,” yogis believe that it not only rejuvenates the body but actually extends life itself. You can practice pranayama as an isolated technique
(i.e., simply sitting and performing a number of breathing exercises), or integrate it into your daily hatha yoga routine.
These first four stages of Patanjali’s ashtanga yoga concentrate on refining our personalities, gaining mastery over the body, and developing an energetic awareness of ourselves, all of which prepares us for the second half of this journey, which deals with the senses, the mind, and attaining a higher state of consciousness.
5. Pratyahara
Pratyahara, the fifth limb, means withdrawal or sensory transcendence. It is during this stage that we make the conscious effort to draw our awareness away from the external world and outside stimuli. Keenly aware of, yet cultivating a detachment from, our senses, we direct our attention internally. The practice of pratyahara provides us with an opportunity to step back and take a look at ourselves. This withdrawal allows us to objectively observe our cravings: habits that are perhaps detrimental to our health and which likely interfere with our inner growth.
6. Dharana
As each stage prepares us for the next, the practice of pratyahara creates the setting fordharana, or concentration. Having relieved ourselves of outside distractions, we can now deal with the distractions of the mind itself. No easy task! In the practice of concentration, which precedes meditation, we learn how to slow down the thinking process by concentrating on a single mental object: a specific energetic center in the body, an image of a deity, or the silent repetition of a sound. We, of course, have already begun to develop our powers of concentration in the previous three stages of posture, breath control, and withdrawal of the senses. In asana and pranayama, although we pay attention to our actions, our attention travels. Our focus constantly shifts as we fine-tune the many nuances of any particular posture or breathing technique. In pratyahara we become self-observant; now, in dharana, we focus our attention on a single point. Extended periods of concentration naturally lead to meditation.
7. Dhyana
Meditation or contemplation, the seventh stage of ashtanga, is the uninterrupted flow of concentration. Although concentration (dharana) and meditation (dhyana) may appear to be one and the same, a fine line of distinction exists between these two stages. Where dharana practices
one-pointed attention, dhyana is ultimately a state of being keenly aware without focus. At this stage, the mind has been quieted, and in the stillness it produces few or no thoughts at all. The strength and stamina it takes to reach this state of stillness is quite impressive. But don’t give up. While this may seem a difficult if not impossible task, remember that yoga is a process. Even though we may not attain the “picture perfect” pose, or the ideal state of consciousness, we benefit at every stage of our progress.
8. Samadhi
Patanjali describes this eighth and final stage of ashtanga, samadhi, as a state of ecstasy. At this stage, the meditator merges with his or her point of focus and transcends the Self altogether. The meditator comes to realize a profound connection to the Divine, an interconnectedness with all living things. With this realization comes the “peace that passeth all understanding”; the experience of bliss and being at one with the Universe. On the surface, this may seem to be a rather lofty, “holier than thou” kind of goal. However, if we pause to examine what we really want to get out of life, would not joy, fulfillment, and freedom somehow find their way onto our list of hopes, wishes, and desires? What Patanjali has described as the completion of the yogic path is what, deep down, all human beings aspire to: peace. We also might give some thought to the fact that this ultimate stage of yoga—enlightenment—can neither be bought nor possessed. It can only be experienced, the price of which is the continual devotion of the aspirant.
Pratyahara: Yoga’s Forgotten Limb
David Frawley
Pratyahara itself is termed as yoga, as it is the most important limb in yoga sadhana.
—Swami Sivananda
Yoga is a vast system of spiritual practices that provides tools for inner growth. It teaches us how to understand the different aspects of our nature and how to harmonize these with the greater universe within and around us. This wonderful inner science shows us how to realize our highest evolutionary potential.
How many people, even yoga teachers, can define pratyahara?
To this end, the classical yoga system (ashtanga yoga) incorporates eight limbs, each with its own place and function. Together they form a complete system for spiritual unfoldment. The eight limbs are: yama (observances), niyama (disciplines), asana (postures), pranayama (breath control), pratyahara (control of senses), dharana (concentration), dhyana (meditation), and samadhi (absorption). Of these, pratyahara is probably the least known. How many people, even yoga teachers, can define pratyahara? Have you ever taken a class in pratyahara? Have you ever seen a book on pratyahara? Can you think of several important pratyahara techniques? Do you perform pratyahara as part of your yogic practices? Yet unless we understand pratyahara we are missing an integral aspect of yoga. Without this aspect the system cannot work.
INNER AND OUTER ASPECTS OF YOGA
Yoga has an outer aspect, which consists of right living, right care of the body, and enhancement of vital energy. This is what yama, niyama, asana, and pranayama are all about. Yama and niyama build a foundation of right behavior through such values as nonviolence and truthfulness and such practices as cleanliness and contentment. Asana makes the body strong and flexible, and pranayama develops our vital energy.
Yoga also has an inner dimension—meditation or the development of higher consciousness. This is the real purpose of yoga, the focus of dharana, dhyana, and samadhi, which together form a single process—samyama, or meditation in the broadest sense.
As the fifth of the eight limbs, pratyahara occupies a central place. Some include it among the outer aspects of yoga, others with the inner aspects. Both classifications are correct, for pratyahara is the key to the relationship between the outer and inner aspects of yoga; it shows us how to move from one to the other.
It is not possible for most of us to move directly from asana to meditation. This requires jumping from the body to the mind, forgetting what lies between. To make this transition, the breath and senses, which link the body and mind, first need to be brought under control and developed properly. This is where pranayama and pratyahara come in. With pranayama we control our vital energies and impulses, and with pratyahara we gain mastery over the unruly senses—both prerequisites to successful meditation.
WHAT IS PRATYAHARA?
The term “pratyahara” is composed of two Sanskrit words, prati and ahara. “Ahara” means “food,” or “anything we take into ourselves from the outside.” “Prati” is a preposition meaning “against” or “away.” “Pratyahara” means literally “control of ahara,” or “gaining mastery over external influences.” It has been compared to a turtle withdrawing into its shell—the turtle’s shell is the mind and the turtle’s limbs are the senses. The term is usually translated as “withdrawal from the senses,” but much more is implied.
In yogic thought there are three levels of ahara, or food. The first is physical food that brings in the five elements necessary to nourish the body—earth, water, fire, air, and ether. The second is impressions, which bring in the subtle substances necessary to nourish the mind—the sensations of sound, touch, sight, taste, and smell that constitute the subtle elements: sound/ether, touch/air, sight/fire, taste/water, and smell/earth. The third level of ahara is our associations, the people we hold at heart level who serve to nourish the soul and affect us with the gunas of sattva, rajas, and tamas (the prime qualities of harmony, distraction, or inertia).
Pratyahara is twofold. It involves withdrawal from wrong food, wrong impressions, and wrong associations, while simultaneously opening up to right food, right impressions, and right associations. We cannot control our mental impressions without right diet and right relationships, but pratyahara’s primary importance lies in withdrawal from or control of sensory impressions, which frees the mind to move within.
By withdrawing our awareness from negative impressions, pratyahara strengthens the mind’s powers of immunity. Just as a healthy body resists toxins and pathogens, a healthy mind resists the negative sensory influences around it. If you are easily disturbed by the noise and turmoil of the environment around you, you need to practice pratyahara. Without it, you will not be able to meditate.
Just as a healthy body resists toxins and pathogens, a healthy mind resists the negative sensory influences around it.
There are four main forms of pratyahara: indriya-pratyahara—control of the senses; karma-pratyahara—control of action; prana-pratyahara—control of prana; and mano-pratyahara—withdrawal of mind from the senses. Each has its special methods.
CONTROL OF THE SENSES
Indriya-pratyahara, or control of the senses, is the most important form of pratyahara, although this is not something that we like to hear in our mass media-oriented culture. Most of us suffer from sensory overload, the result of constant bombardment from television, radio, computers, newspapers, magazines, books—you name it. Our commercial society functions by stimulating our interest through the senses. We are constantly confronted with bright colors, loud noises, and dramatic sensations. We have been raised on every sort of sensory indulgence—it is the main form of entertainment in our society.
The problem is that the senses, like untrained children, have their own will, largely instinctual in nature. They tell the mind what to do. If we don’t discipline them they dominate and disturb us with their endless demands. We are so accustomed to ongoing sensory activity that we don’t know how to keep our minds quiet—we have become hostages of the world of the senses and its allurements. We run after what is appealing to the senses and forget the higher goals of life. For this reason pratyahara is probably the most important limb of yoga for us today.
The old saying “the spirit is willing but the flesh is weak” applies to those of us who have not learned how to properly control our senses. Indriya-pratyahara gives us the tools to strengthen the spirit and reduce its dependency on the body. Such control is not suppression (which causes eventual revolt), but proper coordination and motivation.
THE RIGHT INTAKE OF IMPRESSIONS
Pratyahara is about the right intake of impressions. Most of us are careful about the food we eat and the company we keep, but we may not exercise the same discrimination about the impressions we take in from the senses. We accept impressions via the mass media that we would never allow in our personal lives. We let people into our houses through television and movies that we would never allow into our homes in real life!
What kind of impressions do we take in every day? Can we expect that they will not have an effect on us? Strong sensations dull the mind, and a dull mind lets us act in ways that are insensitive, careless, or even violent.
According to ayurveda, sensory impressions are the main food for the mind. The background of our mental field consists of predominant sensory impressions. We see this when our mind reverts to the impressions of the last song we heard or the last movie we saw. Just as junk food makes the body toxic, junk impressions make the mind toxic. Junk food requires a lot of salt, sugar, or spices to make it palatable because it is largely dead food; similarly, junk impressions require powerful dramatic impressions—sex and violence—to make us feel that they are real, because they are actually just colors projected on a screen.
We cannot ignore the role sensory impressions play in making us who we are, for they build up the subconscious and strengthen the tendencies latent within it. Trying to meditate without controlling our impressions pits our subconscious against us and prevents the development of inner peace and clarity.
SENSORY WITHDRAWAL
Fortunately we are not helpless before the barrage of sensory impressions. Pratyahara gives us many practical tools for managing them properly. Perhaps the simplest way to control our impressions is to cut them off, to spend some time apart from all sensory inputs. Just as the body benefits by fasting from food, so the mind benefits by fasting from impressions. This can be as simple as sitting to meditate with our eyes closed or taking a retreat somewhere free from the normal sensory bombardments—like a mountain cabin.
Yoni mudra (also known as shanmukhi-mudra) is one of the most important pratyahara techniques for closing the senses. It involves using the fingers to block the sensory openings in the head—the eyes, ears, nostrils, and mouth—allowing the attention and energy to move within. It is done for short periods of time when our prana is energized, such as immediately after practicing pranayama. (Naturally we should avoid closing the mouth and nose to the point at which we starve ourselves of oxygen.)
Another method of sense withdrawal is to keep our sense organs open but withdraw our attention from them. In this way we cease taking in impressions without actually closing off our sense organs. The most common method, shambhavi mudra, consists of sitting with the eyes open while directing the attention within, a technique used in several Buddhist systems of meditation. This redirection of the senses inward can be done with the other senses as well, particularly with the sense of hearing. It helps us control our mind even when the senses are functioning, as they are in the normal course of the day.
1. Focusing on Uniform Impressions
Another way to cleanse the mind and control the senses is to put our attention on a source of uniform impressions, such as gazing at the ocean or the blue sky. Just as the digestive system gets short-circuited by irregular eating habits and contrary food qualities, our ability to digest impressions can be deranged by jarring or excessive impressions. And just as improving our digestion may require going on a fast, followed by a mono-diet, like the ayurvedic use of rice and mung beans (khichari), so our mental digestion may require a period of fasting from impressions, followed by a diet of natural but homogeneous impressions.
2. Creating Positive Impressions
Another means of controlling the senses is to create positive, natural impressions. There are a number of ways to do this: meditating upon aspects of nature such as trees, flowers, or rocks, as well as visiting temples or other places of pilgrimage, which are repositories of positive impressions and thoughts. Positive impressions can also be created by using incense, flowers, ghee lamps, altars, statues, and other artifacts of devotional worship.
Another means of controlling the senses is to create positive, natural impressions.
3. Creating Inner Impressions
Another sensory withdrawal technique is to focus the mind on inner impressions, thus removing attention from external impressions. We can create our own inner impressions through the imagination or we can contact the subtle senses that come into play when the physical senses are quiet.
VISUALIZATION
Visualization is the simplest means of creating inner impressions. In fact, most yogic meditation practices begin with some type of visualization, such as a deity, a guru, or a beautiful setting in nature. More elaborate visualizations involve imagining deities and their worlds, or mentally performing rituals such as offering imaginary flowers or gems to imagined deities. The artist absorbed in an inner landscape or the musician creating music are also performing inner visualizations. These are all forms of pratyahara because they clear the mental field of external impressions and create a positive inner impression to serve as the foundation of meditation. Preliminary visualizations are helpful for most forms of meditation and can be integrated into other spiritual practices as well.
LAYA YOGA
Laya yoga is the yoga of the inner sound and light current, in which we focus on subtle senses to withdraw us from the gross senses. This withdrawal into inner sound and light is a means of transforming the mind and is another form of indriya-pratyahara.
CONTROL OF THE PRANA
Control of the senses requires the development and control of prana because the senses follow prana (our vital energy). Unless our prana is strong we will not have the power to control the senses. If our prana is scattered or disturbed, our senses will also be scattered and disturbed.
Pranayama is a preparation for pratyahara. Prana is gathered in pranayama and withdrawn in pratyahara. Yogic texts describe methods of withdrawing prana from different parts of the body, starting with the toes and ending wherever we wish to fix our attention—the top of the head, the third eye, the heart, or one of the other chakras.
Perhaps the best method of prana-pratyahara is to visualize the death process, in which the prana, or the life force, withdraws from the body, shutting off all the senses, from the feet to the head. Ramana Maharshi achieved Self-realization by doing this when he was a mere boy of 17. Before inquiring into the Self, he visualized his body as dead, withdrawing the prana into the mind and the mind into the heart. Without such complete and intense pratyahara, his meditative process would not have been successful.
CONTROL OF ACTION
In addition to sense organs (like the eyes and ears), we also possess motor organs (like the hands and tongue). We cannot control the sense organs without also controlling the motor organs. In fact the motor organs involve us directly in the external world. The impulses coming in through the senses get expressed through the motor organs, and this drives us to further sensory involvements. But because desire is endless, happiness consists not of getting what we want, but of no longer needing anything from the external world.
Just as right intake of impressions gives control of the sense organs, right work and right action gives control of the motor organs. This involves karma yoga—doing the actions necessary to life and avoiding those based on desire and self-gratification. Karma yoga has two parts: outer action or service (seva), and inner action, which consists of various forms of rituals (puja).
Karma-pratyahara can be performed by surrendering any thought of personal rewards for what we do, doing everything as service to God or to humanity. The Bhagavad Gita says, “Your duty is to act, not to seek a reward for what you do.” This is one kind of pratyahara. It also includes the practice of austerities that lead to control of the motor organs. For example, asana can be used to control the hands and feet, control which is needed when we sit quietly for extended periods of time.
WITHDRAWAL OF THE MIND
The yogis tell us that mind is the sixth sense organ, and that it is responsible for coordinating all the other sense organs. We take in sensory impressions only where we place our mind’s attention. The mind also coordinates the sensory and motor organs, for example by linking what the eyes see with the movements of the hand when we pick up a cup from the table. In a way, we are always practicing pratyahara. The mind’s attention is limited, and we give attention to one sensory impression by withdrawing the mind from other impressions. Wherever we place our attention, we naturally overlook other things.
The yogis tell us that mind is the sixth sense organ, and that it is responsible for coordinating all the other sense organs.
We control our senses by withdrawing our mind’s attention from them. According to the Yoga Sutra, “When the senses do not conform with their own objects but imitate the nature of the mind, that is pratyahara.” More specifically, it is mano-pratyahara—withdrawing the senses from their objects and directing them inward to the nature of the mind, which is formless. Vyasa’s commentary on the Yoga Sutra notes that the mind is like the queen bee and the senses are like worker bees. Wherever the queen bee goes all the other bees must follow. Thus mano-pratyahara is less about controlling the senses than about controlling the mind, for when the mind is controlled, the senses are automatically controlled.
We can practice mano-pratyahara by consciously withdrawing our attention from unwholesome impressions whenever they arise. This is the highest form of pratyahara and the most difficult—if we have not gained proficiency in controlling the senses, motor organs, and pranas it is unlikely to work. Like wild animals, prana and the senses can easily overcome a weak mind, so it is usually better to start first with more practical methods of pratyahara.
PRATYAHARA AND THE OTHER LIMBS OF YOGA
Pratyahara is related to all the limbs of yoga. All of the other limbs—from asana to samadhi—contain aspects of pratyahara. For example, in the sitting poses, which are the most important aspect of asana, both the sensory and motor organs are controlled. Pranayama contains an element of pratyahara, as we draw our attention inward through the breath. Yama and niyama contain various principles and practices, like nonviolence and contentment, that help us control the senses. In other words, pratyahara provides
Write a quality improvement proposal, 5-7 pages in length, that provides your recommendations for expanding a hospital’s HIT to include quality metrics that will help the organization qualify as an accountable care organization.
Introduction
Health care has undergone a transformation since the release of the Institute of Medicine’s 2000 report To Err Is Human: Building a Safer Health System. The report highlighted medical errors as a contributing factor leading to poor patient outcomes. The Institute of Medicine challenged organizations to implement evidence-based performance improvement strategies in order to improve patient quality and safety. Multiple governmental and regulatory agencies, such as the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Quality and Research (AHRQ), vowed to strengthen and improve incentives for participation, safety, quality, and efficiency in accountable care organizations (ACOs).
Health information technology (HIT) performs an essential role in improving health outcomes of individuals, the community, and populations. Health organizations, consumer advocacy groups, and regulatory committees have made a commitment to explore current and future opportunities that HIT offers to continue momentum to meet the Institute of Medicine’s goal of improving safety and quality.
Understanding HIT is important to improving individual, community, and population access to health care and health information. HIT enables quick and easy access to information for both patients and providers. Accessible information has been shown to improve the patient care experience and reduce redundancies, thereby reducing health care costs.
This assessment provides an opportunity for you to make recommendations for expanding a hospital’s HIT in ways that will help the hospital qualify as an ACO.
Preparation
In this assessment, you will again assume the role of case manager at Sacred Heart Hospital. This time, you are asked to develop a strategy for tracking quality metrics to help facilitate the hospital’s qualification for ACO status.
Before drafting your proposal, complete the following simulation exercise:
Challenge Details
You continue your work as a newly hired case manager at Valley City Regional Hospital, located in Valley City, North Dakota. As you know, VCRH was recently acquired by Vila Health, a large health care system that operates hospitals and clinics in several Midwestern states.
From: Karen Dellington
To: Inna Marisse Caing
Patient experience.
Care coordination/patient safety.
Preventative health.
So, here’s what I’d like for you to do:
First, I’d like for you to meet with a patient named Caroline McGlade, who has recently been diagnosed with breast cancer. Mrs. McGlade is a typical example of one of our patients who hasn’t gotten enough preventative care. I’d also like for you to look at her EHR—which, as you’ll see, isn’t very thorough. As you think about this case, ask yourself this: how could we be tracking data in cases like this one better to help us to make the improvements we need to qualify for ACO status?
Second, I’d like for you to interview a series of stakeholders who can provide you with information about changes that need to be made in our HIT.
After completing these tasks, I need you to write recommendations for how we can expand our HIT to better include quality metrics—with the ultimate goal of qualifying for ACO status.
This is a challenging assignment, but I know that you’re up to it! Best of luck.
History – 04/24/19
H&P: Mrs. McGlade is a 61-year-old woman with a PMH of breast cancer.
Family Hx Mother:
Father: Alive.
Sister:
Meds on Adm:
Neuro:
Cardio: EKG Normal.
Respiratory:
GU: Menses have ceased.
GI:
POC:
Allergies & Medication – 04/24/19
Lab – 04/23/19
CBC:
RBC: 5.1
HCT: 38.8
HGB: 14.7
WBC: 11.1
MCV: 81
MCH: 31
PLT: 301
BMP:
Glucose: 399
BUN: 15
CR: 1.1
Sodium: 138
Potassium: 4.2Chloride: 106
Chloride: 106
Co2: 23
Calcium: 11
Protein: 7.9
CA-125-1700 U
Primary Care Notes – 04/24/19
04/21/19: Mrs. McGlade is a 61-year-old woman with a lump that may be breast cancer. DX: Dr. McCall, suspected breast cancer
Called Dr. Brown-GYN ONC. Consult expected for tomorrow. Suggested CA-124, HCG, AFP prior to consult.
04/23/19:
04/24/19: MRI negative for spinal cord or brain lesions.
Plan of care: Breast oncology consult.
CBC, BMP, CA-125, HCG, AFP, Paracentesis, in am. PT, SW, CM consult.
GYN/ONC Note – 04/24/19
61-year-old woman with a possible PMH of breast cancer.
Accountable Care Organizations: What Providers Need to Know
The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health & Human Services (HHS), finalized regulations under the Affordable Care Act to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first. Provider participation in an ACO is purely voluntary.
In developing the program regulations, CMS worked closely with agencies across the Federal government to ensure a coordinated and aligned inter- and intra-agency effort to facilitate implementation of the Shared Savings Program.
CMS encourages all interested providers and suppliers to review this program’s regulations and consider participating in the Shared Savings Program.
This fact sheet provides an overview of ACOs.
It’s time to meet Caroline McGlade, a 60-year-old patient who has breast cancer. Remember, you’ve been asked to talk with this patient because she’s a typical example of someone who hasn’t been getting preventative care—a factor that makes it difficult for the hospital to qualify for ACO status. Be sure to refer back to her EHR, and think about ways the EHR could be modified to better collect qualify metrics for patients like this one.
Mrs. McGlade, how are you feeling?
Caroline: I feel just fine. A little scared, I guess. But it’s hard to believe I have cancer. I mean, I don’t feel sick at all. I guess I’ll start feeling sick once they start giving me that chemo. I’m not looking forward to that, believe me!
Can you tell me a little bit about yourself?
Caroline: I guess you could say I’m a pretty typical lady from Valley City—not very exciting! I’ve lived in this county all my life. I grew up on a farm near Tower City. Then I got married to my high school sweetheart and we live on a big plot of land about 45 minutes from here. I wouldn’t want to live anywhere else. Sometimes I wish we had more neighbors, but Mike and I like living in the middle of nowhere! I guess you could say we’re independent spirits? That’s how we were raised—we don’t like to be dependent on other people. We have four kids—our son lives in Valley City and our three girls live in the Fargo-Moorhead area. Nine grandkids so far.
How did you discover the cancer?
Have you ever gotten a mammogram?
Caroline: Yeah. I think twice? Maybe three times? It’s been a long time though. I don’t know…I guess they could’ve caught the cancer earlier if I went more often. But I’ve heard that mammograms aren’t all that important. You can find a lump pretty easy by checking your breasts, right? And I do that once a month or so.
Caroline: Well, I did when I was pregnant—but that was a long time ago. My youngest daughter is 30 years old. And when I needed birth control pills—then I used to go. But there’s no reason for me to go at my age, right? It’s not like I need birth control pills anymore—I mean, I finished with menopause when I was 47! I don’t know—I guess maybe I should have gone more often. But I really hate … you know, putting my legs in those icky metal things? I just don’t like having doctors poking around my private parts. Maybe if there were a woman doctor around here I might have gone more often, but around here there’s not a lot of choice who you see. All the gynecologists I’ve ever been to, they’re old guys who are kind of creepy.
Do you regularly see a primary care physician?
Caroline: No, not anymore. When Dr. Tucker was alive my husband and I used to go… but he died about seven, eight years ago? And we’ve never bothered finding a new doctor. Like I said, there aren’t a lot of doctors around here, and we’d have to drive 45 minutes to get to one. Gas is expensive, so we don’t like to go on trips that aren’t necessary. And I don’t want to go to someone I don’t know. Dr. Tucker, he was my doctor since I was a teenager. I guess we ought to find a new doctor, but we just don’t get sick very often. A few times we’ve gone to Urgent Care, but we don’t like to go running to the doctor every time we have some aches and pains. We can’t stand people who do that.
Have you ever gotten a colonoscopy?
Caroline: NO! No no no. Nobody’s sticking a camera up in there, or whatever it is they do. My husband’s never gotten one either–I’m pretty sure he’d rather die! Besides, those tests costs a fortune.
How do you feel about preventative care?
Caroline: You mean, like shots and such? We got all the immunizations for our kids. Oh, do you mean, like preventative care for adults? Like getting your cholesterol checked and all that? I don’t know. I guess I kind of feel like that’s a waste of time. And it’s expensive too. We just try to eat healthy and get some exercise. Neither one of us is overweight, so it’s not like we’re going to get diabetes or anything like that.
Why haven’t you gotten more preventative care?
Caroline: Well, why would we? Like I said, we’re pretty healthy and we don’t like to run to the doctor for every little thing. If there were a doctor around who I trusted, I guess I would go more often. Plus going to the doctor is expensive. It didn’t used to be so bad when we were younger, but now going to the doctor costs a fortune. My husband and I are doing okay, but we definitely don’ t have money for extras.
Have you always had health insurance?
Caroline: No, we’ve almost never had health insurance. Just during this one period when my husband was working in town for a factory that closed down. But we have health insurance now, thanks to that Obama! We don’t have a choice anymore, do we? Although much as I hate to admit it, maybe it’s a good thing we have insurance. Otherwise I don’t know how we’d pay for cancer treatments.
Do you think your views about health care and preventative care are typical for people in this area?
Caroline: Yeah. I don’t know anyone who goes to the doctor a lot. Most of the people I know, they have even less money than we do. And like I said, people are independent around here. People don’t like to ask for help unless we really need it. So going to the doctor a lot… I guess that’s not something people like to do around here.
From: Karen Dellington
To: Inna Marisse Caing
I see you’ve spoken with Caroline McGlade! I wanted you to meet with her because her case is typical of so many that we see around here. We need to address the types of issues you encountered with this patient—especially regarding preventative care—if we’re going to become an ACO. And before we can do that, we need to gather data on these issues.
I’ve arranged for you to meet with a panel of four people at VCRH so you can ask them some questions about the strategies we need to develop in order to better track quality metrics. The panel will consist of:
Todd Chester, Director of Quality Assurance.
Mary Loudsinger, a social worker.
Pete Wade, Director of Information Technology.
Trish Walstrom, the Care Coordination Manager.
–Karen
EHR Meeting
What is your opinion of the hospital’s EHR?
Trish: Um, well…
Pete: It’s okay, Trish. You don’t have to hold your tongue around me. I know the hospital’s EHR has a lot of problems.
Todd: In all fairness, Pete, it’s not worse than EHRs you’d find at many small-town rural hospitals. We simply haven’t had the budget to improve it.
Todd: We just haven’t made the EHR much of a priority. The wish list of things we need at this hospital is pretty large, and that’s always lower on the list than things like new equipment. But now that there’s this push to become an ACO, we’re going to have to find the funds to upgrade the EHR. Otherwise, we’re never going to be able to track the metrics we need to make improvements.
Trish: And that’s the problem with the EHR, in my opinion. It’s not set up to track much of anything. Patients come in here multiple times, and we have to ask them the same questions over and over again because the EHR just isn’t comprehensive enough. And if the EHR isn’t comprehensive enough to help patients on an everyday basis, it sure isn’t comprehensive enough to be used for data collection purposes.
Mary: Well, in my opinion, one of the biggest problems is that there simply aren’t enough categories to enter information. I wish there was a social work tab so that I could keep track of visits with patients. If we had that tab, we could record things like patient barriers to care, and other important information that might impact their treatment.
Trish: Oh, I totally agree, Mary. There’s just not a lot of places to add non-medical information.
Pete: I’m not sure what to do about that. it would be great if we could add more categories, but that’s not easy. We’d have to work with the vendor, and that could be expensive.
Todd: Oh, I know, Pete. But if we’re ever going to become an ACO, we might need to find a way to make this investment.
Trish: So, here’s a suggestion for you, since you’re the one coming up with a strategy for tracking metrics. Why don’t you take a good look at our EHR and think about places where we could add more categories? And other updates too.
Are there changes that need to be made in how the EHR is used?
Pete: Aren’t they required to fill it out in detail?
Pete: What? Now that sounds like a serious problem. How are we ever going to use the EHR to track quality metrics if people aren’t even using it correctly?
Trish: I’m fine with that. But are you going to address the reasons why people aren’t filling the EHR out completely? It’s not because anyone is lazy. It’s because they’re busy.
How can we better track issues related to preventative care?
Pete: But how do we measure that?
Trish: I agree. For example, the county data doesn’t track what percentage of women are seeing gynecologists, or how often they’re going. There’s data about how many people don’t have a primary physician, but there’s not data about how many women see a gynecologist. And I’d like to see more nuanced data in relation to mammograms. The only stat they provide is how many women over 40 have had a mammogram in the past two years. I’d like to know how often they get mammograms, and how many women have never had one.
Mary: And in addition to these numbers, I’d like to know why. Are women not getting mammograms because of cost? Or because there aren’t enough providers around here? Or because they just don’t think it’s important? I mean, based on my experience, I can tell you why I think women aren’t getting mammograms.
Pete: But we need nuanced data to back that up.
Trish:And I think that’s true for a lot of the county data. There’s good surface information in there, but we need more nuanced data on a lot of different things. I recommend that you take the time to read through the data carefully, and come up with some ideas for areas where we need to do more nuanced research.
Mary: Yes! Where do I ever start?
Mary: Absolutely. Poverty, lack of transportation, lack of access to providers and specialists in this region—those are the big barriers to care that we see all the time.
Mary: Plus there’s just the general attitude of distrust that a lot of people around here have in regard to the health care system.
Pete: I don’t mean to be a downer here, but I’m confused. I know it’s important for you all to track social factors so you can treat patients better. But what does that have to do with tracking quality metrics that would help us to become an ACO?
Todd: Good question, Pete. The thing is, we need to track problems that are making it difficult for us to give the best health care experience we can. And a lot of those problems are directly related to social issues, like poverty and other barriers to care. If we can figure out how to measure these problems more effectively as they relate to health care, we could come up with effective strategies for improving people’s health care experiences.
Are there special population needs we could be tracking better?
Mary: And we’re not tracking other things either, like home care needs for disabled vets.
Pete: For starters, we could add a demographic box for veterans on the EHR.
Mary: Of course. This county may be over 90 percent white, but that doesn’t mean there aren’t people of color around here. We need to do a better job tracking the needs of everyone in this county.
Are there partnerships that the hospital could form with other organizations to track metrics better?
Mary: I think teaming up with the public health department would be a good start, don’t you? They’re already collecting data that we can use. Maybe we could work with them to collect more nuanced data, or different kinds of data.
Todd: That’s a very good idea, Mary. In addition, one thing I think we really need to do is link our EHR with some of the clinics in the area.
Pete: And like I said, that could be expensive.
Todd: I know. But we have to prioritize this.
Trish: I think we could do more than just linking the EHR. We could work with clinics in the area to help us collect data about things like barriers to care and other patient information.
Conclusion
You have completed the Vila Health: Quality Metrics Tracking challenge. Based on this information, you should now be able to make recommendations for strategies that Valley City Regional Hospital can use to track quality metrics better—with the ultimate goal for becoming an ACO.
Investigate strategies for expanding the health information technology (HIT) at a small rural hospital to better track quality metrics.
Recommend strategies for improving the tracking of quality metrics at a small rural hospital so that this hospital can qualify to become an ACO
Develop a proposal to expand Sacred Heart Hospital’s HIT to better include quality metrics—with the ultimate goal of qualifying for ACO status. Use the following template for your proposal:Writing the Proposal
The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your proposal addresses each point, at a minimum. You may also want to read the Quality Improvement Proposal Scoring Guide to better understand how each criterion will be assessed.
How will you collect information and solve the problem of coordinating care for patients who are not getting diagnostic tests, such as mammograms or colonoscopies?
What can you do to track health information from the community or the target population to make necessary improvements?
How can you most effectively and efficiently show the role of informatics in nursing care coordination?
What evidence supports your recommendations?
Describe the main focus of information gathering in health care and how it contributes to guiding the development of organizational practice.
Provide examples to support your QUESTION.
Identify potential problems that can arise with data gathering systems and output.
What suggestions can you make for avoiding those problems?
Write clearly and concisely, using correct grammar and mechanics.
Express your main points and conclusions coherently.
Support main points, claims, and conclusions with relevant and credible evidence, correctly formatting citations and references using APA style.
Is your supporting evidence clear and explicit?
How or why does particular evidence support a claim?
Will your audience see the connection
Format your proposal using APA style:
Use the APA Style Paper Template [DOCX] provided. Be sure to include:
A title page and references page. An abstract is not required.
A running head on all pages.
Appropriate section headings
Essay Elements:
Patient Name: Mr. Harold Smith
You are working at a family medicine clinic with Dr. Hill. She tells you, “The next patient, Mr. Harold Smith, is a 53-year-old male with a chief concern of swelling and pain in his left lower extremity.”
Before you go to see Mr. Smith, a quick review of the chart reveals that he has type 2 diabetes, obesity, hypertension, and hyperlipidemia. You note that he has not been to the office in the past six months, and it appears that he should be out of all of his medications.
When you enter the examination room, Mr. Smith, a middle-aged male, greets you from where he is sitting. You introduce yourself and ask him what brings him to the office today.
He replies, “It’s my left leg. The past four days it has been red, swollen, and painful—and it seems to be getting worse.”
You ask him to tell you more about this problem.
He says, “It began several days ago, and the swelling seems to be getting worse. It hurts all the time; it doesn’t even get better when I rest it. It seems to get a little worse when I move around. It hurts to walk as soon as I try to stand on it.”
After talking with Mr. Smith more, you discover:
Social History: Does not drink alcohol, but does smoke 1.5 packs of cigarettes daily, he is unmarried, and lives in public housing with his three children and one grandchild.
Family History: Father has hypertension. Mother has hypertension, diabetes, and history of a blood clot in her leg.
Review of Systems: No fever or chills, no chest pain, no shortness of breath, and no swelling of the right leg.
You examine Mr. Smith and find:
Vital Signs:
Cardiovascular and lung exam: Unremarkable
Lower extremity exam:
Mr. Smith’s entire left leg is swollen, warm, and erythematous. The measurement of the circumference of the largest left calf section is 3.5 cm larger than his right calf at the same location.
There is pitting edema. The leg is tender to the touch, especially along the distribution of the deep venous system.
Dorsalis pedis and posterior tibialis pulses are palpable on both feet. Digital capillary refill time is two seconds. Deep tendon reflexes are present (2+).
He has decreased sensation and is unable to determine the location of a monofilament test on either foot up to the ankle in a stocking distribution.
You note a 2 cm ulceration on the plantar surface of Mr. Smith’s left foot.
At this point, you excuse yourself to discuss your findings with Dr. Hill, assuring Mr. Smith you will return in a few moments.
Mr. Smith is a 53-year-old male with obesity, type 2 diabetes, hypertension, hyperlipidemia, and tobacco use who presents with a four-day history of left lower extremity edema. He reports no fever, chest pain, dyspnea, known malignancy, trauma, or period of inactivity. On exam he is afebrile. The entire left leg is swollen and erythematous, and his left calf is 3.5 cm larger in circumference than his right. There is an ulcer on the plantar surface of his left foot.
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Dr. Hill praises you, “Very nice clinical reasoning. It looks as though you have correctly narrowed your differential down to two primary diagnoses: cellulitis and deep venous thrombosis (DVT). It is important to make sure when crafting a differential for unilateral lower extremity swelling that DVT is always on that list as it’s a condition that can lead to death if missed. Let’s consider what type of information would be most helpful to obtain next.”
|
Active cancer (treatment ongoing or within previous six months or palliative) |
1 |
|
Paralysis, paresis, or recent plaster immobilization of the legs |
1 |
|
Recently bedridden for more than three days or major surgery within four weeks |
1 |
|
Localized tenderness along the distribution of the deep venous system |
1 |
|
Entire leg swollen |
1 |
|
Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity) |
1 |
|
Pitting edema (greater in the symptomatic leg) |
1 |
|
Collateral superficial veins (non-varicose) |
1 |
|
Previously documented DVT |
1 |
|
Alternative diagnosis as likely or more likely than that of deep vein thrombosis |
-2 |
Low probability 0 or less, moderate probability 1–2, high probability 3 or more.
You conclude, “Given Mr. Smith’s high pretest probability of DVT, I don’t think I would trust a negative D-dimer result even with its high sensitivity. I think we have to get Mr. Smith a Doppler ultrasound instead.”
Dr. Hill agrees. “Ultrasonography is recommended as the initial test in a patient with high pretest probability.” And adds, “are there other diagnostic studies that you would order now?”
C. Complete blood count
E. Electrolytes, glucose, creatinine, and blood urea nitrogen (BUN)
F. Hemoglobin A1C
You and Dr. Hill return to Mr. Smith’s room together. After greeting him, Dr. Hill explains, “Mr. Smith, we have a good idea of what may be causing the issues with your leg. We would like to gather some more information by taking a blood sample and sending you over to radiology for a Doppler ultrasound so that we can determine the best course of treatment for you.”
After Mr. Smith assents to the plan, Dr. Hill washes her hands and asks to take a look at his leg. She agrees with your assessment.
She walks you through a diabetic foot examination:
On Mr. Smith’s exam, Dr. Hill finds 3 out of 10 sites imperceptible using the 10-gram monofilament test, indicating some loss of protective sensation.
She finds Mr. Smith’s dorsalis pedis and posterior tibialis pulses intact bilaterally.
She notes a 2 cm ulcer on the plantar surface of his foot, with some surrounding erythema, and callous formation. The ulcer is deep, including full skin thickness, down to muscles and ligaments, but no exposed tendons, or bony involvement, and there appears to be no abscess formation.
She finds that the skin on Mr. Smith’s feet is dry and his toenails are dystrophic and incurvated, demonstrating inappropriate self-care.
At the end of the diabetic foot exam, Dr. Hill turns to you and asks, “What do you think we should do about his foot ulcer?”
You admit, “I’m not sure about that. Would antibiotics help?”
“They would if his wound is infected, but first we should evaluate the grade of the ulcer,” Dr. Hill explains.
You and Dr. Hill determine that Mr. Smith’s foot ulcer does not require antibiotics at this time, but does require debridement, which you will address after he’s had his tests done. Mr. Smith has his blood drawn and a Doppler ultrasound performed.
A few hours later, you see that the results of the labs have returned:
Complete Blood Count:
|
Lab Value |
Conventional |
SI |
|
WBC |
7.5 x103/μL |
7.5 x109/L |
|
Hgb |
13.7 g/dL |
137 g/L |
|
Hemoglobin A1C |
10.2 % |
.102 |
Chemistry:
|
Lab Value |
Conventional |
SI |
|
Na |
137 mEq/L |
137 mmol/L |
|
K |
4.0 mEq/L |
4.0 mmol/L |
|
Cl |
98 mEq/L |
98 mmol/L |
|
C02 |
25 mEq/L |
25 mmol/L |
|
BUN |
18 mg/dL |
6.3 mmol/L |
|
Creatinine |
1.0 mg/dL |
88 mmol/L |
|
Glucose |
232 mg/dL |
12.7 mmol/L |
Dr. Hill informs you, “I just received a call from the radiologist. It looks as if our suspicions were correct. Doppler ultrasound shows that Mr. Smith has a DVT in the femoral vein. So now the question is: What do we do about it?”
You respond, “Well he needs anticoagulation to prevent a pulmonary embolus (PE), right?”
“Right. His short-term risk of a PE is high, so we need to anticoagulate him right away.”
Dr. Hill calls Mr. Smith’s pharmacy and finds that his insurance will only cover dabigatran and does not cover any other DOAC. Unfortunately, insurance does not cover the necessary pre-treament parenteral agent enoxaparin (injectable low molecular weight heparin) without prior approval, which may take a few days to achieve. (It is late in the day when you are seeing him.) Dr. Hill asks you if you think he would be better managed in the hospital or as an outpatient.
After thinking about it for a minute you respond, “I don’t think it is acceptable to send him home if we can’t ensure that he will be able to get enoxaparin or one of the DOACs that can be used for monotherapy tonight. His day-to-day risk of a pulmonary embolus is too high. Also, I am worried about his ability to adhere to new complicated instructions, given that he has a busy home and work life and has not been able to prioritize his own care. He needs to have a plan for managing his medications and he has this foot ulcer that needs care. I think it would be best to stabilize him in the hospital and work on having a more supportive home environment.”
Dr. Hill replies, “Excellent. I agree that Mr. Smith will be best treated in the hospital. Let’s look into how we will do that.”
You and Dr. Hill decide to have Mr. Smith anticoagulated on LMWH because it doesn’t require laboratory testing and dosage titration and Mr. Smith may be more comfortable if he’s not hooked up to an IV.
Dr. Hill adds, “We only want to use low molecular weight heparin for a short term. After five days we will start dabigatran since he will need a longer course of anticoagulant therapy to reduce his risk of PE. In his case, his risk factors are not readily reversible, which will factor into our thinking about the duration of his treatment. If, for example, he had developed his DVT as a complication of surgery (a common and transient risk factor), we would have less cause for concern about his risk for recurrence of his DVT.”
Dr. Hill asks you if the patient should get a thrombophilia workup, keeping in mind that these workups can be costly.
Having just had a session on value-based care, you respond that since this was the patient’s first thrombosis, you didn’t feel it would be cost-effective to do a thrombophilia workup.
However, Dr. Hill tells you, “We actually got lucky we caught Mr. Smith’s DVT when we did. It could have been worse. I am worried he may have an underlying predisposition to forming clots because of his mother’s history of a DVT and am worried about recurrence.”
Dr. Hill says, “Since we are planning on treating Mr. Smith in the hospital, one of the advantages of inpatient treatment is that we can get the wound team nurse to evaluate his ulcer and make some recommendations. While we have Mr. Smith in the hospital, are there other specialists or team members that we can involve to improve his health?”
You suggest, “What about an endocrinologist to help with diabetes management?”
“Now there’s an interesting thought. What do you think is complicating Mr. Smith’s glucose control?”
You contemplate this, “In thinking about his history, it seems that he has been nonadherent with his medication regimen, diet, exercise program, and his follow-up appointments for some time. He describes a stressful social situation at home with family and financial problems, as well as work-related stress.”
“How do you think an endocrinology consult will help with that?” Dr. Hill wants to know.
“I see your point,” you admit. “His problems in managing his chronic illness seem to be more social than medical.”
“That’s right.” Dr. Hill adds, “It’s possible that an endocrinology consult might be useful down the road, especially if he is brittle or otherwise difficult to control on routine medication, but we really have not had the opportunity to see if standard care will be successful because of his social factors.”
“So, I guess it might be better if we get some recommendations from a diabetes educator, a social worker and maybe even the Pharm D,” you suggest.
“Excellent! Ideally, we could all meet in a room and map out a plan for his care, but this isn’t practical in reality. Instead, our role, as the family clinician, is to assume responsibility for coordinating and directing his care and ensuring that everyone on the team is working toward the same goal.” Dr. Hill explains.
Several days have gone by and you and Dr. Hill are now rounding on your patients in the hospital. When you get to Mr. Smith, you tell Dr. Hill:
“This is Mr. Smith’s third day in the hospital. He says he is feeling better, the pain and swelling in his leg is improving. His temperature is 36.2 C (97.2 F), his pulse is 80 beats per minute, his respiratory rate is 16 breaths per minute, his blood pressure is 128/78 mmHg. On exam, his foot ulcer has some fresh granulation tissue on the wound edges. Labs include his fasting glucose this morning was 128 mg/dL (7.0 mmol/L). His CBC was normal and his platelets are stable from admission.”
Dr. Hill responds, “Good. I just got word from his pharmacy that the enoxaparin has now been approved by his insurance, so if he can inject himself for two more days, he can go home. We will need to arrange a close follow-up with visiting nurses and at our office, so he can continue his treatment for his diabetic foot ulcer.”
You comment, “This all seems so much easier than it would have been if he were taking warfarin. How long would it take to get his INR to the therapeutic range if he were using warfarin?”
Dr. Hill tells you, “It varies a lot from person to person, but it commonly takes at least five days for a patient’s INR to get above 2.0. When starting it, you have to balance speed with the risk of overshooting his INR goal and ending up increasing his risk of bleeding by making him supratherapeutic. It is good to consider warfarin dosing since it is still commonly used. It is a very effective medication, but it can be dangerous as well.”
“What do you think we should do next?” Dr. Hill wants to know.
After contemplating this for a moment, you conclude, “Since his insurance has now approved the prior authorization for 2 days of enoxaparin he can finish the pretreatment phase at home. He has been on enoxaparin for three days now. My understanding is that he needs to be on enoxaparin for 5 days and then he can begin the dabigatran. He will need to be able to give himself the enoxaparin at home for 2 days and then be able to start the oral dabigatran about 12 hours after his last dose of enoxaparin. His floor nurse has been showing him how to give the injections, so I think he will be able to do it. He said he doesn’t like it very much, but he would do it if he has to.”
You continue, “He’s back on his regular medications which have improved his blood pressure and glucose. The foot ulcer has been debrided and is getting better. There doesn’t seem to be much more for us to do in the hospital, so I think he might be ready to go home later today.”
“I agree,” Dr. Hill replies. “What type of arrangements will he need at home?”
“Home health should be able to manage his wound. I would think with that and close follow-up in the office, he should do well,” you predict. “We also need to make sure he understands the timing of the enoxaparin and transition over to the dabigatran, and that he knows where to pick up both his medications.
You also remind Dr. Hill that Mr. Smith’s obesity and smoking still pose tremendous risks to his health and that in future visits to the clinic, he should be counseled regarding weight loss and smoking cessation as well as managed for hypertension, hyperlipidemia, and diabetes.
Assessment 04 –
Informatics and Nursing-Sensitive Quality Indicators
For this assessment, you will prepare an 8–10 minute audio training tutorial (video is optional)for new nurses on the importance of nursing-sensitive quality indicators.Before you complete the detailed instructions in the courseroom, first review the Nursing-Sensitive Quality Indicators below and select the one you’re most interested in. NursingSensitive Quality Indicators reflect the structure, process, and patient outcomes of nursing careNursing-Sensitive Quality Indicators are developed by identifying potential indicators that reflectnursing care and are not represented by current indicators, performing a literature review, anddetermining the validity of the potential indicator in nursing practice. After you select one of the Nursing-Sensitive Quality Indicators below, return to the courseroom to review the detailed instructions and complete your assessment.
CHOSEN TOPIC: Central-line-associated Bloodstream Infections–Outcome.
Introduction
Professional Context
NDNQI® was established as a standardized approach to evaluating nursing performance in relation to patient outcomes. It provides a database and quality measurement program to track clinical performance and to compare nursing quality measures against other hospital data at the national, regional, and state levels. Nursing-sensitive quality indicators help establish evidence-based practice guidelines in the inpatient and outpatient settings to enhance quality care outcomes and initiate quality improvement educational programs, outreach, and protocol development.
The quality indicators the NDNQI® monitors are organized into three categories: structure, process, and outcome. Theorist Avedis Donabedian first identified these categories. Donabedian’s theory of quality health care focused on the links between quality outcomes and the structures and processes of care (Grove et al., 2018).
Nurses must be knowledgeable about the indicators their workplaces monitor. Some nurses deliver direct patient care that leads to a monitored outcome. Other nurses may be involved in data collection and analysis. In addition, monitoring organizations, including managed care entities, exist to gather data from individual organizations to analyze overall industry quality. All of these roles are important to advance quality and safety outcomes.
Reference
Preparation
As you begin to prepare this assessment you are encouraged to complete the Donabedian Quality Assessment Framework activity. Quality health care delivery requires systematic action. Completion of this will help you succeed with the assessment as you consider how the triad of structure (such as the hospital, clinic, provider qualifications/organizational characteristics) and process (such as the delivery/coordination/education/protocols/practice style or standard of care) may be modified to achieve quality outcomes.
Review the nursing-sensitive quality indicators presented in the Assessment 04 Supplement: Informatics and Nursing Sensitive quality Indicators [PDF]
Download Assessment 04 Supplement: Informatics and Nursing Sensitive quality Indicators [PDF]
resource and select one nursing-sensitive quality indicator to use as the focus for this assessment.
Interview a professional colleague or contact who is familiar with quality monitoring and how technology can help to collect and report quality indicator data. You do not need to submit the transcript of your conversation, but do integrate what you learned from the interview into the audio tutorial. Consider these questions for your interview:
What is your experience with collecting data and entering it into a database?
What challenges have you experienced?
What role do bedside nurses and other frontline staff have in entering the data? For example, do staff members enter the information into an electronic medical record for extraction? Or do they enter it into another system? How effective is this process?
Set up and test your microphone or headset using the installation instructions provided by the manufacturer. You only need to use the headset if your audio is not clear and high quality when captured by the microphone.
You may also choose to create a video of your tutorial, but this is not required.
Instructions
For this assessment, first review the nursing-sensitive quality indicators presented in the Assessment 04 Supplement: Informatics and Nursing Sensitive quality Indicators [PDF]
The Council indicates a recording is preferable to a written fact sheet due to the popularity of audio blogs. In this way, new hires can listen to the tutorial on their own time using their phone or other device.
You determine that you will cover the following topics in your audio tutorial script:
Introduction: Nursing-Sensitive Quality Indicator
What is the National Database of Nursing-Sensitive Quality Indicators?
Which particular quality indicator did you select to address in your tutorial?
Collection and Distribution of Quality Indicator Data
According to your interview and other resources, how does your organization collect data on this quality indicator?
How does the organization disseminate aggregate data?
What role do nurses play in supporting accurate reporting and high-quality results?
As an example, consider the importance of accurately entering data regarding nursing interventions.
After completing your script, practice delivering your tutorial several times before recording it.
Additional Requirements
Audio communication: Deliver a professional, effective audio tutorial on a selected quality indicator that engages new nurses and motivates them to accurately report quality data in a timely fashion.
Length: 8–10 minute audio recording. Use Kaltura to upload your recording to the courseroom, or provide a working link your instructor can access.
Script: A separate document with the script or speaker’s notes is required. Important: Submissions that do not include the script or speaker’s notes will be returned as a non-performance.
References: Cite a minimum of three scholarly and/or authoritative sources.
Competencies Measured
Explain how a health care organization uses nursing-sensitive quality indicators to enhance patient safety, patient care outcomes, and organizational performance reports.
Deliver a professional, effective audio tutorial on a selected quality indicator that engages new nurses and motivates them to accurately report quality data in a timely fashion.
NON-PERFORMANCE
PROFICIENT
Describe the interdisciplinary team’s role in collecting and reporting quality indicator data to enhance patient safety, patient care outcomes, and organizational performance reports.
Does not explain how a health care organization uses nursing-sensitive quality indicators to enhance patient safety, patient care outcomes, and organizational performance reports.
Explains how a health care organization uses nursing-sensitive quality indicators to enhance patient safety, patient care outcomes, and organizational performance reports.
Provides a comprehensive, professional, and academic explanation for how a health care organization uses nursing-sensitive quality indicators to enhance patient safety, patient care outcomes, and organizational performance reports.
Does not justify how a nursing-sensitive quality indicator establishes evidence-based practice guidelines for nurses to follow when using patient care technologies to enhance patient safety, satisfaction, and outcomes.
Provides a comprehensive and scholarly justification for how a nursing-sensitive quality indicator establishes evidence-based practice guidelines for nurses to follow when using patient care technologies to enhance patient safety, satisfaction, and outcomes.
Provides a script or speaker’s notes of a tutorial without audio or video on a selected quality indicator, or the tutorial lacks purpose, coherence, or focus or has technical issues that distract from the presentation.
Week 4 Phase 2 Paper
Students will continue their research topic, in this paper students will perform a brief literature review on the topic (Will need at least 5 support articles) and provide the desired methodology for the project. Paper will be approximately 5-6 pages. Use the following as subheadings for your paper.
2. Methodology and design of the study (Be detailed )
3. Sampling methodology
4. Necessary tools
5. Any algorithms or flow maps created.
This will be considered a Library Assignment as you will need to visit the library to obtain information
Chapter 8: Sampling and Chapter 9: Reliability
Library Assignment is required. Library Assignment: This phase of your project will require everyone to visit the University Library or online to obtain information related to their project. Phase 2 is Due Sunday @ 2359 (Worth 10 points) You will need to refer to your research paper rubric for the best possible outcomes for this assignment. You will find this rubric located within your course syllabus under Phase 2.Class you will be asked to continue your research that you have already started. In this paper you are going to conduct a brief literature review on your topic. Please note that everyone will need to have at least five supporting articles related to their chosen topic (3 are peer-review journal articles) and will provide the desired methodology for their project. Your paper will be at least five to six pages (strict adherence to APA guidelines is required). Additionally, class, I will be looking for the quality of your writing, not the quantity. Your writings should be concise, factual and disseminates information.We will commence as follows:
Brief literature review
Methodology and design of the study (Please be detailed-oriented as possible, your methodology should be written as a recipe. Meaning anyone can reproduce your research after reading it).
Sampling Methodology: Qualitative or Quantitative or Mixed method for example
Any algorithms or flow maps that you may create (illustrations)
*** Please submit this assignment through Safe Assign.Please look for the UPLOAD tabs to submit your assignments.
Research Paper Rubric Phase 2-Design (Due by WEEK 4) Students will continue their research topic, in this paper students will perform a brief literature review on the topic (Will need at least 5 support articles) and provide the desired methodology for the project. Paper will be approximately 5-6 pages. Use the following as subheadings for your paper.1. Brief literature review2. Methodology and design of the study (Be detailed )3. Sampling methodology4. Necessary tools5. Any algorithms or flow maps created.This will be considered a Library Assignment as you will need to visit the library to obtain information. Week 4 Validity & Trustworthiness of Qualitative Research
Week 4 Validity & Trustworthiness of Qualitative ResearchTextbooks:
Ruth M. Tappen. (2015). Nursing Research. Advanced Nursing Research: From Theory to Practice. (2nd ed.). ISBN-13: 9781284048308. ISBN-10: 1284048306. Publisher: Jones & Bartlett Learning
Publication Manual American Psychological Association (APA) (6th ed.). 2009 ISBN: 978-1-4338-0561-5
WEEK 7Chapter 10: Validity & Chapter 11: Trustworthiness of qualitative researchRead Chapter 10 & 11Discussion # 4Due Saturday night at 2359Hello Everyone,Welcome to week 4. Thank you for the submissions of your assignments. Please note any comments on your papers. Some comments were mainly for guidance. Continue to refer to your APA 7th edition manual. Understand if you plan to seek higher education (DNP, Ph.D. or Ed.D. studies) or perhaps begin to publish, editors and future professors will have stringent guidelines for research practice.Research is one of those necessary requirements for advanced practice nursing, regardless of the specialty or friend you are entering, you will encounter and be required to conduct or participate in research initiatives. Text reading for this week will require a review of Validity and Trustworthiness of Qualitative research. Let us think what the two topics are.***If you have not heard it before, I will say it now. There is an old saying which states, “All research is flawed.” There is an element of truth to that saying as research is conducted by humans, and we are subject to error. That is it is important to have checks and balances to ensure the best possible outcomes in our research trajectory.Research Validity (Is it true to the intended purpose?)A summarization of chapter 10 reveals the following:Progress has been gained from the initial concept of a “useless face validity” extending to examining the sensitivity and specificity of screening an diagnostic measures, When one selects a measure in their research endeavors, make certain that the validity has been thoroughly evaluated (Tappen, 2015).Article:A Primer on the Validity of Assessment Instrumentshttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184912/Link: How sound is your research? A main premise of validity.http://linguistics.byu.edu/faculty/henrichsen/ResearchMethods/RM_2_18.htmlVideo: Types of Validityhttps://www.youtube.com/watch?v=Hd7GTlQ7SXsTrustworthiness of Qualitative Research (The quality of your qualitative research is essential to what it is for both qualitative and quantitative research studies.)A summary of chapter 11 states the following:One can envision difficulty imagining a nurse scholar or advanced practice nurse mitigating the importance of quality in research as not being significant. The principle investigator or researcher may select principles, criteria or strategies based on the decision or the extent of which scientific adequacy, systematicity, trustworthiness, transparency, or qualities of the researcher, theoretical consistency, aesthesis, literary qualities, and stimulation of social action are desire. This judgment should be based upon the purpose of the study, its philosophical roots, and the approach utilized (Tappen, 2015).Article: Trustworthiness of Research (Start with section 2, Quantitative Research)https://www.munich-business-school.de/insights/en/2017/trustworthiness-of-research/Link: Strategies for ensuring trustworthiness in qualitative research projectshttps://pdfs.semanticscholar.org/cbe6/70d35e449ceed731466c316cd273032b28ca.pdfVideo: Trustworthiness and Validity in Qualitative Research Designhttps://www.youtube.com/watch?v=JXB-22GVbUAVideo: The quality of qualitative researchhttps://www.youtube.com/watch?v=IJSnSLCVsP0***Discussion topic for Week 4 (Worth 1 point)Based on your readings, please answer the following discussion question.What are the perceived challenges do you expect to find with validity and trustworthiness in qualitative research? What steps will you implement to ensure that your research is reliable?Remember: 3 posts are required, one original post and responses to two other colleagues. Your responses much adhere to APA 7th edition guidelines. Resources must support your statements. I am looking forward to some intriguing discussions. Please visit the Writing lab- they are a great resource.
Sampling and Reliability
Population identification
Obtain a sampling frame
Look at a sampling frame specify (this can be done randomly or non-randomly)
Quota sampling.
Judgment (or Purposive) Sampling.
Snowball sampling.
Chapter 9: ReliabilityClass, when it comes to reliability and validity, these concepts are associated with the highest quality of measurement in your research endeavors. Chapter 9 has an emphasis on reliability, although there is mention of validity, much of this content is associated with your reading assignment in Chapter 10. However, since there is an overlap in these concepts, you will hear mention regarding the topic. I hope not to confuse anyone.Please note that reliability is one of the most important qualities of a research tool. Think of reliability as an instrument of measure that determines the degree of consistency with which it measures the attribute for what it is supposed to measure. If a measuring tool is accurate, it is said to be reliable.Estimation of reliability:
Stability – it is the extent to which the same results are obtained repeatedly during testing.
Test/Re-test method (p. 145).
Equivalence – shows the consistency of performance on different forms of the test; it is based on the correlation between performance on the different forms administered at the same time.
Inter rater method – this is estimated by having two or more trained observers watching the same event simultaneously and independently, then recording the relevant variable.
Intra rater method – scores are assessed by two tools by a single researcher, then the method is called the intra-rater method of calculating reliability.
Internal consistency – this shows the consistency of performance on the different pasts of items of the test taken at ta single setting.
Pilot study – it is the entire operation in a miniature version. It is a careful empirical checking of all phases of the study from the collection of data to their tabulation and analysis.
Psychological researchers do not simply assume that their measures work. Instead, they conduct research to show that they work. If they cannot show that they work, they stop using them. You will see this while exploring the methodology section of your research.
ReferencePetty, R. E, Briñol, P., Loersch, C., & McCaslin, M. J. (2009). The need for cognition. In M. R. Leary & R. H. Hoyle (Eds.), Handbook of individual differences in social behaviour (pp. 318–329). New York, NY: Guilford PressFor additional clarification and supplemental resources, please access the following:Video: Understanding Measurement Validityhttps://www.youtube.com/watch?v=kkjjZtFV9ZEVideo: Reliability and Validity of Measurementhttps://www.youtube.com/watch?v=VTHWQOuEfiMArticle: Understanding Reliability and Validity in Qualitative Researchhttps://nsuworks.nova.edu/tqr/vol8/iss4/6/
PATIENT DASHBOARD
Age: 19
Sex assigned at birth: female
Gender identity: nonbinary
Language for medical communication: English
You review the electronic health record (EHR) with Dr. Nayar and consider which aspects of the past medical history you will want to obtain from Chris. The EHR includes their gender identity and pronouns, including the name Chris, different from the legal name, pronouns they/them, and nonbinary gender identity.
Problem list:
Mononucleosis (age 14)
“Can you tell me more about how you hurt your ankle?”
They elaborate, “I was playing soccer last night and was trying to pass the ball to a teammate. Somehow I slipped and fell.”
“Do you know which way you fell on your ankle?”
Chris says, “My ankle really hurts along the outside. I am having a lot of problems walking and it’s a little stiff. It was really swollen yesterday, but not as bad today.”
Mrs. Martinez adds, “I saw their ankle twist inward as they fell to the ground. The coach immediately iced the area and they were able to leave the field under their own power.”
“Have you ever had other difficulties with your ankle?”
“No, this is the first time anything like this has ever happened.”
“Do you have other health concerns you would like to address today?”
When you ask Chris about the signs and symptoms that could indicate a limb-threatening injury, they answer that they have pain only at the ankle, but none of the other symptoms.
You now turn to Chris’s past medical history and they tell you that their only significant past medical history includes: “Some problems with ear infections when I was younger. Around age 14 or 15 I got mono.” On further questioning you learn that Chris has never had any surgeries, they have no allergies, use no substances, and their family history is significant for heart disease.
Vital signs:
Temperature: 37.2 C (98.8 F)
Respiratory rate: 22 breaths/minute
Cardiovascular: Regular rate and rhythm.
Respiratory: Normal breath sounds without wheezes.
SUMMARY STATEMENT
The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:
Epidemiology and risk factors: 19-year-old
Key clinical findings of the present illness using qualifying adjectives and qualifying adjectives and descriptive language.
Acute onset following inversion injury
Initially weight-bearing, but not currently weight-bearing
No tenderness to palpation of the medial malleolar area
Tenderness is present over the lateral malleolus of the right footDIFFERENTIAL DIAGNOSIS
C. Lateral ankle sprain
Dr. Nayar agrees, “That appears most likely given their age and the fact that it’s an acute injury. The mechanism of Chris’s injury gives us a good clue as to what most likely happened to them.”
REVIEWING THE ANKLE EXAM
You and Dr. Nayar concur that (if his exam findings are comparable to yours) Chris does not need radiographs of their ankle or foot.
“Now, let’s go talk with the family and see what we can do,” he suggests. Dr. Nayar enters the room with you and greets Chris and their family.
He addresses Chris,
He says, “Well, let me reexamine your ankle and we will let you know what we recommend.
Chris nods in assent.
Dr. Nayar addresses you as he examines Chris’s ankle. Chris has maximal pain distal to the lateral malleolus. They don’t have any pain along the posterior aspects of the medial or lateral malleoli which is reassuring. Their range of motion is mildly restricted and I appreciate no swelling at this time.”
He continues by testing range of motion with the talar tilt test, as well as the calf squeeze and tibiofibular compression tests.. None of these maneuvers are positive.
Dr. Nayar now tells Chris and their mother that he agrees with you that they have an ankle sprain. Before he can discuss a possible treatment plan, Mrs. Martinez says, “We really want an x-ray. I trust you, but I just want to make sure that their ankle isn’t broken.” Dr. Nayar calmly explains to the family how he has diagnosed an ankle sprain.
Rest
Compression
RESUMING ACTIVITY AFTER ANKLE INJURY
After discussing the various types of ankle support, you tell Chris, “The office has something called an Aircast. This will really help your ankle feel better faster.”
Dr. Nayar addresses Chris, “I know your biggest concern is when you can return to soccer. For now we will need to keep you off the soccer field. If you try to return too early, you may cause further injury.” He gives them a prescription for daily ankle exercises and makes a plan to re-evaluate in one week. He also noted that physical therapy is often very useful if the ankle does not heal quickly.
“So, I want to see you back here in one week,” Dr. Nayar concludes. “Before I let the medical student finish up with you, are you sure that we don’t need to speak about your problems with urination?”
Chris says, “Well, I really don’t know if it’s that big of a deal.”
“OK,” says Dr. Nayar. “I think that it’s important to follow up on this. I am going to have our student ask you a few more questions to get a better handle on things after we get the ankle support for you.”
DIAGNOSING DYSURIA
The next step you would like to take to work up Chris’s symptoms is to see if you can elicit any costovertebral angle (CVA) tenderness and examine their abdomen. You tap Chris’s back below the ribs on both sides and elicit no expression of tenderness. They do not have suprapubic tenderness, rebound, or guarding.
TESTING FOR DYSURIA
After you respond to Chris’s question, you ask if they are ok with their mom coming back to the room (they agree) and have Chris go to the bathroom to leave a clean catch mid-stream urine sample. You excuse yourself to confer with Dr. Nayar. When you find Dr. Nayar in the hallway, you inform him of Chris’s urinary concern, adding that they didn’t have any evidence of an upper urinary tract infection but did have dysuria and frequency.
Together, you review the results of Chris’s urinalysis:
pH: 5.0
Leukocyte esterase: +1
Glucose: Neg
Ketones: Neg
Bilirubin: Neg
Urobilinogen: Neg
Blood: +1
Nitrites: Neg
Sp. Grav.: 1.01
DYSURIA MANAGEMENT
When you return to the exam room, Dr. Nayar sits down and explains, “Chris, I agree with my student that you have a urinary tract infection. We will give you a prescription for an antibiotic to take twice a day for three days. I don’t anticipate there being any problems at the pharmacy, but give me a call if the copay is too expensive and we can work something else out. We would also like to have you schedule a follow-up visit next week to see how your ankle is doing as well as make sure the burning is all cleared up. If the burning is not gone, then we will need to do a pelvic examination to look for other causes for your problem. Is there anything else that we can help you with today?”
Chris shakes their head: “No, I just hope I don’t need that exam your mentioned.”
Dr. Nayar concludes, “All right. We’ll see you next week.”
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