12 1 9-1 Project: Healthcare Quality Improvement Initiative and Evaluation Report Royce

12

1

9-1 Project: Healthcare Quality Improvement Initiative and Evaluation Report

Royce Cleary

Southern New Hampshire University

IHP 604: Healthcare Quality Improvement

Dr. Patricia Thompson, DNP, RN

14 JUL 2024

Memorial Satilla Health Facility

The healthcare organization chosen for the focus of this report is Memorial Satilla Health.  Formerly known as Satilla Regional Medical Center, this healthcare facility was bought by HCA Healthcare in 2017 and renamed (American Hospital Directory, n.d).  This hospital, located in Waycross, GA, is designated as an Inpatient Rehabilitation Facility (IRF) and is listed as a nonprofit corporation.  Inpatient Rehabilitation Facilities are free-standing rehabilitation hospitals and rehabilitation units in acute care hospitals for patients who are able to tolerate three hours of intense rehabilitation services per day (Centers for Medicare & Medicaid Services, nd).

Metric Analysis

Validity and Quality

Ensuring validity and quality in reports provides management with dependable and credible information to guide their decision-making. Validity pertains to how accurately a method measures what it is intended to measure, and reliability refers to the trustworthiness of a source (Middleton, 2019). CMS (Centers for Medicare and Medicaid Services) serves as a cornerstone in the American healthcare system by ensuring that millions of American citizens receive essential medical coverage. CMS uses advanced data analytics to track patient outcomes and measure provider performance. As a reputable government agency, CMS monitors numerous metrics to identify healthcare facilities that meet national benchmarks. CMS is widely recognized for its credibility and precision given its high level of government authority.

Insights and Opportunities

Memorial Satilla Health Hospital, located in Waycross, GA, recently reported to the CMS (Centers for Medicare and Medicaid Services) a successful return-to-home and community rate of 57.99%, which falls short of the national average of 66.93% (CMS, 2022). A successful return to home and community for an inpatient rehabilitation facility (IRF) is defined as a discharge without readmission within 31 days or expiration. The data utilized comes from the CMS Care Compare tool and a study by Middleton et al. (2018). According to the Centers for Medicare & Medicaid Services (CMS) (2022), this facility treated around 274 patients with various conditions ranging from amputations to neuromuscular disease.  Middleton et al. (2018) described a retrospective study involving Medicare beneficiaries (487,862 individuals) who achieved successful returns.  The study of the covered 1,154 IRFs revealed that 63.7% of these patients experienced a successful community discharge, almost equaling the present national average.  Drawing on the findings of Middleton et al. (2018), it is evident that a quality improvement initiative is crucial for enhancing patient outcomes.

Improvement Explanation

The practice of using benchmark metrics is widespread in the healthcare field. According to the Memorial Satilla Health facility, the metrics they provided to the Center or Medicare and Medicaid Services reveal a sharp decline in positive outcomes between facility percentages and national benchmarks. However, when this data is compared to Middleton et al. (2018), the difference in outcomes is significant.

Improvement Tool Determination

Upon reviewing the Memorial Satilla Health Hospital IRF rate, the proposed improvement method involves integrating two rehabilitative programs: a transitional living program and occupational therapy. These programs can provide individuals with a structured environment and improve a patient’s ability to perform daily tasks and activities independently. The selected improvement methods are derived from current rehabilitative therapy recommendations, focusing on available programs suitable for all Memorial Satilla Health IRF patients.

Framework to use in Improvement Initiative

The implementation and assessment of these methods will follow the Plan-Do-Study-Act (PDSA) framework. Through PDSA, patients will be introduced to the new programs, and their progress will be recorded meticulously and compared against the national benchmarks and the study rates of Middleton et al. (2018). The level of data integrity will ensure the effectiveness of the proposed improvement initiative. The PDSA framework was chosen for its dual prospective and retrospective capabilities, addressing the current substandard rate while establishing a forward-looking improvement strategy.

References

Medicare.gov. (n.d.). Find healthcare providers: Compare care near you. Medicare. https://www.medicare.gov/care-compare/details/inpatient-rehabilitation/11T003?city=Waycross&state=GA&zipcode=

Middleton, F. (2019, July 3). Reliability vs. validity in research: Difference, types and examples. Scribbr. https://www.scribbr.com/methodology/reliability-vs-validity/#:~:text=Whatisvalidity,thephysicalorsocialworld.

Centers for Medicare and Medicaid Services. (n.d.). Inpatient rehabilitation facilities. CMS.gov. https://www.cms.gov/medicare/health-safety-standards/certification-compliance/inpatient-rehabilitation-facilities#:~:text=IRFsarefreestandingrehabilitation,intenserehabilitationservicesperday.

Middleton, A., Graham, J. E., Bettger, J. P., Haas, A., & Ottenbacher, K. J. (2018, November 2). Facility and Geographic Variation in Rates of Successful Community Discharge After Inpatient Rehabilitation Among Medicare Fee-for-Service Beneficiaries. Europe PMC. https://europepmc.org/article/MED/30646352