Quality Improvement Project Plan

Sarah Rousseau

Ferris State University

Quality Improvement Project

The quality improvement project I will be working on is changing our current medication administration practice to a BID

medication administration practice. The goal for this project is that with a change in medication administration times the resident will

be able to sleep until they wake naturally, and not on the schedule of the staff. The hope is that with a more restful night of sleep

residents will have more energy and be more alert potentially decreasing falls and behaviors. This will be achieved one unit at a time.

The project will involve evaluating all residents and their current medication regimen. Then, evaluating which medications need to be

changed from their current orders to BID, as well as whether the change is appropriate. This will involve discussion with the ADON

of the unit, the primary care physician, the residents, and their families. Once all medications have been reviewed, each order in the

electronic medication administration record will then have to be discontinued and input with the new parameters. Staff will need to be

educated on the changes that involve them. Ongoing review of falls and behaviors throughout implementation will be done on a

monthly basis.

Research

I am currently a part of the fall QAPI committee in my workplace. We review falls each month for every unit, looking for ways to

reduce the number of falls in the facility. Upon review of the last two years we noticed that there was an increase of falls from 2013 to

2014, the increase was 200 falls more in one year. We had to come up with a way to keep our residents safer. There are so many

different ways that facilities try to reduce falls such as; alarms, restraints, and 1:1 staff for those that frequently fall. The facility that I

work for is currently trying to reduce alarm use as we have found that it does not decrease falls but notify us that one has occurred.

Through our discussions we started talking about the regular routines of our residents and what we could possibly do to change or

improve them to have an impact on our number of falls.

Through discussion we realized that for most of our residents they are being woken up on average every 2 hours to be offered the

toilet, or to have their briefs change in order to prevent skin breakdown. Then they are woken up anywhere between 4 am and 730 am

to get up and get ready for breakfast, staff do not take into account if the resident was awake on and off all night long. Through

discussions we noted an area we thought that we could have an impact on. We started by monitoring sleep patterns to see if what we

believed to be the case was, and we were not surprised with our results. The current practice was evaluated and changed; residents are

no longer woken up in the middle of the night unless it is absolutely necessary. After 6 months the number of falls decreased, but not

as much as I thought they could be. We realized residents were not being woken in the night anymore unless necessary, but they were

still being woken up early in the morning because of breakfast and the restrictions of the medication administration times.

Brassington, King, and Bliwise (2000) did a study in order to determine if sleep patterns and daytime sleepiness were related to

reported falls in the previous year in the elderly population. The study found “that nighttime sleep problems were independently

associated with both occurrence and frequently of falling over the previous year” (p. 1239). Latimer, Cumming, Lewing, Carrington,

and Le Couteur (2007) completed a similar study, the results showed that with “1526 community-dwelling Americans, it was found

that falls in the previous year were associated with difficulty falling asleep at night, waking up during the night, daytime sleepiness, or

napping during the day” (p. 65). Bergeron et al. (2008) wrote an article which looked at ways to improve sleep in the elderly

population. The study reviewed the prevalence of disturbed sleep in the long term care (LTC) setting. In it the authors state “45% to

75% of elderly persons residing in LTC facilities have disturbed sleep”. Some common complaints of the elderly included waking too

early. If the introduction of a BID med pass with lengthened administration times can have even a small positive impact on falls than it

will be a good thing.

Site

The Grand Traverse Pavilions is a 240 bed long-term care facility. We have a 31 bed sub-acute rehab center, an 8 bed secured

dementia unit, a 40 bed secured dementia unit and 4 general long-term care units. The introduction of the new medication

administration will start on the unit with the most falls in the previous month that are not related to specific factions, such as changes

in ambulation status. I would like to begin with one unit and work from unit to unit until they have all been successfully implemented.

Interdisciplinary Team

The Grand Traverse Pavilions in Traverse City, MI is where the new system will be instituted. My preceptor for this project is

Renee Cunningham, RN, MSN. Renee is the Director of Nursing at the Eden Center in Kalkaska, MI; she has been in long-term care

for over 30 years and has a vast amount of experience and knowledge. I will also be working with the ADON for each unit, the fall

QAPI head Dawn Budzinski, staff development which includes Susan Arnold and Jamie Wilson, the DON Holly Edmondson, the

Medical Director Mark Jackson, the CNA staff of each unit, and the dietary department. Agency and Preceptor agreement is Appendix

QSEN

a) Quality – Attitude – Commit to concepts of transparency, managing variability measurement and accountability

-I will be working closely with those involved in this project. We will plan to meet bi-weekly to discuss the progress of the

project and review and concerns or issues that may arise after implementation.

b) Teamwork and Collaboration – Skill – Continuously plan for improvement in self and others for effective team development and

functioning

-I plan to routinely check in with the floor staff to see how implementation is going, discuss any concerns that they may be

having and then meet with the fall QAPI committee to discuss the concerns and how we will address them. The interdisciplinary team

will be working closely together on this project to ensure that we are doing what we believe to be in the best interest of the residents

and their safety. I understand that what is implemented at first will most likely not be the finished product and as a group we will

continuously adapt as needed

c) Evidence-based practice – Knowledge – Identify efficient and effective search strategies to locate reliable sources of evidence.

-I believe that this process will take longer than the 120 hours and I will continue to see this project through, review available

literature, and apply the findings as the interdisciplinary group see appropriate. I will also be discussing the implementation of this

new system with some other facilities in the area that have already done this, to find out what they have learned and how it has

affected the residents.

Scope and Standards of Practice

a) Standard 5 – Implementation

- I will be working with an interdisciplinary team to implement this project, and follow its progression. We will work together

to change and adapt as needed

-This project is based on health promotion. The risks associated with falls in the elderly population are something we cannot

turn our backs on. We need to do something to decrease the number of falls. The hope is that this project will have some impact.

-I will work closely with the floor staff as well as administration through implementation and follow-up of the project.

b) Standard 7 – Quality of Practice

-I believe that quality of practice is so important for nursing administrators. This project is using the nursing process to

implement a new intervention for the safety of our residents, and we will continually review the outcomes with evaluation.

-I am taking knowledge from research and discussion to initiate changes

-This is a quality improvement project that I hope to have a positive effect on the nursing practice of the nurses in our facility

c) Standard 11 – Collaboration

-The members of the interdisciplinary team will attempt to meet regularly to discuss impacts of the project

- I will continue to participate in the fall QAPI committee and discuss further ways to reduce the number of falls within our

facility.

RCA

The fall QAPI committee meets bi-weekly to get together and discuss the falls that have occurred and ways to decrease falls.

We have discussed completing an RCA, but have been unable to complete one. I decided to get together and discuss this with a few of

the floor nurses from different shifts to get their input; the attached RCA (Appendix B) is what we came up with. We started by

discussing anything we thought about that was contributing to the increase in falls. We kept coming back to the residents with an

increase in falls that may have been previously stable. We then started looking at why that would have changed. The different ideas

then began to emerge which included; disease progression, mealtime, medication administration times, toileting habits, staff

disturbances, and shared rooms. Because of this project I really wanted to discuss their thoughts about medication administration

times. Nurses had all different reasons for this, we are scheduling medications throughout the day including while residents are

sleeping. On one of the units residents are woken up in the middle of the night to get a breathing treatment. Staff discussed that this is

not something we do at home, very few people would ever wake themselves in the middle of the night to take their medications nor

would they wake up early in the morning for medications. Typically we take our medications upon rising. So that is the idea, taking

medications upon rise and at bedtime, like most of us do at home.

Theory and Leadership

I plan to use the Kurt Lewin Change Management Model. Kurt Lewin developed the theory of change management, and in his

theory there are three steps: unfreeze (when change is needed), change (develop the process for change), refreeze (establish stability)

(Mitchell, 2013, P. 32). We have identified the need for change and we are now in the change phase, we are planning and preparing to

make the changes necessary to return to stability. I hope to be a transformational leader. According to Giltinane a transformational

leader is one that have a clear vision and can inspire other to follow the plan (2000, p. 37).

The Change Management Model is my guide through this whole process. The first step according to Lewin is to unfreeze, this

is already starting through our process of evaluation. We are evaluating the current system and realizing that there may be flaws to the

old way of thinking. We need to unfreeze this way of thinking not only for the interdisciplinary team but for the facility as a whole. I

work with quite a few nurses who have been around a long time and frequently when any changes are made there is a lot of

complaining, they often will say “this is how it has always been”. To me this is not a reason not to change, but a good reason for

change. We all know that healthcare is always changing and our nursing practice needs to change as well. The next step in the process

will be to implement the change. This is being achieved in a multitude of steps. The first step is going to be evaluating all of the

current medication regimens, evaluate with the ADON what can be changed and what cannot be changed, and discuss changes with

the primary care physician and families. Then we will need to discontinue all medications, change them to the new system to start on

the same day of the month. Notify the pharmacy of the changes. Meet with the unit staff to discuss the changes for each shift

(midnights will no longer wake residents and get them dressed for breakfast unless that is the residents choosing, day shift will no

longer wake residents to get them to breakfast by the scheduled time, nursing will no longer wake residents to administer medications

unless it is specifically ordered by the physician). Monthly we will evaluate the number of falls on the unit to see if there is a decrease

since implementation of this project, we will also review all medications again to see if there have been any changes to what was

implemented. After one month of successful implementation, the project will then be instituted on another unit. The process will then

begin again until all units have been successfully changed. I believe that it will take six months to a year for this to be successfully

implemented and become stable. Once this is achieved we will reach the final step of the Lewin Change Management Model which is

to refreeze. My hope is that through this project I will be a transformational leader. I hope that this project has a positive impact for the

residents and the staff. I know that there will be staff that is not on board with the whole idea, and I am hoping that I will be able to

help them understand.

Bernard Bass (1990) said that transformational leadership “occurs when leaders broaden and elevate the interests of their

employees, whey they generate awareness and acceptance of the purposes and mission of the group, then they look beyond their own

self-interest for the good for the group” (p. 21). The concept of transformational leadership comes from four key concepts; charisma,

inspiration, intellectual stimulation, and individualized consideration (p. 22). I plan to implement the element of charisma by

providing a mission for key stakeholders in the project as well as the frontline staff that will help to implement the plan. If those

involved do not buy into what the project is and why we are doing it, than I cannot possibly hope for a successful outcome. The next

element of inspiration I plan to achieve through detailed expectations, I want those involved in the project to be as excited about the

potential results as I am. Bass says intellectual stimulation is achieved when the leader “promotes intelligence, rationality, and careful

problem solving” (p. 22). This will be an ongoing element throughout project implementation and follow-up, we will be continually

problem-solving when issues arise so that we can achieve our expected outcomes. Individualized considerations will be implemented

throughout the process. I will be meeting with staff members to discuss the project and what we are hoping to achieve. I will continue

to coach staff as we make necessary changes. I hope that I can get others to believe in this project as strongly as I do, I know that it

will be difficult to get some to understand that it is for the benefit of the residents.

Assessment and Informatics

Throughout the project I will assess the impact of the project through falls reviews. I will review the falls that occurred on the unit

over the last month. I will be looking at the cause of the fall, and if sleep may have had an impact. I will also be assessing the number

of falls monthly to see if there is an increase or decrease. When the project is implemented on a new floor, staff will be conducting

sleep studies throughout implementation on those that are frequent fallers. They will then be reviewed to see if there is a correlation

between sleep and decreased falls. Throughout the process I will interview residents monthly to see if they feel this has had a positive

impact on their sleep habits. Those residents with cognitive impairment will be unable to participate in the interview process, so

regular staff members that care for those residents will be interviewed. I will survey staff after the first two weeks of implementation

to see if they feel this project has had an impact on the residents in a positive or negative way. This will be achieved through a survey

that will be available on each unit after implementation. I will take those surveys and compile the answers to share with the

interdisciplinary team.

Informatics is going to play a role in this project as well. I will develop the survey and compile the answers using Microsoft word.

I am also hoping to be able to create an in-service tool for nursing that will be available through our online system. Fall numbers and

assessments will be kept in a file on my computer for analysis. I will have access to all fall reports for analysis. The medication

administration record is electronic so all medication changes will be implemented electronically.

Predictions

My predication for this project is that it will have a positive impact for our residents. The study by Stone, Ensrud, and Acoli-

Israel (2008) found that disturbances in sleep patterns can be linked to increased risk of falls. They found that of the participants in the

study those with less than 5 hours of sleep duration were at the greatest risk of falls, and those with 7-8 hours of sleep were at the

lowest risk (2008, P. S21). I am hoping that allowing residents to sleep until they naturally awaken will increase their sleep duration

decreasing their risk of falls. I know that we cannot possibly stop all falls, but with the implementation of this project we may be able

to decrease the risk a little thus, decreasing the risk for injuries related to falls. I project that we will see a decrease of 10% in the

number of falls in the facility as a whole over the next 12 months.

Goals

I. Assess (May 21-28, 2015)

a. Discuss project with Fall QAPI committee

b. Decide which unit would like to implement first (potentially unit with greatest number of falls)

c. Interview staff on current situation, and what they believe could be changed

II. Review (June 1 – 15, 2015)

a. Review all current medication administration times on unit chosen

b. Review possible changes with Physician

c. Review changes with ADON

d. Discuss changes to current dining for breakfast

i. Continue with scheduled breakfast for those who are awake

ii. Offer continental breakfast items:

1. Cold cereals

2. Hot cereal

3. Toast

4. Frozen waffles

e. Discuss changes with staff development so they may adjust orientation to reflect new system

f. Discuss with social work for monitoring of those with behavior medications for any adverse reactions to the changes in

medication administration times

g. Develop new medication administration policy and procedure guide for facility

III. Application (June 16 – 25, 2015)

a. Notify residents/families of new BID medication administration and the impact on resident care

i. Changes in sleep schedule

ii. Dining schedule

iii. Medication administration parameters

b. Meet with all staff on unit chosen to discuss changed

i. No longer wake residents in the night for medications unless specifically ordered by physician

ii. No longer wake residents for breakfast

iii. Offer breakfast upon rising and ensuring residents are offered a balanced meal

iv. Administer medications upon rising

c. Discontinue all medication being changed on the midnight shift prior to implementation

d. Input all medications with new administration parameters

IV. Implementation (June 30 - July 1, 2015)

a. Changeover of medications will need to occur on the midnight shift so that new administration can begin the next day

on the day shift

b. Monitor sleep patterns with changes

c. Monitor number of falls

d. Interview staff/residents about the changes

i. Positive or negative impact

ii. Improved sleep?

iii. Changes in behaviors

V. Review (Beginning July 8, 2015 this will be ongoing)

a. Review the number of falls over the previous month since implementation

b. Review causes of falls (possibly attributed to changes in sleep patterns)

c. Review sleep patterns

d. Review any changes that needed to be made to medications due to adverse effects of project

e. Discuss with social worker any negative impacts on behaviors related to medication changes

f. Monitor participation in nursing online in-service

g. Evaluate staff surveys

VI. Change/Update (July – ?)

a. Discuss findings of surveys, and review and changes that need to be made to plan

b. Continue to implement project on each unit until building is completed (if project has positive impact)

c. Continue to meet with interdisciplinary team throughout implementation and then quarterly after to monitor progress

d. Update and implement any changes as team sees fit (ongoing)

e. Project at this time is not going to be implemented on sub-acute rehab unit as residents are short term.

Title of Quality Improvement Project: BID Medication Administration

Goals with QSEN/ANA Support Sub-Objectives to meet Goal Activities to meet Each Sub-objective Timeline for eachGoal 1: State Goal

Establish BID medication administration system

Meets QSEN Competency(ies)/KSA(s):- Evidence-based practice –

knowledge- Teamwork and Collaboration

Meets ANA Scope & Standards for specialty role:

- Quality of Practice- Collaboration

1.1Evaluate Medications

1.2Recommend Changes

1.3

Implement Changes

1.1Review all current medications and evaluate which can be adjusted to accommodate new administration schedule

1.2Review with Physician, ADON and families for final approval on all medication changes

1.3Discontinue all current medication and re-enter using recommendations and new parameters

1.1June 1-15, 2015

1.2

June 1-15, 2015

1.3June 30 – July 1, 2015

Goals with QSEN/ANA Support Sub-Objectives to meet Goal Activities to meet Each Sub-objective Timeline for eachGoal 2: State Goal

Implement staff guideline changes

Meets QSEN Competency(ies)/KSA(s):- Quality- Teamwork and Collaboration

Meets ANA Scope & Standards for specialty role:

- Implementation

2.1

Write midnight shift care protocol, and medication administration policy

2.2

Evaluate falls

2.3

Evaluate behaviors

2.1

Review current policies and procedures, make changes to meet new standards and discuss with Fall QAPI and administration regarding changes.

2.2Review falls bi-weekly and complete RCA as appropriate

2.3Review behaviors that occurred in the previous month with social worker to find

2.1

June 1-15, 2015

2.2

July – August 2015

2.3

- Quality of Practice- Collaboration

if there has been any negative effects of the change in medications.

July – August 2015

References

Bass, B. M. (1990). From transactional to transformational leadership: Learning to share the vision.

Organizational Dynamics, 18(3), 19-31.

Bergeron, C. A., Crecelius, C. A., Murphy, R., Roth Maguire, S., Osterweil, D., Simonson, W., . . . Zee, P. C. (2008, September 5).

Improving sleep management in the elderly. Annals of Long Term Care

http://www.annalsoflongtermcare.com/article/8283

Brassington, G. S., King, A. C., & Bliwise, D. L. (2000). Sleep problems as a risk factor for falls in a sample of community-dwelling

adults aged 64-99 years. Journal Of The American Geriatrics Society, 48(10), 1234-1240.

Endeshaw, Y. W., Ouslander, J. G., Schnelle, J. F., & Bliwise, D. L. (2007). Sleep and sleep disorders in older persons:

Polysomnographic and Clinical correlates of behaviorally observed daytime sleep in nursing home residents.

The Journal of Gerontology, 62(1), 55-51.

Giltinane, C. L. (2013). Leadership styles and theories. Nursing Standard, 27(41), 35-39.

http://dx.doi.org/10.7748/ns2013.06.27.41.35.e7565

Goldman, S. E., Ancoli-Israel, S., Boudreau, R., Cauley, J. A., Hall, M., Stone, K. L., . . .

Newman, A. B. (2008). Sleep problems and associated daytime fatigue in community-dwelling older

individuals. The Journal of Gerontology, 63(10), 1069-1075.

Kuo, H.-K., H. Yang, C. C., Yu, Y.-H., Tsai, K.-T., & Chen, C.-Y. (2010). Gender-specific

association between self reported sleep duration and falls in high-functioning older adults.

The Journal of Gerontology, 65A(2), 190-196.

Latimer Hill, E., Cumming, R. G., Lewis, R., Carrington, S., & Le Couteur, D. G. (2007). Sleep disturbances and falls in older people.

The Journal of Gerontology, 62A(1), 62-66.

Lesage, S., & Scharf, S. M. (2007). Beyond the usual suspects: Approaching sleep in elderly people.

The Journal of Gerontology, 62(1), 53-54.

Martin, J. L., Marler, M. R., Harker, J. O., Josephson, K. R., & Alessi, C. A. (2007). A

multicomponent nonpharmacological intervention improves activity rhythms among nursing home

residents with disrupted sleep/wake patterns. The Journal of Gerontology, 62(1), 62-72.

Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37.

Stenholm, S., Kronholm, E., Sainio, P., Borodulin, K., Era, P., Fogelholm, M., . . . Koskinen, S.

(2010). Sleep-related factors and mobility in older men and women. The Journal of Gerontology,

5A(6), 649-657.

Stone, K. L., Ensrud, K. E., & Ancoli-Israel, S. (2008). Sleep, insomnia and falls in elderly patients. Sleep Medicine, 9(Suppl.),

S18-S22.

Appendix A

Appendix B

Increase in Falls Over

Last 12 Months

Meal TimeStaff Disturbances

Toileting Habits

Shared RoomMedications

Disease Progression

Check and change q 2hr

Up to the restroom

Loud roommate

Care of roommate

Not Quiet

Use of fall risk medications ie: psychoactive meds

Too many meds

Strict administration time

Increased lethargy

Day and Night confusion

Loud Staff

Wake for breakfast

Nurses administering medications too early

Breakfast served at once

Waking to get to breakfast on time

No option to eat later