HCS310: Case Study 1: A Summer Internship Journal

HCS310: Case Study 1: A Summer Internship Journal.

Owner:	Date:	Case:
Define and Analyze the Problem		Develop, Implement, and Control Solution(s)
Background: What is the context of the issue? Who are the key players and what are their viewpoints? Are there conflicts to be resolved? Briefly explain the history. How does the problem fit within the organization’s goals? Why is this problem important to the patient/organization? What are the consequences of the problem? Why is a change needed? What are the symptoms of the problem?		Future State:Draw a diagram of a new way to work. Create measureable targets for new way to work. What are the success factors? Define requirements of future state.
Problem Statement: Be specific. Is the focus of improvement appropriately scoped to be described to sufficient detail within this A3? Avoid defining a problem as its consequence, symptom or solution.  A sentence or two describing Where, When, what, How Much, How Do You Know, and What is “The Pain”?
Current State:What is going on?  Use facts.  Be visual – use Pareto charts, pie charts, sketches.  Draw a diagram of what happens now. Identify problems explicitly in the diagram. What are the key measures or metrics that can describe the current state?		Identify, Test, and Implement CountermeasuresWhat will be done to test and validate those countermeasures? (Think quality improvement cycles). Countermeasure #1: Countermeasure #2: Countermeasure #3:
		Implementation Plan: Must include consultation of all this impacted. Item What Who When
Problem Analysis:Use the simplest problem-analysis tool that will suffice to find the root cause of the problem: Five whys, fishbone diagram, FMEA, etc. Does the problem above contain multiple root causes? Do causes align to explicitly illustrated problems in the current state section? Prioritize problems.
		Measure and Control Improvements: Primary Metric Baseline Target Current Define operational effectiveness. Chart, as appropriate. This data becomes the new Current State in the Continuous Quality Improvement cycle. Define verification plan. Define plan to sustain and control changes. Develop Control Plan.
		Follow-up & Lessons Learned:What issues remain that need to be closed?  What worked?  What could be improved?

Zachary Pruitt, PhD, MHA, CPH; Candace S. Smith, PhD, RN, NEA-BC; Eddie Pérez-Ruberté, MS       © Springer Publishing Company, LLC

Instructions

OBJECTIVES

HCS 310

Case Study 1: A Summer Internship Journal

 

Describe the major components of patient throughput/patient flow, including various access points for inpatient admissions, boarding, discharge turnaround time (TAT), and patient discharge.

Analyze multiple root causes of patient wait times in the patient flow.

Identify area for needed change in patient throughput process.

Describe importance of seeking input from others to identify problems and develop solutions.

Understand how to communicate quality management problem-solving in order to impact decision-making and influence change.

SUMMARY

 

The University of Montana Medical Center (UMMC) recently renovated and expanded their ED, a project that cost the facility a few million dollars. With the expansion of the ED, the facility has experienced increase patient volume. Unfortunately, since the center did not expand the number of inpatient rooms, more patients means patient boarding in the ED. The high volume of patients and the long wait times could lead to numerous bad outcomes, such as poor patient satisfaction scores, employee burnout, and even financial loss.

 

The new administrative intern, Ben Barrett, decided that he wanted to address ED boarding for his internship report. Right away, he came up with two different solutions to the problem at hand: ED patient diversion or hiring additional hospitalists to see more patients. The CEO, John Laidlaw, vetoed these ideas. Instead, he instructed the intern to look at all of the entry points across the hospital. To the intern’s surprise, the issue of long waiting times was not unique to the ED. Barrett then learned that there were even long waiting times for patients being discharged. If the end of the process is getting backed up, you can bet the beginning of the process will experience backup as well.

 

Therefore, the problem Barrett decided to address was the inefficient patient throughput process causing late discharges, long wait times for discharges, and long wait times for admissions. During his analysis, he noted that some units have much better turnaround times (TATs). This suggests something can be done to improve other units. Through analyzing more data, interviewing leadership and staff, and summarizing his findings on a fishbone diagram, Barrett discovered that improvement in discharge efficiency is associated with discharges before 11 a.m. The key drivers of this problem were the lack of a defined time for providers to submit discharge paperwork and lack of a standardized “bed-ahead” discharge procedure. With the development and implementation of policies and procedures across the whole medical center, UMMC can reach the goals of a 90-minute average TAT and an average patient wait time of 30 minutes. The wait times of concern include the ED and the Cardiac Catheterization Lab.

Discussion Questions Ch 1

1. Why does the U.S. healthcare system have lower value than other comparable high-income counties?
2. How does U.S. healthcare fail to meet W. Edwards Deming’s definition of quality?
3. Why is healthcare quality management an imperative in today’s healthcare

environment?

4. Why is healthcare quality management an imperative in today’s healthcare

environment?

5. Choose the top three most serious healthcare quality examples from this

chapter. Explain why you chose these examples.

________________________________________________________________________________________________________

NUR 415: Quality Improvement Case Study 2: Medication Safety Initiative Journal

Owner: Dr. Elena Ramirez, DNP, RN, CPHQ

Date: September 29, 2025

Case: Reducing Medication Administration Errors in Inpatient Units

Define and Analyze the Problem

Develop, Implement, and Control Solution(s)

Background: The context of this issue revolves around a mid-sized community hospital, Riverside General Hospital (RGH), which serves a diverse urban population with high admission rates for chronic conditions like diabetes and hypertension. Key players include frontline nurses, pharmacists, unit managers, and the hospital’s quality improvement (QI) committee, with viewpoints ranging from nurses citing workload pressures to pharmacists emphasizing barcode scanning inconsistencies. Conflicts arise between time constraints for documentation and the need for double-checks, exacerbated by recent staffing shortages post-pandemic. Historically, RGH has seen a 15% rise in medication errors since 2023, per internal audits, fitting into the organization’s goal of achieving zero-harm events as outlined in its 2025 strategic plan. This problem is critical to patients due to risks of adverse drug events (ADEs), which contribute to prolonged stays and readmissions; for the organization, it leads to regulatory fines and litigation costs exceeding $500,000 annually. Consequences include patient harm, eroded trust, and burnout among staff. Change is urgently needed to align with Joint Commission standards, with symptoms manifesting as near-miss reports spiking 20% quarterly and error rates at 8 per 1,000 doses administered.

Future State: Envision a streamlined workflow where nurses use integrated electronic health record (EHR) alerts and mobile barcode scanners for 100% compliance. Draw a diagram illustrating a linear process: Order entry → Pharmacist verification → Nurse scan-and-administer → Real-time documentation. Measurable targets include reducing errors to <2 per 1,000 doses, achieving 95% barcode scan adherence, and shortening administration time by 25%. Success factors: Staff training buy-in, IT support, and multidisciplinary audits. Requirements: Updated EHR modules, weekly huddles, and a feedback loop for ongoing refinement.

Problem Statement: At RGH inpatient units, medication administration errors occur daily during peak shifts (7 AM–3 PM), resulting in 8 incidents per 1,000 doses as tracked by incident reports and EHR audits, causing patient harm and $200,000 in annual avoidable costs—the pain of delayed care and trust erosion demands immediate, targeted QI intervention.

Current State: Current processes involve manual order reviews and sporadic barcode use, leading to distractions and illegible handwriting overrides. Use facts: 2025 Q1 data shows 65% of errors from wrong-dose selections (Pareto chart: top category). Sketch a flowchart: Physician order → Manual transcription → Nurse pull from Pyxis → Administer without scan (bottlenecks at transcription and scanning). Key metrics: Error rate (8/1,000), scan compliance (70%), administration TAT (15 minutes average). Explicit problems: High interruption rates (n=45/week) and inconsistent training.

Identify, Test, and Implement Countermeasures

What will be done to test and validate those countermeasures? Employ PDSA (Plan-Do-Study-Act) cycles: Pilot on one unit for 4 weeks, measure pre/post data, adjust based on staff surveys.

Countermeasure #1: Implement mandatory barcode scanning with EHR pop-up alerts for high-risk meds (e.g., insulin). Test via simulation training and shadow audits.

Countermeasure #2: Standardize shift huddles for med reconciliation, involving nurses and pharmacists. Validate through error log reductions and satisfaction scores.

Countermeasure #3: Develop a “quiet zone” protocol during peak administration hours to minimize interruptions. Pilot with signage and volunteer monitors, tracking interruption incidents.

Implementation Plan: Must include consultation with all impacted stakeholders (nurses, pharmacists, physicians, IT, patients via focus groups).

Problem Analysis: Employ a fishbone diagram (causes: People—training gaps; Process—interruptions; Technology—EHR glitches; Environment—noise). Root causes via 5 Whys: Errors stem from rushed scanning (why? Interruptions); Interruptions from understaffing (why? Budget cuts). Multiple roots align with current state diagram (e.g., 40% errors at transcription). Prioritize: Barcode non-compliance (high impact/frequency).

Measure and Control Improvements:

Define operational effectiveness: Sustained error reduction via monthly audits, aligning with Six Sigma defect goals (<3.4/1M opportunities). Chart via run chart showing pre/post trends. Verification plan: Bi-weekly random audits by QI team. Sustain changes: Embed in policy, annual refreshers. Control Plan: Dashboard monitoring, escalation for drifts >10%.

Follow-up & Lessons Learned: Remaining issues: IT glitches in alerts (to resolve Q4 2025). What worked: Huddles boosted team communication (90% satisfaction). Improvements: Extend pilot to all units sooner; enhance patient education on med safety.

Dr. Elena Ramirez, DNP, RN, CPHQ; Prof. Marcus Hale, PhD, MBA; Sarah Kline, MSN, RN © Academic Press, 2025

Instructions

OBJECTIVES NUR 415 Quality Improvement Case Study 2: Medication Safety Initiative Journal

• Describe core elements of medication safety protocols, including order verification, administration safeguards, and error reporting in inpatient settings.
• Analyze root causes of medication errors using tools like fishbone diagrams and 5 Whys.
• Identify opportunities for process change in medication workflows to enhance patient safety.
• Explain the value of interprofessional collaboration in QI initiatives for error reduction.
• Demonstrate effective communication of QI findings to drive policy changes and foster a culture of safety.

SUMMARY

Riverside General Hospital (RGH) underwent a 2024 EHR upgrade to improve documentation, yet medication errors persist amid rising patient acuity and nurse turnover. The upgrade aimed to reduce manual entries but inadvertently increased alert fatigue, contributing to a 12% error uptick in 2025.

New QI intern, Jordan Lee, RN, targeted med administration errors for their capstone project, initially proposing more staff hires—a solution rejected by CFO Lisa Chen due to budget limits. Instead, Chen directed a holistic review of the med-use continuum, revealing bottlenecks not just in administration but also in order entry and discharge reconciliations. Delays at discharge med handoffs were backing up inpatient flows, mirroring upstream issues.

Lee’s analysis uncovered superior performance in the ICU (error rate: 3/1,000) linked to routine barcode protocols and pre-shift huddles. Using data from 2025 audits, staff interviews, and a Pareto chart, key drivers emerged: Inconsistent scanning (55% of errors) and peak-hour distractions. Implementing standardized procedures—alert customization, huddle mandates, and interruption protocols—across RGH could achieve targets of <2 errors/1,000 doses and 95% scan compliance. Focus areas: Med-Surg and Telemetry units, where errors impact high-acuity cardiac patients most.

Discussion Questions Ch. 2

1. Why does medication error prevalence in U.S. hospitals lag behind international benchmarks despite advanced technology?
2. How does the U.S. healthcare system’s fragmented med-use process contradict Deming’s principles of variation reduction?
3. Why is medication safety QI essential in the 2025 post-EHR era amid staffing challenges?
4. Why is medication safety QI essential in the 2025 post-EHR era amid staffing challenges? (Repeated for emphasis on evolving risks.)
5. Select the top three most critical medication error examples from this chapter (e.g., wrong-dose insulin, omitted antibiotics, unlabeled infusions). Explain your choices based on harm potential and preventability.