Healthcare Quality Improvement Initiative and Evaluation Report

Precious Teasley

Southern New Hampshire University

IHP-604-Q1480 Healthcare Quality Improvement 23TW1

Professor Barbara Brophy

November 8, 2023

Background

The healthcare organization selected is Mass General Brigham. Mass General Brigham is located in the state of Massachusetts and is considered the biggest healthcare facility based on the number of employees with approximately 74,000 employees working as physicians, nurses, support staff, researchers, and carers (Mass General Brigham, 2023). The medical facilities affiliated with Mass General Brigham include Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital (MGH) which have also performed exceptionally well.

Metric Analysis

The two metrics that will be used for the hospital are hospital readmission rate and patient satisfaction score. According to Dukhanin et al., (2018), the hospital readmission rate is the proportion of patients readmitted within 30 days following discharge. It is an important metric that shows whether patients at the hospital are receiving proper care during hospitalization. A lower rate of hospital readmission rate means that patients are getting proper care during hospitalization and transferring easily to post-discharge treatment. According to a report by the Centre for Health Information and Analysis (2022), the Risk Standardization Readmission Rate for Mass General Brigham was 16%. This is quite higher than the national average even though the state of Massachusetts is usually ranked as having the highest hospital readmission rates. There is a lot that has to be done by the organization to improve on this metric. The higher rate of hospital readmission shows the ineffectiveness of treatment during past hospitalization (Wang et al., 2022).

The patient satisfaction score is a consumer experience metric that shows the satisfaction levels of the patient based on the overall treatment the patient has received. According to Doupe et al., (2019), hospitals and other health organizations use surveys to collect patient satisfaction levels, which represent their care perspective. This metric rates how happy the patient is with their healthcare on a scale of 1-5. The patient satisfaction score for Mass General Brigham between the period April 2021 to March 2022 was 81% (. This is higher than the national average which is 71%. A higher patient satisfaction score is good for the organization as it shows that the patient is satisfied with the healthcare received. However, patient satisfaction score looks at various aspects of the hospital like admission, rooms, quality of meals, communication with nurses and doctors, tests and treatment, visitors and family, discharge, and personal issues. This gives an overall assessment of the hospital showing whether the patient is satisfied with the treatment received. There is room for improvement in certain areas of the hospital like rooms and meals which received the lowest scores.

The data for the hospital readmission rates is received from the Centre for Health Information and Analysis. This is an independent state agency that offers an objective analysis of quality, utilization, and access to mass healthcare systems. The data for the patient satisfaction score are derived from surveys done by patients. The data is available on the hospital’s website and is comparable with the national average.

Opportunity for Improvement

Metrics for hospital readmission rate is quite important. It can help in reducing mortality rates in the hospital. This is because when there is an increase in hospital readmission, there is likely to be an increase in mortality rates. There is a link between an increase in mortality rates and an increase in readmission rates (Gangu et al., 2022). Metrics on hospital readmission rates can also help the hospital find areas where they will make improvements to avoid losing money. Hospitals know that when the readmission rates are high the cost and quality of care are adversely affected.

The metrics for patient satisfaction score consist of various areas that may need improvement in the hospital. The metrics include data for admission, rooms, quality of meals, communication with nurses and doctors, tests and treatment, visitors and family, discharge, and personal issues. All these are different areas and departments in the hospital that can be analyzed to find room for improvement. According to the metrics for patient satisfaction score for Mass General Brigham (2023), the overall score surpasses the national average. However, some areas need improvement and create opportunities for the management of the hospital to make significant changes. An example would be making changes in communication between patients and medical staff like nurses and the physician. This is likely to improve the patient satisfaction score.

Root cause analysis is an evidence-based quality improvement tool that is applicable in healthcare. It is a methodology used to look into an occurrence and help find health system flaws that might not be obvious at first glance. The primary purpose of Root cause analysis is to pinpoint the system faults that caused or contributed to the incident, as well as to offer suggestions for mitigating or preventing a similar occurrence from happening again (Kwok et al., 2020). It is multidisciplinary and follows a methodical approach that aims to address three queries: What took place? Why did it take place? How can we make sure that doesn’t happen again?

Root cause analysis can be used as a problem-solving tool for the issues that the hospital is facing. The tool can be applied differently at the hospital to help in finding system vulnerabilities that are leading to the problems. When looking at the issue of the high rate of hospital readmissions, Root cause analysis can effectively be used in pinpointing the system vulnerabilities that are leading to the high rates. The tool can then be used in coming up with solutions to the vulnerabilities that would help in reducing the high rate of hospital readmissions. It can also be used to show why certain aspects of the patient satisfaction score have lower scores than others. The tool will pinpoint the exact issues that are leading to lower scores in certain aspects and help in coming up with solutions that will help in increasing the scores.

Recommendations

The hospital should apply Root Cause Analysis (RCA) as a strategy that will help them in identifying any system faults that caused or contributed to an incident. This tool is effective as it will also help in coming up with solutions to the problem and ensuring the prevention of similar occurrences. The recommendation to the organization is to use RCA in improving the quality of health care and delivery. This will help the organization in reducing the rate of hospital readmissions and improve the various aspects of patient satisfaction scores.

Evaluation