Running Head Improvement Plan Toolkit

Running Head Improvement Plan Tool Kit

This improvement plan tool kit aims to enable nurses to implement and sustain safety improvement measures in health care settings in a geropsychiatric unit. The tool kit has been organized into four categories with three annotated sources each. The categories are as follows: general organizational safety and quality best practices, environmental safety and quality risks, staff-led preventive strategies, and best practices for reporting and improving environmental safety issues.

Paper For Above instruction

Ensuring safety and quality improvement in geropsychiatric units is a vital challenge confronting healthcare professionals. These settings are particularly susceptible to adverse events such as falls, medication errors, and behavioral incidents, all of which can cause serious harm or death to vulnerable populations, especially older adults with cognitive impairments. An effective improvement plan integrating evidence-based practices, organizational culture, proactive environmental management, staff engagement, and reliable reporting mechanisms is essential to mitigate these risks and promote a safety-centric culture in such specialized environments.

Introduction

The imperative to enhance patient safety and elevate quality of care in geropsychiatric units necessitates comprehensive and systematic approaches rooted in evidenced-based strategies. This paper constructs a detailed improvement plan based on scholarly sources, focusing on organizational safety practices, environmental risk mitigation, staff-led initiatives, and reporting improvements that collectively foster a culture of safety, accountability, and continuous quality improvement. The integration of these components can substantially reduce sentinel events, including falls, medication errors, and behavioral incidents, thereby improving patient outcomes and staff satisfaction within these complex settings.

Organizational Safety and Quality Best Practices

The foundation of effective safety improvement in geropsychiatric units begins with fostering a reflective and learning organization. Sherwood and Horton-Deutsch (2015) emphasize the importance of adopting pedagogical approaches that promote reflective learning. They suggest that cultivating a safety culture involves engaging staff in debriefings, self-evaluation, and formal education programs that emphasize critical thinking about practice behaviors. These strategies promote a shift from traditional didactic training to interactive, learner-centered approaches that improve critical competencies related to patient safety. Moreover, Fleiszer et al. (2016) highlight the significance of sustainability in safety practices, asserting that best practice guidelines remain effective long-term when supported by strong relationships, routinization, and adaptability. Their study underscores that institutionalizing safety protocols through consistent adherence and cultural embedding is critical for enduring improvements. Kossaify et al. (2017) further support this by emphasizing team-based efforts and ethical leadership, fostering collaboration, self-awareness, and communication—key elements for a robust safety culture that reduces errors and sentinel events through shared responsibility and ethical decision-making. Implementing these principles enables organizations to develop reflective, sustainable, and ethically grounded practices that underpin continuous quality improvement.

Environmental Safety and Quality Risks

Environmental hazards, particularly falls and unsafe infrastructure, pose significant risks in geropsychiatric settings. Powell-Cope et al. (2014) delineate the various factors contributing to falls, including environmental design and patient characteristics, advocating infrastructural modifications such as geriatric-friendly fixtures like raised toilet seats and non-slip flooring to reduce fall risks. Wong Shee et al. (2014) reinforce this by demonstrating the utility of electronic sensor bed and chair alarms, which alert staff when patients with cognitive impairments attempt to leave their beds or chairs, thus preventing falls. Moreover, Chari et al. (2016) explore lighting modifications, such as installing LED lights in critical areas, which significantly improve visual cues, reducing fall incidents during nighttime hours. These studies collectively suggest that targeted environmental modifications—optimized lighting, safe fixtures, and alerting devices—are critical interventions to mitigate physical hazards. Implementing a comprehensive environmental safety assessment followed by infrastructural enhancements based on these evidence-based strategies can significantly diminish fall-related sentinel events in geropsychiatric units.

Staff-Led Preventive Strategies

Proactive, staff-led interventions are pivotal in preventing adverse events. Morgan et al. (2016) introduce 'intentional rounding,' a structured routine whereby nurses periodically check on patients to address their needs and identify potential safety hazards. This strategy has demonstrated a 50% reduction in falls when consistently applied, emphasizing the importance of systematic, proactive engagement by nursing staff. Moncada and Mire (2017) advocate for multifactorial fall prevention that includes regular assessments of balance, medications, and environmental hazards, combined with patient education on safety precautions. Additionally, Isaac et al. (2018) highlight the value of involving caregivers and utilizing personalized care plans derived from non-clinical patient insights, which significantly lessen the likelihood of falls and adverse behaviors. These staff-driven strategies underscore the necessity of active engagement, routine assessments, and individualized care planning to effectively prevent sentinel events. Encouraging staff empowerment and cultural support for these interventions ensures sustained adherence and improved safety outcomes.

Reporting and Improving Environmental Safety Issues

Effective reporting systems are fundamental in identifying safety hazards and fostering a transparency-oriented safety culture. Tan (2015) underscores that bedside reporting and open communication during shift handovers enable staff to promptly share pertinent safety concerns, behavioral changes, or environmental hazards. Barriers to effective communication can be mitigated through staff education and promoting a patient-centered approach emphasizing care and safety during handovers. Stergiopoulos et al. (2016) address the importance of adverse event reporting, noting that underreporting of medication errors and other incidents hampers safety initiatives. Implementing standardized, easy-to-use electronic reporting systems facilitates the timely documentation of errors and near misses, enabling organizations to analyze trends and implement targeted corrective actions. Lozito et al. (2018) demonstrate that campaigns like 'Good Catch' bolster safety culture by encouraging staff to identify and report hazards or mistakes proactively, thereby reducing potential sentinel events. Cultivating an environment in which staff feel empowered and responsible for reporting safety issues is crucial for ongoing quality improvement in geropsychiatric care settings.

Conclusion

Achieving sustained safety improvements in geropsychiatric units hinges upon a multifaceted approach that integrates organizational safety culture, environmental modifications, proactive staff strategies, and robust reporting mechanisms. Reflective organizational practices foster continuous learning and adaptability (Sherwood & Horton-Deutsch, 2015; Fleiszer et al., 2016), while environmental safety investments such as infrastructural modifications, alarms, and lighting enhancements are essential to mitigate physical hazards (Powell-Cope et al., 2014; Wong Shee et al., 2014; Chari et al., 2016). Staff-led interventions like intentional rounding and personalized care plans leverage frontline engagement to prevent sentinel events effectively (Morgan et al., 2016; Moncada & Mire, 2017; Isaac et al., 2018). Moreover, fostering a culture of transparent reporting, supported by standardized electronic systems and staff empowerment (Tan, 2015; Stergiopoulos et al., 2016; Lozito et al., 2018), ensures hazards are promptly identified and addressed. Collectively, these evidence-based strategies can lead to a safer environment, improved patient outcomes, and a resilient safety culture within geropsychiatric units.

References

  • Chari, S. R., Smith, S., Mudge, A., Black, A. A., Figueiro, M., Ahmed, M., ... & Haines, T. P. (2016). Feasibility of a stepped wedge cluster RCT and concurrent observational sub-study to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: A protocol for a pilot trial. Pilot and Feasibility Studies, 2(1).
  • Fleiszer, A. R., Semenic, S. E., Ritchie, J. A., Richer, M.-C., & Denis, J.-L. (2016). A unit-level perspective on the long-term sustainability of a nursing best practice guidelines program: An embedded multiple case study. International Journal of Nursing Studies, 53, 204–218.
  • Isaac, L. M., Buggy, E., Sharma, A., Karberis, A., Maddock, K. M., & Weston, K. M. (2018). Enhancing hospital care of patients with cognitive impairment. International Journal of Health Care Quality Assurance, 31(2), 173–186.
  • Kossaify, A., Hleihel, W., & Lahoud, J.-C. (2017). Team-based efforts to improve quality of care, the fundamental role of ethics, and the responsibility of health managers: Monitoring and management strategies to enhance teamwork. Public Health, 153, 91–98.
  • Lozito, M., Whiteman, K., Swanson-Biearman, B., Barkhymer, M., & Stephens, K. (2018). Good catch campaign: Improving the perioperative culture of safety. AORN Journal, 107(6), 705–714.
  • Moncada, L. V. V., & Mire, G. L. (2017). Preventing falls in older persons. Am Fam Physician, 96(4), 240–247.
  • Powell-Cope, G., Quigley, P., Besterman-Dahan, K., Smith, M., Stewart, J., Melillo, C., & Friedman, Y. (2014). A qualitative understanding of patient falls in inpatient mental health units. Journal of the American Psychiatric Nurses Association, 20(5), 328–339.
  • Sherwood, G., & Horton-Deutsch, S. (2015). Reflective organizations: On the front lines of QSEN and reflective practice implementation. Retrieved from proquest.com.library.capella.edu/lib/capella/detail.action?docID=#
  • Stergiopoulos, S., Brown, C. A., Felix, T., Grampp, G., & Getz, K. A. (2016). A survey of adverse event reporting practices among US healthcare professionals. Drug Safety, 39(11), 1117–1127.
  • Wong Shee, A., Phillips, B., Hill, K., & Dodd, K. (2014). Feasibility, acceptability, and effectiveness of an electronic sensor bed/chair alarm in reducing falls in patients with cognitive impairment in a subacute ward. Journal of Nursing Care Quality, 29(3), 253–262.

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