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Capstone Project- Part 8 The first orders (Part 1,2, 3, 4, 5) #226133, 226279, 226280, 226281, 226567, 226568, 226623, 2266721, 226910 and the writer #1747. Location of Practice Experience: Saint Joseph Pain and Rehabilitation Center Storyboard Instructions The Practice Experience Project Storyboard is a brief, visual summary of a completed quality improvement initiative. The storyboard highlights key aspects of a quality improvement effort by documenting the Practice Experience Project from beginning to end. The course template uses a PowerPoint format to complete this assignment. You only need to provide two slides, no more. The first slide is the summary of your project; the second slide is the reference page. You will need to choose the most pertinent information from your practice experience and Capstone Paper to complete the Storyboard. No voiceover is required. I have included the 2 different papers that writer #1747 has wrote for the 2 part Capstone Project that the Storyboard summarizes. I have also included the storyboard (powerpoint) template that the references go on as well. Also the grading rubric is included. This has to be in APA 7th edition and references have to be 5 years or less. Thank you!!   Wrong-Site Surgeries at St. Joseph Pain and Rehabilitation Center: Quality Improvement Plan and Resources  The clinical practice problem of concern at the St. Joseph Pain and Rehabilitation Center is a lack of observation of time-out procedures and protocols by the OR nurses and surgeons (Jeanette & Elizabeth, 2016). This has led to the occurrence of a rising number of cases of wrong-site, wrong-patient, wrong-side, and right patient but wrong procedure operations. The Joint Commission on Accreditation of Healthcare Organizations or JCAHO has recommended a universal protocol for time-outs that should be followed strictly by all healthcare organization OR staff (Pellegrini, 2017). This is aimed at preventing the occurrence of sentinel events and particularly wrong-site surgeries. At this facility within the past year alone there has been a rise in the number of these sentinel events. Using data rom the facility’s EHR dashboard, the Quality Improvement Committee determined that the rise in the rate of these sentinel events is actually 20% compared to the previous year. One of the reasons that have been attributed to this is the lack of proper supervision and control by the nurse leaders responsible. This has left the OR staff complacent such that they have reached a point of overlooking some of the time-out elements and procedures. Being a quality improvement (QI) issue, there is a need for the systematic solution of the problem by using an evidence-based QI initiative that is data-driven and evidence-informed. The main reason why this particular practice problem is chosen is due to the fact that it is not a commonly mentioned or even discussed quality benchmark. A lot of focus has been on other quality benchmarks or indicators such as pressure ulcer rates, accidental patient fall rates, readmission rates, and rates of hospital-acquired infections or HAIs. The purpose of this paper is to present the problem, outline the quality improvement plan, cite the resources that may be required for a successful solution, and draw conclusions. Performance Improvement Plan To effectively have the OR staff and surgeons follow the time-out protocols and lower the rate of wrong-site surgeries as sentinel events, a plan of action must be put in place. This is the implementation plan for the QI initiative. In this case, the plan can be summarized in three parts. These are:

1. Preparation
2. Delivery (training, role play, and supervised implementation), and

• Evaluation

Preparation This will be the initial stage of collating data about the problem and putting resources together and coming up with the timeframe for the intervention. It is also the stage during which the buy-out of the OR staff and surgeons will be sought to guarantee their willing participation and acceptance of the problem. Critically, the nursing management will have to come up with an ingenious solution to the scheduling issue since all the OR staff will need to go through the quality improvement program aimed at reducing the rate of wrong-site surgeries as sentinel events. It may mean for instance that one team of OR staff and surgeons will work a half-day shift covering for the morning procedures and attending the training in the afternoon. Then the other half of the staff who had attended the morning session will cover the afternoon shift performing the remaining procedures for the day. Preparation will also entail looking for evidence-supported interventions that will be applied to the OR staff so that they can implement it in practice. These are discussed below in the ‘Delivery’ stage. Proper planning also means that the resources that will be needed for successful project implementation will have to be assembled and confirmed in terms of availability. The nature of these resources is usually material, fiscal, and human. They are also discussed here below with regard to this particular QI initiative for the reduction of wrong-site surgeries. Delivery This is the stage of the evidence-based practice plan in which the actual interventions are applied to enable the correction of the practice problem identified. In this case, the OR staff will be taken through the universal protocol by the JCAHO step by step. Areas that are not clear will be clarified and the importance of observing the protocol will be discussed. Consequences of not observing the time-out procedure will also be presented. These include a threat to the termination of licensure to practice as well as the risk of litigation for the Tort of Negligence as medical malpractice. There are other interventions that will be required of the OR staff attending the QI program. They will include the removal of the blame-and-shame culture and embracing team spirit and responsibility. The safety of the patient should be a collective responsibility and no particular person should be singled out because of a problem that may occur. Practicing effective communication through the removal of barriers such as a hierarchical pecking order in which the surgeon is authoritative and infallible is another evidence-backed measure. This is because a situation like that will make a subordinate staff member be afraid of mentioning anything wrong that they observe during procedures. For instance, the surgeon may have skipped an important opportunity for time-out but the subordinate staff will be afraid of mentioning this to him. The result is a rise in the number of unwanted sentinel events. Everybody in the OR usually has a purpose or role to play in the procedure. For this reason, there should be no distractions. Everybody must observe situational awareness and drop everything they are doing when the time for time-out comes. The OR staff must also always use perioperative checklists to thoroughly verify patient identity and site of procedure. The purchase and installation of an interactive electronic checklist system (IECS) in the OR will be another of the evidence-based interventions for QI and performance improvement (Rothman et al., 2016; Palatnik, 2016). This will be invaluable in facilitating time-outs and cutting down on human error. The hospital should also reconsider using chlorhexidine-based skin preparation solutions and in their place try iodine-based ones. This is because available evidence suggests that chlorhexidine-based solutions – although effective antimicrobial agents – will easily erase markings made to identify operation sites. This is not the case with iodine-based solutions (Maiwald et al., 2017). This is not from an antimicrobial efficacy standpoint but from a patient safety consideration. Evaluation This is about ascertaining whether the QI initiative for performance improvement managed to achieve the objectives it set out to achieve. Success will be represented by a drop in specific measurable outcomes such as rates of sentinel events, the number of litigations related to sentinel events from the OR, and mortality from wrong-site surgeries or WSS. If successful, evaluation will also involve instituting measures that will enable uninterrupted supervision or control in the OR. Resources Needed to Implement Project Resources are always required for the successful implementation of any project. Access to resources always requires the availability of money/ funds. For this reason, the directors at St. Joseph East Pain and Rehabilitation Center must allocate a budget for the QI initiative for performance improvement. Because procedure scheduling will still be going on as usual (the OR will not be shut); there will be need to cover for the shortage that will be created by the staff attending the QI training. Locums will have to be hired to plug the deficit and regular staff may also be called upon to do extra shifts and accumulate extra full-time equivalents or FTEs. These will all impact the payroll. The resource persons from JCAHO who will facilitate the training will also have to be facilitated by materials bought such as flip charts, overhead projectors, computers, pens, and notebooks. Most importantly, though; the institution will require a substantial amount of fiscal resources to purchase the integrated electronic checklist system or IECS. Money will also be needed to install it and train staff on its usage. The materials for training are important to make the training more efficient, and the IECS as a fixed asset is important in improving patient safety for the long term. Summary The clinical problem of wrong-site surgeries (WSS) is very important for the reputation of a healthcare institution such as St. Joseph East Pain and Rehabilitation Center (SJEPRC) and its OR staff. These are sentinel events that place the safety of the patients at risk. To correct performance and improve the quality of care, the concerned organization must have a plan and the resources required. In the case of SJEPRC, the plan was defined by preparation, delivery of the evidence-based interventions during training followed by implementation, and then evaluation of success or failure. Some of the interventions for evidence-based practice (EBP) for SJEPRC are purchasing and installing the IECS to reduce unintentional errors related to timeout; and a change to iodine-based skin preparation solutions as opposed to chlorhexidine-based solutions. Last but not least, the healthcare institution that is SJERPC will require a budget set out for this change project. This money will buy equipment and pay staff.    References Jeanette, H., & Elizabeth, L. (2016). “Time-out” in the operating room. Professional Case Management, 2(4), 209-212. https://www.nursingcenter.com/journalarticle?Article_ID=3550308&Journal_ID=54025&Issue_ID=3550196 Maiwald, M., & Widmer, A.F. (2017). WHO’s recommendation for surgical skin antisepsis is premature. The Lancet Infectious Diseases, 17(10), 1023-1024. https://doi.org/10.1016/S1473-3099(17)30448-6 Palatnik, A. (2016). To err is human. Nursing Critical Care, 11(5), 4. https://doi.org/10.1097/01.CCN.0000490961.44977.8d Pellegrini, C.A. (June 1, 2017). Time-outs and their role in improving safety and quality in surgery. Bulletin of the American College of Surgeons. https://bulletin.facs.org/2017/06/time-outs-and-their-role-in-improving-safety-and-quality-in-surgery/ Rothman, B.S., Shotwell, M.S., Beebe, R., Wanderer, M.Phil., J.P., Ehrenfeld, J.M., Patel, N., Sandberg, W.S. (2016). Electronically mediated time-out initiative to reduce the incidence of wrong surgery: An interventional observational study. Anesthesiology, 125(3), 484-494. https://doi.org/10.1097/ALN.0000000000001194