WGU C815 Quality and Performance Management
and Methods Task 1 |Latest Update with Complete
Solution
Quality and Performance Management and Methods - C815
Task 1
Evaluating Quality Improvement Programs in an HIM Department
Instructor: Ashley Killingsworth
A1.
One..quality..improvement..(QI)..initiative..Fielder..Medical..has..implemented..is..reducing
catheter-
associated..urinary..tract..infections..(CAUTI)...Fielder..has..educated..its..doctors..and..nurses..on..best
..practices..associated..with..catheter..use...The..goal..is..to..remove..the..catheter..as..quickly..as..possib
le,..find..alternative..methods..for..urine..evacuation,..and..improve..sterile..techniques..when..insertin
g..catheters.
This..is..a..crucial..QI..initiative..as..it..helps..to..prevent..kidney..and..bladder..infections..that..
could..ultimately..lead..to..sepsis..in..patients...It..also..reduces..the..use..of..antibiotics..and..the..risk..of..
producing..antibiotic..resistance..in..the..bacteria..associated..with..CAUTIs.
Another..QI..initiative..that..Fielder..has..implemented..is..rescuing..patients..with..severe..sepsis/septi
c..shock...Fielder..joined..with..state..agencies..to..identify..best..practice..“bundles”..to..reduce..the..m
ortality..rate..of..patients..who..have..developed..sepsis..while..already..an..inpatient..or..are..septic..upon
..admission.
Fielder..has..implemented..this..important..QI..initiative..to..help..save..their..patients'..lives.
They..can..also..share..their..best..practices..with..other..facilities..to..help..reduce..the..mortality..rate..at..
those..facilities.
One..last..QI..initiative..Fielder..has..implemented..in..their..facility..is..reducing..the..readmissi
on..rate...Fielder..Medical..staff..do..this..by..identifying..patients..who..are..at..risk..for..readmission,..s
uch..as..those..who..have..been..readmitted..in..the..past..or..have..certain..health..conditions...Staff..can.
, .reduce..readmissions..by..providing..better..healthcare..and..education..to..patients..and..their..familie
s.
This..QI..initiative..is..essential..as..it..helps..reduce..the..emotional..and..financial..burden..on..t
he..hospital's..most..vulnerable..population...It..also..helps..reduce..the..financial..burden..on..the..facilit
y..and..insurance..companies.
A2.
The..CAUTI..initiative..does..follow..Fielder..Medical’s..current..process...The..program..build
s
upon..the..success..of..other..infection..prevention..initiatives..that..Fielder..has..implemented,..such..as.
.the..CLABSI..initiative..and..ventilator-associated..pneumonia.
Fielder..Medical’s..best..practice..“bundles,”..as..well..as..monitoring..patients..and..collecting..data..o
n..their..patients..with..sepsis,..has..shown..a..significant..reduction..in..the..mortality..rate..of..those..pati
ents...This..suggests..that..the..doctors..and..nurses..who..follow..the..sepsis..protocols..put..in..place..by
..Fielder..Medical..are..effectively..saving..lives.
Fielder..Medical’s..readmission..initiative,..which..provides..patients..with..better..care..and..e
ducation,..helps..patients..transition..to..either..the..home..or..nursing..facility..after..discharge..and..pre
vents..readmissions...Identifying..at-
risk..patients..and..providing..a..strong..education..to..the..patient..and..family..members..has..been..sho
wn..to..help..lower..30-day..readmission..rates.
A3.
CMS..implemented..a..Hospital-Acquired..Condition..Reduction..Program..(HAC)..as..part..of
its..Value-
Based..Payment..program...CAUTI..is..one..such..infection..that,..if..a..patient..should..acquire..during..t
heir..stay,..the..hospital..will..receive..a..reduced..payment...Fielder..Medical..Center..does..comply..wi
th..CMS..in..the..CAUTI..reduction..initiative..by..promoting..patient..safety..by
implementing..best..practices..in..prevention,..educating..its..healthcare..team,..and..using..proper..steri
le..techniques..during..catheter..insertion.. . (CMS,..2024a)..The..Centers..for..Disease..Control..and..Pr
evention..(CDC)..also..has..guidelines..for..preventing..CAUTIs,..which..Fielder..Medical..Center..co
mplies..with...These..guidelines..include..using..catheters..only..when..necessary,..removing..them..as..
soon..as..the..patient..no..longer..requires..them,..and..using..proper..sterile..technique..when..inserting..t
he..catheter...(CDC,..2024)
In..2015,..CMS..and..The..Joint..Commission..implemented..sepsis..core..measures..that..hosp
itals..must..utilize..and..report..on..to..reduce..mortality..rates...(Esposito..et..al.,..2018)..According..to..B
arbash..et..al...(2019),..early..intervention..has..decreased..mortality..rates..in..sepsis..patients...The..C
MS..Program..Severe..Sepsis..and..Septic..Shock:..Management..Bundle..(SEP-
1)..has..several..protocols..or..“bundles”..that..a..facility..must..follow..and..report..on...These..protocol
s..are..usually
team-
driven..and..include..lactate..measurement,..sampling..blood..cultures,..administering..antibiotics,..and
..other..measures...CMS..has..put..these..protocols..in..place..as..they..have..been..shown..to..lower..mort
ality..rates..associated..with..sepsis...(CMS,..2020)..Fielder..Medical..Center..does..comply..with..the..C
MS..protocols..as..they..use..the..best..practice..“bundles”..and..compile..data..to..ensure..compliance.
and Methods Task 1 |Latest Update with Complete
Solution
Quality and Performance Management and Methods - C815
Task 1
Evaluating Quality Improvement Programs in an HIM Department
Instructor: Ashley Killingsworth
A1.
One..quality..improvement..(QI)..initiative..Fielder..Medical..has..implemented..is..reducing
catheter-
associated..urinary..tract..infections..(CAUTI)...Fielder..has..educated..its..doctors..and..nurses..on..best
..practices..associated..with..catheter..use...The..goal..is..to..remove..the..catheter..as..quickly..as..possib
le,..find..alternative..methods..for..urine..evacuation,..and..improve..sterile..techniques..when..insertin
g..catheters.
This..is..a..crucial..QI..initiative..as..it..helps..to..prevent..kidney..and..bladder..infections..that..
could..ultimately..lead..to..sepsis..in..patients...It..also..reduces..the..use..of..antibiotics..and..the..risk..of..
producing..antibiotic..resistance..in..the..bacteria..associated..with..CAUTIs.
Another..QI..initiative..that..Fielder..has..implemented..is..rescuing..patients..with..severe..sepsis/septi
c..shock...Fielder..joined..with..state..agencies..to..identify..best..practice..“bundles”..to..reduce..the..m
ortality..rate..of..patients..who..have..developed..sepsis..while..already..an..inpatient..or..are..septic..upon
..admission.
Fielder..has..implemented..this..important..QI..initiative..to..help..save..their..patients'..lives.
They..can..also..share..their..best..practices..with..other..facilities..to..help..reduce..the..mortality..rate..at..
those..facilities.
One..last..QI..initiative..Fielder..has..implemented..in..their..facility..is..reducing..the..readmissi
on..rate...Fielder..Medical..staff..do..this..by..identifying..patients..who..are..at..risk..for..readmission,..s
uch..as..those..who..have..been..readmitted..in..the..past..or..have..certain..health..conditions...Staff..can.
, .reduce..readmissions..by..providing..better..healthcare..and..education..to..patients..and..their..familie
s.
This..QI..initiative..is..essential..as..it..helps..reduce..the..emotional..and..financial..burden..on..t
he..hospital's..most..vulnerable..population...It..also..helps..reduce..the..financial..burden..on..the..facilit
y..and..insurance..companies.
A2.
The..CAUTI..initiative..does..follow..Fielder..Medical’s..current..process...The..program..build
s
upon..the..success..of..other..infection..prevention..initiatives..that..Fielder..has..implemented,..such..as.
.the..CLABSI..initiative..and..ventilator-associated..pneumonia.
Fielder..Medical’s..best..practice..“bundles,”..as..well..as..monitoring..patients..and..collecting..data..o
n..their..patients..with..sepsis,..has..shown..a..significant..reduction..in..the..mortality..rate..of..those..pati
ents...This..suggests..that..the..doctors..and..nurses..who..follow..the..sepsis..protocols..put..in..place..by
..Fielder..Medical..are..effectively..saving..lives.
Fielder..Medical’s..readmission..initiative,..which..provides..patients..with..better..care..and..e
ducation,..helps..patients..transition..to..either..the..home..or..nursing..facility..after..discharge..and..pre
vents..readmissions...Identifying..at-
risk..patients..and..providing..a..strong..education..to..the..patient..and..family..members..has..been..sho
wn..to..help..lower..30-day..readmission..rates.
A3.
CMS..implemented..a..Hospital-Acquired..Condition..Reduction..Program..(HAC)..as..part..of
its..Value-
Based..Payment..program...CAUTI..is..one..such..infection..that,..if..a..patient..should..acquire..during..t
heir..stay,..the..hospital..will..receive..a..reduced..payment...Fielder..Medical..Center..does..comply..wi
th..CMS..in..the..CAUTI..reduction..initiative..by..promoting..patient..safety..by
implementing..best..practices..in..prevention,..educating..its..healthcare..team,..and..using..proper..steri
le..techniques..during..catheter..insertion.. . (CMS,..2024a)..The..Centers..for..Disease..Control..and..Pr
evention..(CDC)..also..has..guidelines..for..preventing..CAUTIs,..which..Fielder..Medical..Center..co
mplies..with...These..guidelines..include..using..catheters..only..when..necessary,..removing..them..as..
soon..as..the..patient..no..longer..requires..them,..and..using..proper..sterile..technique..when..inserting..t
he..catheter...(CDC,..2024)
In..2015,..CMS..and..The..Joint..Commission..implemented..sepsis..core..measures..that..hosp
itals..must..utilize..and..report..on..to..reduce..mortality..rates...(Esposito..et..al.,..2018)..According..to..B
arbash..et..al...(2019),..early..intervention..has..decreased..mortality..rates..in..sepsis..patients...The..C
MS..Program..Severe..Sepsis..and..Septic..Shock:..Management..Bundle..(SEP-
1)..has..several..protocols..or..“bundles”..that..a..facility..must..follow..and..report..on...These..protocol
s..are..usually
team-
driven..and..include..lactate..measurement,..sampling..blood..cultures,..administering..antibiotics,..and
..other..measures...CMS..has..put..these..protocols..in..place..as..they..have..been..shown..to..lower..mort
ality..rates..associated..with..sepsis...(CMS,..2020)..Fielder..Medical..Center..does..comply..with..the..C
MS..protocols..as..they..use..the..best..practice..“bundles”..and..compile..data..to..ensure..compliance.
