Assignment Task:
In preparation for your root cause analysis, read the fall prevention policy of Happy Health Hospital. Next, use the provided data set to examine the data that the hospital collected on the 17 patients who fell in the past two quarters. Note that in the first tab of the data set, you will see the total number of falls for the past four quarters. The hospital has collected additional data on the patients who fell in the last two quarters, which is represented in the other tabs of the data set. In addition, the electronic health records quality review should be used as a tool to assist in your analysis of both the patent data and the hospital's current policy.
For the second piece of your final project, you will create a visual presentation to communicate the findings of your root cause analysis to internal stakeholders and decision makers at the hospital.
Part I of the project is divided into three milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three, Five, and Seven. Part I and Part II will both be submitted in Module Nine.
This project addresses the following course outcomes:
- Evaluate the quality of healthcare data within data sets for making well-informed decisions
- Determine the root cause of a patient safety issue through analysis of health data
- Analyze the current data management policies of a healthcare organization for informing process changes
- Develop data management policies within a healthcare organization for ensuring the quality of data in compliance with laws and established data quality standards
Prompt
Root Cause Analysis
Imagine that you are the quality manager at Happy Health Hospital. In response to a concern regarding patient falls occurring in the hospital, you have been tasked with performing a root cause analysis. You will begin by ensuring that you have a good quality data set that can be used to perform your analysis. You will then analyze patient data for the patients who fell in the last two quarters. You will identify trends among the patients who fell to determine the apparent cause of the safety issue. You will also consider how the hospital's current fall prevention data management policy could be contributing to the issue and to make recommendations for improvements.
Specifically, the following critical elements must be addressed:
I. Data Evaluation: In this section, you will examine the provided data set to ensure that you have quality data on which to base your analysis.
1. Reliable
- Identify the primary and secondary information sources that comprise the provided data set.
- Explain how each data source is maintained, including any regulatory policies or standards that govern the data.
2. Sufficient: Explain whether you have enough patient data to analyze in order to determine the trends and root cause of the falls. Defend your response.
3. Relevant
- Explain whether the data available has a logical relationship with the issue being addressed.
- Identify the data components that will be most useful in your analysis of the patient safety issue, and explain why those specific components are relevant.
4. Quality: Based on your evaluation of the data set, explain what you determined about its overall quality.
II. Data Analysis: In this section, you will analyze patient data from the data set to identify trends among the patients who fell, and to determine the apparent cause of the safety issue. Use the data set and your findings from your electronic health record quality review to inform your responses.
1. Assess what the data reveals about the prevalence of the patient falls over the past four quarters.
2. Analyze the trends and patterns that are apparent between the patients in the data set.
3. Determine what appears to be the root cause of the patient falls, using your findings of trends and patterns to support your response.
III. Documentation Processes: In this section, you will review the hospital's current data management policy and practices to identify areas for improvement. Use the data set and your findings from the electronic health record quality review to inform your responses.
1. Explain what your analysis of the data set reveals about inconsistencies in the hospital's current data collection practices and propose data validation and cleaning practices to facilitate data access and retrieval reporting. Consider these trends:
- Were the fall risk assessments for the patients completed and documented within three days of admission?
- Were vital signs for the patients taken and documented within 12 hours of admission?
- Who reviewed the patients' medication profiles?
2. Explain what the data reveals about whether employees are abiding by the hospital's fall prevention documentation policy, Propose how the hospital should improve data collection, incorporating data validation and data cleaning into the processes. Defend your response.
3. Compare the hospital's fall prevention documentation policy with established regulatory standards and identify the areas in which it does not align. Consider the following:
- Is the hospital not requiring documentation of certain data components suggested by the regulatory standards?
- Is the appropriate healthcare professional reviewing and documenting the patients' medication profile?
IV. Data Management Recommendations: In this section, you will propose changes to the hospital's current fall prevention data management policy regarding when the organization documents data, what data they should document about the patients who fall, and who is responsible.
1. Propose a stricter policy regarding when to complete and document a patient's fall risk assessment, and explain how this change will impact the timeliness of the data.
2. Recommend what data elements the hospital should be capturing, and explain how this change will impact data quality.
3. Propose a policy regarding who should be responsible for completing and documenting the review of a patient's medication profile, and explain how this change will impact data integrity.
4. Explain how your policy recommendations align with the laws and standards that govern data quality and defend how these improvements to the hospital's data management policies may mitigate the patient safety issue occurring in the hospital.
5. Propose database tools such as python, Power BI or R that could help facilitate data retrieval and analysis.