Addressing Quality and Regulatory Standards Through Clinical Projects

MODULE DIRECTIONS: 

Each of your clinical settings is governed or guided by standards for practice. For this activity, you will lead a discussion related to a quality, safety, or regulatory issue which focuses on your project. 

Provide a brief paragraph to introduce your setting and regulatory agency, and explain how your project addresses a quality/regulatory standard. Seek input from your peers on recommendations that would support or strengthen your project – this is a brainstorming discussion! Consider these recommendations as you prepare the written assignment.

MY ORIGINAL POST: 

Regulatory Agency

My clinical facility is a rehabilitation center in Queens, NY. Bariatric surgery is among the many services provided at the facility. The New York State Health Department establishes regulations for rehabilitation centers and services across the state. Section Section 85.34: Rehabilitation services (n.d.) states that services must be medically necessary and a part of a comprehensive approach to meeting the patient’s needs. Services must be directed, not only to the patient, but also to family members and caregivers who will be involved in the rehabilitation (Section 85:34, n.d.). While additional regulations are included in the document, I found these to be the most relevant to my clinical project. 

Patient education is a core component of comprehensive care. For bariatric patients, weight loss strategies can either mitigate the need for surgery or help them to reach the goals established by their bariatric surgeon. Additionally, weight loss strategies can help to ensure that the surgery achieves long-term goals as the patient must be able to maintain the weight loss associated with the surgery. It is important that the least invasive approach to reaching patient goals is implemented in the rehabilitation center. 

Due to this focus, I have chosen to complete a PowerPoint presentation on weight loss and weight management strategies for bariatric patients who receive care at the clinic. To further meet the requirements established by the New York State Health Department, I will direct the presentation to both patients and other key stakeholders in their weight loss journey. I would appreciate input as to how I might organize the presentation to include these different audiences. I feel that this approach will meet the regulations as it fulfills the requirement of comprehensive care and coordinated care. Most importantly, I feel that this clinical project will help to improve patient outcomes before, during, and after their direct care at the bariatric center. 

Reference

Section 85.34: Rehabilitation services. (n.d.). New York State Health Department. https://regs.health.ny.gov/content/section-8534-rehabilitation-services 

POST # 1 THAT NEEDS A RESPONSE: 

In my clinical setting at Millard Fillmore Suburban Hospital in Williamsville, NY, my preceptor is a float pool nurse leader and supervisor. Moreover, the hospital operates under various regulatory standards to ensure the quality and safety of patient care. One such regulatory agency is the Centers for Medicare & Medicaid Services (CMS), which sets forth guidelines and regulations for hospitals to maintain accreditation and receive reimbursement for services provided. Additionally, the hospital adheres to standards set by The Joint Commission (TJC), a nonprofit organization that accredits and certifies healthcare organizations and programs in the United States.

My project focuses on creating patient education materials regarding substance and alcohol abuse. This initiative aligns with several quality and regulatory standards to promote patient safety, education, and well-being. Substance abuse and alcoholism are significant public health concerns, with statistics highlighting their impact on individuals and communities. According to the Substance Abuse and Mental Health Services Administration (2021), approximately 21 million people in the United States aged 12 or older struggling with substance use disorder in 2020. Moreover, alcohol abuse contributes to over 140,000 deaths annually in the United States (National Institute on Alcohol Abuse and Alcoholism, 2023). By providing education on substance and alcohol abuse, including statistics, risks, effects, and available resources for support and treatment, the project aims to empower patients to make informed decisions about their health. Furthermore, my project fulfills regulatory standards related to patient safety and health promotion. It aligns with the CMS Hospital Inpatient Quality Reporting Program, which emphasizes patient education as a critical component of healthcare delivery (Centers for Medicare & Medicaid Services, 2023). Also, my project supports TJC’s standards related to patient-centered care and effective communication. Patient education materials on substance and alcohol abuse promote a patient-centered approach by acknowledging individual needs and preferences. By delivering information in a clear and accessible manner tailored to the patient’s understanding and language proficiency, my project ensures effective communication and enhances patient engagement in their care.

References

Centers for Medicare & Medicaid Services. (2023, December 27). Hospital Inpatient Quality Reporting Program. CMS.gov. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/inpatient-reporting-program 

National Institute on Alcohol Abuse and Alcoholism. (2023). Alcohol-related emergencies and deaths in the United States. U.S. Department of Health and Human Services. https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-related-emergencies-and-deaths-united-states#:~:text=The%20Alcohol%2DRelated%20Disease%20Impact,behind%20tobacco%2C%20poor%20diet%20and 

Substance Abuse and Mental Health Services Administration. (2021, October). Key substance use and mental health indicators in the United States: Results from the 2020 national survey on drug use and health. U.S. Department of Health and Human Services.  https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf

DISCUSSION # 2 THAT NEEDS A RESPONSE: 

Currently I am completing my capstone at NYU Langone’s Geriatric clinic. My preceptor is a Nurse Practitioner who foresees her own patients daily on regulatory checkups. Within NYU Langone, The Joint Commission oversees the safety patient handling of this corporation. The Joint Commission accredits and certifies more than 22,000 health care organizations and programs in the United States, including hospitals and health care organizations that provide ambulatory and office-based surgery, behavioral health, home health care, laboratory and nursing care center services (What Is the Joint Commission & Why Does Accreditation Matter, 2019). In order to accomplish their goals, the Joint Commission develops comprehensive performance standards for health care organizations and programs, including quality of patient care, adherence to medication safety standards, infection control procedures and patient rights (Follow-Up Appointment – Requirement | Advanced DSC – Inpatient Diabetes | Delivering or Facilitating Clinical Care DSDF, 2016). 

My project will incorporate this safety regulation by highlighting the importance of sterile procedure when inserting insulin syringes or cleaning equipment related to this matter. Especially when checking someone’s sugar with equipment at my facility, it is important to clean the glucometer with wipes after handling bodily fluids of another. In my project this will be highlighted to promote safety for patients and the team working with equipment at the facility. Although this is an extreme importance for NYU Langone’s facility, it is also important for patients to take care of the materials they use when at home to check their blood sugar. This includes how to clean home glucometers and how to discard needles and other sharps used. 

References

Follow-up Appointment – Requirement | Advanced DSC – Inpatient Diabetes | Delivering or Facilitating Clinical Care DSDF. (2016, April 11). The Joint Commission. Retrieved February 13, 2024, from https://www.jointcommission.org/standards/standard-faqs/advanced-dsc—inpatient-diabetes/delivering-or-facilitating-clinical-care-dsdf/000001806/

What is the Joint Commission & Why Does Accreditation Matter. (2019, July 18). Turning Point of Tampa. Retrieved February 13, 2024, from https://www.tpoftampa.com/what-is-the-joint-commission-and-why-does-accreditation-matter/