DNP- Patient Outcomes and Sustainable Change

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I need help responding to the attached 3 posts in 200 words each. Please provide references for each 

PEER RESPONSES FOR Patient Outcomes and Sustainable Change

Assessment Description

Reflecting on the “IHI Module QI 202: Addressing Small Problems to Build Safer, More Reliable Systems,” describe how your direct practice improvement project achieves clinical improvement. How will you achieve widespread change? How would the widespread change of your DPI Project be affected if it were implemented in a country with universal health care. Describe how the health outcome would be impacted. Provide supporting evidence.

Shabnampreet Kaur

The IHI module QI 202:  Addressing Small Problems to Build Safer, More Reliable Systems, reflects on the presence of small problems in healthcare systems and how to overcome these small problems to build safer systems. Steve Spear used various examples to make the readers understand the concept of small loopholes and workarounds which distract the employees resulting in mistakes and sometimes these mistakes become catastrophes(Institute for Healthcare Improvement, 2022b). Also, he suggested ways to address them and make healthcare safer. My DPI project which is fall prevention among older adults achieves clinical improvement by building stronger techniques for addressing the reasons and suggesting ways to improve strength, gait, and balance using tai chi as the intervention. Currently, at the practice site, there is only a shift-to-shift report as the standard criteria for fall reporting. Many times people forget to bring to the provider’s notice that they experience a fall in the past 3 months. And sometimes if falls are reported, the shift duty nurses forget to enter them into the EHR system. Also, there is currently no special protocol for fall screening. Screening and assessment can help providers know about the population prone to falling and then they can work towards achieving the aim of fall prevention by devising various patient-centered interventions, My DPI project will streamline the process of screening all the older adults above the age of 65 years with CDC STEADI Stay Independent questionnaire (Centers for Disease Control and Prevention.,2020). Those screened at risk will undergo assessment for fall risk factors using a Timed up and go, 30-second chair rise and balance test, with identification of medicines as per Beers criteria, measurement of orthostatic blood pressure, and asking about potential home hazards. Those having poor balance gait and strength will be enrolled in a 12-week tai chi exercise program as the intervention. In order to achieve widespread change, teamwork and collaboration are needed at the levels of the project. Potential sources of mistakes will be addressed in the first place, the commonest of all being linking the fall risk assessment to the patient’s e-chart. If my DPI project were implemented in a country with universal healthcare, the widespread change of the project will be affected in multiple ways. Universal healthcare coverage means all people have full access to healthcare services whenever and wherever they need them. Although in terms of accessibility and affordability, it is easier for the patients to receive the care, it can affect the quality of care(Zieff et al., 2020). Due to the long wait times in the universal healthcare system, people would not be able to get screened for their fall risk factors and receive appropriate referrals on time which will deteriorate their condition and increase fragility. With government rationing of medical services like controlled distribution of services, price setting, budgeting, etc people will have to wait for a longer time to get receive tailored interventions for fall prevention based on their risk factors. For example, based on the risk factor evaluation, the patient has poor gait and balance, and he is referred to an evidence-based exercise program like tai chi or physical therapy, but due to higher demand for these services, they are not able to get these interventions in a timely manner leading to poorer health outcomes. Therefore the overall health outcomes will be impacted evidenced by the increased number of falls and fallers, higher hospitalization rate, and mortality rate followed by economic burden. 

Centers for Disease Control and Prevention. (2020, October 16). STEADI – Older Adult Fall Prevention.

Institute for Healthcare Improvement. (2022b, August).
QI 202: Addressing small problems to build safer, more reliable systems.

Zieff, G., Kerr, Z. Y., Moore, J. B., & Stoner, L. (2020). Universal Healthcare in the United States of America: A Healthy Debate.
56(11), 580.

Bonnie Flores

This week’s IHI Module 202 provided excellent examples of how little issues can arise and create larger problems. A good example was when there were many people who kept stepping over the tripping hazard rather than fixing it or alerting others to its existence. My direct practice improvement (DPI) project will focus on the implementation of the Society of Critical Care Medicine’s Intensive Care Unit (ICU) Liberation Bundle for mechanically ventilated patients. There are many issues that critically ill patients face when intubated. For example, delirium rates increase, patients become deconditioned, length of stay increases, and mortality rates increase (DeMellow et al., 2020). There are other conditions that my bundle does not address including ventilator-associated pneumonia (VAP) and hospital-acquired pressure injuries (HAPI); therefore, I will not discuss these issues.

My DPI includes coordinating breathing trials with sedation reduction, increasing exercise and mobility, increasing family engagement, pain assessment and prevention, and delirium assessment and prevention (Society of Critical Care Medicine, 2020). When the full bundle is implemented patient outcomes improve, thus leading to decreases in delirium rates, decreased days on the ventilator, and decreased length of stay, all of which can contribute to decreased mortality and increased quality of life (DeMellow et al., 2020). In my current organization, there are pieces of the bundle in place, but the full bundle is not currently being utilized. I am looking forward to implementing this project so that I can start this project in my ICU to improve the health and outcomes of my patients, realize change, and then spread the change to other ICUs within the Southern California region. This is a very real possibility since my organization utilizes unit-based teams where tests of change and quality improvement projects are highly valued to improve the quality of care and reduce cost. If my facility sees an improvement, then other facilities within the healthcare organization will adopt the project; thus, leading to wider spread throughout the state and nation.

Were this project to be implemented in a country with national health coverage, then there may be the same challenges that we face in the United States. For example, the greatest challenge will be to get buy-in from nurses who are already working at maximum capacity. Since nurses are in short supply across the globe, asking any nurse to do extra may prove to be difficult. A benefit of this project is that it has great potential to reduce costs by focusing on harm prevention. In a country with universal health coverage, preventive care is a priority (Zieff et al., 2020). When patients are given equitable access to healthcare and preventive healthcare then, then the overall health of the population increases, thus lowering hospitalizations and the need for the invasive treatment that will be utilized in my DPI project (Zieff et al., 2020).


DeMellow, J. M., Kim, T. Y., Romano, P. S., Drake, C. & Balas, M. C. (2020). Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design.
Intensive & Critical Care Nursing, 60.

Society of Critical Care Medicine. (2020). ICU Liberation.
Society of Critical Care Medicine. Retrieved on May 17, 2022, from

Zieff, G., Kerr, Z. Y., Moore, J. B., & Stoner, L. (2020). Universal healthcare in the United States of America: A healthy debate. 
56(11), 580.

Misty Walton

The “IHI Module QI 202: Addressing Small Problems to Build Safer, More Reliable Systems,” highlighted eight steps for systems to take to support quality and safety, how to support the teams and how to support the patients and families. Each of these three highlighted sections in the module demonstrate a systems approach across the continuum of care to improve patient quality and safety. My direct practice improvement project will achieve clinical improvements in geriatric orthopedic patients’ pain management through listening to music as an intervention. A reduction in self-reported pain with a non-pharmacological intervention that is nurse driven and reduces pain also decreases anxiety (Schneider, 2018). In Scheider’s (2018) study one hundred percent of participants reported that they would recommend listening to music as a pain reduction intervention and numeric reported pain scores decreased from 5.53 to 3.97 post the listening to music for twenty minutes. Elective orthopedic surgery patients struggle with pain management which may impact their recovery, sleep, ability to participate in therapy and mobility (Sampognaro & Harrell, 2021). The Joint Commission and other regulatory agencies have called for a reduction of opiate usage across the country facing the opiate epidemic. Multimodal post operative pain control methods add non-pharmacological methods to help to reduce pain (Sampognaro & Harrell, 2021). Widespread change will be achieved in alignment with the eight recommendations noted in the IHI Module 202 focusing on creating safe care across the continuum. Non-pharmacological modalities should be introduced and integrated at doctors’ offices and clinics. Prescriptions and education may be provided prior to surgery. Patients should be encouraged to make a playlist of music and record pain prior to listening and after which may be continued in follow-up visits and other areas of their health. Success demonstrated from the pilot of the DPI on an orthopedic floor will help demonstrate to all the stakeholders the impact and importance for buy in to spread.  

Access to healthcare and early interventions is key to reducing pain and chronic pain in geriatric patients. A universal healthcare system would allow access to non-pharmacological modalities (NPM) for treatment of pain and education on those modalities across the continuum of care. Veteran Affairs facilities have more success with a usage of NPM 49.9 percent of the time for pain management versus 39.8 percent have begun to share their studies and learning from cross sectional studies (Mannes et al., 2022). This shift is a culture change that begins with access to care for all and educating doctors in doctors’ offices and clinics on benefits of modalities such as listening to music on pain. There are numerous studies examining the impact on surgical populations of all ages and throughout the process from pre-operative visits to home care. Small and Laylock (2020) report that more than twenty five percent of post operative patients report severe pain, and this number of reporting has not changed overtime recommending adding modalities to support pain management and improve overall patient outcomes.  


Mannes, Z. L., Stohl, M., Fink, D. S., Olfson, M., Keyes, K. M., Martins, S. S., … & Hasin, D. S. (2022). Non-pharmacological treatment for chronic pain in US veterans treated within the veterans health administration: Implications for expansion in US healthcare systems. 
Journal of General Internal Medicine, 1-10. 

Sampognaro, G., & Harrell, R. (2021). Multimodal Postoperative Pain Control After Orthopedic Surgery. n: StatPearls. StatPearls Publishing, Treasure Island (FL); 2022. PMID: 34283438. 

Schneider M. A. (2018). The effect of listening to music on postoperative pain in adult orthopedic patients. 
Journal of holistic nursing: Official journal of the American Holistic Nurses’ Association
36(1), 23–32. 

Small, C., & Laycock, H. (2020). Acute postoperative pain management. 
Journal of British Surgery
107(2), e70-e80.

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