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How the patient, family, or population problem impacts the quality of care, patient safety
Explain how the patient, family, or population problem impacts the quality of care, patient safety, and costs to the system and individual.
Cite evidence that supports the stated impact. Note whether the supporting evidence is consistent with what you see in your nursing practice. Explain how state board nursing practice standards and/or organizational or governmental policies can affect the problem's impact on the quality of care, patient safety, and costs to the system and individual. Describe research that has tested the effectiveness of these standards and/or policies in addressing care quality, patient safety, and costs to the system and individual. Explain how these standards and/or policies will guide your actions in addressing care quality, patient safety, and costs to the system and individual. Describe the effects of local, state, and federal policies or legislation on your nursing scope of practice, within the context of care quality, patient safety, and cost to the system and individual. Propose strategies to improve the quality of care, enhance patient safety, and reduce costs to the system and individual. Discuss research on the effectiveness of these strategies in addressing care quality, patient safety, and costs to the system and individual. Identify relevant and available sources of benchmark data on care quality, patient safety, and costs to the system and individual. The patient problem is obesity.
Sample Answer
Supporting Evidence and Nursing Practice Consistency
Evidence: A study published in the Obesity journal found that healthcare costs for individuals with obesity are significantly higher across all categories (inpatient, outpatient, pharmacy) compared to non-obese individuals, confirming the cost burden. Furthermore, the Agency for Healthcare Research and Quality (AHRQ) consistently lists VTE and SSIs as safety issues exacerbated by obesity.
Consistency with Nursing Practice: This evidence is highly consistent with my nursing practice. We frequently encounter:
Safety Issues: Struggling to find appropriately sized blood pressure cuffs, requiring two or three staff members and specialized lifts for transfers (increasing staff injury risk), and delayed wound healing due to poor perfusion in surgical incisions.
Cost/Quality Issues: The need to wait for a bariatric bed or CT scanner with weight limits, which delays care and increases LOS. Staff frequently use sub-optimal equipment, compromising the standard of care.
Policy Effects on Care
State Board Nursing Practice Standards and Organizational/Governmental Policies
State board nursing practice standards and facility policies directly affect the problem's impact by setting mandatory levels of competence, equipment, and protocols.
Requires mandatory staff training on bariatric lifts, safe patient handling, and skin-care protocols. It mandates the availability of specialized bariatric equipment (beds, wheelchairs, commodes). Effect: Directly improves patient safety by reducing staff injuries, falls, and pressure ulcers, which in turn reduces costly HACs.
Research on Safe Patient Handling and Mobility (SPHM) programs has shown that implementing mandated SPHM policies and equipment in hospitals can significantly reduce patient falls and pressure injury rates in bariatric patients while also decreasing staff musculoskeletal injuries, thus reducing system costs (American Journal of Nursing).
State Board Standards (Competency)
Defines the registered nurse's responsibility to provide safe, competent care for all populations, implicitly including required knowledge of pharmacokinetics (drug distribution) in obese patients and proper assessment techniques. Effect: Aims to improve quality of care by reducing medication errors and diagnostic oversight caused by inaccurate assessments.
Research often focuses on nursing education. Studies show that integrating bariatric-specific content into nursing curricula and continuing education is associated with increased nurse confidence and improved adherence to evidence-based guidelines, a proxy for improved care quality.
Governmental Policy (CMS)
The Centers for Medicare & Medicaid Services (CMS) refusal to reimburse hospitals for certain Hospital-Acquired Conditions (HACs), such as VTE, pressure ulcers, and certain SSIs. Effect: Reduces system cost by shifting the financial burden of poor patient safety to the hospital, creating a powerful financial incentive to implement bariatric safety protocols.
Multiple studies following the implementation of the CMS HAC Reduction Program (since 2008) have demonstrated a significant decline in the incidence of targeted HACs nationally, suggesting that financial penalties drive improvements in safety-related care quality (The New England Journal of Medicine).
Guidance for Nursing Actions
These standards and policies are the foundation of my actions:
Patient Safety: I will strictly adhere to organizational SPHM policies, always utilizing bariatric equipment and engaging an appropriate number of staff for mobility tasks to prevent falls and back injuries.
Care Quality: I will consult pharmacists and use bariatric-specific dosing guidelines to prevent medication errors, rather than relying on standard weight calculations, to ensure optimal drug efficacy and safety.
Cost Mitigation: By preventing HACs (e.g., rigorous skin checks and repositioning every 2 hours as per protocol), I directly reduce the financial penalty the hospital would otherwise incur, translating clinical quality into cost reduction.
Policy and Legislative Effects on Scope of Practice
Local, state, and federal policies govern what nurses can do, which affects all three impact areas.
Policy/Legislation
Impact on Scope & Care
State Full Practice Authority (FPA) Legislation for NPs
Scope: Broadens the scope of Nurse Practitioners (NPs) to diagnose, treat, and prescribe independently without physician oversight.
Effect on Care/Cost: In areas with FPA, NPs can manage chronic obesity-related conditions (diabetes, hypertension) and prescribe obesity medications (e.g., GLP-1 agonists) in primary care settings. This increases access to quality care, particularly in rural areas, and reduces system costs by utilizing lower-cost NP services instead of higher-cost specialist/physician visits.
Federal HIPAA and Confidentiality Laws
Scope: Requires strict adherence to patient privacy regarding diagnoses.
Effect on Safety/Quality: While protecting patient rights, the need for caution when discussing weight issues in open settings (e.g., patient hallways) affects care quality by restricting impromptu education opportunities and ensuring documentation is secure. Patient safety is protected by ensuring stigmatizing information isn't shared.
Organizational/State Policy on RN-Initiated Protocols
Scope: Allows RNs to independently initiate certain protocols (e.g., VTE prophylaxis, glucose checks, fall risk assessments) without a direct physician order.
Effect on Safety/Cost: Allows for the immediate application of evidence-based care to high-risk obese patients. This is a direct tool to enhance patient safety and reduce costs by preventing complications like VTE and critical hypoglycemia.
Proposed Strategies and Effectiveness Research
Strategies to Improve Care Quality, Safety, and Reduce Costs
Use a mandatory, standardized handoff checklist that requires specific communication about the patient's weight, mobility status, necessary equipment, and specific medication dosing rationale (e.g., "Enoxaparin dosed at 1.5 mg/kg per pharmacy consult").
Research on standardized handoff communication (e.g., using SBAR or similar formats) has shown it reduces communication failures, which are a leading cause of patient harm. Specifically, customizing SBAR for high-risk populations decreases adverse events and improves information transfer (The Joint Commission Journal on Quality and Patient Safety).
Establish or partner with nurse-led, community-based clinics focused on intensive lifestyle intervention, nutritional counseling, and medication management for individuals with obesity.
Studies on community-based, multidisciplinary weight management programs have demonstrated long-term weight loss and a reduction in risk factors for comorbidities (like A1C and blood pressure). This reduces future inpatient utilization and chronic disease costs, offering a strong return on investment (Diabetes Care).
Automated Clinical Decision Support (CDS) for Dosing (Safety/Quality)
Implement electronic health record (EHR) alerts that fire when a non-standard weight-based medication (like certain antibiotics or anticoagulants) is ordered for a patient with a BMI over 35, requiring the prescriber to confirm a bariatric-specific dose or consult pharmacy.
Research on CDS systems has consistently shown they reduce medication errors. Specifically, CDS systems for weight-based dosing have been proven to increase adherence to correct dosing protocols for high-risk drugs in obese patients, significantly enhancing patient safety (Journal of the American Medical Informatics Association).
Relevant and Available Sources of Benchmark Data
To measure the success of these strategies, benchmark data is essential:
Care Quality & Patient Safety:
National Database of Nursing Quality Indicators (NDNQI): Provides facility-level data on pressure ulcer prevalence, patient fall rates, and nurse-sensitive indicators, allowing comparison against national and regional peer hospitals.
CMS Hospital Compare Data: Includes public data on Hospital-Acquired Conditions (HAC) rates (e.g., VTE, SSIs) and patient experience measures (HCAHPS), which are highly sensitive to bariatric care quality.
Costs to the System and Individual:
Internal Hospital Financial/Utilization Data: Length of Stay (LOS) for bariatric vs. non-bariatric patients, cost-per-case data, and readmission rates (especially for cardiac or surgical issues).
The Medical Expenditure Panel Survey (MEPS): A public, nationally representative survey that provides detailed data on the healthcare utilization and costs of individuals in the US, allowing for high-level cost comparisons across BMI categories.