NUR 409 Module 3 Performance Gap Activity Example

Performance Gap Activity: Time-Critical First Doses After Emergency Department Transfer on 5 East

[Student Name]

Southern New Hampshire University

NUR 409: Strategies for Quality Improvement in Healthcare

Module Three Performance Gap Activity

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Performance Gap Activity: Time-Critical First Doses After Emergency Department Transfer on 5 East

A performance gap is the distance between what a unit is doing and what it should be doing, measured the same way at both ends. This activity measures that distance for the lead process measure defined in Module 2: the share of first time-critical doses that arrive on time, meaning inside a half-hour window, after patients move from the emergency department to 5 East, a composite medical unit. The audit shows a gap of 24 percentage points, and nearly two thirds of the late doses trace to two causes that the unit and its partners can change: missing last-dose times at handoff and medications not yet available when the dose is due. All data in this activity are composite figures.

Current State

Over eight weeks, the unit's quality champion reviewed every patient admitted from the emergency department who had at least one designated time-critical medication ordered, following the hospital's list built from national guidance (Institute for Safe Medication Practices, 2011). The audit identified 120 first doses due on the unit. Of these, 85 reached the patient no more than half an hour from the time set by the downstairs dose, a rate of 71%. Among the 35 late doses, the median delay was 95 minutes, and 9 were more than three hours late. Two doses were duplicated, given on the unit after already being given downstairs, which the balancing measure captured. Performance was lower for patients who arrived on the night shift (63%) than for daytime arrivals (78%).

Desired State

The desired state is that at least 95% of first time-critical doses after transfer are given within 30 minutes of their due time, with no duplicated doses. The 95% target follows the national guidance's half-hour window for this class of drugs, while allowing for rare situations, such as a patient off the unit for imaging, in which a short delay is unavoidable and documented. The desired state also includes a process feature: every transfer handoff records the time of the last dose of each time-critical medication.

Sizing the Gap

The gap is 24 percentage points. In practical terms, at the audit's volume of about 15 eligible first doses a week, reaching 95% would mean roughly 3 or 4 fewer late doses every week, or about 180 fewer late time-critical doses a year on one unit. Measured in time, the 35 late doses in the audit represented more than 60 hours of cumulative delay. The gap is larger at night, which suggests that any solution must work when staffing, pharmacy coverage and senior support are thinnest.

Causes of the Gap

The quality champion reviewed each late dose and asked the nurses involved what happened. Table 1 groups the 35 late doses by primary cause.

Table 1

Primary Causes of Late First Time-Critical Doses After Transfer, 8-Week Audit

Note. Composite data. Each late dose was assigned one primary cause after chart review and a brief interview with the nurse involved.

Which Causes the Unit Can Change

The two leading causes account for 66% of late doses, and both are system issues rather than individual failings. Missing last-dose times reflect a handoff that does not require them. Structured handoff programs can reduce errors. When nine children's hospitals introduced a standardized handoff program for resident physicians, the error rate per 100 admissions went from 24.5 before the program to 18.8 after it, and preventable adverse events went from 4.7 to 3.3 (Starmer et al., 2014). That study involved physician handoffs, not nurse-to-nurse transfers, but it supports adding required elements to the transfer handoff. Medication availability depends on pharmacy verification and cabinet stocking, which the unit cannot fix alone but can raise with pharmacy. The third cause, arrival during the medication pass, is a workload issue that a better handoff alone will not solve; it may need a rule that the receiving charge nurse assigns any time-critical dose due within an hour of arrival to a nurse who is free. The fourth cause, schedules restarted at unit times, is a pharmacy and order-entry issue.

What the Audit Cannot Show

The audit has limits the team should keep in mind. Eight weeks is a short window, and 120 doses is a modest sample, so the night-shift difference could narrow or widen with more data. Assigning one primary cause to each late dose simplifies events that often had several contributing factors; a missing last-dose time and a busy medication pass may both have played a part in the same delay. Interviews took place days after some events, when memories were less precise. Finally, the audit relied on documented administration times, which may not match the moment a dose was actually given. None of these limits changes the size of the gap enough to alter the priorities, but they are a reason to keep measuring weekly rather than treating this snapshot as the final word.

The audit also points to stakeholders who must be part of any fix: the emergency department nurses who give report, the pharmacists who verify orders and stock cabinets, the charge nurses who assign admissions and the unit nurses who receive them.

Aim Statement

Improvement science recommends a clear aim that states what will improve, by how much and by when, before any change is tested (Langley et al., 2009). The aim for 5 East is: within six months, raise the on-time rate for first time-critical doses after emergency department transfer from 71% to 95%, with no duplicated doses, including for patients who arrive at night. The team will pursue this aim through changes to the handoff, medication availability and receiving-nurse assignment, tested one at a time.

Conclusion

5 East gives about seven in ten first time-critical doses on time after transfer, well short of the 95% target. The gap is larger at night, and two system causes, missing last-dose times at handoff and unavailable medications, explain two thirds of it. With the gap sized and its causes ranked, the next step is a closer look at a single delayed dose through root cause analysis in Project One, to understand how these causes combine in a real event.

References

Institute for Safe Medication Practices. (2011). ISMP acute care guidelines for timely administration of scheduled medications. https://www.ismp.org/sites/default/files/attachments/2018-02/tasm.pdf

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., . . . Landrigan, C. P. (2014). Changes in medical errors after implementation of a handoff program. The New England Journal of Medicine, 371(19), 1803-1812. https://doi.org/10.1056/NEJMsa1405556