Advanced Nursing Practice Field Experience With HIV

Advanced Nursing Practice Field Experience

Lolita Knight

Proposal Form

Please refer to separate submission in Taskstream

CHSI is committed to providing the best quality medical care possible for its population of underserved patients. This summary addresses my proposal for the Advanced Nursing

Practice Field experience. One new policy recommended by the Riverside County Health

Department is to include HIV screening and testing with all routine physical exams. The organizational change I am investigating is increasing provider compliance by including HIV

screening and testing with routine physical exams. The population affected by this change will be the underserved population in Riverside County. My change leader is Evelyn Pearson-

Ray MSN, RNP, and Nurse Educator for the organization. My plan for conducting this investigation is to create a team of stakeholders, measure provider compliance of including HIV

screening and testing with routine physical exams, evaluate staff knowledge, provide necessary training, re-evaluate staff's knowledge of HIV screening and testing, evaluate patient population, review current and new policy for HIV screening and testing, implement policy changes, re-

measure as needed, analyze and evaluate results. This paper reviews this initiative and provides an overview of an analytical approach to evaluate its effectiveness.

C. Completion of QIA Form

Please refer to separate document submitted in Taskstream

C1. Summary of Data Collected

HIV screening and testing study time period was July 2013 to July 2014. The goal was to increase HIV screening and testing with routine physical exams. Provider compliance was 65%

in July 2013 and increased to 95% since implementation of policy. Goal met at 95%.

Section I.

This section of the Quality Improvement Activity (QIA) form addresses selection and methodology. The reason this project was important to my organization is because

HIV screening and testing will increase patient education, testing, and treatment of HIV by identifying status and prevention of complications and transmission. The quantifiable measure for this study was to increase the number of patients screened and tested for HIV during routine physical exams. No benchmark was used in this project. This study was established by recommendation of the riverside county health department. The baseline goal of this study was an organizational goal of 95% by increasing provider compliance to test and screen for HIV

during routine physical exams. Data sources included were patient medical records. Data was collected from 20 patient charts every quarter totaling 100/year. Random sampling technique was used for this study.

Section II.

Section two of the form describes the actual data collected and results. An initial baseline rate of

65% provider compliance in the first quarter of July 2013. The first measure of provider compliance was at the rate of 75% in October 2013, with an improvement of 10% from the baseline. Re-measurement 2 was at 85%, with an increase of 10% from the previous quarter. Re-measurement 3 was at 90% provider compliance, with a 5% increase from the last quarter. The last quarter of re-measurement 4 was at 95% Goal met, improvement by 5% from last quarter and overall improvement by 30%. No further re- measurement required.

Section III.

Section three addresses the analysis cycle of the project. The analysis took place over one calendar year July 2013 to July 2014 and covers one quantifiable measure. In comparison to the initial measurement of 65%, rates continued to improve over the next reported period showing quarterly until the goal was met at 95%; with an overall improvement by 30

percent. No changes to goals implemented in this study. No national benchmarks for this study.

The overall trend of the post data implementation did not require re-measurement due to provider compliance goals having been met. Each quarter's results were compared to previous measurements to determine if progress towards the objective achievement were made.

Section IV.

This section of the QIA form addresses the interventions that were implemented to influence change. The interventions that had the most impact on this change project were building the team including the clinic administrator, nurse educator, nurse manager, and nurse practitioner to review, revise, and approve policies and procedures and implementation of staff training for HIV

screening and testing. The interventions addressed the barriers of personnel lacking adequate training in HIV medicine.

C1a. Data Collection Methods Used:

As previously described in the summary and complete QIA form, data sources for this intervention included medical records of patients that received routine physical exams at the clinic.

C1b. Appropriateness

The data collection methods were appropriate because Retrospective analysis of clinical data is often found in the patient's medical record; however, this method of data collection can be inappropriate for this change project because medical records are intended for patient care and the data are not systematically recorded for research purposes. The baseline data supported the need for change due being below the baseline goal by 30%. This revealed the importance of provider compliance in implementation of the organizational change and goals.

C2. Improvement of Data Collection Measures

Data was obtained from the patient medical record or using the Medical/treatment record abstraction. The advantages of using data obtained from the medical record via surveying record review consist of the capability to get big quantities of clinical data. The development of a data collection tool started with the investigator's assessment of whether the essential data are obtainable in the patient medical record. This assessment is most often based on preceding experience and in cooperation with clinical staff, preferably nurses, who authenticate most often in the medical record. The researchers produced a structured data abstraction tool in order to obtain data from the medical records of the tested patients for the index hospital stay, which includes treatment at two facilities if the patient was transferred during the acute stay. The data collection tool was founded lightly on an instrument utilized from an earlier AMI study called the Cooperative Cardiovascular Project (CCP)

The numerator data often are the first finding that leads to a belief that there is an epidemic. The numerator is the amount of persons aged 13 years and older at HIV diagnosis, who were diagnosed from 2013-2014, and with a stated CD4 or HIV viral load (VL) total inside 3 months of their original HIV analysis. The denominator for this proportion are those in 2013-2014 population aged 13 years and older gotten from the records that reflect the Total Population, of White/Not Hispanic or Latino, Black or African-American/Not Hispanic or Latino, Hispanic or Latino). What criteria are looked at?

Criteria for selecting Stakeholders

Blood is regularly collected from clients.

A reliable laboratory for being able to process the specimens and transport them to the laboratory that will be piloting HIV testing.

The location is available to surveillance staff.

On-site team associates are eager to collaborate and are trained to do the surveys.

The site offers services to a sufficiently big number of clients.

On-site HIV testing and counseling services or referral to such services should be obtainable to clients contained within in the survey

The sample size was random but included the volume of patients identified as having routine physical exams compared to the total volume of patients checked into the clinic. The Quality risk management team decided that 20 random charts per quarter (100/yr) were sufficient to allow us to assess the deficiencies (if any) and make room for improvements.

The data collection used will be surveys. Surveys are commonly utilized with key stakeholders, particularly customers and workers, to discover needs or measure satisfaction. The sample size is appropriate for this study because it is necessary to produce results among variables that are meaningfully different.

The data collection measures could have been improved by using standardized chart review forms to ensure that data collection is consistent. Techniques used in data collection and analysis could have been improved. The expertise of the team consisted of a quality risk management team that included the clinic administrator, nurse manager, nurse educator, and a nurse practitioner. Barriers to the organizational change included the lack of knowledge within the practice of HIV medicine, screening and testing. Our organization needed to identify, implement, and learn the policies and procedures for the organizational change.

The data collection used was

D1. Evaluation

The effectiveness of the change project in this setting was evaluated by looking at the effects on the organization, evaluating the success of the stakeholders in their roles and determining ways to improve the project. Positive effects of HIV screening and testing during routine physical exams made patients aware of their risk and if necessary changes of lifestyle to decrease those factors and prevent infection. The team reviewed the progress achieved in implementing the action plan for HIV screening and testing. Evidence that the change was successful by reviewing documentation of HIV screening, the order of test, and test results recorded in patient records. To continue to maintain the affected change and control HIV,

the staff and stakeholders will need to share responsibility for HIV control at the community level from the affected patient population. No further testing required due to meeting baseline goal. The organizational change was successful meeting goals at 95% provider compliance.

Baseline

Baseline information then can be used to define management goals and plans for the stakeholders involved with the HIV screening. In the case of formerly treated patients who present for an original evaluation with a new health care provider, it is serious to get a whole antiretroviral (ARV) history (as well as drug resistance testing results, if accessible), if possible through the review of historical medical records. Freshly diagnosed patients ought to also be asked about any previous use of ARV agents for stoppage of HIV infection.

D1a. Implementation effects

Implementation of this project affected the organization and quality care outcomes by strengthening the collaboration between HIV testing, screening, and primary health services in providing more comprehensive care, prevention and control of HIV at a community level. This project will help the organization meet its goals by maintaining implemented improvement of the organizational change. Some unintended or unplanned effects included obstacles which were encountered in implementation of the change. The change optimized methods of HIV prevention and improved healthcare by educating patient on risk factors. The stakeholders and the intended population had positive outcomes due the change by increasing awareness and decreasing the transmission of HIV. The effects on culture of safety were by promoting safe sex and the importance enabling HIV to be detected during routine medical exams.

D2. Stakeholder Roles

The stakeholders of this project were the clinic administrator, nurse manager, nurse educator, medical providers, and the medical director. The stakeholders were successful in their roles because they assisted with reviewing the progress made in implementing the action plans,

analyzed obstacles and agreed on further action if necessary to battle HIV in the community.

When came to leadership, the stakeholders were effective. This is because they were able to keep the communication lines opened. The stakeholders were able to communicate effectively in terms of relating their vision. Components of each of their roles were required in mixed degrees to successfully manage the communication challenges of different situations. For example, being able to adapt to the different cultures of the patients and even being empathetic to their backgrounds. The stakeholders as leaders were able to understand that these roles and were able to determine the degree of attention that the current communication program demanded from each role.

One thing that I felt could have been better was to have more impact, more careful communication planning and management, and clearness and stability of messages. These were key factors the stakeholders missed. Awkwardly, many communication efforts were focused only on the delivery of a message, and they neglected the vital preparation and management of the procedure.

D3. Improvement

The change project could have been improved by using qualified trainers that may have been working for the organization or hire outside experts. Techniques and data utilized in the analysis could have included using chart review forms. The focus of the study was too broad. The study needed to include an additional number of patients to identify and analyze the high risk population. Also, the study needed to identify or include additional stakeholders because more expertise was required in the IT department to include mastery of specific software applications to improve EMR documentation.