Name Class Professor Gaps Occur in Various

Name Class Professor Gaps occur in various situations. They can be in lesson plans or healthcare. When it comes to the MICU, practice gaps happen. To implement a quality improvement proposal one needs to see what works and how to use it to meet the needs of the proposal. Early Progressive Mobility in a Medical Intensive Care Unit has shown to be helpful in meeting the medical goals of patients. In this proposal, evidence as well as strategies will show how important it is for patients to gain mobility early on in recovery and the problems these kinds of programs face. The MICU or ICU is for patients who are very ill. When in the ICU, it's been demonstrated patients acquire weakness from the acute onset of neuromuscular/functional impairment caused by unknown factors other than their critically ill condition. This weakness impairs ventialtor wearing and functional mobility. (AACN PEARL, n.d., p. 20) The weakness although acute in the beginning, continues after release in 60% of patients. " In addition to weakness, other factors in the critical care environment such as sleep deprivation, lack of social interaction, nutritional state, sedation, and an ICU culture that promotes bed rest contribute further to functional decline." (Perme, 2009, p. 212-221) Some even experience continued muscle disyfunction for as long as up to one year after their illness. "Considerable published evidence indicates that patients in intensive care units have high morbidity and mortality, high costs of care, and a marked decline in functional status. " (Perme, 2009, p. 212-221) To combat this issue, early mobilty must be implemented. Evidence-based information proves early physical and occupational therapy shows decrease in hospital LOS up to three days as well as reduced delirium incidences and best of all, kncrease return to independent functioning. Most who adopt early mobility protocols use active or passive range of motion, then progress to sitting position, then sitting towards edge of bed, standing, and as the patient gets stronger, transferring and walking. Patients who should participate in Early Mobility protocols are all mechanically ventilated patients as well as anyone who wishes to. "Health care professionals who work in ICUs face complex challenges in caring for critically ill patients, many of whom receive mechanical ventilation for prolonged periods. " (Perme, 2009, p. 212-221) Overall this kind of program benefits all patients who have participated. Patients must be screened and assessed in order to participate. "The Early Mobility Protocol consists of a two-step process that starts with a safety screen and moves to the mobility protocol for those who pass. " (European Society of Intensive Care Medicine., 2011, p. 65) Ultimately the goal of this program is to get patients moving, not necessarily to walk, although that is the ultimate goal. A lot of the issues in attempting to implement such a program is the lack of availiability of physical therapists to treat the patients. Physical therapy is in high demand in several areas of the hospital. (Duarte, 2012, p. 181) To acquire physical therapists for the MICU from a limited pool proves difficult. If more people train to become physical therapists, availability would increase along with treated patients. There is a need for physical therapy, especially from patients getting mechanical ventiliation. ("A framework for diagnosing and classifying int... [Crit Care Med. 2009] - PubMed - NCBI", n.d., p. 2) A key part of the program is the evaluation by the physical therapist in order to set mobility goals and focus on individual functional capability. A plan of care for mobility is a crucial step to get things started. A long with the need for physical therapists, is the need for physicians and nurses to work together with the physical therapist to develop a treatment plan. Patients have varying medical issues and mobility may be harder for some than others. Here is a plan from a hospital proven to have positive results from the Early Mobility Program: "This early mobility and walking program has been used by one of us (C.P.) at the Methodist Hospital, Houston, Texas, since 1996. No scientific data have been reported, but the program has been well accepted by patients, physicians, physical therapists, nurses, and family members. We think that early mobility in the ICU can lead to the following positive outcomes: Minimizing complications of bed rest Promoting improved function for patients Promoting weaning from ventilatory support as a patient's overall strength and endurance improve Reducing length of hospital stay Reducing overall hospital cost Improving patients' quality of life" (Perme, 2009, p. 212-221) Early mobility is crucial in improving the overall health of the patient and reducing the costs of healthcare in Intensive Care Units. If some funding is allocated to hiring and training more physical therapists, the costs of patients in the ICU as a whole will be reduced. Seeing things from a different perspective offers ways for people to understand how to solve a problem. To allow for others to see the benefits of early mobility, one must generate a global aim statement to promote awareness of the need for personnel and communication to create a successful program.

"Global Aim Statement" We aim to improve Early Progressive Mobility in a Medical Intensive Care Unit in various hosptial settings. The process begins with screening and evaluating critically ill patients with multiple medical problems on life-support or receiving various medications. Examples of this would be: Such noticeably unstable cardiovascular status, sedation, paralysis, burns, comatose state, and severe orthopedic or neurological deficits. These patients are more susceptible to losing mobility long term and require immediate intervention. The goal is identify them and when they reach stable condition, begin proggreive movement therapy. Supine based therapeutic are emphasized, especially during Phase 1 of the program. The goals for this phase are for patients to gain the ability to turn side to side and unsupported sitting.The goal for out-of-bed activities is to improve orthostatic tolerance such as standing and sitting. Later on in Phase 2 patients will learn to walk with the assistance of a walker to a chair and then across a larger distance.If a patient is too critical, just developing better orthostatic tolerance is preferred. The application of consistent verbal cues for sequencing allows for greater patient' participation. Phase 3 includes patients able to walk with a walker or with assistance. Here the aim is to increase walking distance and develop muscle endurance. Clinicians who mobilize patients need to be aware of how much assistance is required, as well as hemodynamic responses to activity, and ventilatory and oxygen requirements. Evaluation containing this information is important when developing treatment options and safety mesaures. Communication between the team of heathcare personnel is a must to determine adequate ventilatory and/or oxygen support so patients can withstand increased activity. Phase 4 are for patients no longer in need of ventilatory support and/or have been transferred out of the ICU. Patients in this phase still have weakness and limitations but can participate more in therapy. Supplemental oxygen is provided via a tracheostomy collar or through a nasal cannula if the tracheostomy is closed. For independence to be achieved after hospital discharge, patients undergoing therapy in this phase must be trained to perform functional actions. By working on this process we expect to decrease overall healthcare costs. We also expect increased mobility in patients in the program. Patients will have less symptoms than when not in the program. And most importantly, the recovery time for patients will be shortened. "When mobility is a corecomponent of care, it can enhance key outcomes for patients, improving gas exchange, reducing rates of VAP, shortening the duration of mechanical ventilation, and enhancing long-term functional ability" (Vollman, n.d., p. s3-s16) It is important we work on this now because people are suffering needlessly. A simple movement regime could better the lives of thousands of patients. This program allows for better communication between healthcare personnel which in places like the ICU could save lives. Finally, it will allow for higher patient satisfaction. "Progressive mobility is the term used to describe the graded application of the following positioning and mobility techniques: elevation of the head of the bed, manual turning, passive and active range-of-motion exercises, continuous lateral rotation therapy (CLRT) and prone positioning (if criteria met), movement against gravity, upright/leg-down position (tilt table and bed egress), chair position, dangling, and ambulation."(Vollman, n.d., p. s3-s16) "Often, they are left in a stationary position for a prolonged period and establish a "gravitational equilibrium" over time, making it more difficult to adapt to a position change." (Vollman, n.d., p. s3-s16) In terms of the issue on a microsystem level, first one is to look at what a microsystem improvement framework is and how it can be utilized to continually improve unit perforances as well as enhance comprehension of quality improvement methods. A micro-system as defined in a healthcare setting: "is a small group of people who work together on a regular basis to provide care to discrete subpopulation of patients. It has clinical and business aims, linked processes, shared information environment and produces performance outcomes. They evolve over time and are embedded in larger organizations." (Garber, Gross, & Slonim, 2010, p. 36) For a macro-organization to work, building blocks such as these micro-systems are developed. If issues present in micro-systems, such as the team assembled in the Early Progressive Mobility program, the program overall will not function properly. Communication and evaluation performed by the micro-system, delivers the results necessary for the macro-system to succeed. Below is a picture demonstating a general micro-system in action. "A change towards a higher level of group performance is frequently short-lived, after a "shot in the arm", group life soon returns to the previous level. This indicates that it does not suffice to define the objective of planned change in group performance as the reaching of a different level. Permanency of the new level, or permanency for a desired period, should be included in the objective. (MacKenzie & American Group Psychotherapy Association., 1992, p. 72-76)

The picture explains the beginning of the system: people with healthcare needs. The process involves Orientation, plan of care, and care management, ending with: people with healthcare needs met and then feedback fueling the cycle. When there is a problem with the micro-system, for instance, lack of feedback from patients, the team involved in the program will not know if the patient is progressing or worsening. Progress between patient and medical team involves constant evaluationand communication. Even if the patient is unable to give feedback, the medical team must frequently monitor and evaluate the patient for progress. The clinical question that must be addressed and is a problem in the microsystem of the Early Progressive Mobility Program is if patient safety and quality care is met. Feedback as mentioned before is an important process of a micro-system. Quality care enables patients to give positive feedback. Positive feedback thusly incurs more funding for programs such as these, a continued level of success, and more people becoming involved in a successful program. The diagnosis connects with the IOMS Quality Aims (patient safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability) by allowing for quality care and patient satisfaction and focus to take center stage. A lot of what the IOMS Quality Aims entails is what is necessary to improve the problem presented in the micro-system. It is all about feedback and how well people with healthcare needs are met. One of the best things IOMS offers is the concept of patient treatment customization. ("Team-Administered Protocol Encourages Mobility in Respiratory Intensive Care Unit Patients, Leading to Shorter Length of Stay | AHRQ Innovations Exchange", n.d., p. 84) Patients come in all shapes and sizes. Each patient presents a unique combination of problems and should be addressed in a unique way allowing for the patient to be the source of control and making transparency necessary. The more information is shared by the medical team and the patient, the more priority the patient will put on recovery and the better the outcome overall. Another important facet is decreasing waste. Continually decreasing waste promotes focus on important things such as observation and patient to healthcare worker relationship. If someone is wasting supplies on an unnecessary procedure because he/she does not know what the treatment is, that is harmful to the flow of the micro-system. The diagnosis connects specifically to patient safety. (Needham & Korupolu, n.d., p. 99) Patient safety in an ICU is of the highest priority. All the other aims work great in supporting an efficient micro-system, but if the safety of the patient is jeopardized, the patient's life could be lost. These patients are under critical care. Some cannot move, others are close to dying. Patient safety is the first and foremost thing to consider whenever attempting continuation of a micro-system. Safety is the primary and fundamental cornerstone of the health care system. If care is not provided in a safe manner in a safe environment, the success rate decreases and the percentage of a good outcome occurring is lessened greatly. 2. Treat the microsytem: In order for one to treat problems arising in a microsystem, one has to discuss ways of how a problem can be solved. Ways to to do this are the PDSA cycle. Below is a picture demonstrating the cycle in action.

For people to fully understand and develop methods of prolem-solving, there must be a discussion to discover where the problem lies and how it affects the microsystem. The problem for the Early Progressive Mobility Program is patient safety. To use the model in relation to the PDSA cycle, the medical staff must ask what can be done to increase patient safety while mobilizing them. What can be done to evaluate more efficiently their need or lack there of for safety protocols? Who will monitor the patient regularly? Where will the patient be in a matter of days? Will they be transferred to another part of the hospital? ICU patients move sometimes within days from ICU and get treated by different medical staff. When will their plan of care be implemented? All these questions must be asked so the answers get researched and implemented. When the plan forms and gets carried out, then an analysis determines whether or not the next cycle needs a change of action. It is often difficult and timely to pursue this kind of problem-solving, but the rewards far outweigh the efforts. Patients and medical staff receive the latest information and become familiar with the process. A specific aim statement helps generate the focus to then formulate new plans to implement in the PDSA cycle. Without a clear and concise aim, attention will remain diverted. For any progress to be made within a microsystem, goals must be established and communicated to everyone involved. This will generate continual and progressive success.

"Specific Aim Statement"

Early Progressive Mobility in a Medical Intensive Care Unit will redesign and re-evaluate its care delivery model for our critically ill patients. We will accomplish this through recognition that changes are necessary to improve care. Showing commitment to our patients' health and safety is priority. We seek to address this through the Kotter's Change Theory and the Lewin's Change Model. Both these models address problems within the current system while also prioritizing changes to establish a consistent flow of improvement. We expect our process procedures to show improvement within 3 months (by July 2013) and outcome procedures to show improvement within six months (by October 2013).Any improvement made will be marked by monitoring the following measures within our target group: 70% with two HgbA1c three months apart annually 70% with HgbA1c

Kotter's Change Theory in dealign and managing change is: "The fundamental purpose of management is to keep the current system functioning. The fundamental purpose of leadership is to produce useful change." (Kotter, 2012, p. 120) In his book:Leading Change, he identifies and covers the sequential change process for organizational change. The basics of this model state with any change made to the system or organization, there must be focus placed on people. People are not machines and need to have their limits addressed and understood before planning or implementing change. Patients especially must be communicated with to know their limits and their capabilties. John Kotter identified specific problems encountered when applying change within the organization and came up with an 8 step change process in sequential order. The first step in the theory is to establish a sense of urgency. People need to believe change is imperative in order to be convinced to participate. If the change seems urgent and crucial in success of the program, more people will be willing to cooperate. One way to do this is to identify the cost and consequences if the unit does not take action. Another way Kotter discusses is gathering support from people outside of the unit or organization. Second Step in Kotter Theory is to form a powerful guiding coalition. Teamwork is essential for any task. Without the support and expertise from other people, plans fail. The third step in Kotter Theory is to create a change vision. Uniting everyone with a strategy and vision allows for a sharper focus. Only accepting the best ideas that will produce good results are encouraged. Ways to attain a clear vision are to get concise on the organizational values and create a one or two sentence summary that clarifies the future of the organization after the changes are implemented. Step four: Communicate the Vision entails involving as many people as possible and communicating the foundation of the change. Keping things simple and short are best. Step five: Empower Others to Act on the Vision is where the execution of the change vision starts. This is where to take a long term perspective to identify processes or systems in place that are getting in the way of the change vision. This step is mainly about acquiring feedback from as many people involved as possible. The sixth step: Plan for and Create Short-Term wins. This step is used to motivate the team. Success as Kotter explains, breeds more success. Momentum early on enables small changes which lead to bigger changes within the organization. Ways to do this are to evaluate the pros and cons for each of the targets and reward people for their effots. The seventh step: Consolidate Improvements and Produce More Change. True lasting change doesn't happen overnight, and requires persistence and patience. Setting solid targets and continual building of momentum aids in this. The final step, the eigth step is: Make Change Stick. Maintaining continuous effort to reinforce the changes are indeed working help build confidence in the changes made. To achieve this one can promote people who support the change and recruit new people. Kotter also identified the 8 associating pitfalls that can prevent a change process. Not Establishing a Great Enough Sense of Urgency Not Creating a Powerful Enough Guiding Coalition Lacking a Vision Under communicating the Vision by a Factor of Ten Not Removing Obstacles to the New Vision Not Systematically Planning for and Creating Short-Term Wins Declaring Victory too soon Not Anchoring Changes in the Corporation's Culture (Kotter, 2012, p. 126)

Kurt Lewin, another person who developed a theory of change, proposed a three stage theory of change commonly referred to as Unfreeze, Change, Freeze (or Refreeze). Although some might consider it outdated, the Kurt Lewin model is still very relevant and can be used inconjunction with other methods. In fact, a lot of modern change models are based on the Kurt Lewin model. This model can be done simply or intricate, depending on the organization's need. The first stage is the Unfreezing stage. It is considered one of the more important stages to understand in order to know what change is. This stage is about preparing for change. It involves getting to a point of understanding that a change must be made. It allows for someone to get out of their comfort zone to realize the what it takes to make a change. An example of this is a nearing deadline. The sense of urgency, as discussed in Kotter's theory propels the need for change. The Force Field Analysis or the factoring in of the pros and cons is a way to determine whether or not the change is wanted and if the risks outweigh the reward. The second stage is: Change or Transition. Lewin states change is a process and named it a transition. "Transition is the inner movement or journey we make in reaction to a change." Lewin explains the second stage is the hardest because people are at their most fearful and resistant. Patience and understanding is key in this step because it takes a while for others to learn about the new changes and accept them. Support is key here and will help others to join. Allowing others input in the process and using role models helps people keep sight of where they are going. In the final stage, Kurt Lewin refers to this stage as freezing. This stage is about establishing stability once the changes have been made. The changes are implemented and become the new norm. People take time to form a routine within this change and develop connections. This step, although critiqued by others, can be adapted to fit a desired change. The biggest changes take the longest times to stabilize.