HLTH5633 Module 2 improvement aim and target paper example

From 71 to 95 Percent by June 30: Setting a Target and a Date for Critical Result Acknowledgment

Student Name

American College of Education

HLTH5633: Advanced Quality Management for Healthcare Administrators

Module 2 Assignment

Instructor Name

July 10, 2028

Defining What Is Measured

The event analysis in the previous module found that a critical potassium result at a composite 260-bed community hospital was telephoned to a unit, taken by a secretary and not seen by anyone who could act for more than two hours. Its root causes were a notification process that accepted any listener and the absence of an electronic alert. Before setting any target, the improvement team defined the measure precisely. A critical result is acknowledged when the licensed nurse or physician responsible for the patient documents receipt in the electronic record, either by answering the laboratory's direct call and entering the read-back or by acknowledging the electronic alert. The interval is measured from the time the result is final in the laboratory system to the time of acknowledgment.

The definition matters because the hospital already reported a critical result measure: the proportion of critical results called by the laboratory within 15 minutes, which was 98 percent. That measure described the laboratory's side of the process, which national data suggest is rarely the slow step, since the median laboratory in a large multi-institution study notified someone within about five minutes once testing was complete (Valenstein et al., 2008). A measure that stops at the phone call will always look good; the new measure follows the result all the way to a caregiver with the authority to respond.

The Baseline

The team measured the new definition retrospectively for the three months before the event, using laboratory timestamps and electronic record documentation for the hospital's six medical-surgical units. There were 612 critical results. Of these, 435, or 71 percent, reached documented acknowledgment by the patient's own nurse or physician inside 30 minutes. The median time to acknowledgment was 22 minutes, and 55 results, 9 percent, took longer than 60 minutes. By month, the proportion within 30 minutes was 68, 73 and 72 percent. By shift, it was 79 percent on days, 70 percent on evenings and 61 percent on nights, with the lowest performance in the hour around each shift change.

The baseline confirms that the event was not an isolated failure. Nearly one in ten critical results waited more than an hour for a responsible caregiver to see it, and the pattern by shift matches the conditions identified in the event analysis.

Choosing the Target

The team considered three targets. A target of 85 percent within 30 minutes would be achievable with modest effort, but it would still leave about 30 results a month on these units reaching the responsible caregiver late, and it would not require the process redesign the event analysis recommended. A target of 100 percent would be ideal in principle but would treat every rare exception, such as a result acknowledged at 31 minutes during a rapid response elsewhere on the unit, as failure, which tends to produce gaming of documentation rather than better care. A target of 95 percent within 30 minutes, with no more than 1 percent exceeding 60 minutes, requires the stronger actions from the event analysis, direct calls to the assigned nurse with escalation and an electronic alert for the most dangerous values, and is still attainable.

Langley et al. (2009) describe a good improvement aim as time-specific and measurable, with a numerical goal that is ambitious enough to require changes to the system rather than more effort within it. The 95 percent target meets that test: the baseline of 71 percent cannot become 95 percent through reminders. Accreditation standards expect hospitals to report critical results on a timely basis and leave the definition of timely to each organization (The Joint Commission, 2024), which means the hospital is choosing its own standard and should choose one it would defend after an event like the one that started this work.

Choosing the Date

The date depends on how long the changes take to implement. The direct-call process requires unit-issued mobile phones and a nurse assignment feed from the staffing system to the laboratory, which the information systems team estimates at four months. The electronic alert for the most dangerous values requires configuration and testing, about three months, run in parallel. Allowing two months for training and stabilization after both are in place, and three months of data to confirm the result, the team set June 30 of the following year, eleven months from the start, as the date by which the target must be met. An interim milestone of 85 percent by the end of February gives the team an early signal of whether the changes are working.

Knowing When the Target Is Met

With about 200 critical results a month on these units, the monthly proportion will vary by chance even if the underlying process does not change. At 95 percent, the expected random variation from month to month is roughly plus or minus three percentage points, so a single month at 95 percent could reflect a process running at 92 percent. The team therefore defined success as three consecutive months at or above 95 percent, displayed on a control chart that distinguishes common cause variation from real change. Provost and Murray (2011) describe how control charts help improvement teams avoid reacting to random variation and recognize genuine shifts in performance, which is exactly the distinction a target needs. A target reached once is a data point; a target held for three months is a result.

Who Owns the Target

A target without an owner drifts. The team assigned the aim jointly to the director of medical-surgical nursing and the laboratory director, because the process crosses both departments and neither can meet the target alone. Each unit manager owns the result for their unit and will see a unit-level control chart every month. The hospitalist medical director owns the physician side of acknowledgment, particularly at night when escalation calls reach hospitalists. The patient safety committee will review progress monthly until the target has been sustained, then quarterly.

Ownership also shapes how misses are handled. When a critical result exceeds 60 minutes, the unit manager reviews the case within a week to find out where it stalled, not to assign blame but to see whether the new process has a gap. The first cases reviewed after implementation are expected to reveal problems the design did not anticipate, such as nurses on break with their phones handed off, and those findings will feed directly into adjustments before the February milestone.

The Aim Statement

The final aim reads: By June 30, 95 percent of critical laboratory results on the six medical-surgical units will be acknowledged by the responsible licensed nurse or physician within 30 minutes of result finalization, with no more than 1 percent taking longer than 60 minutes, sustained for three consecutive months, from a baseline of 71 percent within 30 minutes and 9 percent over 60 minutes. That sentence contains the measure, the population, the target, the tail limit, the date, the sustainment rule and the baseline, and it can be quoted to anyone who asks what the team is trying to achieve.

References

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.

Provost, L. P., & Murray, S. K. (2011). The health care data guide: Learning from data for improvement. Jossey-Bass.

The Joint Commission. (2024). National patient safety goals: Hospital program. The Joint Commission.

Valenstein, P. N., Wagar, E. A., Stankovic, A. K., Walsh, M. K., & Schneider, F. (2008). Notification of critical results: A College of American Pathologists Q-Probes study of 121 institutions. Archives of Pathology & Laboratory Medicine, 132(12), 1862-1867. https://doi.org/10.5858/132.12.1862