Case Analysis: 30-Year Old in the Nursing Home

Based on the information presented in the case study, prepare a PowerPoint presentation. You will analyze a complex case using concepts and skills related to quality improvement, patient safety, and other disciplines relevant to system-level improvement. You will develop a specific plan to improve the “gap” in the system of care, including defining key measures and proposing changes, as part of an inter-professional team, and anticipate likely challenges to planned improvements.

You will include content on: process map and ideal process map, root causes, rules for the system, improving part of the system and measures, change and test plan, and leadership challenges and solutions. Please use the evaluation tool entitled PowerPoint Peer Evaluation Form; you will complete an evaluation on each of your colleagues’ presentations. A minimum of 6 slides is required, not including reference pages. Your colleagues will comment on the presentation and ask questions to clarify the content. This presentation is worth 20 points towards your final grade.

Case Analysis: A 30-year old in the Nursing Home http://www.ihi.org/education/ihiopenschool/resources/Pages/Activities/AdvancedCaseStudy2010.aspx 

Use the following outline to complete an in-depth case analysis. 

1. Overall Process Map For Carla’s care in this case study, draw a picture or a diagram of the overall care process. Flowcharts and stick figures both work very well. Show the major steps in her story.

2. What contributed to this adverse event? From the overall care process map, create a list of things that went wrong in the care experienced by Carla and her providers. These do not need to be in any particular order. Group these problems and errors into sensible categories. Examples include “communication breakdown” and “equipment failure.” Use the “ask why five times” method and/or a fishbone diagram to organize your thinking. (To learn about fishbone diagrams, see PS 104: Root Cause and Systems Analysis.)

3. Create Rules for the System Read “Redesigning Health Care with Insights from the Science of Complex Adaptive Systems.” To download this free article, go to the Institute of Medicine’s Crossing the Quality Chasm page. Select PDF BOOK – Free; click Download Report. You will be asked to establish an account with National Academies Press. Enter your information and click “Continue.” You’ll be directed back to the original Crossing the Quality Chasm page. Select “PDF Chapters.” Click “Appendix B: Redesigning Health Care with Insights from the Science of Complex Adaptive Systems.” Open or save article. Based on this article, create one or more simple rules that might guide the development and evolution of Carla’s ideal health care system.

4. The Ideal Process Map Based on the rule(s) you just developed, draw a picture or a diagram of the ideal overall care process for Carla. Feel free to use diagrams or a process map here rather than text.

5. Improving Part of the System Identify at least one process in Carla’s case that, if improved, could have moved Carla’s care closer to the ideal. For each of the processes you identify, create an aim statement for improvement. A good aim statement specifies “how good, by when, for whom.”

6. How would you know the changes made a difference? Suggest measures that could be used to Track the progress of your improvement effort (process measures) Assess the impact of improvement on the targeted population (outcome measures) Monitor the costs associated with improvement (balancing measures)

7. What changes will you make? What changes in the current system of care would you recommend testing? (i.e., are there small-scale, incremental changes that would be beneficial? Are there new care processes that need to be designed and implemented?)

8. Plan Your Tests Provide a plan to test the changes you have proposed. What questions do you hope to answer with this test, and what do you predict the answers are? What changes will be tested? How will the changes be tested (consider small scale early)? Who will run the test? Where and when will the test take place? What information is important to collect? Why is it important? Who will collect the data? Who will analyze the data prior to study? Where will data be kept? When will the collection of data take place? How will the data (measures or observations) be collected?

9. What challenges might leadership face? What obstacles might the organization’s leaders need to overcome in order to implement your suggested changes? How could you help leaders overcome these challenges?