Group Management for Just Culture Discussion

The concept of a fair and just culture refers to the way an organization handles safety issues. Humans are fallible; they make mistakes. In a just culture, ‘hazardous’ human behavior such as staff errors, near–misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems—not to identify and punish the individual.
—Pepe & Caltado, 2011

This Discussion examines the opportunities of managers in working with groups to promote change that facilitates the delivery of safe, high–quality care.

To Prepare

• Review the information on just culture presented in the Learning Resources.
• For this discussion, you will use the Regulatory Decision Pathway found in Russell, K. A. & Radtke, B. K. (2014).
• Examine an adverse event at the unit level in your organization or one with which you are familiar and apply the Regulatory Decision Pathway.
• Compare the findings of the Regulatory Decision Pathway  to what actually happened at the unit in your organization. Was the event deemed: bad intent, reckless, at risk, or human error? According to the pathway, do you now think it was the correct action?
• Think about how a nurse leader–manager may use just culture as a framework to create or maintain a focus on accountability and outcomes throughout a group. What actions could be taken if a systems–related error was made or if an error resulted from risky behavior? Group Management for Just Culture Discussion

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• How might role conflict and/or ambiguity have contributed to the situation?

Post a description of an adverse event in your organization and your analysis of the issue using the Regulatory Decision Pathway. Explain how role conflict or ambiguity might have influenced this situation. Apply the principles of just culture as you explain how you, as the group’s manager, would handle the situation.

Read a selection of your colleagues’ responses.

Respond to at least two of your colleagues on two different days using one or more of the following approaches:

• Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
• Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
• Validate an idea with your own experience and additional research.
• Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

Reference
Pepe, J., & Cataldo, P. J. (2011). Manage risk, build a just culture. Health Progress. Retrieved from http://www.outcome–eng.com/wp–content/uploads/2012/01/manage–risk.pdf
Russell, K. A. & Radtke, B. K. (2014). An evidence–based tool for regulatory decision–making: regulatory decision pathway. Journal of Nursing Regulation, 5(2), 5–9.

Marquis & Huston, Leadership roles and management functions in nursing, 2015 Group Management for Just Culture Discussion

Change Management Plan Outline

In this NRP/508 Change Management Plan Outline assignment you will select a health policy issue that is of national concern. The general criteria for the health policy issue you select is the following: The policy is having a negative impact upon health care or the policy is missing components and this exclusion produces negative consequences in health care. The policy is one that has a national scope and so can be affected by federal policy or by changes to federal policy. For example, conservative lawmakers are trying to defund Planned Parenthood because they offer abortion services to those who want or need them. But abortion services only make up 3% of the services provided by Planned Parenthood. The other 97% is providing contraception to help prevent unintended pregnancies (approximately 579,000 in a single year), providing more than 270,000 Pap tests and more than 360,000 breast exams in a single year (critical services for cancer detection), providing more than 4.2 million tests and treatments for STDs (including 650,000 HIV tests), providing educational programs and outreach to 1.5 million people a year, and providing affordable general medical care and counselling services to its clients NRP/508 Change Management Plan Outline. In this case, if the health policy that defunds Planned Parenthood were to pass, what is missing from the policy is addressing how the other 97% of the services they offer will be provided for. The health policy issue would be the consequences to defunding Planned Parenthood and the ramifications it will have as a result of eliminating all services.

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Review Box 7-3 Example of Policy Decision Brief and Box 7-4 Example of a One-Page “Leave-Behind” Summary of a Nursing Policy Issue located on p. 68 in Ch. 7 of Policy & Politics for additional examples of health policy issues NRP/508 Change Management Plan Outline.

 

Utilize this Change Management Plan Outline as a guide for developing your Change Management Plan. Incorporate the work you completed in previous weeks into your final plan.

 

Research a health policy issue that is of national concern that you will use as the subject for a change management plan.

 

Develop a 1,050- to 1,400-word Change Management Plan using John Kotter’s eight-step change model from Week 3.

 

Include the following in your plan;

 

• What current health policy issue exist that are of national concern that affect the NP?
• What evidence is there to support the need to address the policy? Does the evidence indicate a sense of urgency regarding the issue?
• How is the policy issue represented in the media and what type of influence does this have on you implementing change in this area?
• What are the ethical consequences if changes aren’t implemented?
• Identify stakeholders that will assist you in implementing the change, including opportunities for interprofessional relationships.
• Develop a plan for how and where you see the policy issue making an impact.
• Identify potential barriers that will hinder you from implementing change in this area and how you will face them to keep the change process progressing NRP/508 Change Management Plan Outline.
• Create a strategy that will gain the support of your congressional representative or of one your senators and drive them to introduce legislation that will address the policy issue.
• How can you use Kurt Lewin’s change management model to solidify change in this area?

 

Cite and reference using APA guidelines.

Change Management Plan Outline
Kotter’s Eight-Step Change Model	Questions to Ask	Weekly Individual Assignment
Step 1: Establish a sense of urgency.   ·         Develop a problem statement.	·         What current health policy issue exists that is of national concern? ·         What evidence-based practice exists that shows this policy is an issue? ·         What evidence supports the reason for the change? ·         What are the consequences if changes are not implemented?	Establishing a Sense of Urgency (Week 2) NRP/508 Change Management Plan Outline
Step 2: Create a guiding coalition.	·         Identify stakeholders that will assist you in implementing the change. ·         Who is directly impacted by the health policy? ·         What are the roles of each party involved in the change management plan? ·         Identify how each party will help implement change in the policy issue?	Professional Organization Evaluation (Week 3) NRP/508 Change Management Plan Outline
Step 3: Develop a vision and strategy.	·         Develop a plan for how and where you see the policy issue making an impact.	Policy Issue Presentation (Week 5)
Step 4: Communicate the change vision.	·         Create a strategy for how you will communicate this change to your legislative representative. ·         How will the passing of this bill improve health care?	Petition Letter (Week 6)
Step 5: Empower broad-based action.	·         Identify potential barriers that will hinder you from implementing change in this area and barriers that could keep the bill from becoming a law. ·         How will you face these barriers to keep the change process moving? ·         What is your strategy for removing the barriers?	Bill Proposal (Week 6)
Step 6: Generate short-term wins.	·         Identify short organizational improvements that relate to the change effort. ·         Do you need to reallocate resources to support the work effort? ·         How will you communicate progression with stakeholders? NRP/508 Change Management Plan Outline	Continuous Quality Improvement Plan (Week 8)
Step 7: Consolidate gains to produce more change.	·         Identify and emphasize early successes to help propel the bill to future success. ·         Establish specifically defined milestones to help gage the bill’s progress. ·         Identify and evaluate setbacks early on to formulate strategies to avoid possible setbacks in the future. ·         Evaluate the short-term wins from Step 6 to remove unnecessary processes and resources. ·         Maximize the value of the short-term wins from Step 6 to increase the bill’s momentum and persuade the stakeholders to increase their commitment to ensuring that the bill be made law.
Step 8: Anchor change in organizational culture. NRP/508 Change Management Plan Outline	·         How can you use Kurt Lewin’s change management model to solidify change in this area to ensure that people do not go back to the old way of thinking after change has been implemented?

NRP/508 Change Management Plan Outline

 

NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population

Individuals that identify within the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) population have been shown to be at a greater risk for increased health disparities (WPATH, 2019).  About 3.5% Americans identify themselves as lesbian, gay, or bisexual while 0.3% identify themselves as transgender (Hafeez, Zeshan, Tahir, Jahan, & Naveed, 2017). The LGBT community consists of almost every race, ethnicity, religion, age, and socioeconomic group in the United States (Hafeez et al., 2017).  The purpose of this paper is to research the effectiveness of specialized training regarding the LGBT population of patients.  By approaching this topic with a way to reduce discrimination will also assist in decreasing health disparities in the LGBT population within the healthcare settings.

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The Spirit of Inquiry Ignited

The topic of LBGT in the healthcare setting has transpired over the years and has become more prevalent than ever today.  Discrimination among this population is often felt at various places and within the healthcare arena (Martos, Wilson, & Meyer, 2017).  The LGB population report that 56% of them experience discrimination while 73% of the transgender patients felt like they face discrimination in the health care setting (Hanneman, 2014).  Evidence-based practice (EBP) has shown that with the implementation of specialized education and special training for employees and clinicians regarding the LGBT population, these interventions can be successful at decreasing feelings of discrimination and increasing healthcare delivery.  NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population. With the use of EBP and a team approach, such an implementation of specialized training can be successfully implemented and done for all clinical and non-clinical employees that communicate or come in contact with any LGBT patient within the healthcare setting.NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population

The PICOT Question Formulated

PICOT:  In the LGBT population of patients (P), would specialized training designed towards this population (I) as compared to traditional diversity training (C) decrease the rate of discrimination for this population in the healthcare arena (O)? NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population.

Search Strategy Conducted

South University Library was accessed with the objective of finding supportive data for the PICOT.  Databases accessed within SU Library included the Cochrane Database of Systematic Reviews, CINAHL, JAMA, and PubMed.  Articles showed that EBP data was found to support the PICOT.  Both level I and II studies were found when searching the studies and researching the process.  The key terms used were LGBTQ, LGBT, healthcare discrimination, and LGBT competent.

Critical Appraisal of the Evidence Performed

An evaluation table was used to evaluate validity, reliability, and applicability to practice (See Appendix). The table analyzed five different studies by population, comparison, outcomes, and time frames. The evidence from each of the studies suggests that this is a change that needs to be implemented in the health care setting and high-level reviews also show this.  One study implied and revealed that knowledge gaps about the LBGT population within the healthcare arena is very prevalent (Butler, Schwer, Burgess, Call, Przedworski, Rosser, Larson, Allen, Fu, & Kane, 2017).  Specialized competency training that focuses on the LGBT population can definitely aid providers to understand the need to inquire about the patients’ gender identity and sexual orientation (Kenya, Lebron, & Carrasquillo, 2017).  The LGBT patient population are at an increased rate for health disparities and feelings of discrimination (Kenya et al., 2017).  Another study revealed that interventions are being taken into consideration regarding this population in healthcare arenas everywhere to help decrease both the feelings of discrimination as well as the health disparities that are prevalent (Lunn, Wanjun,  Zack, Thompson, Blank, & Yehia, 2017). NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population.

A positive impact of implementing LGBT specialized healthcare training versus traditional cultural and diversity training has been shown to improve the ability of health care professionals to provide more effective healthcare to this patient population thus reducing disparities and feelings of discrimination (Kenya et al., 2017).  These specialized competencies that are being offered have been found to provide a significant benefit to the provider as well as making the patient feel more comfortable (Shetty, Lancaster, Wilson, Quinn, & Schabath, 2016).  The specialized training also was shown to promote providers and other employees in the health care setting to understand the need to inquire about the patients’ gender identity and sexual orientation thus making them feel more comfortable (Kenya et al., 2017).  When the LGBT patients were surveyed about their experience after the implementation of this specialized training, it revealed they rated they care they received an overall score of 9/10 in the 105 LGBT participants with 10 being the most excellent service possible (Shetty et al., 2016).  It is a step by step process to get such interventions implemented  but studies have shown it is well worth it in order to prove the best quality care possible for this population within health care (Kenya et al., 2017).

Evidence Integrated with Clinical Expertise & Patient Preferences to Inform a Decision & Practice Change Implemented

The plan for this project is based on the EBP researched.  There is various evidence of research as well as clinical expertise on this subject that will have a positive impact on this patient population and reducing overall feelings of discrimination within the healthcare setting.  Specialized competency training will be done for all employees; both clinical and non-clinical that communicate and come in contact with these patients.  It is important to provide the specialized training competencies and other programs that are live, online and done annually at competencies (Margolies, Joo, & McDavid, 2012).  This training will be mandatory for all employees.  The practice change will be implemented utilizing a team approach using the IOWA Model.  The problem focused triggers is identifying the clinical problem.  Researching internal and external data must be done as well (Brown, 2014).  Process improvement data, and risk management data are all part of the focused triggers. Getting buy in, organizing and planning is all an important part of the implementation to do a Pilot. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population.

New research, clinical guidelines, organization standards and guidelines, philosophies of care, and last but not least questions from Institutional Standards Committees will all be reviewed for the project. Other known knowledge focused triggers should be considered as well.   This topic is a priority for the organization and for the LGBT population of patients to not be discriminated or feel like they are being discriminated against in the health care setting.  A team approach must be formed and relevant research and related literature as well as critique and synthesis research for using in practice has to be conducted.  There has to be enough sufficient research which there is for this topic (Brown, 2014).  All clinical and non-clinical employees and staff will have to attend live face to face specialized training sessions focusing on the care of the LGBT population.  This competency will also become part of the annual competency requirements.  The change will be piloted for 90 days and then data collected and analyzed about how the LGBT patients felt about their visits. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population.

 

Outcome Evaluated

The evaluation plan includes four important steps that must be implemented and followed in order to have a successful project with successful outcomes.  The first step includes clarifying objectives/goals. This step will help identify which major program components should be evaluated. One way to do this is to make a table or chart of program components and elements to share with the team.  This will be done in staff meetings as well as email reminders.  Step two includes developing evaluation questions. Evaluation will include the impact on the LGBT population, assessment of objectives, and planning issues. The brief survey questions will be done via an iPad every time a patient within the LGBT population is checking out from their appointment and setting up for next appointment times.   Step three consists of the development of an evaluation method. The evaluation method will be used as a monitoring and feedback system. As aforementioned, the brief survey questions will be done via iPad when the patient is checking out.  The survey will consist of five brief questions inquiring how they perceived there visit that day.  This data will be accessible weekly and improvements will be made along the way based on the feedback received.  The final step will be to analyze and tally the information to determine what improvements need to be implemented into the new program. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population. he final step (step four) is the development of a timeline of evaluation activities. This step should begin in the beginning of any project. The evaluation needs to be planned and thought about upfront. To get a concise idea of what the staff and employees will be doing and how well it is being done, it is important to always try to pay attention to the evaluation from the very start. The pilot project will be planned and evaluated for success.  When any needed changes, problems, or  improvements are needed; these will be added when appropriate. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population

Project Dissemination

The step by step approach of this project dissemination uses the IOWA Model.  The Iowa Model was selected for this project because clinicians find it intuitively understandable and it has been used in numerous academic settings and healthcare institutions (Brown, 2014).  The results and data from the surveys will be disseminated and shared among clinicians and staff members.  If changes or improvements are needed, it will be implemented.  As the results are disseminated, ways to consistently improve this will be added and carried out.  Once the pilot has been in place and outcomes to be achieved are selected, analysis of the data has to be done to see what the overall outcome is.   Baseline data has to be collected prior to the implementation.  The process and outcomes are evaluated after a Pilot is done.  Modification of the practice guideline is done as needed.  Other evidence to use is case reports, expert opinions, scientific principles, and theory (Melnyk et al., 2014).  The project will be presented to the Clinical Practice Manager, Physicians, Nurse Practitioners, the Interdisciplinary team, the Education department, and both Congress and Legislation that are involved in the support of the LGBT population.  Last but not least, this will be presented to the LGBT patients involved.  Once approved, using EBP guidelines the project will be fully implemented in the facility/organization.

Once the change is implemented into practice, there must be proper monitoring and analyzing of the process and outcomes.  The outcome reveals that the overall specific training that is mandatory has an effect on the attitudes and care provided for this patient from the clinician and all other employees perspective. The overall LGBT patient felt as if they were not discriminated against, rated the care they received as better, and were more compliant.  The goal is for the patient in the LGBT population to feel more comfortable with clinicians, less discrimination, and have a better overall experience since all of the employees and staff will  have already had the specialized training for caring and approaching the LGBT population.  New knowledge and evaluation of quality care should continuously be evaluated (Brown, 2014). NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population

Conclusion

EBP has shown that this change is very much appropriate for adoption and implementation into practice. Pushing for the best well-being for the LGBT patients is important (Rice & Schabath, 2018).  When they have feelings of non-discrimination, they will seek health care more often and be compliant (Rice et al., 2018).  They will also feel more comfortable and have a trusting relationship with their providers and seek medical attention when needed.  It is important to consistently continue to educate all clinical and non-clinical staff in these settings.  Initiating proper care while at the same time leaving the LGBT patient with feelings of non-discrimination at all times is the goal and outcome (Butler et al, 2019). NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population

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References

Butler, M., Schwer, N., Burgess, D., Call, K., Przedworski, J., Rosser, S., Larson, S., Allen, M., Fu, S., & Kane, R. (2017). Improving Cultural Competence to Reduce Health Disparities. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles

Hafeez, H., Zeshan, Z., Tahir, T., Jahan, and Naveed, S. (2017). Health care disparities among lesbian, gay, bisexual, and transgender youth: A literature review.  Doi: 10.7759/cureus.1184 . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478215/

Hanneman, T. (2014).  Healthcare equality index 2014: Promoting equitable and inclusive care for lesbian, gay, bisexual and transgender patients and their families. Retrieved from Human Rights Campaign Foundation.

Healthy People 2020 (2018). Lesbian, Gay, Bisexual, and Transgender Health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health

Kenya, S., Lebron, C. N., & Carrasquillo, O. (2017). Beyond Sensitivity. LGBT Healthcare Training in U.S. Medical Schools: A Review of the Literature. American Journal of Sexuality Education, 12(2), 148–169. https://doi.org/10.1080/15546128.2017.1298070

Keuroghian, A., Ard, K., & Makadon, H. (2017). Advancing health equity for lesbian, gay, bisexual and transgender (LGBT) people through sexual health education and LGBT-affirming health care environments.  Sex Health, 14(1): pp 119-122.  Doi: 10.1071/SH16145

Lunn, M.R., Wanjun, C., Zack, M., Thompson, W.W, Blank, M., & Yehia, B.R. (2017).

Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators. Doi:10.1089/lgbt.2016.0087

Margolies, L., Joo, R., McDavid, J (2012). Best practices in creating and delivering

LGBTQ cultural competency trainings: for health and social service agencies.

Retrieved from https://cancer-network.org/wp-content/uploads/2017/02/best_practices.pdf

Martos, A. J., Wilson, P. A., & Meyer, I. H. (2017). Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: Origins, evolution, and contemporary landscape. PLoS One, 12 NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population

Rice, D., & Schabath, M. B. (2018). The future of LGBT cancer care: practice and research implications. Seminars in Oncology Nursing, 34(1), 99–115. https://doi.org/10.1016/j.soncn.2017.12.007

Shetty, G., Sanchez, J. A., Lancaster, J. M., Wilson, L. E., Quinn, G. P., & Schabath, M. B. (2016). Oncology healthcare providers’ knowledge, attitudes, and practice behaviors regarding LGBT health. Patient Education and Counseling, 99(10), 1676–1684. Retrieved from South University Library at https://doi.org/10.1016/j.pec.2016.05.004

World Professional Association for Transgender Health [WPATH]. (2019). Guidelines and standards of care. Retrieved from https://wpath.org/    NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population

 

Appendix

I.             Evidence/Evaluation Table

 

SU Library Database, CIAHNL, PubMed	Study #1: Lunn, M.R., Wanjun, C., Zack, M., Thompson, W.W, Blank, M., & Yehia, B.R.   Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators	Study #2: Butler, M., Schwer, N., Burgess, D., Call, K., Przedworski, J., Rosser, S., Larson, S., Allen, M., Fu, S., & Kane, R.   Improving Cultural Competence to Reduce Health Disparities	Study #3: Kenya, S., Lebron, C. N., & Carrasquillo, O.   Beyond Sensitivity. LGBT Healthcare Training in U.S. Medical Schools: A Review of the Literature	Study #4: Shetty, G., Sanchez, J. A., Lancaster, J. M., Wilson, L. E., Quinn, G. P., & Schabath, M. B.   Oncology healthcare providers’ knowledge, attitudes. And practice behaviors regarding LGBT health	Study #5: Martos, A. J., Wilson, P. A., & Meyer, I. H.   Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: Origins, evolution, and contemporary landscape.
(p) Population:	Sexual minority adults	LGBT adolescents (ages 13-17), young adults (ages 18-25) and adults Overall gender disparities experienced by women (in relationship to men) were not considered in this review. Biological sexual development and disorders of sexual development are not part of this review.	The LGBT Population	388 oncology providers at a single institution focused on the LGBT population	The population density of LGBT people was explored NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population
(i) Intervention:	The study aimed to characterize the sociodemographic characteristics of sexual minority (i.e., gay, lesbian, bisexual) adults and compare sexual minority and heterosexual populations on nine Healthy People 2020 leading health indicators (LHIs).	Cultural competence/culturally appropriate care provider education and training Cultural competence/culturally appropriate care clinic-based interventions targeted to patients Cultural competence/culturally appropriate care clinic-based interventions targeted to providers	Training future physicians to address the health needs of the lesbian, gay, bisexual, and transgender (LGBT) population can potentially decrease health disparities faced by such individuals.	This study was conducted and done to assess knowledge, attitudes, and practice behaviors of oncology providers regarding LGBT health.	The intervention focused on the location and types of services provided by “LGBT community health centers” today in relation to the population density of LGBT people
(c) Comparison	Heterosexual adults	Usual care Head-to-head trials of different strategies	As compared to the non-LGBT population	Survey based responses of providers in one institution, (not compared to another institution)	As compared to non-same sex (Non-LGBT) households.
(o) Outcome:	Differences between sexual minorities and heterosexuals suggest the need for targeted health assessments and public health interventions aimed at reducing specific negative health behaviors.	Intermediate outcomes Provider training and motivation outcomes (competencies, knowledge, changes in attitudes). Provider behavior, such as clinical decision making, communication Provider beliefs/cognitions about the priority population, reducing stereotyping, stigmatization Improved access to health services Utilization of health services Patient experience/satisfaction Patient health behaviors Use of preventive services and other access to care measures Final health or patient-centered outcomes – reduced disparities in terms of Patient medical care outcomes Patient mental health care outcomes (depression, substance use) Adverse effects of intervention(s) Unintended negative consequences of intervention	The 13 programs reviewed provided data suggesting a positive impact of LGBT healthcare training.	Providers that receives cultural competency training can understand the need to inquire about the patients’ gender identity and sexual orientation.	LGBT community health centers are concentrated within urban hubs and coastal states and are more likely to be present in areas with a high density of same-sex couples. LGBT community health centers do not operate in 13 states. The most common health services provided are wellness programs, HIV/STI services, and counseling services.
(t) time:	Over one year.	Depends on the purpose of the intervention.	90 days	3 months	6 months

 

 

1. Evidence Synthesis Table

 

Citation   Lunn, M.R., Wanjun, C., Zack, M., Thompson, W.W, Blank, M., & Yehia, B.R. (2017). Sociodemographic Characteristics and Health Outcomes Among Lesbian, Gay, and Bisexual U.S. Adults Using Healthy People 2020 Leading Health Indicators. Doi:10.1089/lgbt.2016.0087	Design   Randomized Clinical Trial	Sample size:   228,893,944 adults with sexual minority adults represented 2.4% of the U.S. population	Major Variables:   Using a nationally representative, cross-sectional survey (National Health Interview Survey 2013–2015) of the civilian, noninstitutionalized population (228,893,944 adults), nine Healthy People 2020LHIs addressing health behaviors and access to care, stratified using a composite variable of sex (female, male) and sexual orientation (gay or lesbian, bisexual, heterosexual), were analyzed individually and in aggregate.	Study findings: Strengths and weaknesses   Factors negatively affects LGBT adults (∼2.4% of the U.S. population); health.   Social determinants of health warrant further investigation and consideration for targeted interventions	Level II Evidence obtained from at least one well designed Randomized Controlled Trail (RCT)	Evidence Synthesis   This study provided evidence that LGBT adults represent ∼2.4% of the U.S. population and experience a number of significant health disparities.
Butler, M., Schwer, N.,NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population Burgess, D., Call, K., Przedworski, J., Rosser, S., Larson, S., Allen, M., Fu, S., & Kane, R. (2017). Improving Cultural Competence to Reduce Health Disparities.	Design   Qualitative Analysis	Sample size: Adequate?   12 studies were included	Major Variables:   Over 37,000 nonduplicated English-language citations were reviewed; 56 unique studies were identified as of June 2015: 20 randomized controlled trials (RCTs) and 5 observational studies for individuals with disabilities; 5 RCTs (6 manuscripts) and 6 observational studies for LGBT populations; and 14 RCTs (15 manuscripts), 4 observational studies, and 2 systematic reviews for members of racial and ethnic minorities. Interventions fell into four broad categories: (1) provider trainings and education; (2) interventions providing alteration of an established protocol, or the delivery of an established protocol, to meet the needs of a target population; (3) interventions prompting patients to interact with the formal health care system or health care providers; and (4) interventions aimed at providing culturally competent care at the point of service.	Study findings: Strengths and weaknesses   The medium or high risk of bias of the included studies, the heterogeneity of populations, and the lack of measurement consensus prohibited pooling estimates or commenting about efficacy in a meaningful or responsible way. The term “cultural competence” is not well defined for the LGBT and disability populations and is often conflated with patient-centered or individualized care. There are many gaps in the literature; many large subpopulations are not represented.	Level of evidence   Level V Evidence from systematic reviews of descriptive and qualitative studies.	Evidence Synthesis   None of the included studies measured the actual effect of cultural competence interventions on health care disparities. Rather, the training interventions measured changes in professional attitudes toward the population of interest.
Kenya, S., Lebron, C. N., & Carrasquill, O. (2017). Beyond Sensitivity. LGBT Healthcare Training in U.S. Medical Schools: A Review of the Literature. American Journal of Sexuality Education, 12(2), 148–169. https://doi.org/10.1080/15546128.2017.1298070 NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population	Design   Comprehensive database analysis w/ at least one RCT	Sample size: Adequate?     A specific number was not included in the sample size. A comprehensive literature search to identify studies on LGBT healthcare training in U.S. medical schools. Studies published between January 2000 and September 2016 that described the program and reported on at least one quantitative evaluative measure were included in our review.  With the found 13 studies meeting our inclusion criteria. The programs had high levels of variability in curricular content, educational strategies used, duration, and evaluation methods.	Major Variables:   Despite wide variability in their training approaches, the 13 programs we reviewed provided data suggesting a positive impact of LGBT healthcare training. NSG 6999 Specialized Training in Health Care Settings Results in Reduced Rates of Perceived Discrimination in the LGBT Patient Population	The programs had high levels of variability in curricular content, educational strategies used, duration, and evaluation methods. Many programs utilized an interactive experience involving a standardized patient. The majority of participants in such programs felt this approach was an effective learning strategy. All programs reported that participants felt the training improved their ability to provide more effective healthcare to LGBT patients.	Level III Evidence obtained from well-designed controlled trials without randomization, quasi-experimental	The 13 programs reviewed provided data suggesting a positive impact of LGBT healthcare training that improved their ability to provide more effective healthcare to LGBT patients.
Shetty, G., Sanchez, J. A., Lancaster, J. M., Wilson, L. E., Quinn, G. P., & Schabath, M. B. (2016). Oncology healthcare providers’ knowledge, attitudes, and practice behaviors regarding LGBT health. Patient Education and Counseling, 99(10), 1676–1684. https://doi.org/10.1016/j.pec.2016.05.004	Design     Observational study	Sample size: Adequate?   Sample size was 388.  The size of the study group was adequate.	Major Variables: This study revealed knowledge gaps about LGBT health risks. Cultural competency training may aid oncology providers to understand the need to inquire about patients’ gender identity and sexual orientation	Study findings: Strengths and weaknesses 108 providers participated in the survey (28% response rate). <50% answered knowledge questions correctly. 94% stated they were comfortable treating this population. 26% actively inquired about a patient’s sexual orientation when taking a history. 36% felt the need for mandatory education on LGBT cultural competency at the institution.	Level IV Evidence from a well-designed case control/cohort studies.	The study was survey based.  With the surveys completed by the providers, intervention for providing competency for the providers did provide a significant benefit for them and the care of the LGBT patients.
Martos, A. J., Wilson, P. A., & Meyer, I. H. (2017). Lesbian, gay, bisexual, and transgender (LGBT) health services in the United States: Origins, evolution, and contemporary landscape. PLoS ONE, 12(7), 1–18. https://doi.org/10.1371/journal.pone.0180544	Design   Comprehensive Data base analysis	Sample size: Adequate?   The population density of LGBT people was explored. An online search of LGBT community health centers was conducted between September-December 2015.	Major Variables:   LGBT community organizations in the United States have been providing health services since at least the 1970s. However, available explanations for the origins of LGBT health services do not sufficiently explain why health in particular has been so closely and consistently linked to LGBT activism. Little is also known regarding how LGBT health services may have evolved over time with the growing scientific understanding of LGBT health needs.	Study findings:   LGBT community health centers are concentrated within urban hubs and coastal states and are more likely to be present in areas with a high density of same-sex couples. LGBT community health centers do not operate in 13 states. The most common health services provided are wellness programs, HIV/STI services, and counseling services.	Level III Evidence obtained from well-designed controlled trials without randomization, quasi-experimental	With the comprehensive data base analysis, it was found that the LGBT community health centers have adapted over time to meet the needs of LGBT people but significant gaps in service remain in the United States, and LGBT community health centers  requires significant transformation going forward in order to continue serving LGBT people.

 

Electronic health records PICOT Evidence Table Worksheet

Abstract

Evidence synthesis is a crucial part of gathering background literature to support a proposal. Medication errors continue to be a problem plaguing healthcare institutions globally, the implementation of electronic health records has been proven to be an alleviating solution for this challenge. Five studies were evaluated in this proposal; the evidence synthesized supported the presented PICOT. The literature provided by the five studies in the synthesis evaluation table proved that electronic management of medications significantly reduces medication errors, and especially prescribing errors. Electronic health records PICOT Evidence Table Worksheet.

 

Evidence Table Worksheet

PICOT Question

In patients admitted to a psychiatric institution that converted from paper charting to electronic health records (P), does the implementation of electronic health records (I) compared to paper charting (C) decrease medication errors (O) within 6 months of its implementation (T). Electronic health records PICOT Evidence Table Worksheet 

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1. Will you have a comparison group or will subjects be their own controls?

The subjects will be their own control; the same group will be evaluated. The institution’s medication error event rate will be compared before electronic health records implementation and 6 months after its implementation

2. Is a ‘time’ appropriate with your question—why or why not? Yes, the time is ideal for my PICOT. The institution under study is plagued with a high rate of medication safety events; it is possible to collect sufficient data within 6 months to evaluate the difference electronic health records made on the rate of medication errors Electronic health records PICOT Evidence Table Worksheet.

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I.      Evidence Synthesis

 

(Database) ex: Cochran	Study #1 Al-Sarawi, Polasek,Caughey,and Shakib (2019)	Study #2 (Vaidotas, Yokota, Negrini, et al., 2019).	Study #3 Loguidice, (2014)	Study #4 (Hodgkinson, Larmour,Lin,et al., 2017)	Study #5 (Priya,Thottumkal, Warrier, et al., 2017)	Synthesis
(p) Population	3 South Australian public hospitals	4 Emergency departments (ED) in Brazil- A total of 327,017 patients were seen during this study	79 residents in a long term care facility in the United States	379 patients in an outpatient clinic in Australia	A quaternary care hospital in India	Multiple sample sizes and institution were evaluated as it relates to electronic health records and medication errors.
(i) Intervention	Implementation of an electronic prescribing system (e-prescribing) to reduce the rate of medication errors	Comparative analysis of medication error rates in the 4 ED: 2 ED had an electronic health records system implemented and the other 2 still used paper charting	Implementation of an integrated electronic health records system and an 8 hour orientation on the correct use of the electronic health records system	Implementation of an integrated electronic medication prescribing and dispensing system Electronic health records PICOT Evidence Table Worksheet	Prescriptions were audited using an electronic prescription auditing tool.	The studies primarily used comparative descriptive analysis to prove the effectiveness of various electronic health records systems in reducing medication error rates. The most compelling evidence was portrayed by Priya et al (2017) that proved the electronic auditing tool prevented an astonishing 140 medication errors out of a possible 226 interventions
(c) Comparison	Comparing the rate of medication errors in the 3 hospitals before and after the implementation of the e-prescribing system	The rate of medication errors were compared between the 2 emergency departments with an electronic health records system implemented and the other 2 without an electronic health records system implemented	Comparing the rate of medication discrepancies per resident before and after electronic health records implementation	Before and after study comparing the rate of medication errors before and after the electronic medication system implementation	226 interventions were compared in a before and after audit for medication errors.	The studies compared a pre and post implementation status of medication error rates before and after an electronic medication system implementation
(o) Outcome	The e-prescribing system decreased medication errors from 67.7 per 100 orders to 2.8 per 100 orders	The 2 emergency departments that had an electronic health records system implemented had less medication errors than the emergency departments without electronic health records system implemented at a rate of 88 per million opportunities vs 164 per million opportunities.	Medication errors decreased from 9.2 per resident before implementation to 2.9 per resident after implementation	Implementation of an electronic integrated medication system reduced medication error rates by 93%	Of the 226 prescriptions that were audited, the electronic prescription auditing tool prevented 140 medication errors	Electronic systems decreased the rate of medication errors in all five studies
(t) time	Within two (2) years (2012-2014)	One (1) year	Within two (2) months	One (1) year	One (1) year	The time frame for all studies ranged from two (2) months to two (2) years

 

 

1. Evaluation Table

 

Citation	Design	Sample size: Adequate?	Major Variables:   Independent Dependent	Study findings: Strengths and weaknesses	Level of evidence	Evidence Synthesis
Al-Sarawi, Polasek,Caughey,and Shakib (2019)	A prospective structured medication chart audit before and after electronic prescribing system implementation.	3 South Australian public hospitals were audited; adequate. The sample size consisted of a small peripheral community hospital, a general metropolitan hospital and a general rural hospital. This sample size captures data from various perspectives.	The implementation of an electronic prescribing system (independent variable) in correlation with medication errors (dependent variable).	Strengths -Demonstrates a positive connection between electronic prescribing systems in the reduction of medication errors. -Used differing sites (rural, community and metropolitan) to capture diverse data -Evidence obtained from at least 1 well-designed large multi-site   Weaknesses -Demographic locations limited to Australia.	II	Electronic management of medications significantly reduces medication errors, and especially prescribing errors.
(Vaidotas, Yokota, Negrini, et al., 2019).	A cross- sectional, retrospective, descriptive, comparative study of medication errors	A total of 327,017 patients were seen in the 4 emergency departments under study	Medication errors were lower in the emergency departments that had electronic health records implementation as opposed the other two that were still paper charting.	Strengths Evidence obtained from a well-designed large multi-site. Weaknesses -Findings cannot be generalized due to one study conducted in one geographical location -Failure to report the specific sample population used: elderly, adults or children since medication dosages in children, adults and elderly have different dosing	II	The findings of this study support the use of EMRs (Electronic Medical Records) in EDs to reduce the rates of medication errors. There were 88 events per million opportunities in the departments with electronic medical record and 164 events per million opportunities in the units with paper charting. Medication errors are a threat to patient safety and contribute towards adverse events, drug reactions and frequent visits to the ED
Loguidice, (2014)	Comparative study	79 residents in a long term care facility in the United States. Sample size adequate for gathering information on that population for that particular study.	The total and average number of medication discrepancies after electronic health records implementation	Strengths -Proves that electronic health records plays a significant role in the reduction of medication errors   Weaknesses -Findings cannot be generalized due to one study conducted in one geographical location – 8 hour orientation on correct use of EHR is limited	IV	The findings of this study support the use of EHRs (Electronic Health Records) in long term care facilities to reduce the rates of medication errors
(Hodgkinson, Larmour,Lin,et al., 2017).	Before and after intervention study	379 patients in an outpatient clinic in Australia. Sample size adequate for the information the authors wanted to retrieve from that population.	Implementation of an integrated electronic medication prescribing and dispensing system (independent variable), decreased the rate of medication errors (dependent variable).	Strengths -Proves that electronic prescribing system plays a significant role in the reduction of medication errors Weaknesses -Findings cannot be generalized due to one study conducted in one geographical location	IV	The study concluded that the implementation of an electronic prescribing system significantly decreased the rate of prescribing errors in the population of study
(Priya, Thottumkal,Warrier,Krishna & Joseph, 2017)	Cross sectional comparative study.	1 quaternary care hospital in India. Sample size adequate. This is the largest hospital in that geographical location with a bed count of 370	Implementation of an integrated electronic medication auditing tool (independent variable), decreased the rate of medication errors (dependent variable).	Strengths -Proves that electronic prescription auditing tool reduces the rate of medication errors Weaknesses -Findings cannot be generalized due to one study conducted in one geographical location	IV Electronic health records PICOT Evidence Table Worksheet	The study supported the notion that an electronic auditing tool decrease the number of medication errors

 

 

Week Four Worksheet

PICOT

In patients admitted to a psychiatric institution that converted from paper charting to electronic health records (P) , does the implementation of electronic health records (I) compared to paper charting ( C) decrease medication errors (O) within 6 months of its implementation (T). Electronic health records PICOT Evidence Table Worksheet

 

Research Tool	Search Tips	Search Terms &  Limits	Findings	Features
CINAHL CINAHL is an SU subscription-only resource that offers full text access to 336 scholarly journals and indexes over 3,000 journals from the fields of nursing and allied health. Indexed journals do not provide access to full-text. Just because it is indexed in does not mean the library has full-text access to the journal. SU can always request articles for students via Interlibrary Loan, but the service is not instantaneous	§  Look at the Major Subject Heading in the Full Record §  Use the Limits Feature: o    Example: Publication Type=Systematic Review §  Try the CINAHL Heading search:	Keyword search: Electronic health records AND Medication errors Limits: Full texts 2015-2020   CINAHL Heading search: Electronic health records AND medication errors Limits: Publication= systematic review Full texts 2015-2020	377             5       5	·         Simple ·         Easy to navigate ·         Modifiable search criteria
PubMed PubMed is a free health science citation & abstracts index from the National Center for Biotechnology Information at the U.S. National Library of Medicine.	§  Look at MeSH Terms in Full Record §  Use the Limits Feature: o    Examples: Article Type=Meta-Analysis; Age=All Adult §  Look for the open access Free articles!	Keyword search: Electronic health records and medication errors Limits: full-text; 5 years   MESH search: Limits: full-text; 5 years	2         2 Electronic health records PICOT Evidence Table Worksheet	·         Difficulty understanding MeSH terms ·         Limited results found for my topic ·         Best feature was sorting by ‘best match’ or ‘similar articles’
Cochrane Library Cochrane Library provides access to the Cochrane Library of Systematic Reviews. Full text of reviews are subscription only. Index summaries are a public resource. Indexed journals do not provide access to full-text. Just because it is indexed in does not mean the library has full-text access to the journal. SU can always request articles for students via Interlibrary Loan, but the service is not instantaneous	§  Use the Simple Search and the Advance Search Features §  Allows you to search with MeSH Terms §  Check out the New Reviews  Browse reviews by topic	Keyword search: Electronic health records and medication errors   Limits:2015-2020   MESH search: Limits:2015-2020	0       0   0	·         No result found ·         Limited MeSH options   ·         Harder to navigate for additional search options
Dynamed	·         Use the Simple Search and the Advance Search Features ·         Allows you to search with MeSH Terms ·         Check out the New Reviews Browse reviews by topic	Keyword search: electronic health records and medication errors   Also browse by: electronic health records	Electronic health records PICOT Evidence Table Worksheet         56	·         No result generated for electronic health records and medication errors   ·         I was able to get general information on electronic health records (very minimal at that). 56 search results generated, but not specific to medication errors.   ·         MeSH search in this database was difficult to navigate.
TRIP Database TRIP is a clinical search engine to locate publicly available clinical evidence.	§  Limit to: §  Systematic Reviews §  Guidelines-US	Keyword search: Electronic health records and medication error   Limits: 2015-2020	2,096   137 PICO results	·         Easy to navigate ·         Yielded multiple results ·         The PICO search option was an asset ·         The color coding associated with the type of research or article makes it visually appealing
SU Library Search	·         Library Search is setup just like an EBSCO ·         The Library even has a specialized PICOT search setup in Library Search—must go to Advance search to get to PICOT option	Keyword search: electronic health records and medication errors   Limit: 2015-2020	3,643     5 PICO results found	·         My most commonly used database ·         The PICOT search option was the best ·         Easy to use ·         Produced many result options

 

Conclusion

Medication errors are among the leading causes of harm to patients. Sources of error include dose administration, monitoring response, history taking, prescribing errors, and medication management cycle. The literature provided in the five studies supported that prescribing errors are the most serious types of medication errors. The literatures concluded in their studies that management of medications significantly reduces medication errors, and especially prescribing errors Electronic health records PICOT Evidence Table Worksheet.

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References

Al-Sarawi F, Polasek T, Caughey G & Shakib S. (2019). Prescribing errors and adverse drug         reaction documentation before and after implementation of e-prescribing using the Enterprise Patient Administration System Fares. Journal of Pharmacy Practice and       Research, 1(49), 27–32.

Hodgkinson, M., Larmour, I., Lin, S., Stormont, A., & Paul, E. (2017, April 1). The impact of an integrated electronic medication prescribing and dispensing system on prescribing and dispensing errors: a before and after study. Journal of Pharmacy Practice and Research, 47(10), 110-120. doi: 10.1002/jppr.1243

Loguidice, C. (2014, July 10). Using Electronic Health Records to Reduce Medication Errors in Long-Term Care. Annals of Long Term Care, 22(8), 22-29. doi:https://eds-b-ebscohost-com.su.idm.oclc.org/eds/detail/detail?vid=4&sid=29fde5e8-ba50-4a83-8076-77bd34d4d33d%40pdc-v-sessmgr05&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=107816281&db=rzh

Priya, K., Thottumkal, A., Warrier, A., Krishna, S., & Joseph, N. (2017, October 5). Impact of electronic prescription audit process to reduce outpatient medication errors. Indian Journal of Pharmaceutical Sciences, 79(6), 1017-1021. doi:https://eds-b-ebscohost-com.su.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=1&sid=29fde5e8-ba50-4a83-8076-77bd34d4d33d%40pdc-v-sessmgr05 Electronic health records PICOT Evidence Table Worksheet

Vaidotas, M., Yokota, P. K. O., Negrini, N. M. M., Leiderman, D. B. D., Souza, V. P. D., Santos, O. F. P. D., & Wolosker, N. (2019). Medication errors in emergency departments: is electronic medical record an effective barrier? Einstein (São Paulo), 17(4).