Benchmark – Capstone Project Change Proposal

Benchmark – Capstone Project Change Proposal

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Readmission of patients due to medical condition is common. Patients of Heart failure tend to be readmitted frequently. However, studies have shown that readmission due heart failure can be reduced or prevented if adequate, appropriate and timely care management is provided to the patients and caregivers (Bradley, E. H., et al, 2013). Healthcare professional, especially nurses, play a key role in educating both the patient and the care givers on care management. To reduce readmission, evidenced-based practice of nurses educating the patient and care giver has been adopted. Discharge follow-ups are to be done. However, implementing the evidence-based practice is challenging due to barriers such resources allocation and the complex nature of hospitals.

Problem Statement

30-day readmission for heart failure patients is a global concern, healthcare organizations are researching on ways to reduce it. Studies have shown that early readmission occur due to poor patient outcomes, mostly attributed to missed care, due to lack of adequate knowledge on care management (Ziaeian, B., & Fonarow, G. C., 2015). Readmission are still on the rise and the mortality rate among the readmitted is also high. The study therefore, focuses on continuous education of the heart failure patient and home-based care givers with frequent follow ups by the nurses in order improve patient outcomes.

Purpose of the Change Proposal

Educating and training the heart failure patients and care givers on how to manage the HF condition, as a strategy to reduce 30-day readmission. Most of the patients and care givers don’t have enough knowledge on how to manage the HF condition. Timely follow up is done to assess the condition and the impact of education on HF management.


The PICOT focused on patient and care giver education and training as a good intervention for reducing 30-day heart failure readmission. Nurses and other healthcare professionals should educate and train the patients and care givers not only on discharge instructions, but it should include medication intake, monitoring of symptoms and lifestyle of the heart failure patient. Therefore, it is crucial for nurses to change on how they give discharge information to patients buy educating and training them, including practical demonstration, not only giving them written discharge information. Teach-back (Howie-Esquivel, J., et al, 2015) is employed to get the best out of the training and the following strategies are used.

Implementation of the process change will involve giving adequate training on the patient as well as the care giver before the patient is discharged. Once implemented, the outcome results are expected within the first 30 days of discharge of a well-trained patient and care giver. A time span of approximately six months, with follow up and assessment of the process, is adopted. Patients discharged after training are observed carefully, whether they are re-hospitalized within 30 days of being discharged. If there are readmission, readmission rates, severity of the condition during readmission and even mortality rates following readmission.

  • Creating training supporting culture
  • Providing well-developed materials to patients
  • Identifying the key learner
  • Evaluating learning

Literature Search Strategy Employed

The literature used for the study was obtained specifically from journal of nursing articles. The articles were limited to the last five years. This was meant to improve the credibility and accuracy of the collected information by focusing on the current content. Use of internet helped in searching for these articles.

Evaluation of the Literature

As stated above, the literature used only focused on recent (not more than years) articles from journal of nursing. All these articles acknowledge heart failure as a global pandemic and as one as one of the reasons for hospitalizations and early readmission in the United states. They also acknowledge that many strategies have been put in place to reduce early HF patients readmission and that health organizations are still researching on these strategies.

The researchers used various methods to collect information. Some reviewed past literature, others carried out evidence-based studies while others reviewed data from cardiac hospital databases. The size used for each study was reasonable enough to acquire the information they needed. This shows how relevant enough the articles are to be used for further research. The diverse settings and populations used for the study improve information accuracy. There are, however, a few limitations noted. The studies suggest various interventions to reduce early HF readmission but most of them do not give clear directions on how the hospitals can implement them.

Applicable Change

Health facilities have been educating the patients but has not been efficient enough to enable the patients manage themselves well after discharge. The usual kind of training in most health facilities is to provide a handout containing post-discharge instructions. Most patients do not read it while other may but not understand them clearly (Peter, D., et al, (2015). This results in missed care that leads to patients being readmitted. It should be noted that most HF patients are old age who need to be trained with a lot of caution. The proposed change therefore focuses on how to strategize this the training and follow-ups to benefit the patient. Nurses have the responsibility to offer high quality care to patients and proper training should be one of them.

Training Strategy

Identifying the key learner

Nurses should take into account the type of person being trained at any given time. This is to do with age, gender, degree of disease effect among other factors. This enables the trainer to prepare appropriate training materials.

Evaluating learning

The trainer should be able to evaluate whether the trainee understands the concepts. Teach-back mechanism is the best method to gauge the level of understanding.

Creating training supporting culture

The health facility should have developed training supporting culture to ensure continuity in training among the patients.

Providing well-developed materials to patients.

These materials should be easy to understand and direct to the point. This is to prevent boredom that may arise from reading a lot of complicated content that may make the patient to stop reading.

Follow-ups Strategy

It is not just enough to train the patients and discharge them. It is crucial to do patient follow-ups up to a certain period of time. This is to ensure that the patient continues to implement what they learnt and in case they forget they can be reminded. Follow-ups also enable monitoring patient recovery progress. Planned readmission can be scheduled where necessary. To ensure successful follow-up activity, nurses can be assigned specific patients and required to bring patient reports to their managers. This will require the health facility to ensure that nurse-patient ratio is as recommended otherwise more registered nurses will be needed.

Proposed Implementation Plan with Outcome Measures

Notify nurses and other Relevant staff on the change

The health facility will first make the nurses aware of the suggested changes. This will help them prepare well for what is ahead of them. They will be told the specific changes that are expected to be implemented to enhance patient training.

Train nurses on how to offer the proposed training planning

The nurses will then be taken through a thorough training session of how they are expected to train the patients.

Assign patients to nurses

The nurses will then be assigned specific patients to check on to ensure they understand what they are being trained. The same patients will be follow-up by the assigned nurses after discharge.

Patient training Before discharge

The patients will then be trained taking into account the proposed training tactics.

Post-discharge Follow-ups

Nurses will be expected to do patient follow-ups to ensure that they practice what they are taught and to monitor their recovery process.

Evaluate outcomes

The health facility will compare the patient outcomes after training implementation with the outcomes before. The expected result is that patient outcomes improve due to improved care management and consequently reduce 30-day readmission.

Potential Barriers to Plan Implementation, and How to Overcome

Implementing process of the evidenced-based practices is demanding and requires well laid down strategies to address such difficulties. Implementing the evidence-based practice is challenging due to barriers such allocation resources and the complex nature of hospitals. Some of the identified barriers to smooth implementation of the evidence-based practices are listed below;

Changing the current practice: it is difficult to change the prevailing practice model; it will lead to resistance from the management if not well explained. it can be overcome by explaining the importance and how it will improve the patient outcome

Lack or minimal trust in the evidence-based practice: it is expected that some healthcare professionals will have little trust or can’t trust the practice. Explaining the well the practice will help in overcoming the practice.

Patients not taking the training seriously and sticking to the teachings: this is due to patients not taking strictly the teaching on how to manage the condition and follow the prescription and suggested lifestyle. Frequent follow ups, through phone calls and physical visits, will assess the situation and correct the situation.


Bradley, E. H., Curry, L., Horwitz, L. I., Sipsma, H., Wang, Y., Walsh, M. N., … Krumholz, H. M. (2013). Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circulation. Cardiovascular quality and outcomes, 6(4), 444–450.

Ziaeian, B., & Fonarow, G. C. (2015). The Prevention of Hospital Readmissions in Heart Failure. Progress in cardiovascular diseases, 58(4), 379–385

Howie-Esquivel, J., Carroll, M., Brinker, E., Kao, H., Pantilat, S., Rago, K., & De Marco, T. (2015). A Strategy to Reduce Heart Failure Readmissions and Inpatient Costs. Cardiology research, 6(1), 201–208. doi:10.14740/cr384w

Peter, D., Robinson, P., Jordan, M., Lawrence, S., Casey, K., & Salas-Lopez, D. (2015). Reducing readmissions using teach-back: enhancing patient and family education. Journal of Nursing Administration.

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