PEER RESPONSES FOR Patient Outcomes and Sustainable Change Assessment Description Reflecting on the "IHI Module QI 202: Addressing Small Problems to Build Safer, More Reliable Systems," describe how your direct practice improvement project achieves clinical improvement. How will you achieve widespread change? How would the widespread change of your DPI Project be affected if it were implemented in a country with universal health care. Describe how the health outcome would be impacted. Provide supporting evidence. Shabnampreet Kaur The IHI module QI 202:  Addressing Small Problems to Build Safer, More Reliable Systems, reflects on the presence of small problems in healthcare systems and how to overcome these small problems to build safer systems. Steve Spear used various examples to make the readers understand the concept of small loopholes and workarounds which distract the employees resulting in mistakes and sometimes these mistakes become catastrophes(Institute for Healthcare Improvement, 2022b). Also, he suggested ways to address them and make healthcare safer. My DPI project which is fall prevention among older adults achieves clinical improvement by building stronger techniques for addressing the reasons and suggesting ways to improve strength, gait, and balance using tai chi as the intervention. Currently, at the practice site, there is only a shift-to-shift report as the standard criteria for fall reporting. Many times people forget to bring to the provider's notice that they experience a fall in the past 3 months. And sometimes if falls are reported, the shift duty nurses forget to enter them into the EHR system. Also, there is currently no special protocol for fall screening. Screening and assessment can help providers know about the population prone to falling and then they can work towards achieving the aim of fall prevention by devising various patient-centered interventions, My DPI project will streamline the process of screening all the older adults above the age of 65 years with CDC STEADI Stay Independent questionnaire (Centers for Disease Control and Prevention.,2020). Those screened at risk will undergo assessment for fall risk factors using a Timed up and go, 30-second chair rise and balance test, with identification of medicines as per Beers criteria, measurement of orthostatic blood pressure, and asking about potential home hazards. Those having poor balance gait and strength will be enrolled in a 12-week tai chi exercise program as the intervention. In order to achieve widespread change, teamwork and collaboration are needed at the levels of the project. Potential sources of mistakes will be addressed in the first place, the commonest of all being linking the fall risk assessment to the patient's e-chart. If my DPI project were implemented in a country with universal healthcare, the widespread change of the project will be affected in multiple ways. Universal healthcare coverage means all people have full access to hea.

1. PEER RESPONSES FOR Patient Outcomes and Sustainable
Change
Assessment Description
Reflecting on the "IHI Module QI 202: Addressing Small
Problems to Build Safer, More Reliable Systems," describe how
your direct practice improvement project achieves clinical
improvement. How will you achieve widespread change? How
would the widespread change of your DPI Project be affected if
it were implemented in a country with universal health care.
Describe how the health outcome would be impacted. Provide
supporting evidence.
Shabnampreet Kaur
The IHI module QI 202: Addressing Small Problems to Build
Safer, More Reliable Systems, reflects on the presence of small
problems in healthcare systems and how to overcome these
small problems to build safer systems. Steve Spear used various
examples to make the readers understand the concept of small
loopholes and workarounds which distract the employees
resulting in mistakes and sometimes these mistakes become
catastrophes(Institute for Healthcare Improvement, 2022b).
Also, he suggested ways to address them and make healthcare
safer. My DPI project which is fall prevention among older
adults achieves clinical improvement by building stronger
techniques for addressing the reasons and suggesting ways to
improve strength, gait, and balance using tai chi as the
intervention. Currently, at the practice site, there is only a shift-
to-shift report as the standard criteria for fall reporting. Many
times people forget to bring to the provider's notice that they
experience a fall in the past 3 months. And sometimes if falls
are reported, the shift duty nurses forget to enter them into the
EHR system. Also, there is currently no special protocol for fall
screening. Screening and assessment can help providers know
about the population prone to falling and then they can work
towards achieving the aim of fall prevention by devising various

2. patient-centered interventions, My DPI project will streamline
the process of screening all the older adults above the age of 65
years with CDC STEADI Stay Independent questionnaire
(Centers for Disease Control and Prevention.,2020). Those
screened at risk will undergo assessment for fall risk factors
using a Timed up and go, 30-second chair rise and balance test,
with identification of medicines as per Beers criteria,
measurement of orthostatic blood pressure, and asking about
potential home hazards. Those having poor balance gait and
strength will be enrolled in a 12-week tai chi exercise program
as the intervention. In order to achieve widespread change,
teamwork and collaboration are needed at the levels of the
project. Potential sources of mistakes will be addressed in the
first place, the commonest of all being linking the fall risk
assessment to the patient's e-chart. If my DPI project were
implemented in a country with universal healthcare, the
widespread change of the project will be affected in multiple
ways. Universal healthcare coverage means all people have full
access to healthcare services whenever and wherever they need
them. Although in terms of accessibility and affordability, it is
easier for the patients to receive the care, it can affect the
quality of care(Zieff et al., 2020). Due to the long wait times in
the universal healthcare system, people would not be able to get
screened for their fall risk factors and receive appropriate
referrals on time which will deteriorate their condition and
increase fragility. With government rationing of medical
services like controlled distribution of services, price setting,
budgeting, etc people will have to wait for a longer time to get
receive tailored interventions for fall prevention based on their
risk factors. For example, based on the risk factor evaluation,
the patient has poor gait and balance, and he is referred to an
evidence-based exercise program like tai chi or physical
therapy, but due to higher demand for these services, they are
not able to get these interventions in a timely manner leading to
poorer health outcomes. Therefore the overall health outcomes
will be impacted evidenced by the increased number of falls and

3. fallers, higher hospitalization rate, and mortality rate followed
by economic burden.
Centers for Disease Control and Prevention. (2020, October 16).
STEADI - Older Adult Fall Prevention.
CDC https://www.cdc.gov/steadi/index.html
Institute for Healthcare Improvement. (2022b, August).
QI 202: Addressing small problems to build safer, more
reliable systems.
IHI.
https://education.ihi.org/topclass/topclass.do?expand-
New_CourseHome-id=431628485-activitytype=28-
learningPage=TrainingHistory
Zieff, G., Kerr, Z. Y., Moore, J. B., & Stoner, L. (2020).
Universal Healthcare in the United States of America: A
Healthy Debate.
Medicina,
56(11), 580.
https://doi.org/10.3390/medicina56110580
Bonnie Flores
This week’s IHI Module 202 provided excellent examples of
how little issues can arise and create larger problems. A good
example was when there were many people who kept stepping
over the tripping hazard rather than fixing it or alerting others
to its existence. My direct practice improvement (DPI) project
will focus on the implementation of the Society of Critical Care
Medicine’s Intensive Care Unit (ICU) Liberation Bundle for
mechanically ventilated patients. There are many issues that
critically ill patients face when intubated. For example,
delirium rates increase, patients become deconditioned, length
of stay increases, and mortality rates increase (DeMellow et al.,
2020). There are other conditions that my bundle does not
address including ventilator-associated pneumonia (VAP) and
hospital-acquired pressure injuries (HAPI); therefore, I will not
discuss these issues.
My DPI includes coordinating breathing trials with sedation

4. reduction, increasing exercise and mobility, increasing family
engagement, pain assessment and prevention, and delirium
assessment and prevention (Society of Critical Care Medicine,
2020). When the full bundle is implemented patient outcomes
improve, thus leading to decreases in delirium rates, decreased
days on the ventilator, and decreased length of stay, all of
which can contribute to decreased mortality and increased
quality of life (DeMellow et al., 2020). In my current
organization, there are pieces of the bundle in place, but the full
bundle is not currently being utilized. I am looking forward to
implementing this project so that I can start this project in my
ICU to improve the health and outcomes of my patients, realize
change, and then spread the change to other ICUs within the
Southern California region. This is a very real possibility since
my organization utilizes unit-based teams where tests of change
and quality improvement projects are highly valued to improve
the quality of care and reduce cost. If my facility sees an
improvement, then other facilities within the healthcare
organization will adopt the project; thus, leading to wider
spread throughout the state and nation.
Were this project to be implemented in a country with national
health coverage, then there may be the same challenges that we
face in the United States. For example, the greatest challenge
will be to get buy-in from nurses who are already working at
maximum capacity. Since nurses are in short supply across the
globe, asking any nurse to do extra may prove to be difficult. A
benefit of this project is that it has great potential to reduce
costs by focusing on harm prevention. In a country with
universal health coverage, preventive care is a priority (Zieff et
al., 2020). When patients are given equitable access to
healthcare and preventive healthcare then, then the overall
health of the population increases, thus lowering
hospitalizations and the need for the invasive treatment that will
be utilized in my DPI project (Zieff et al., 2020).
References
DeMellow, J. M., Kim, T. Y., Romano, P. S., Drake, C. &

5. Balas, M. C. (2020). Factors associated with ABCDE bundle
adherence in critically ill adults requiring mechanical
ventilation: An observational design.
Intensive & Critical Care Nursing, 60.
https://doi.org/10.1016/j.iccn.2020.102873
Society of Critical Care Medicine. (2020). ICU Liberation.
Society of Critical Care Medicine. Retrieved on May
17, 2022, from
https://www.sccm.org/getattachment/Clinical-
Resources/ICULiberation/ABCDEF-Bundles/ICULIB-
Infographic-Final-(1).pdf?lang=en-US
Zieff, G., Kerr, Z. Y., Moore, J. B., & Stoner, L. (2020).
Universal healthcare in the United States of America: A healthy
debate.
Medicina,
56(11), 580.
https://doi.org/10.3390/medicina56110580
Misty Walton
The "IHI Module QI 202: Addressing Small Problems to Build
Safer, More Reliable Systems," highlighted eight steps for
systems to take to support quality and safety, how to support the
teams and how to support the patients and families. Each of
these three highlighted sections in the module demonstrate a
systems approach across the continuum of care to improve
patient quality and safety. My direct practice improvement
project will achieve clinical improvements in geriatric
orthopedic patients' pain management through listening to music
as an intervention. A reduction in self-reported pain with a non-
pharmacological intervention that is nurse driven and reduces
pain also decreases anxiety (Schneider, 2018). In Scheider's
(2018) study one hundred percent of participants reported that
they would recommend listening to music as a pain reduction
intervention and numeric reported pain scores decreased from
5.53 to 3.97 post the listening to music for twenty minutes.

6. Elective orthopedic surgery patients struggle with pain
management which may impact their recovery, sleep, ability to
participate in therapy and mobility (Sampognaro & Harrell,
2021). The Joint Commission and other regulatory agencies
have called for a reduction of opiate usage across the country
facing the opiate epidemic. Multimodal post operative pain
control methods add non-pharmacological methods to help to
reduce pain (Sampognaro & Harrell, 2021). Widespread change
will be achieved in alignment with the eight recommendations
noted in the IHI Module 202 focusing on creating safe care
across the continuum. Non-pharmacological modalities should
be introduced and integrated at doctors' offices and clinics.
Prescriptions and education may be provided prior to surgery.
Patients should be encouraged to make a playlist of music and
record pain prior to listening and after which may be continued
in follow-up visits and other areas of their health. Success
demonstrated from the pilot of the DPI on an orthopedic floor
will help demonstrate to all the stakeholders the impact and
importance for buy in to spread.
Access to healthcare and early interventions is key to reducing
pain and chronic pain in geriatric patients. A universal
healthcare system would allow access to non-pharmacological
modalities (NPM) for treatment of pain and education on those
modalities across the continuum of care. Veteran Affairs
facilities have more success with a usage of NPM 49.9 percent
of the time for pain management versus 39.8 percent have begun
to share their studies and learning from cross sectional studies
(Mannes et al., 2022). This shift is a culture change that begins
with access to care for all and educating doctors in doctors'
offices and clinics on benefits of modalities such as listening to
music on pain. There are numerous studies examining the
impact on surgical populations of all ages and throughout the
process from pre-operative visits to home care. Small and
Laylock (2020) report that more than twenty five percent of
post operative patients report severe pain, and this number of
reporting has not changed overtime recommending adding

7. modalities to support pain management and improve overall
patient outcomes.
References
Mannes, Z. L., Stohl, M., Fink, D. S., Olfson, M., Keyes, K. M.,
Martins, S. S., ... & Hasin, D. S. (2022). Non-pharmacological
treatment for chronic pain in US veterans treated within the
veterans health administration: Implications for expansion in
US healthcare systems.
Journal of General Internal Medicine, 1-10.
Sampognaro, G., & Harrell, R. (2021). Multimodal
Postoperative Pain Control After Orthopedic Surgery. n:
StatPearls. StatPearls Publishing, Treasure Island (FL); 2022.
PMID: 34283438.
Schneider M. A. (2018). The effect of listening to music on
postoperative pain in adult orthopedic patients.
Journal of holistic nursing: Official journal of the
American Holistic Nurses' Association,
36(1), 23–32.
https://doi.org/10.1177/0898010116677383
Small, C., & Laycock, H. (2020). Acute postoperative pain
management.
Journal of British Surgery,
107(2), e70-e80.