Part 1

Practice Clinicians in Long-Term Care

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Ten patients with heart failure with reduced ejection fraction diagnoses were selected, reviewed, and compared with AHA guidelines. None of the charts audited had ARNI (angiotensin receptor-neprilysin inhibitor) known as Entresto is part of the AHA recommendation for management of heart failure with reduced ejection fraction. Four patients with African American (AA) heritage are not on Hydralazine and only one patient was one SGLT2i as indicated by the guideline (Heidenreich et al., 2022). All ten charts reviewed had full code status indicating a lack of understanding of disease trajectory and recommendations.

Part II

One leadership approach utilized to lead the team is the transformational style. The approach allows leaders to inspire a shared vision characterized by efforts to take ownership of nurses’ roles and perform beyond expectations (Specchia et al., 2021). Additionally, the transformational approach encourages nurses to demonstrate higher moral values and integrity across the care continuum. Servant leadership is another consideration that allows a leader to encourage the workforce through empowering and uplifting everyone within the advanced care setting (Alam et al., 2019). The servant leader understands the needs of the team and identifies new and better ways of helping workers to solve problems.

The rationale for selecting transformational and servant leadership is because of the need to encourage diversity of thoughts, create a culture of trust, and foster personal and professional development in others. Listening to team members and understanding the workplace demands make transformational and servant leaders accountable for their actions and words (Alam et al., 2019). A leader might utilize servant leadership by allowing team members to express their ideas and expectations when implementing a new procedure, structure, or process. Leaders can utilize a transformational approach when there is greater uncertainty when adopting new protocols. The leader clarifies the purpose of the change and encourages a shared vision toward improving the quality and safety of patient care.

Practice Change Interventions

Intervention one: Evidence-based palliative-focused CHF protocol

Recommendations and progression from literature. The protocol reminds the care team about standards and practices that enable them to maintain the best possible quality of life. The intervention includes efforts necessary for nurses to support patients, relieve symptoms, and protect patients from discomfort (Heidenreich et al., 2022). Compliance with CHF protocols enhances the cooperation of all advanced practice clinicians to provide the best care in all stages of palliative care.

Intervention operational logistics. The implementation team includes full-time and part-time nurse practitioners, and physician assistants working at Optum senior complex care management program. There will be weekly chart review of all charts at the long-term care facility for compliance with the NYHA class IV guidelines. There will be retraining for providers for those charts not in compliance with the guidelines through weekly briefings. A multifaceted implementation strategy is crucial to enhance compliance with evidence-based CHF protocols. The implementation stage entails making the care team aware of the trends and the need for a holistic approach for handling patients with advanced CHF. Advanced practice clinicians will acquire knowledge and skills in collaborating and sharing accurate and complete information to deliver more efficient services.

Intervention two: Adopting the American Heart Association guidelines on advanced CHF care.

Recommendations and Progression From Literature

Consistent utilization of the guidelines makes nurses more responsive to patients’ needs. The intervention encourages high-quality communication, clarity of goals, and shared decision-making to offer adequate support to patients and families (Mechler & Liatonio, 2019). AHA guidelines are at the center of improved and evidence-based practices for heart failure patients. The standards make it easier for advanced practice clinicians to understand and utilize patient-centered and holistic treatment guidelines across the continuum (Mechler & Liatonio, 2019). For instance, there are opportunities to identify high-risk heart failure patients on time using identification checklists.

 Intervention operational logistics

Educational sessions, reminders, and the use of decision support systems will help improve the use of AHA’s guidelines across the care continuum. A measure of AHA guidelines adherence is also crucial to make informed conclusions on the level of compliance. In this sense, the measures of adherence include self-reported adherence and charts review for six weeks.

Improvement Model / Framework

Proposed Outcomes

·        Careful assessment of patient’s medical condition and demographics to prevent the risk of heart failure

Part III

The data to be collected is on compliance rates with CHF protocols. The details include compliance with guideline-directed medical therapy,

Compliance with titrating practices for ensuring target dose

Data on tritration accuracies provide accurate and informed evidence on the level of compliance.

Ensure patients have hydralazine

Data collected on compliance with CHF protocols and AHA’s guidelines on ensuring patients access to hydralazine.

Ejection fraction of >35

The nurse manager in an advanced care setting

The nurse manager in advanced practice setting

The nurse manager and advanced practice clinicians responsible for managing the data.

The nurse manager and advanced practice clinicians handling patients at risk of CHF.

The data will be collected on the fourth week after implementing the intervention

Data collected on the fourth week of the implementation

Data collected on the third week of the implementation stage.

Data collected from the second week to the fifth weeks of the implementation process.

Data stored in secured computers within the advanced care setting

Data stored in electronic health record system within the advanced care unit.

Records stored on EHRs to ascertain compliance with CHF protocols and AHA guidelines across the care continuum.

Data stored in EHRs for easy tracking of compliance with protocols and guidelines on ejection fraction

The data will be protected using log-on credentials to prevent unauthorized access. The primary investigator, executive sponsors, and nurse manager will have access to protected information.

Access privileges used to restrict access to unauthorized parties.

Access privileges to nurse leaders including the nurse manager and CNO

Log-in requests and access privileges to the nurse manager and the CNO.

Demographic aspects such as age and disabilities are crucial. The information makes the care team responsive to patients’ needs based on adequate knowledge of health complexities and best practices for reducing the risk of heart failure (Riahi & Khajehei, 2019).

Data on past titration near misses and errors necessary to determine progress made with the intervention (Heidenreich et al., 2022).

Data on deviations from the protocols and guidelines necessary to determine robustness of safety culture, staff knowledge and skills in preventing error (Riahi & Khajehei, 2019).

Data on deviations from the recommended rate and frequency of errors recorded to determine the level of compliance and effectiveness of interventions.

·        Optum’s leadership support is crucial to empower the nursing team to respond positively to the intervention.

·        Compliance with CHF protocols helps strengthen Optum’s brand credibility.

·        Optum has adequate financial resources to support initiatives meant to improve the quality and safety of patient care.

·        There is no guarantee that the nursing team will adhere to new compliance measures due to other factors such as incentives and employee engagement practices associated with a dedicated workforce.

·        The project team may overlook aspects such as the physical environment and patient characteristics that make individuals vulnerable to heart failure.

·        The intervention provides a sustainable approach for overcoming issues such as medication errors and medical negligence observed in palliative care.

·        The intervention encourages patients to share experiences about their encounters with nurses.

·        Successful outcomes reinforce Optum’s safety and quality culture, which boosts consumer confidence and trust.

·        Ineffective employee engagement may undermine the workforce’s willingness to embrace recommended compliance protocols.

·        The facility may have to spend more on training existing and new staff to cope with the CHF protocols.