Prepare an 8 page data analysis and quality improvement initiative proposal based on a health issue of professional interest to you. The audience for your analysis and proposal is the nursing staff and the interprofessional team who will implement the initiative.
“A basic principle of quality measurement is: If you can’t measure it, you can’t improve it” (Agency for Healthcare Research and Quality, 2013).
Health care providers are on an endless quest to improve both care quality and patient safety. This unwavering commitment requires hospitals and care givers to increase their attention and adherence to treatment protocols to improve patient outcomes. Health informatics, along with new and improved technologies and procedures, are at the core of virtually all quality improvement initiatives. The data gathered by providers, along with process improvement models and recognized quality benchmarks, are all part of a collaborative, continuing effort. As such, it is essential that professional nurses are able to correctly interpret, and effectively communicate information revealed on dashboards that display critical care metrics.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
- Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
- Outline a QI initiative proposal based on a selected health issue and supporting data analysis.
- Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
- Analyze data to identify a health care issue or area of concern.
- Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality.
- Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality.
- Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
- Apply effective communication strategies to promote quality improvement of interprofessional care.
- Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
Reference
Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals. Retrieved from https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk5.html#tiptop
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
Reflect on QI initiatives focused on measuring and improving patient outcomes with which you are familiar.
- How important is the role of nurses in QI initiatives?
- What quality improvement initiatives have made the biggest difference? Why?
- When a QI initiative does not succeed as planned, what steps are taken to improve or revise the effort?
Quality Improvement Examples and Results
These resources explore the effectiveness and lessons learned from various quality improvement initiatives.
- Ohde, S., Terai, M., Oizumi, A., Takahashi, O., Deshpande, G. A., Takekata, M., . . . Fukui, T. (2012). The effectiveness of a multidisciplinary QI activity for accidental fall prevention: Staff compliance is critical. BMC Health Services Research, 12, 197.
- Berman, J., Nkabane, E. L., Malope, S., Machai, S., Jack, B., & Bicknell, W. (2014). Developing a hospital quality improvement initiative in Lesotho. International Journal of Health Care Quality Assurance, 27(1), 15–24.
These articles showcase examples of strategic QI projects.
- Nazir, A., Dennis, M. E., & Unroe, K. T. (2015). Implementation of a heart failure quality initiative in a skilled nursing facility: Lessons learned. Journal of Gerontological Nursing, 41(5), 26–33.
- Schoenfelder, S. L., Wych, S., Willows, C. A., Harrington, J., Christoffel, K. K., & Becker, A. B. (2013). Engaging Chicago hospitals in the baby-friendly hospital initiative. Maternal and Child Health Journal, 17(9), 1712–1717.
This resource evaluates a QI initiative based on a communication strategy.
- Wysham, N. G., Mularski, R. A., Schmidt, D. M., Nord, S. C., Louis, D. L., Shuster, E., . . . Mosen, D. M. (2014). Long-term persistence of quality improvements for an intensive care unit communication initiative using the VALUE strategy. Journal of Critical Care, 29(3), 450–454.
Benchmarks for Quality Indicators
These databases provide recognized benchmarks for quality indicators.
In this assessment, you will propose a quality improvement (QI) initiative proposal based on a health issue of professional interest to you. The QI initiative proposal will be based on an analysis of dashboard metrics from a health care facility.
- Analyze data from the health care facility to identify a health care issue or area of concern. You will need access to reports and data related to care quality and patient safety. If you work in hospital setting, contact the quality management department to obtain the data you need.
- You will need to identify basic information about the health care setting, size, and specific type of care delivery related to the topic that you identify. You are expected to abide by HIPAA compliance standards.
Option 2
If you do not have access to a dashboard or metrics related to a QI initiative proposal:
- You may use the hospital data set provided in the media piece titled Vila Health: Data Analysis. You will analyze the data to identify a health care issue or area of concern.
- You will follow the same instructions and provide the same deliverables as your peers who select Option 1.
Instructions
Analyze dashboard metrics related to the selected issue.
- Provide the selected data set in the proposal.
- Assess the stability of processes or outcomes.
- Delineate any problematic variations or performance failures.
- Evaluate QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and non-governmental bodies on quality improvement.
- Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization and the interprofessional team.
- Outline a QI initiative proposal based on the selected health issue and data analysis.
- Identify target areas for improvement.
- Define what processes can be modified to improve outcomes.
- Propose strategies to improve quality.
- Define interprofessional roles and responsibilities as they relate to the QI initiative.
- Provide recommendations for effective communication strategies for the interprofessional team to ensure the success of the QI initiative. Briefly reflect on the impact of the proposed initiative on work-life quality of the nursing staff and interprofessional team.
- Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
The numbered points below correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your Quality Improvement Initiative Evaluation addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion.
- Analyze data to identify a health care issue or area of concern.
- Identify the type of data you are analyzing (from your institution or from the media piece).
- Discuss why the data matters, what it is telling you, and what is missing.
- Analyze dashboard metrics and provide the data set in the proposal.
- Present dashboard metrics related to the selected issue.
- Delineate any problematic variations or performance failures.
- Assess the stability of processes or outcomes.
- Evaluate the quality of the data and what can be learned from it.
- Identify trends, outcome measures and information needed to calculate specific rates.
- Analyze what metrics indicate opportunities for quality improvement.
- Outline a QI initiative proposal based on a selected health issue and supporting data analysis.
- Identify benchmarks aligned to existing QI initiatives set by local, state, or federal health care policies or laws.
- Identify existing QI initiatives related to the selected issue, and explain why they are insufficient.
- Identify target areas for improvement, and define what processes can be modified to improve outcomes.
- Propose evidence-based strategies to improve quality.
- Evaluate QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and non-governmental bodies on quality improvement.
- Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization and the interprofessional team.
- Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality.
- Define interprofessional roles and responsibilities as they relate to the data and the QI initiative.
- Explain how you would you make sure that all relevant roles are fully engaged in this effort.
- Explain what non-nursing concepts would you incorporate into the initiative?
- Identify how outcomes to measure the effect of the intervention affect the interprofessional team.
- Briefly reflect on the impact of the proposed initiative on work-life quality of the nursing staff and interprofessional team. Describe how work-life quality is improved or enriched by the initiative.
- Apply effective communication strategies to promote quality improvement of interprofessional care.
- Identify the kind of interprofessional communication strategies that will be effective to promote and ensure the success of this performance improvement plan or quality improvement initiative.
- In addition to writing, identify communication models (like CUS, SBAR) that you would include in your initiative proposal.
- Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
- Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
QI data
Hi! I heard through word of mouth that you were looking for some possible areas of improvement in the hospital. I’ve got some data from SAMC’s in-home hospice program that might be useful.
I realize that you may not be familiar with the hospice program, so I also set up some meetings with a few people with a stake in the program. I’m hoping they can give you some context for the data you’re looking at.
Let me know if you need anything!
Sienna Pope,
Director of Medical Support Services
Hospice and Home Health Adverse Event Data 2014-2015
Per Vila Health policy, these figures include near misses as well as events that resulted in some level of harm or potential harm to the patient, for both home health care and hospice care patients. This is a summary of the data; a downloadable spreadsheet that provides all the data you will need for your presentation is also available below.
| Unit – Year |
LOS Less than 7 Days |
IPU Admission |
Pain Level 7-10 More than 24 Hours |
Inadequate Symptom Relief More than 24 Hours |
| Hospice 2014 |
50 |
47 |
13 |
13 |
| Hospice 2015 |
46 |
27 |
17 |
22 |
Quality improvement initiatives are a critical tool in the ongoing effort to improve patient care at health care organizations. But without data, many QI initiatives would fail — or the problem behind them might never be detected. That’s why data, and the dashboards that present data in a comprehensible fashion, are essential for QI efforts to succeed.
In this activity, you will assume the role of a quality assurance analyst at St. Anthony Medical Center. You will be offered both a dataset that you can use to outline a quality improvement initiative, and input from stakeholders who can help you contextualize the data.
Educational Goals
After completing the activity, you will be prepared to:
- Analyze data to identify a health care issue or area of concern.
- Outline a QI initiative proposal based on a selected health issue and supporting data analysis.
- Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work–life quality.
