cf_qi_initiative_propEXAMPLE.pdf

Running head: QUALITY IMPROVEMENT INITIATIVE PROPOSAL 1

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Data Analysis and Quality Improvement Initiative Proposal

Learner’s Name

Capella University

Quality Improvement for Interprofessional Care

Data Analysis and Quality Improvement Initiative Proposal

Month, Year

Comment [JS1]: Good job with the
submission. It follows the rubric. For

the most part is written in scholarly

voice. The submission is clear and

concise. References and citations are

used to support your opinion and

position with relevant evidence.

Please see my tracked changes for

areas of revision.

QUALITY IMPROVEMENT INITIATIVE PROPOSAL 2

Data Analysis and Quality Improvement Initiative Proposal

I. Introduction

Health care professionals are constantly striving to improve the quality of care and safety

provided to their patients. The culture of care quality and patient safety depends on a strong and

supportive work environment that promotes leadership, evidence-based practice, effective

communication, and interprofessionalism. Nurse leaders play a crucial role in establishing this

culture and directly influence quality outcomes across an organization.

II. Problems and Needs

The role of nurse leaders in maintaining the quality in the nursing and clinical

departments is discussed using the example of TrueWill General Hospital (TGH), a

multispecialty hospital in the United States. As part of an annual assessment of organizational

quality, the hospital’s quality management office completed its analysis of dashboard metrics for

the surgical units for the year 2016–2017. The office released the data in its Quality and Safety

Report 2016–2017. The surgical units’ data included adverse events and near misses and used

four quality indicators: length of stay (LOS) exceeding 7 days, patient readmission rates, pain

level between 7 and 10 for more than 24 hours, and patients with pressure ulcers.

III. Proposed Solution

The results of the analysis showed that three quality indicators—pain levels, readmission

rates, and pressure ulcers—performed below the hospital’s benchmarks (see Table 1 and

Appendix for data and descriptions of indicators and benchmarks). The connection between these

indicators and the services of the surgical units’ nurses will be discussed in this proposal for a

quality improvement initiative. The proposal will analyze the relational patterns between the

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QUALITY IMPROVEMENT INITIATIVE PROPOSAL 3

indicators and the data, identify assumptions governing health care quality and nursing

characteristics, determine methods to discover the root causes of quality issues, and recommend

a framework as well as strategies to improve quality outcomes in the surgical units.

Analysis of Dashboard Metrics to Identify Quality Issues

The patients who require round-the-clock perioperative care are admitted to TGH’s

surgical units, which are equipped for general, orthopedic, urologic, and ambulatory surgery. The

critical nature of patients admitted to these units makes quality and safety the units’ highest

goals. Quality and safety outcomes are regularly evaluated. The units are staffed by teams of

interdisciplinary professionals: physicians, nurses, therapists, dieticians, pharmacists, and

ancillary medical staff.

Table 1

Quality and Safety Report 2016–2017

Unit – Year

LOS

exceeding 7

days

Patient

readmission

Pain level

between 7 and

10 for more

than 24 hours

Patients with

pressure

ulcers

Total

Surgical

2015
43 29 15 14 101

Surgical

2016
31 43 30 25 129

The data available from the Quality and Safety Report in Table 1 revealed that the

annual patient readmission rates increased from 29 incidents in 2016 to 43 in 2017. Similarly,

the number of patients who experienced pain for more than 24 hours without relief doubled

from 15 in 2016 to 30 in 2017. Pressure ulcers, a common quality and safety issue in surgical

patients, also increased to 25 from 14 in 2016. Conversely, the units reported a drop in the

number of patients whose LOS exceeded 7 days—from 43 in 2016 to 31 in 2017.

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QUALITY IMPROVEMENT INITIATIVE PROPOSAL 4

The outcomes are a cause for concern because they can affect the hospital’s

stakeholders—the patients, health care professionals, and the organization—in various ways.

Patient readmissions are a costly outcome for TGH because the Patient Protection and Affordable

Care Act, through its Hospitals Readmissions Reductions Program, financially penalizes

hospitals with higher than expected readmissions (Bartel, Chan, & Kim, 2014). Hefty penalties

are enforced because readmissions are thought to be the result of poor follow-up care (Abelson,

2013).

Furthermore, studies have found an association between LOS and the risk of

readmissions. Bartel et al. (2014) reviewed prior literature on the impact of decreasing patient

LOS and increasing readmission rates and concluded that a patient who stays for an additional

day may reach a higher level of stability. At TGH, health care professionals may have faced

immense pressure to reduce patient LOS to control per capita health costs. The pressure could

have forced the units’ nurses and doctors to rush through patient care plans and hasten the

process of educating patients regarding post-discharge behavior. Furthermore, patients who are

readmitted may lose trust in the ability of their health care providers to provide complete and

quality care.

Just as readmissions are a quality issue that affects all stakeholders, high pain levels and

pressure ulcers affect the surgical units’ nurses and patients. This inference is based on the theory

of nurse-sensitive patient outcomes, which explains that pain and pressure ulcers are patient

outcomes that depend on the quantity and quality of nursing (Stalpers, de Brouwer, Kaljouw, &

Schuurmans, 2015). Based on this inference, it can be assumed that there could be issues in the

performance and quality of nursing in TGH’s surgical units.

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QUALITY IMPROVEMENT INITIATIVE PROPOSAL 5

Moreover, there is evidence linking pressure ulcers and postoperative pain to a higher

risk of readmissions (Kirkner, 2017; Lyder et al., 2012). While TGH’s data do not directly link

pressure ulcers and pain to readmission rates, it is possible to theorize that reducing pressure

ulcers and pain in patients will also reduce readmissions. Therefore, the surgical units’ nurses can

help prevent readmissions by preventing ulcers and managing pain in patients more efficiently.

The standard of nursing quality is an important predictor of favorable quality outcomes.

Based on the analysis of the data in the report, TGH’s nurse leaders met with the units’ nurses to

examine the nursing factors that contributed to the unfavorable outcomes. The nurse leaders

identified the problem to be the transactional leadership style practiced by the perioperative

charge nurses. Transactional leadership is defined as an exchange relationship that clearly

distinguishes the follower from the leader and is focused on the contingent reward system with

individuals being rewarded or punished based on their performance (Thomas, 2016).

Transactional leadership may have become the dominant style of leadership in TGH’s surgical

units because of the lack of training and incompetence among nurses. The nurse leaders decided

to change the leadership style of charge nurses with a quality improvement (QI) initiative based

on the data analysis. The proposal for the QI initiative will identify an ideal leadership style and

propose strategies to implement the style. Knowledge gaps or areas of uncertainty that require

further evaluation will also be discussed in the proposal.

Outline for the Quality Improvement Initiative Proposal

Charge nurses occupy a frontline position in influencing the staff engaged in patient care

(Thomas, 2016). They are responsible for functions such as coordinating and evaluating nurse

staffing plans, balancing unit budgets, and making patient assignments. However, the

transactional leadership at TGH was ineffective because the charge nurses were not skilled

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Comment [JS2]: This reference is
too old to be viable for relevant
evidence-based practice. In health
care, it is important to use up-to-date
references that are not more than 5

years old. I might suggest finding a

more recent reference.

QUALITY IMPROVEMENT INITIATIVE PROPOSAL 6

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

enough to notice nurse dissatisfaction, prevent conflicts and competition among the nurses, or

establish effective communication channels. The surgical units’ nurses were not given any

guidance by the charge nurses on accomplishing quality improvement tasks or participating in

collaborative and interprofessional efforts. Because of the transactional leadership’s tendency to

reward or punish staff based on performance (Thomas, 2016), the nursing staff paid more

attention to accomplishing tasks such as discharging patients quickly than to ensuring patient

satisfaction.

The QI initiative will provide strategies that support the transition from transactional to

transformational leadership. Transformational leaders focus on internalizing ethical and

professional values in their team members and assist in aligning those values with organizational

goals. A transformational leader’s optimism, selfless service, and creativity motivate and

encourage teams. It is worth noting that the motivational and inspirational aspects of

transformational leadership will significantly change the work environment and the nurses’

commitment to the organization (Thomas, 2016).

The quality improvement model that is best suited to introduce and implement

transformational leadership is the Plan-Do-Study-Act (PDSA) model. Hence, the model will

serve as the framework for the QI initiative. The model is effective when there is a need for

accelerated change, as in TGH’s case. The four steps of the framework can effect systemic

change that will promote long-term improvement and implementation of the initiative on a larger

scale. Various strategies incorporated into the PDSA steps will be discussed briefly (Thomas,

2016). 1. Plan: This step involves setting up an interdisciplinary team. While the nurse

leaders already identified the problem to be transactional leadership through

discussions and the analysis, the interprofessional team will validate the previous

QUALITY IMPROVEMENT INITIATIVE PROPOSAL 7

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

results using a Multifactor Leadership Questionnaire survey. The survey will be

distributed to the nurses as well as other perioperative health care professionals.

After the results of the survey are analyzed, the team will define achievable goals

such as establishing a transformational leadership style and improving the

affected quality indicators.

2. Do: In this step, the team, with support from the organization, will create a

strategic plan to achieve the defined goals. Examples of strategies include

introducing training modules for leadership development and quality and safety

education.

3. Study: The results from the implementation of strategies devised in the previous

steps are analyzed. Observations are based on different interprofessional

perspectives and are set against the performances of TGH’s surgical units, not just

nursing.

4. Act: In the final step of the PDSA model, the goals set in step one are reevaluated

to determine whether the strategies were effective. TGH can carry out the step by

calculating data on the four quality indicators and noting increases or decreases in

the quality outcomes. Based on that evaluation, the PDSA cycle is deemed

complete or renewed with new goals and strategies.

Despite the effectiveness of the PDSA model, knowledge gaps and areas of uncertainty

may still affect the QI process. First, the use of just four indicators to measure quality outcomes

in the surgical units can give a partial or narrow understanding of the issues. Further evaluation

should be done using indicators such as mortality and patient satisfaction and nurse-sensitive

indicators such as nurse perception of job and level of nursing education.

QUALITY IMPROVEMENT INITIATIVE PROPOSAL 8

Secondly, the data only shows problems affecting the hospital’s surgical units.

Foundational theories such as systems theory explain how problems in one part of the

organization affect performance and quality outcomes in other parts. However, there is a lack of

data on quality issues from other departments at TGH that could be connected to the issues seen

in the surgical unit. Therefore, the team spearheading the QI efforts can take steps to include data

from other units and departments to create a comprehensive QI initiative. Another area of

uncertainty is the studies connecting nursing leadership and patient outcomes. Most studies do

not test whether nursing leadership directly improves patient outcomes; they merely analyze the

connection conceptually. Understanding the relationship between leaders and patient outcomes

requires interventions and longitudinal studies with continuous observations (Wong, 2015).

To achieve better patient outcomes by changing the nursing leadership, the proposed QI

initiative will be guided by various interprofessional perspectives. The perspectives will support

patient safety, cost-effectiveness, and work-life quality for nurses and other units’ staff. Each

perspective will address an aspect relevant to TGH, such as leadership and teamwork. The

discussion will also identify assumptions that highlight the importance of these perspectives.

Integration of Interprofessional Perspectives That Support Quality Improvement

Over the years, efforts to improve health care quality and safety drew inspiration from

various interprofessional perspectives. The perspectives important to TGH are leadership theory,

systems theory, and collaborative relationships. The identification of these specific perspectives

and their integration into the hospital’s QI initiative are based on assumptions made on the

factors that influence patient outcomes.

One assumption is that health care systems are interconnected and problems in one unit

or department can affect other parts of the system (Huber, 2017); problems in the surgical units

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QUALITY IMPROVEMENT INITIATIVE PROPOSAL 9

can affect the quality of other hospital departments. When quality is compromised in multiple

departments, the organization will be unable to function properly and achieve its goals of

providing quality and safe care for patients. Poor nursing performance and quality also affect the

performance of doctors, therapists, pharmacists, dieticians, and other interdisciplinary

professionals working in the surgical unit. These health care professionals work alongside nurses

and depend on them to carry out care plans effectively, quickly, and cost-effectively.

Another assumption is that nurse leaders such as charge nurses can learn and develop

leadership attributes (Thomas, 2016) that will help them improve their leadership style.

However, leadership development can only take place if the organization is supportive and

allocates appropriate resources and facilities. The third and last assumption guiding the

conceptual basis of the initiative is that anyone—not just executives or managers—can practice

leadership (Smith-Trudeau, 2016).

The main theme explored in these assumptions is leadership; it is an important systems

theory factor and collaborative relationships are influenced by leadership styles. Although the

connection between leadership and patient safety needs to be further evaluated, experts agree that

certain leadership styles obtain better results than others do. In particular, experts have compared

the effectiveness of transactional leadership to transformational leadership in achieving patient

safety. Transactional leadership, as was observed in TGH, is ineffective, as it focuses on rewards

rather than outcomes. Conversely, transformational leadership engenders a higher level of

competence that helps in guiding and motivating team members to follow a higher level of ethics

and evidence-based care, thereby improving the outcomes for patients (Thomas, 2016).

Transformational leaders are also more competent when introducing cost-reduction plans while

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10 QUALITY IMPROVEMENT INITIATIVE PROPOSAL

maintaining quality in their units. They are more skilled than transactional leaders at

organizational and administrative management, which is an essential skill for budgeting.

Transformational leadership is also the preferred leadership strategy in implementing

systems theory approaches. Systems theory is important in QI, as it focuses on understanding

root causes and symptoms of quality and performance problems (Huber, 2017). By

understanding latent causes of quality issues, TGH can focus on proactive quality measures that

prevent quality and safety issues in the long term. Such approaches are known to be cost-

effective and sustainable.

Transformational leadership’s focus on people through effective interpersonal

relationships and charismatic influence is also beneficial for establishing collaborations among

teams and developing optimum work-life quality for staff. The surgical units at TGH, consisting

of interprofessional staff, depend on a sense of shared goals among staff. The nurses are the

largest staff group in the surgical units and issues within their workforce such as nonalignment

of goals affect other units’ staff. Transformational leaders are capable of guiding nurses in

building respectful and positive relationships with their colleagues.

These interprofessional perspectives will act as guides for the QI team as they implement

the PDSA steps. The perspectives are especially useful in facilitating open and transparent

communication. The QI proposal will suggest communication strategies that are imperative

when expanding the proposal into a full-fledged QI program. The proposal will also provide

assumptions that will guide those suggestions.

Effective Communication Strategies to Promote Quality Improvement

Communication is a key leadership duty and facilitates the smooth functioning of different

organizational systems (Huber, 2017). Without effective communication methods,

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QUALITY IMPROVEMENT INITIATIVE PROPOSAL 11

leaders will not be able to convey organizational goals and decisions or implement QI changes.

At TGH, the charge nurses could not communicate care plans to their nursing staff or coordinate

with other units’ leaders and interdisciplinary professionals to achieve ideal outcomes. Their

ineffective communication methods also set a bad example for the nursing staff, who look to

their leaders for guidance and instruction.

Therefore, it is important to develop communication strategies before the QI strategies

are implemented. Well-defined communication channels will promote interprofessional efforts in

patient care and quality improvement. The assumptions guiding the strategies are as follows: (a)

Leaders facilitate and mediate effective interprofessional collaborations in care delivery, which

can only happen if the leaders are competent in communication skills; (b) Quality improvement

is a resource-intensive effort, but coordinating and utilizing those resources requires open and

honest communication among organization, patients, and interprofessional staff; (c) Nursing

autonomy in decision making is important for improving the performance of nursing staff, but

autonomy is a product of mutual respect and effective communication among all

interprofessional staff, including management and administrative staff.

Based on these assumptions, a few communication strategies to implement the QI

initiative and promote interprofessional care or teamwork are recommended. The strategies are

as follows: (a) training the QI team in verbal, nonverbal, written, and electronic means of

communication, which will improve relations within the team and will be useful during

interprofessional collaborations; (b) setting up team documentation, where all team members

will enter details of ideas, meeting minutes, and QI-related data; during the Do stage of the

PDSA, team documentation will be implemented at the unit level and all staff present during a

patient visit will enter details into the patient record, assist with order entry, and

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QUALITY IMPROVEMENT INITIATIVE PROPOSAL 12

process prescriptions (Bodenheimer & Sinsky, 2014); (c) setting up a weekly QI team meeting

where team members will receive a copy of the agenda in advance and provide feedback on

meeting goals; post-meeting, members will be sent copies of all communication via e-mail to

maintain transparency (Thomas, 2016); and (d) briefing units’ staff on decisions made in these

meetings and, when needed, e-mailing summaries of the meeting minutes to all staff members so

specific groups or individuals will not feel excluded from the QI efforts.

As the QI process progresses, the team can add more communication strategies into the

PDSA model or make improvements to the existing strategies. After all, the PDSA model for

quality improvement was selected because it allows experimentation, quick pilot testing of plans,

and implementing the plans on a larger scale after analyzing the results (Thomas, 2016). The

onus of organizing and coordinating the QI efforts falls on the nurse leaders heading the team.

They must develop their leadership competency to inspire similar changes in the charge nurses.

IV. Conclusion

Data- and outcome-driven organizations must constantly analyze their quality indicators

and implement changes that improve all clinical and organizational outcomes. Quality and safety

evaluations, such as the one conducted at TGH, often reveal hidden issues that are influencing

patient outcome negatively, such as ineffective leadership styles. Leadership is important in

uncovering the latent problems and implementing changes that improve quality and safety.

However, as displayed at TGH, leadership itself depends on factors such as interprofessional

care and teamwork, communication, and highly qualified health care professionals. The absence

of these factors can affect patient outcomes drastically. Understanding this interdependence

among organization, leadership, and staff is key to high-quality performance and patient safety.

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QUALITY IMPROVEMENT INITIATIVE PROPOSAL 13

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References

Abelson, R. (2013, March 29). Hospitals question Medicare rules on readmissions. The New York

Times. Retrieved from http://nytimes.com/2013/03/30/business/hospitals-question-

fairness-of-new-medicare-rules.html

Bartel, A. P., Chan, C. W., & Kim, H. (2014, September). Should Hospitals Keep Their Patients

Longer? The Role of Inpatient and Outpatient Care in Reducing Readmissions (Report

No. 20499). Retrieved from the National Bureau of Economic Research website:

http://nber.org/papers/w20499

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires

care of the provider. Annals of Family Medicine, 12(6), 573–576. Retrieved from

https://ncbi.nlm.nih.gov/pmc/articles/PMC4226781/

Huber, D. L. (2017). Leadership and nursing care management (6th ed.) Philadelphia: W.B.

Saunders. http://dx.doi.org/10.7748/nm.21.6.13.s14

Kirkner, R. M., (2017, May 7). Postop pain may be a predictor for readmission. ACS Surgery

News. Retrieved from http://mdedge.com/acssurgerynews/article/137637/pain/postop-

pain-may-be-predictor-readmission

Lyder, C. H., Wang, Y., Metersky, M., Curry, M., Kliman, R., Verzier, N. R., & Hunt, R. H.

(2012). Hospital‐acquired pressure ulcers: Results from the national Medicare patient

safety monitoring system study. Journal of the American Geriatrics Society, 60(9), 1603–

1608. Retrieved from http://henlearner.org/wp-content/uploads/2012/03/hospital-

acquired-pressure-ulcers.pdf

Smith-Trudeau, P. (2016). Nursing leadership at all levels: The art of self-leadership. Vermont

Nurse Connection, 19(4) 4–5. Retrieved from

Comment [JS3]: I would suggest
locating a more recent reference.

QUALITY IMPROVEMENT INITIATIVE PROPOSAL 14

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

http://web.a.ebscohost.com.library.capella.edu/ehost/pdfviewer/pdfviewer?vid=1&sid=63

1c6937-3dbc-466d-ba31-b5e5aec17013%40sessionmgr4010

Stalpers, D., de Brouwer, B. J. M., Kaljouw, M. J., & Schuurmans, M. J. (2015). Associations

between characteristics of the nurse work environment and five nurse-sensitive patient

outcomes in hospitals: A systematic review of literature. International Journal of Nursing

Studies, 52(4), 817–835. Retrieved from

http://sciencedirect.com.library.capella.edu/science/article/pii/S0020748915000061?_rdo

c=1&_fmt=high&_origin=gateway&_docanchor=&md5=b8429449ccfc9c30159a5f9aeaa

92ffb&ccp=y

Thomas, C. D. (2016). Transformational leadership as a means of improving patient care and

nursing retention (Doctoral dissertation). Retrieved from ProQuest. (Order No.

10125747).

Wong, C. A. (2015). Connecting nursing leadership and patient outcomes: State of the

science. Journal of Nursing Management, 23(3), 275–278. Retrieved from

http://onlinelibrary.wiley.com.library.capella.edu/doi/10.1111/jonm.12307/full

QUALITY IMPROVEMENT INITIATIVE PROPOSAL 15

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Appendix

Description of Quality and Safety Report 2015–2016

The Quality and Safety Report data for the year 2015–2016 represents four recognized

quality indicators in health care. The calculations are based on the total number of adverse events

and issues, differentiated by type, documented in TGH’s surgical units for 2015–2016. The

length of stay is calculated for patients who are admitted for more than 7 days. Patient

readmissions describe revisits by former surgical patients to the emergency department or

surgical units within 30 days of their discharge. The revisiting patients may sometimes require

additional hospital stay, which might be related to their surgical procedures.

The third indicator is based on medical pain where pain is rated on a scale of one to 10—

one being the mildest pain and 10 the most severe. TGH chose numbers between 7 and 10 on the

scale because a pain level between 7 and 10 that lasts for more than 24 hours is considered a

patient safety issue. The final indicator denotes pressure ulcers, which are injuries caused to skin

tissue resulting from prolonged pressure on the area. Patients bed-ridden after medical

procedures are at high-risk of pressure ulcers. The ideal benchmark for each indicator is zero,

which means that the goal of TGH is to prevent extended stays, readmissions, prolonged pain

without relief, and pressure ulcers in surgical patients.

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