Data analysis and Quality Improvement Initiative Proposal

Identify the type of data you are analyzing from your institution or from the Vila Health activity.

The Vila Health activity contains quantitative data. Quantitative data constitutes data that can be counted and expressed in numerical values. The data in the activity clearly points out the number of patients experiencing various events within St. Anthony Medical Center. The number of patients as expressed in the spreadsheet is an example of continuous data (Hulsebos et al., 2019), which is data that can assume any value depending on various other factors within the heath care institution.

Data analysis and Quality Improvement Initiative Proposal

Explain why data matters. What does data show related to outcomes?

Data is essential within any health care institution. It clearly points out the current situation of the facility and guides where improvement is needed. It facilitates better services, improved policies and is essential in informing decision making. Furthermore, data is important in the development of newer and more improved products and services.

Data collection facilitates the creation of holistic approaches to patients. In addition, data enables the creation of personalized treatment methods, creates advanced treatment methods, improves communication between health care providers and patients and most importantly enhances health outcomes (Pandey et al., 2020).

Analyze the dashboard metrics. What else could the organization measure to enhance knowledge?

            The Vila Health activity points out the length of stay within a hospice unit and compares data between 2014 and 2015. It further goes ahead to compare admissions into the integrated procedures unit (IPU) between the same years.

Pain levels among patients ranging between seven and ten and lasting more than twenty-four hours in addition to inadequate symptom relief for more than twenty-four hours is also compared between 2014 and 2015. The organization can also focus on the number of available health care professionals during each shift while also analyzing the relationship between health care professionals and patients.

Present dashboard metrics related to the selected issue that are critical to evaluating outcomes.

Length of hospital stay expresses the duration of time that a patient spends in hospital running from the time the patient is admitted to the day he or she is discharged. The length of hospital stay is represented as years, quarters, months, weeks, days or even hours (Martinez et al., 2018). The length of hospital stay may be used as a whole or may be split further into various categories dependent on the diagnosis.

Assess the institutional ability to sustain processes or outcomes.

To sustain processes or outcomes, it is important to embrace quality improvement initiatives as the new norm rather than an addition to the routine care offered. According to Rosen et al. (2018), self-evaluation is a key step in assessing achievements and outcomes in relation to the organization’s mission and vision.

This evaluation provides a report of where the organization is currently and provides an avenue to sustain desirable outcomes that have been achieved in reference to the data collected.

Evaluate data quality and its implications for outcomes.

Data quality informs how well-suited data is to accomplishing and serving its purpose. Within our health care facility, the data meets the criteria to be categorized as quality data. It is accurate, complete, consistent, timely and valid (Schmidt et al., 2019).

It provides a comparison of the number of patients experiencing various events within the health care setting between 2014 and 2015. Data quality means that the obtained data is accurate and can therefore be used for analysis of the organization’s current state and consequently inform decision making.

Examine the nursing process for variations or performance failures that could lead to an adverse event or near miss.

Nursing practitioners play a critical role in ensuring patient safety while consequently offering direct care to patients. As Colldén-Benneck et al. (2019) notes, nurses spend majority of the time with patients and play a major role in care coordination, communication with patients, while also closely monitoring patients for deterioration and identifying errors within the care delivery system.

A limited number of nurses within a unit during a specific shift may mean that the nurses may miss out on vital aspect as their focus is on a large number of patients resulting to adverse events or a near miss. Poor communication with patients may also lead to failure to identify complications early leading to adverse events or near miss.

Identify trends, measures, and information needed to critically analyze specific outcomes.

            Improvement of health care outcomes is dependent on effective measurement of outcomes through the collection of data. Within health care facilities, key outcome measures include mortality, readmissions, safety of care, effectiveness of care, patient experience, timeliness of care and the efficient and effective use of imaging (Cummings et al., 2018). The transparency of data is another important indicator in analyzing specific outcomes.

Specify desired outcomes related to prevention of adverse events and near misses.

Prevention of adverse events and near miss translates to a great reduction in the risk experienced by patients within care settings as individuals are not waiting for the harm to occur. Based on the findings by Sanko et al. (2018), triggering improvements within identified weak areas in the care delivery process is another desired outcome. Planning and implementation of harm mitigation strategies to counter harmful adverse events and near miss is a key desired outcome.

Analyze which metrics indicate future quality improvement opportunities.

            Metrics are essential as they communicate vital information regarding a process or activity within an organization consequently informing decision making. Metrics should be smart, measurable, attainable, realistic and timely (SMART) (Hady et al., 2020).

The length of stay is an essential metric that provides data regarding the efficiency of care. The longer the stay, the greater the risk of developing hospital acquired infections. Analyzing this metric provides an avenue for future improvement opportunities.

Determine benchmarks aligned to existing QI initiatives set by local, state, or federal health care policies or laws.

            Benchmarking offers a chance to compare and assess health care services within an institution against other health care organizations at the local, state or national level. The core principles associated with benchmarking within the health care setting include quality maintenance, improved customer satisfaction, improved patient safety and continuous improvement (Campbell et al., 2020).

A common benchmark within health care systems is the reduction of hospital acquired infections including central line-associated bloodstream infections, ventilator associated pneumonia and catheter associated urinary tract infections.

Identify any internal existing QI initiatives in your practice setting or organization related to the selected issue. Explain why they are insufficient.

Length of hospital stay can be improved through making certain procedures outpatient and reducing the time it takes for admission form the emergency department. In addition, ensuring proper placement of patients is also important.

Although these initiatives may go a long way in quality improvement, they may prove insufficient. Several other factors such as the patient’s financial status which are out of the institution’s reach may increase the length of stay overriding previous efforts.

Evaluate external national or international QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and nongovernmental bodies on quality improvement.

Implementation of process changes is essential in addressing the length of stay in health care settings. Responsible authorities can establish a governance program that oversees the implementation of standard clinical processes systemwide with the aim of reducing care variation and consequently ensuring activities of the institution align with those of larger organizations. For instance, Azimi et al. (2020) showed that data driven improvement initiatives led to a 0.6-day reduction in the length of stay while also saving approximately $24 million across the health care system.

Define target areas for improvement and the processes to be modified to improve outcomes.

Key target areas for improvement so as to achieve desired outcomes include the leadership structure, financial alignment and focus on staff members. The leadership structure is essential in implementation of any quality improvement initiatives as they provide a platform and resources to improve outcomes. Engaging staff members is important as they play a vital role in achieving the quality improvement initiatives.

The process entails having a clearly defined improvement goal and clearly outlining strategies aimed at achieving the set goals and objectives (Shorey et al., 2019). Writing down the action plan towards achieving the objectives is a good modification that can be made to improve desired outcomes.

Propose evidence-based strategies to improve quality.

Quality improvement in healthcare is important and geared towards making health care effective, safe, patient centered, timely, equitable and efficient. Evidence based strategies aimed at improving quality in health care settings include establishing a quality improvement infrastructure as well as application of proven quality improvement strategies and tools (Li et al., 2018). Integrating and optimizing health information technology is a key step towards improving quality within any setting.

Analyze challenges that meeting prescribed benchmarks can pose for a health care organization and the interprofessional team.

            Each health care institution is faced by various challenges affecting the interprofessional team as they strive to meet prescribed challenges. Ethnic differences presenting challenges in cultural beliefs, language disparities and consequently communication hinderances are some of the challenges that make it difficult to achieve prescribed benchmarks (Wiens et al., 2019).

Define interprofessional roles and responsibilities relating to data and the QI initiative.

The management structure of the facility has a role to play in data analysis. Through engagement of other key partners including health care professionals and other vital stakeholders, they will sit down and identify improvements and weaknesses that require to be addressed.

Donovan et al. (2018) contends that a team may be constituted comprising of all parties involved with the aim of coming up with strategies aimed at improving outcomes with input being taken from all involved parties to ensure fairness and that no single individual feels left out. The proposed strategies will then be implemented by all including the management team and staff members so as to achieve set goals and objectives.

Explain how to ensure all relevant interprofessional roles are fully engaged in this effort.

Clearly defining the roles of each and every team involved is an important first step in ensuring all parties remain fully involved. This is followed by the provision of a platform that facilitates interaction and allows exchange of ideas. Rewarding and recognizing outstanding teams is key in ensuring all are involved in the task at hand.

Facilitating and encouraging open communication through forums such as team building activities fosters cohesion and ensures that the team is driven towards achieving the objectives (Tadic et al., 2020). Sharing relevant knowledge, insights and resources is another key step in ensuring full engagement by all involved parties.

Identify how outcomes will be measured and data used to inform interprofessional team performance related to specific tasks.

Assessment of outcomes involves testing the adherence to the new or revised practices. According to Schmutz et al. (2019), it also involves assessing by how the new guidelines are steered towards achieving patient centered care while also improving patient experience and satisfaction regarding the quality of care. The data obtained from these assessments will be key in informing the interprofessional team of which practices to continue with and those that require modification or dropping.

Reflect on the impact of the proposed initiative on work-life quality of the interprofessional team.

Working together on the quality improvement initiative fosters cohesion and collaboration among team members. This translates to improved communication which is consequently important in improving quality of care given to patients.

Reducing the length of stay means that there are fewer patients that require to be attended to. This minimized the strain on health care professionals as they offer health care consequently improving the quality of care to the available patients (Shabir et al., 2020). Reduced length of stay translates to improved bed management efficiency translating to increased profits which is a plus for the management of the institution.

Describe how the initiative enhances work-life quality due to improved strategies supporting efficiency.

Reduced length of stay translates to fewer patients at a particular time within the unit. This means there is reduced work for the health care professionals translating to fewer incidences of staff being overburdened and consequently burnout (Holland et al., 2019).

There is also grater job morale and motivation as positive results of care are evident translating to improved job satisfaction. All this are important in improving the overall quality of care and communication between patients and health care professionals.

Identify interprofessional communication strategies that will help to promote and ensure the success of the QI initiative.

Communication amongst the interprofessional team members is critical to achieve success of the quality improvement initiative. It is important to employ engaged listening which involves actually listening and trying to comprehend and understand what is being said.

Using non-verbal communication including hand gestures during discussions is important during communication to ensure involved parties remain attentive. Being clear and concise, exuding confidence, having an open mind and demonstrating empathy are other important features of communication that are vital in achieving success as a team (Renfro et al., 2018).

Confidence makes it clear to other team members that one is sure of what he or she is saying. Having an open mind and demonstrating empathy makes it possible to be receptive of other people’s thoughts and opinions which is important to minimize or eliminate conflicts consequently translating to success. Being clear and concise while communicating means that everyone hears and comprehends what is being said and consequently acts on what was discussed.

It also minimizes the need for repetition. Exchanging feedback is another important component of communication and facilitates the exchange of ideas and proposals among team members who consequently act upon received feedback.

Identify communication models.

The Situation Background Assessment Recommendation (SBAR) is a technique employed in facilitating communication between members of a health care team regarding a patient’s condition. This communication model is quite easy to comprehend and recall. It is practically useful in framing most conversations, especially critical conversations that need to be acted upon almost immediately.

This communication techniques makes it possible to establish expectations of what the conversation hopes to achieve, while at the same time outlining how team members will work so as to achieve set goals and expectations (Shahid et al., 2018).

This is a critical component of developing teamwork while at the same time enhancing patient safety and satisfaction. The major goal of this communication technique is to standardize conversations and the communication process in general so as to improve both the effectiveness and efficiency of communication.

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Assessment 3: Instructions: Data Analysis and Quality Improvement Initiative Proposal

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Prepare an 8-10 page data analysis and quality improvement initiative proposal based on a health issue of interest. Include internal and external benchmark data, evidence-based recommendations to improve health care quality and safety, and communication strategies to gain buy-in from all interprofessional team members responsible for implementing the initiative.

Introduction

Health care providers are perpetually striving to improve care quality and patient safety. To accomplish enhanced care, outcomes need to be measured. Next, data measures must be validated. Measurement and validation of information support performance improvement. Health care providers must focus attention on evidence-based best practices to improve patient outcomes.

Health informatics, along with new and improved technologies and procedures, are at the core of all quality improvement initiatives. Data analysis begins with provider documentation, researched process improvement models, and recognized quality benchmarks. All of these items work together to improve patient outcomes. Professional nurses must be able to interpret and communicate dashboard information that displays critical care metrics and outcomes along with data collected from the care delivery process.

For this assessment, use your current role or assume a role you hope to have. You will develop a quality improvement (QI) initiative proposal based on a health issue of professional interest. To create this proposal, analyze a health care facility’s dashboard metrics and external benchmark data. Include evidence-based recommendations to improve health care quality and safety relating to your selected issue. Successful QI initiatives depend on the support of nursing staff and other members of the interprofessional team. As a result, a key aspect of your proposal will be the communication strategies you plan to use to get buy-in from these team members.

 

Preparation

To develop the QI initiative proposal required for this assessment, you must analyze a health care facility’s dashboard metrics. Choose Option 1 or 2 according to your ability to access dashboard metrics for a QI initiative proposal.

Option 1(I have No access)

If you have access to dashboard metrics related to a QI initiative proposal of interest to you, complete the following:

    • 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. For example, in a hospital setting, you would contact the quality management department to obtain the needed data. It is your responsibility to determine the appropriate resource to provide the necessary data in your chosen health care setting. If you need help determining how to obtain the needed information, consult your faculty member for guidance.
    • Include in your proposal basic information about the health care setting, size, and specific type of care delivery related to the identified topic. Please abide by Health Insurance Portability and Accountability Act (HIPAA) compliance standards.

Option 2(Preferred  option Data sheet attached separately)

If you do not have access to a dashboard or metrics related to a QI initiative proposal:

    • Use the hospital data set provided in Vila Health: Data Analysis. You will analyze data to identify a health care issue or area of concern.
    • Include in your proposal basic information about the health care setting, size, and specific type of care delivery related to the identified topic.

Instructions

Use your current role or assume a role you would like to have. Choose a quality improvement initiative of professional interest to you. Your current organization is probably working on quality improvement initiatives that can be evaluated, so consider starting there.

To develop your proposal you will:

    • Gather internal and external benchmark data on the subject of your quality improvement initiative proposal.
    • Analyze data you have collected.
    • Make evidence-based recommendations about how to improve health care quality and safety relating to your chosen issue.

Remember, your initiative’s success depends on the interprofessional team’s commitment to the QI initiative. Think carefully about these stakeholders and how you plan to include them in the process, as they will help you develop and implement ideas and sustain outcomes. Also, remember how important external stakeholders, such as patients and other health care delivery organizations, are to the process. As you are preparing this assessment, consider carefully the communication strategies you will employ to include the perspectives of all internal and external stakeholders in your proposal.

The following numbered points 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 proposal addresses all of the content below. (use of this bullets point more preferred). You may also want to read the scoring guide to better understand the performance levels related to each grading criterion.

1: 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 Vila Health activity.
  • Explain why data matters. What does data show related to outcomes?
  • Analyze the dashboard metrics. What else could the organization measure to enhance knowledge?
  • Present dashboard metrics related to the selected issue that are critical to evaluating outcomes.
  • Assess the institutional ability to sustain processes or outcomes.
  • Evaluate data quality and its implications for outcomes.&

2: Determine whether any adverse event or near-miss data needs to be factored in to outcomes and recommendations.

  • Examine the nursing process for variations or performance failures that could lead to an adverse event or near miss.
  • Identify trends, measures, and information needed to critically analyze specific outcomes.
  • Specify desired outcomes related to prevention of adverse events and near misses.
  • Analyze which metrics indicate future quality improvement opportunities.

3: Develop a QI initiative proposal based on a selected health issue and supporting data analysis.

  • Determine benchmarks aligned to existing QI initiatives set by local, state, or federal health care policies or laws.
  • Identify any internal existing QI initiatives in your practice setting or organization related to the selected issue. Explain why they are insufficient.
  • Evaluate external national or international QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and nongovernmental bodies on quality improvement.
  • Define target areas for improvement and the processes to be modified to improve outcomes.
  • Propose evidence-based strategies to improve quality.
  • Analyze challenges that meeting prescribed benchmarks can pose for a health care organization and the interprofessional team.

4: Communicate QI initiative proposal based on interdisciplinary team input to improve patient safety and quality outcomes and work-life quality.

  • Define interprofessional roles and responsibilities relating to data and the QI initiative.
  • Explain how to ensure all relevant interprofessional roles are fully engaged in this effort.
  • Identify how outcomes will be measured and data used to inform interprofessional team performance related to specific tasks.
  • Reflect on the impact of the proposed initiative on work-life quality of the interprofessional team.
  • Describe how the initiative enhances work-life quality due to improved strategies supporting efficiency.

5: Determine communication strategies to promote quality improvement of interprofessional care.

  • Identify interprofessional communication strategies that will help to promote and ensure the success of the QI initiative.
  • Identify communication models, such as SBAR and CUS, to include in your proposal.
    • SBAR stands for Situation, Background, Assessment, Recommendation.
    • CUS stands for “I am Concerned about my resident’s condition; I am Uncomfortable with my resident’s condition; I believe the Safety of the resident is at risk.”
  • Consult this resource for additional information about these fundamental evidence-based tools to improve interprofessional team communication for patient handoffs:

6:Communicate QI initiative proposal in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.

7: Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.

Example Assessment: Refer to QI Initiative Proposal Exemplar [PDF] for an idea of what an assessment given a proficient or higher rating on the scoring guide would look like.

Additional Requirements

  • Submission length: 8-10 typed, double-spaced pages of content plus title and reference pages.
  • Font: Times New Roman, 12 point.
  • Number of references: Cite a minimum of five current scholarly and/or authoritative sources to support your QI initiative proposal. Currentmeans no older than 5 years unless a seminal work.
  • APA formatting: Citations and references need to adhere to APA style and formatting guidelines. Consult these resources for an APA refresher:

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

  • Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
    • Determine whether any adverse event or near-miss data must be factored in to outcomes and recommendations.
  • Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
    • Develop 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.
    • Communicate QI initiative proposal, based on interdisciplinary team input, to improve patient safety and quality outcomes and work-life quality.
  • Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
    • Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.
    • Determine evidence-based communication strategies to promote quality improvement of interprofessional care.
    • Communicate QI initiative proposal in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.