Data analysis and quality improvement initiative proposal

Prepare an 5-7-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 inter-professional team who will implement the initiative.

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.

Dashboard Metrics

In 2018 Lehigh General Hospital (218 beds) has shown more healthcare associated infections (HAIs) than predicted

Lehigh General Hospital 2018 SIR Report (4 Quarters)

SIR Q1 Q2 Q3 Q4
CLABSI <1.0 1.045 1.339 3.695 3.633
CAUTI <1.0 3.769 2.903 2.324 2.281
C diff <1.0 0.677 1.134 1.218 1.471

 

CLABSI – central line-associated bloodstream infection

CAUTI – catheter-associated urinary tract infection

C diff – Clostridioides difficile is a bacterium that causes diarrhea and colitis

SIR – Standardized infection ratio

The Standardized Infection Ratio (SIR) is the primary summary measure used by the National Healthcare Safety Network (NHSN) to track healthcare associated infections (HAIs). SIR greater than 1.0 indicates that more HAIs were observed than predicted; conversely, an SIR less than 1.0 indicates that fewer HAIs were observed than predicted.

https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf

 

 

EACH AREA BELOW (1 to 6) MUST BE COVERED

  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 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.
  2. 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 inter-professional team.
  2. Integrate inter-professional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality.
    • Define inter-professional 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 inter-professional team.
    • Briefly reflect on the impact of the proposed initiative on work-life quality of the nursing staff and inter-professional team. Describe how work-life quality is improved or enriched by the initiative.
  2. Apply effective communication strategies to promote quality improvement of inter-professional care.
    • Identify the kind of inter-professional 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.
  2. Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
  3. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

 

Number of references: Cite a minimum of five sources (no older than seven years, unless seminal work) of scholarly, peer-reviewed, or professional evidence that support your evaluation, recommendations, and plans.

 

 

You can use these references if you want but don’t need to

Quality Improvement Examples and Results

These resources explore the effectiveness and lessons learned from various quality improvement initiatives.

These articles showcase examples of strategic QI projects.

This resource evaluates a QI initiative based on a communication strategy.

Benchmarks for Quality Indicators

These databases provide recognized benchmarks for quality indicators.