MSN-FP 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

Sample Answer for MSN-FP 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal Included After Question

Data Analysis and Quality Improvement Initiative Proposal Overview 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: o 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. o Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.  Analyze data to identify a health care issue or area of concern.

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Questions to Consider

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. o How important is the role of nurses in QI initiatives? o What quality improvement initiatives have made the biggest difference? Why? o When a QI initiative does not succeed as planned, what steps are taken to improve or revise the effort?


NURS FPX 6610 Assessment 2 Patient Care Plan

A Sample Answer For the Assignment: MSN-FP 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

Title: MSN-FP 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

Quality improvement is the process followed to analyze the performance of an organization as well as efforts to improve performance (Dixon-Woods & Martin, 2016). Quality improvement programs are important because they result in improved outcomes for patients, enhanced staff efficiency and reduced waste linked to process failure. Hospitals handle lives and thus specific standards have to be met since even government and insurance reimbursement for patient care follows the health outcomes instead of procedures undertaken. Any quality improvement program should ensure that improvements are seen in areas like safety, effectiveness, access and patient-centeredness approach.  The purpose of this paper is to analyze data from Washington Hospital to establish a health care issue or area of concern, come up with a quality initiative proposal following the established health issues and supporting data analysis, integrate inter-professional perspectives to optimize safety, cost-effectiveness and work-life quality and apply effective communication strategies to enhance inter-professional care.

Health Care Issue

Hospital Overview

Washington Hospital always strives to meet the Institute for Healthcare Improvement recommendations, which are improved patient experience, improved population health and reduced cost of health care. WH is a 341-bed, acute care hospital that offers full range of care services and advanced medical technology and it was among America’s 100 best hospitals. The ratings are obtained from data collated from various departments and some of the quality indicators used are 30-day readmission rates, pain control, fall rate, and discharge information.

30-day readmission rate is selected because it ensures that the hospital has an incentive to enhance care coordination and communication and caregivers and patients are involved in post-discharge planning. The rates are also used by CMS to penalize hospitals whose rates are beyond the national standard. Actually any hospital with a high readmissions rate gets a 3% deduction in their Medicare payment (Wasfy et al., 2017). The discharge planning helps in reducing readmissions rates and at the same time helps in enhancing patient satisfaction with nursing care. Discharge planning offers tech back and post-discharge care information to the patients which enhances trust and self-management. The fall rates are calculated to reduce serious complication likes intracranial bleeds and fractures and ensure that patient safety within the hospital is optimized.

Data Preview

The unit managers at Washington Hospital closely follow patient outcomes and quality indicators. The unit managers ensure that all the practitioners are updated on the progress during the monthly staff unit. The last report that was generated indicated a remarkable improvement in all the four indicators; 30-day readmission rates, pain control, falls and discharge information as outlined in table 1 below. 

Table 1.

Washington Hospital Performance Report 2018-2019

Year     30-day readmission rate (target)    Discharge information (target)    Pain control                (target)         Falls (target)
2018              11.2 %                  (11.6%)                80.5%               (90.6%)                60.1%             (70.7%)            50      (0)
2019              9.4%                     (9.4%)                  85.3%               (90.6%)                66.2%             ( 70.7%)           40      (0)

As indicated in Table 1 above, the hospital has seen a reduction in the 30-day readmission rates since in 2018 the rates were 11.2% while in 2019 they have reduced to 9.4% as per the current month of the year. The reduced rates can be linked to the increased percentage in the amount of discharge information offered which currently stands at 85.3 % from 80.5% in 2018. Pain management is also used as an indicator of patient satisfaction and better scores motivate patients to come back for other services ad refer their family and friends to the hospital. The hospital target is 70.7% and the current score is 66.2%. Although it is an improvement from the previous score of 60.1%, the hospital still has a long way to meet the set targets. Additionally, the hospital fall rates are below the set mark of zero rates since the falls experienced in 2018 were 50 while in 2019 they are 40.

Response to Data

Comparing the data generated in the two years, there is an improvement in pain control, discharge information, readmissions rates, and unassisted falls. Nevertheless, there is a need to come up with a quality initiative to ensure that the set targets are achieved. Using the information presented in the hospital performance report, all inpatient unit managers were requested to schedule meetings with nursing and auxiliary staff to analyze the reason why the set targets have not been achieved and come up with QI initiative that can enhance the outcomes. From the discussion, all nurses agreed that although there was an improvement in most of the indicators, the most affected part was the fall rates. The efforts already in place which is the use of call lights seem to stall the reduction process and the unit managers proposed that the quality initiative required should target the fall rates and ensure that the zero rate target set is achieved. 

Quality Improvement Initiative Proposal

Intentional Rounding

There was an unanimous agreement that the quality initiative should help in handling fall rates. Patient fall rates are normally calculated using the number of fall events per 1000 patient days and the score indicates how a hospital maintains patient safety (Hicks, 2015). The initiative proposed was that the clinical nurse leader establishes an inter-professional team to implement a project that increases the day between patient fall events. The solution forwarded was enhancement of intentional rounding process and addressing the basic needs of the patients.  The project is borrowed from the AHRQ guidelines that postulate that intentional rounding is effective when targeting to reduce patient falls within a hospital (AHRQ, 2019). Hourly rounding helps nurses address patient needs like personal belongings, pain, position, and toileting needs.

Research also outlines that the use of intentional rounding minimizes the use of call lights among the patients, enhances patient satisfaction and reduces patient falls within the hospital setting (Jenko, Panjwani & Buck, 2019). Additionally, intentional rounding is defined as a structured approach where a nurse assesses patients at specific times to meet their fundamental needs. Intentional rounding follows six steps which are introducing oneself, expectations setting, questioning patient needs, using the 4 P’s which are positioning, placement, pain, and personal needs, offering the patient needs and documenting the care offered. Intentional rounding, therefore, offers patient-centered care which not only decreases patient risk evens but also enhances patient satisfaction.

Implementation Plan

To help in implementation, the project team established the root causes of fall events in the unit. The proactive risk assessment was used to establish the causes of falls within the hospital. The expected areas that may present as problematic are inconsistent intentional rounding, unreliable fall risk assessment, absence of an effective hand-off communication of high-risk patients and poor reports on falls data and event to frontline staff (Jenko, Panjwani & Buck, 2019).  From the assessment, the team realized that the hospital had inconsistent intentional rounding.

The team then decided to use the plan-do-study-act (PDSA) cycle to test changes seen in the hospital. The changes were to be assessed by measuring the current state of the fall events, analyzing and discovering fall causes, coming up with targeted solutions and lastly sustaining and spreading improvements. The project team came up with a visual cue laminated poster aimed at reminding the patients to request for assistance before visiting the bathroom or standing up. A daily monitoring tool was set to help in capturing data on the usefulness of the poster and a falls prevention brochure created to educate patients and families about falls. 

Standardizing Intentional Rounding

Although the AHRQ guidelines propose a multi-intervention approach, the hospital will adopt only two interventions, which are standardizing the intentional rounding and training patient and family on how to prevent falls (AHRQ, 2019). The project team expects that a standardized intentional rounding will reduce the fall rates to zero and it will handle toileting issues which are the major cause of the falls within the hospital. The unit leaders will have to also do their own rounding to assess how the nurses are communicating with patients and families on fall prevention. The unit leader will use a leader rounding tool to monitor the compliance levels of the unit staff.

Initiative Evaluation

The initiative will be analyzed by taking a baseline and current fall data obtained from the hospital quality database. Every fall event will be recorded and day between falls analyzed and then an analysis executed to monitor the changes in percentages of fall risk (Hicks, 2015). Every unit will have champions mainly a nurse and patient care technician who will be trained on how to fill the data collection form and execute the new work process. The nurse leader rounds will assist in assessing the staff competencies on patient rounding. The data obtained will then be analyzed by the project team and then a decision will be made on whether to maintain the project, make changes or plan another quality initiative.

Inter-professional Perspective

Prevention of hospital falls is crucial because they are linked to liabilities, delayed rehabilitation, increased patient length of stay and greater care costs (Jenko, Panjwani & Buck, 2019). To enhance the effectiveness of any quality initiative, there is a need to have inter-professional collaboration. Interprofessional collaboration offers clarity of professional roles and responsibilities, effective teamwork, common vision and coordination of action plans (Lasater et al., 2016). In the current initiative, the hospital aims at reducing fall rates through a standardized intentional rounding. Generally, falls prevention is left to nurses however it is a complex issue that should be approached using multiple perspectives.

Roles and Responsibilities

The proposed initiative will adopt an interprofessional perspective where the hospital administrators will be responsible for creating a safety culture and support the implementation of research-based clinical practice. The physician will help in conducting careful assessment of patient history, balance and mobility, peripheral nervous systems, cognition and medication review (Lasater et al., 2016).  Physiotherapists, on the other hand, will test the function of the patients as well as the walking and balance abilities. The assessment will be used by the nurses to establish patient at greater risk of falls to ensure that rounding efforts are maximized around these patients.  A selected nurse and patient care technician from each will collect the data that will be used for monitoring the project while the clinical nurse leader will lead the team and asses staff compliance to the project.

Use of High-Reliability Organization Model in the Intervention

To ensure that every member executes their roles as expected, training will be held and a monthly meeting set to address any setback found and reinforce the best practices. The project will also be handled using HRO model whose focus is safe reliable performance (Padgett et al., 2017). The project team will build expectations in their roles, routines, and strategies. The expectations will ensure that they follow an order and can predict the outcomes surrounding patient falls. The model also imparts mindfulness that will empower the team to manage unexpected events. The team will be able to establish early warning signs and thus will offer timely response towards unexpected events.

Work-Life Balance for the Team

The initiative expects to reduce the fall rates within the hospital. However, the effects expected are reduced length of stay, lesser readmissions and increased hospital safety (Khalifa, 2019).The reduced fall rates will enhance the work-life balance of the team because reduced readmissions and reduced length of stay mean that the emergency department will not be overcrowded. Beds will be available for patients and physicians will be able to offer quality care to their patients. research indicates that high numbers of patient increases chances of making errors thus number of errors will reduce in the hospital. Once the project achieves its objectives, the team will have an increased feeling of belonging to an efficient work community.  The level of staff burnout will decrease which eventually will reduce staff turnover and enhance the overall productivity of the hospital (Khalifa, 2019).

Communication Strategies

Interprofessional communication occurs when team members communicate in a collaborative and responsible manner (Foronda, MacWilliams & McArthur, 2016). To enhance communication, good listening skills will be fostered as well as mutual respect for all team members. All members will be offered a chance to contribute and an environment where they feel comfortable to give constructive feedback will be created. Additionally, members will be expected to communicate clearly and offer sufficient information. Any information required will be presented in a timely manner and appropriate health care providers will be notified of the patient’s condition (Foronda, MacWilliams & McArthur, 2016). The members will be expected to be polite and respectful, respond to other team members and review notes from nurses and other health care professionals.

To ensure a standardized approach to communication, the Situation, Background, Assessment, Recommendation (SBAR) tool will be used. Any message will be prepared using the SBAR framework and the messenger will ensure that the recipient of the message has understood the information. The tool will be used to communicate patient fall risk factors and suggest intervention, change in patient status, fall occurrence and environmental concerns (Reuben et al., 2017). The tool was selected because it outlines standardized prompt questions in four sections that ensure that information shared is focused and concise. It reduces the need for repetition reducing occurrence of errors and prompts team members to develop information using the right level of detail.


An analysis of Washington Hospital reveals that it has improved in almost all the indicators although it has not achieved the set targets. An evaluation from the unit managers led to a decision of reducing the fall rates to hit the set benchmark of zero rates. The selected initiative was standardizing intentional rounding and educating patients and families. The project is to be executed by an interprofessional team and they will be using the SBAR tool as their communication tool.


AHRQ (2019). Tool 3B: Scheduled Rounding Protocol | Agency for Healthcare Research & Quality. [online] Available at: [Accessed 3 Oct. 2019].

Dixon-Woods, M., & Martin, G. P. (2016). Does quality improvement improve quality?. Future Hospital Journal, 3(3), 191-194.

Foronda, C., MacWilliams, B., & McArthur, E. (2016). Interprofessional communication in healthcare: An integrative review. Nurse education in practice, 19, 36-40.

Hicks, D. (2015). Can rounding reduce patient falls in acute care? An integrative literature review. Medsurg Nursing, 24(1), 51.

Jenko, M., Panjwani, Y., & Buck, H. G. (2019). Intentional Rounding With Certified Nursing Assistants in Long-Term Care: A Pilot Project. Journal of gerontological nursing, 45(6), 15-21.

Khalifa, M. (2019). Improving Patient Safety by Reducing Falls in Hospitals Among the Elderly: A Review of Successful Strategies. Studies in health technology and informatics, 262, 340-343.

Lasater, K., Cotrell, V., McKenzie, G., Simonson, W., Morgove, M. W., Long, E. E., & Eckstrom, E. (2016). Collaborative falls prevention: interprofessional team formation, implementation, and evaluation. The Journal of Continuing Education in Nursing, 47(12), 545-550.

Padgett, J., Gossett, K., Mayer, R., Chien, W. W., & Turner, F. (2017). Improving patient safety through high-reliability organizations. The Qualitative Report, 22(2), 410-425.

Reuben, D. B., Gazarian, P., Alexander, N., Araujo, K., Baker, D., Bean, J. F.,  & Leipzig, R. M. (2017). The STRIDE Intervention: Falls Risk Factor Assessment and Management, Patient Engagement, and Nurse Co-management. Journal of the American Geriatrics Society, 65(12), 2733.

Wasfy, J. H., Zigler, C. M., Choirat, C., Wang, Y., Dominici, F., & Yeh, R. W. (2017). Readmission rates after the passage of the hospital readmissions reduction program: a pre–post-analysis. Annals of internal medicine, 166(5), 324-331.