Sample Answer for NUR 630 Benchmark – Hospital-Associated Infections Data Included After Question
The purpose of this assignment is to examine health care data on hospital-associated infections and
determine the best methods for presenting the data to stakeholders. Use the scenario below and the “Hospital
Associated Infections Data” Excel spreadsheet to complete the assignment.
You have been tasked with displaying Centers for Medicare and Medicaid Services (CMS) hospital quality
measures data for a 5-year period on four quality measures at your site. After examining the data, identify
trends and determine the best way to present the actionable information to stakeholders.
Create a 12-15-slide PowerPoint (not including title and reference slides) presenting the data to the
stakeholders. Address the following in your PowerPoint:
- What conclusions can be drawn for each quality measure over the 5-year period?
- What trends do you see for each quality measure over the 5-year period?
- When comparing each quality measure, is the quality measure better than, worse than, or no diferent from
the national benchmark over time?
- Based on your examination of the data, which of the quality measures should you prioritize and why?
- Develop a quality improvement metric and related measures to improve care processes, outcomes, and the
patient experience relating to the identifed area of opportunity.
- Explain how you would monitor the metric and use collected data for improvement.
Include a title slide, references slide, and comprehensive speaker notes.
- Refer to the resource, “Creating Efective PowerPoint Presentations,” located in the Student Success Center, for
additional guidance on completing this assignment in the appropriate style.
Page 19 Grand Canyon University 2022 © Prepared on: Feb 11, 2022
Use a minimum of two peer-reviewed, scholarly sources as evidence.
While APA style is not required for the body of this assignment, solid academic writing is expected, and
documentation of sources should be presented using APA formatting guidelines, which can be found in the
APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar
with the expectations for successful completion.
You are not required to submit this assignment to LopesWrite.
This benchmark assignment assesses the following programmatic competency:
MSN Leadership in Health Care Systems
6.6: Develop and monitor continuous quality improvement metrics and measures to improve care processes,
outcomes, and the patient experience.
A Sample Answer For the Assignment: NUR 630 Benchmark – Hospital-Associated Infections Data
Title: NUR 630 Benchmark – Hospital-Associated Infections Data
The promotion of safety, quality and efficiency in nursing practice is important. Nurses utilize best practice interventions to ensure that the optimum health outcomes of their populations are achieved. However, issues such as hospital acquired infections threaten the realization of such outcomes in patient care. Hospital acquired infection refers to those that patients develop while in the hospital setting. Hospital acquired infections are associated with adverse outcomes that include increase in the costs of patient care, prolonged hospital stay, and risk for mortality. Therefore, it is essential that nurses and other healthcare providers explore effective interventions that can be used to prevent hospital acquired infections in their practice.
The selected indicators for examination are four. They include surgical site infections post-colon surgery central-line associated blood stream infections, surgical site infections from abdominal hysterectomy, and catheter-associated urinary tract infections. The infections arise from the increased exposure of the patients to pathogens. It also arises due to the lack of aseptic and infection prevention interventions in healthcare. Central line and catheter-associated urinary tract infections arise from the poor handling of catheters and intravenous lines.
5-Year Trend for Catheter-Associated Urinary Tract Infections
The five year trend for catheter associated urinary tract infections for the hospital shows a declining trend from 2011 to 2015. Generally, the hospital witnessed a sharp decline in the rates of the catheter-associated urinary tract infections from 2011 through 2015. The sharp decline translates into the effectiveness of the interventions adopted in the organization to limit and prevent catheter-associated urinary tract infections.
5-Year Trend for Surgical Site Infections Post-Colon Surgery
The five-year trend of surgical site infections post-colon surgery reveals worrying trends. Accordingly, the statistics shows that the performance of the hospital in this quality indicator worsened over time. The worsening can be seen from the sharp rise in the rates of surgical site infections from 0.273 n 2011 to 3.55 in 2015. The implication of the worse performance is that the interventions that were adopted to prevent infections after colon surgery were ineffective. Therefore, the hospital needs to re-examine its interventions to identify areas of improvement to enhance the safety, quality, and efficiency of patient care.
5-Year Trend for Central Line-Associated Blood Stream Infections
The analysis of trends in the central line-associated blood stream infections for the hospital shows a slight rise in the rate of infections from 2011 to 2015. Accordingly, the rate of infection in 2011 was 2.845 rising to 3.422 in 2015. The data also shows that the interventions used between 2011 and 2012 to prevent central line-associated blood stream infections were effective. This can be seen from the decline in rate from 2.845 in 2011 to 2.203 in 2012. However, the hospital could not sustain the improvements as seen from the sharp rise in rates to 3.062 in 2015 and ending at 3.422 in 2015. Therefore, the hospital should re-examine the factors that caused the lack of sustained improvement in the indicator between 2013 and 2015.
5-Year Trend for Surgical Site Infections from Abdominal Hysterectomy
The analysis of the 5-year trend for surgical site infections from abdominal hysterectomy shows worsening in trends. For instance, there was a sharp rise in the rate between 2011 and 2015. Accordingly, the rate of infections in the hospital was 1.148 in 2011, rising to 4.608 in 2015. The hospital has been unsuccessful in implementing change interventions to address the issue across the above years.
National Comparison: Catheter-Associated Urinary Tract Infections
The comparison of the statistics of the hospital and national average for catheter-associated urinary tract infections shows that the hospital has been performing averagely in preventing the infections. The average performance can be seen from the lack of improvement in rates between 2011 and 2015. The initial performance of the hospital between 2011 and 2013 was worse than the national average. Improvements were seen in 2014 where the performance was better than the national average and 2015 when they were similar. It therefore remains uncertain whether the hospital will report an improvement, decline or stagnation of the rates in the years after 2015. As a result, adopting quality improvement interventions is recommended for the practice site.
National Comparison: Surgical Site Infections Post-Colon Surgery
The comparison of national and hospital data for surgical site infections after colon surgery shows declining trends. The hospital initially outperformed the national average in the rates of infections between 2011 and 2012. The rates were better than the national average. However, there was a sharp decline between 2014 and 2015 as seen from the worst performance in the hospital when compared to the national average.
National Comparison: Central Line-Associated Blood Stream Infections
The performance of the hospital when compared to the national average in central line-associated blood stream infections has been above average. This can be seen from the improvement in performance from worst than national average in 2011 to better than the national average in 2012 and 2013 and no different performance in 2014 and 2015. Therefore, the hospital should strive to improve its existing practices and processes to achieve better outcomes in the next years.
National Comparison: Surgical Site Infections from Abdominal Hysterectomy
The hospital performed poorly in the surgical site infections when its rates are compared with the national average. The poor performance can be seen from the change in performance from better than the national average to not different and worst than between 2012 and 2015. The worse performance implies that the systems and processes used to safeguard patient safety, quality and efficiency of care have been ineffective. As a result, revisions and quality improvement interventions are needed in the hospital.
Which Measures to Prioritize?
The measures to prioritize are surgical site infections due to abdominal hysterectomy and surgical site infections due to colon surgery. The need for the prioritization of these measures arises from the fact that the hospital has been performing poorly when compared to the national average. Unlike the other indicators, the hospital’s performance has been worst than the national average. The implication of the current performance is that the patients are increasingly predisposed to poor health outcomes if responsive interventions are not implemented. Therefore, priority measures should be adopted to ensure the optimum health and outcomes of the patients undergoing colon surgery and abdominal hysterectomy.
Quality Improvement Metrics and Metric Monitoring
A number of quality improvement metrics can be used in determining the effectiveness of the interventions used to prevent and reduce surgical site infections following abdominal hysterectomy and colon surgery in the hospital. One of them is determining the rates of surgical site infections before and after the implementation of improvement strategies. The determination of the rates will provide an accurate picture about the effectiveness of the adopted interventions. The second approach is undertaking the cost of care that surgical patients incurred before and after the implementation of improvement interventions.
The cost-differences will provide insights into the cost-efficiency and feasibility of the adopted interventions. The other metric is the average stay of surgical patients in the hospital before and after the implementation of the interventions (Oecd, 2017; Organization, 2017). A reduction in the average stay of hospital duration by surgical patients will imply that the adopted interventions were effective. The last metric is mortality rate due to post-surgical sepsis in the hospital (Sartelli et al., 2021). A reduction in mortality rate following the adoption of responsive interventions to address the problem will imply the effectiveness of the changes in the hospital.
The monitoring of the quality improvement metrics can be achieved in three ways. One of the ways is focusing on process measures. Process measures will assess the effectiveness of the interventions that were used to address the safety indicators. Process measures will assess the effectiveness of interventions such as training, coaching, mentorship, and active involvement of the healthcare providers in addressing the issue of surgical site infections. The other approach is focusing on the outcome measures. Outcome measures assess the effectiveness of the interventions in achieving the projected outcomes.
Outcome measures will focus on aspects such as rates of surgical site infections, mortality rate, costs of care, and average hospital stay among post-surgical patients. The last approach is the evaluation of organizational systems, policies and procedures. The successful implementation of interventions to address the issue requires a change in institutional policies, processes and systems. The hospital should implement policies that support the use of best practice interventions in infection prevention (Soneja & Khanna, 2021; Surani, 2020). Therefore, quality improvement interventions will be considered successful if the hospital adopts the desired measures to support them.
´Oecd. (2017). Tackling Wasteful Spending on Health. OECD.
´Organization, W. H. (2017). Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. World Health Organization.
´Sartelli, M., Coimbra, R., Pagani, L., & Rasa, K. (2021). Infections in Surgery: Prevention and Management. Springer Nature.
´Soneja, M., & Khanna, P. (2021). Infectious Diseases in the Intensive Care Unit. Springer Singapore.
´Surani, S. (2020). Hospital Acquired Infection and Legionnaires’ Disease. IntechOpen.