Assessment 3 : Data Analysis and Quality Improvement Initiative Proposal

Assessment 3 : Data Analysis and Quality Improvement Initiative Proposal

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

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

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 dataon the subject of your quality improvement initiative proposal.
• Analyze datayou have collected.
• Make evidence-based recommendationsabout 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. 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 Concernedabout 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:
     • Agency for Healthcare Research and Quality (AHRQ). (n.d.). Module 2: Communicating change in a resident’s condition. https://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/ltcmod2ap.html

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 aminimum of five current scholarly and/or authoritative sources to support your QI initiative proposal. Current means 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:
  • Evidence and APA.
  • APA Module.
  • American Psychological Association. (n.d.). APA style. https://www.apastyle.org/

Competencies Measured

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

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• 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.

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Data Analysis and Quality Improvement Initiative Proposal Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Analyze data to identify a health care issue or area of concern.	Does not analyze data to identify a health care issue or area of concern.	Attempts to analyze data, but misses trends or opportunities for quality improvement, or does not persuasively link data to a health care issue or area of concern.	Analyzes data to identify a health care issue or area of concern.	Analyzes data to identify a health care issue or area of concern; evaluates data quality.
Determine whether any adverse event or near-miss data must be factored in to outcomes and recommendations.	Does not determine whether any adverse event or near-miss data must be factored in to outcomes and recommendations.	Attempts to determine whether any adverse event or near-miss data must be factored in to outcomes and recommendations; however, omissions and/or errors exist.	Determines whether any adverse event or near-miss data must be factored in to outcomes and recommendations.	Determines whether any adverse event or near-miss data must be factored in to outcomes and recommendations. Specifies the criteria by which the determination is made.
Develop a QI initiative proposal based on a selected health issue and supporting data analysis.	Does not develop a QI initiative proposal based on a selected health issue and supporting data analysis.	Attempts to develop a QI initiative proposal, but proposal is missing benchmarks, is not evidence-based, is impractical, or is not clearly linked to the selected health issue or supporting data analysis.	Develops a QI initiative proposal based on a selected health issue and supporting data analysis.	Develops a QI initiative proposal based on a selected health issue and supporting data analysis. Proposal identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty where further information could improve the proposal.
Communicate QI initiative proposal, based on interdisciplinary team input, to improve patient safety and quality outcomes and work-life quality.	Does not communicate QI initiative proposal, based on interdisciplinary team input, to improve patient safety and quality outcomes and work-life quality.	Attempts to communicate QI initiative proposal, based on interdisciplinary team input, but misses relevant roles or concepts related to patient safety and quality outcomes and work-life quality.	Communicates QI initiative proposal, based on interdisciplinary team input, to improve patient safety and quality outcomes and work-life quality.	Communicates QI initiative proposal, based on interdisciplinary team input, to improve patient safety and quality outcomes and work-life quality. Identifies assumptions on which the inputs are based.
Determine evidence-based communication strategies to promote quality improvement of interprofessional care.	Does not determine communication strategies to promote quality improvement of interprofessional care.	Attempts to determine communication strategies to promote quality improvement of interprofessional care, but strategies are limited and/or not evidence-based.	Determines communication strategies to promote quality improvement of interprofessional care.	Determines multiple 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.	Does not communicate QI initiative proposal in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.	Attempts to communicate QI initiative proposal in a professional, effective manner, but lapses, omissions, and/or errors detract from the overall message.	Communicates QI initiative proposal in a professional, effective manner, writing content clearly and logically, with correct use of grammar, punctuation, and spelling.	Communicates QI initiative proposal in a professional, effective manner, writing content clearly and logically, with error-free use of grammar, punctuation, and spelling. Proposal includes multiple specifics, examples, and references to current scholarly and/or authoritative sources.

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