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Assessment 3 Instructions: 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.


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.


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.


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. You may also want to read the scoring guide to better understand the performance levels related to each grading criterion.

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.&

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.

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.

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.

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:

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

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

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. 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:

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.


Data Analysis and Quality Improvement Initiative Proposal
Student’s Name

Institutional Affiliation



Data Analysis and Quality Improvement Initiative Proposal

There is a constant pursuit for improvement in the quality of care among hospitals across

the world. Improving the quality of care increases the positive health outcomes among patients,

leads to a better working environment, and also raises the reputation of the hospitals as more

people seek their services. However, the improvement in quality can only be realized through

efficient quality improvement innovations, support from the administration and the medical staff,

evidence-based practices, continuous learning, the working together of different healthcare

stakeholders, and effective communication.
Nurses play a great role in contributing to quality improvement initiatives in healthcare

organizations. They are involved in frequent interactions with the patients and this makes them

important in every effort to improve the quality of care. The dashboard metrics from a healthcare

organization can help to identify the different problems in a healthcare institution and can be the

foundation of quality improvement initiatives. The aim of quality improvement is to improve on

the weaknesses in the hospital to ensure a high-quality care to all the patients. The Vila Health

dashboard provides the hospice information for the year 2014 and 2015. The information

includes both near misses and events that resulted in potential harm to the patients. The quality

indicators used in the report are the length of stay, inpatient unit, pain, and symptom.
Analysis if the dashboard metrics

Patients in hospice care require a lot of attention from the physicians and nurses in a

healthcare facility. The level of care offered to patients in hospice care determines the level of

quality offered at the hospital. It shows how the hospital takes care of its most vulnerable patients

and this can be used as a benchmark on whether the hospital upholds the highest quality

standards. Interdisciplinary professionals such as nurses, dieticians, ancillary medical staff,

pharmacists, physicians, and therapists attend to the patients in hospice care. They all work

together to ensure the safety and comfort of these patients.


Table 1

Hospice Unit-Year LOS IPU Pain level Symptom
2014 50 47 13 13
2015 46 27 17 22

The data from the hospice care revealed that the length of stay decreased from 50 to 46

days and the IPU number also decreased from 47 to 27. On the contrary, there was an increase

the number of patients with a high pain level from 13 in the year 2014 to 17 in the year 2015 and

the symptoms also increased from 13 in 2014 to 22 in the year 2015.
Inasmuch as some of the quality indicators showed an improvement, the increase in the

patients experiencing high pain and symptoms is not a good indication of the quality of care at

the hospital. High-quality care should be effective, safe, reliable, patient-centered, equitable, and

efficient (Sfantou et al., 2017). The poor management of pain in hospice care lowers the quality

of life for the patients (Cea et al., 2016). The assessment and management of pain in hospice care

have a direct effect on the quality of care for the patients. The reduction in the length of stay is

not significant enough to portray quality improvement at the hospital. The length of stay in the

hospital influences the rate of readmission. A long length of stay at the hospital is associated with

high rates of readmission (Sud et al., 2017). Therefore, hospitals should strive to lower the length

of stay of patients to improve the quality of care. The rate of readmission as a result of staying

long at the hospital has a high cost on both the patients and the hospital. In the United States,

hospitals readmit approximately 20% of Medicare patients within 30 days after discharge and

this leads to an annual cost of $17 billion (Sud et al., 2017). The readmissions also show that

there is a low quality of care at the hospital and this is a bad reputation that most hospitals would

like to avoid.
The information about the length of stay, pain level, and symptoms portray a deficiency

in the quality of care and this can have negative implications on the healthcare stakeholders.


They lower the satisfaction of the patients with the quality of care, and this limits the number of

patients that the hospital attends to due to the lost confidence in the capabilities of the hospital

and its staff. The reduction in the number of patients has an effect on the hospital revenue and

also lowers the reimbursement from insurance companies and this can lower the motivation of

the staff which further affects the quality of care negatively. The length of stay, symptoms, and

pain level indicate the need for quality improvement.
Quality Initiative Proposal

Efficient nursing leadership is important in improving the quality of care for patients in

every healthcare setting. Effective leadership is essential to improving the quality of care in

healthcare organizations (Sfantou et al., 2017). Therefore, a change in leadership will help in

enhancing the quality of care in the healthcare facility. The repercussions on hospitals in case of

readmission, which increases with the length of stay, encourage hospitals to lower the length of

stay for patients and improve other quality measures such as the pain level and symptoms for the

hospice care patients. In the year 2012, the Centers for Medicare and Medicaid Services (CMS)

instigated the Hospital Readmission Reduction Program (HRRP). The HRRP allows Medicare

and Medicaid Services to lower the payments to hospitals that have high rates of readmission

within 30 days after a patient is discharged (Khouri et al., 2017). Therefore, every hospital must

strive to improve the quality of care offered to its patients.
The existing quality improvement initiatives are ineffective. The leadership style does not

motivate the nursing staff enough to ensure they contribute to improving the quality of care for

the hospice patients. Effective leadership should motivate the healthcare staff and lead to visible

improvements within the care facilities. The lack of any significant improvement after a whole

year shows the level of incompetence in the leadership. It portrays a lack of commitment,

dedication, leading by example, and encouraging the nurses to become better through motivating

them and providing an environment for their development.


The leadership style can be changed to ensure an improvement in quality. The patient

outcome can be improved by encouraging healthcare staff such as nurses in the hospice care unit

to acquire more skills through different learning methods or working closely with the

experienced nurses in the facility. The motivation of nurses will help them to feel like part of the

organization and will improve their productivity. Leadership determines the level of trust that

healthcare staff has with the healthcare facility. Good leadership results in the development and

strengthening of trust and this promotes the productivity of the nursing staff. Therefore, a change

in the style of leadership will result in positive improvements that further lower the length of

stay, the symptoms, and the number of patients who experience high levels of pain. Changing

from the current leadership style to transformational leadership will help to improve the health

outcomes. Transformational leadership is portrayed by motivating the staff and developing good

relationships with them. Transformational leaders inspire staff respect, confidence and

communicate loyalty through their shared vision which leads to improved productivity, job

satisfaction, and the strengthening of employee morale (Sfantou et al., 2017). Transformational

leadership in the organization will help to improve the productivity of the nurses, enhance their

job satisfaction, and improve their morale leading to better health outcomes for the hospice

The Model for Improvement can be used as an evidence-based strategy for improving the

quality of hospice care. The strategy offers a way to structure the improvement projects and it

contains two distinct parts. The first section has three questions that ask what is to be

accomplished, how to determine if there is an improvement and the changes that will result in the

improvement. The hospital aims to accomplish better quality of care for the hospice patients. It

will know if there are improvements based on the number of patients who experience the

different measures of quality. For example, a significant decline in the number of patients who


stay long at the hospital or experience great pain will indicate an improvement. The necessary

change to achieve improvement in quality is the transformational leadership style. The Model for

Improvement has a Plan-Do-Study-Act (PDSA) cycle that will also help to implement the

changes at the hospital. The stages of the PDSA cycle include planning, doing, studying, and

Plan: This is the initial stage and includes planning for the test. The hospital can plan for

this change by identifying methods of collecting data during the test to know if they are

making changes. They can also plan the section of the hospice care to use for the initial

Do: It involves trying out the test on a small scale. The hospital can use a small section of

the hospice care or a sample of patients to test the effect of the change in leadership style.
Study: It involves comparing band analyzing the data collected before the study and after

implementing the change. It helps to understand the effectiveness of the change and

whether it is worth implementing.
Act: At this stage, the change is refined based on the discovery from the comparisons and

analysis of data.
Quality indicators approved by the Agency of Healthcare Research and Quality include

mortality, utilization, and volume indicators. Therefore, the changes in the volume of patients can

help in determining the level of the quality of care in a hospital. The interprofessional team can

meet the challenge of not understanding the full scope of the problem since only four quality

indicators are used in the experiment. They should use the other indicators set by the benchmark

such as mortality and utilization indicators to understand the extent of the problem. The available

information also shows only the problem existing in the hospice care and no other areas within

the facility. This limits the implementation of the change to the hospice care unit only yet the

problem could be emanating from a different department in the hospital. Including information


from other departments in the hospital and testing the change in leadership on them too can help

to improve the situation in the whole hospital.
Integrate Interprofessional Perspectives to Lead Quality Improvements

Interprofessional perspectives can help in improving the quality of care. The

professionals are gifted in different areas and they can combine their knowledge and skills in

specific areas to improve the quality of care in healthcare organizations. Interprofessional

collaboration is the ability of every healthcare professional to embrace the complementary

responsibilities in a team, share problem-solving responsibilities, work cooperatively, and make

decisions that contribute to efficient patient care (Busari, Moll, & Duits, 2017). The nurses and

physicians will have to work collaboratively to improve the quality of care. I will ensure the

roles are fully engaged by ensuring that there are professionals assigned to every part of

improving the quality of care. There will be people responsible for every quality indicator from

the provided data. The initiative will incorporate the concept of interpersonal relationships. It

will help in improving the relationship between the team members and lead to better outcomes.

The outcomes to measure the effect of the intervention will help the interprofessional team to

understand whether they succeeded in developing a good team that can improve care or not. It

will provide guidance on what they should improve on and what they are doing best and should

maintain. The proposed initiative will improve the work-life quality of the staff and the

interprofessional team through collegial relationships. Collegial relationships between healthcare

professionals improve their work-life quality and promote job satisfaction (Nowrouzi et al.,

2016). It will empower the nurses and members of the interprofessional team leading to better

work-life quality.
Effective Communication Strategies to Promote Quality Improvement

Effective communication is essential for the success of the interprofessional team. The

Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) can help in


improving communication among the members of the interprofessional team. The tools provided

by the strategy give an evidence-based framework that enhances communication in teams. The

strategy eliminates subjectivity and emotional charge to allow team members to work together

effectively (Keller et al., 2013). This provides a good environment for communication and

increases confidence and competence when responding to and resolving conflicts. The proposal

will also include the SBAR communication model. The model is effective in effective

assessment of situations. It looks into the situation and background before making an assessment

and recommendations. This helps to provide a better perspective when solving problems because

of the vast information acquired using the communication model.

It is essential for healthcare facilities to continuously improve their quality to ensure

better care for the patients. An interprofessional team can work together to improve the quality of

care and lower the number of patients who experience excessive pain and also decrease the

length of stay in the hospital, leading to lower readmission rates. Improving the quality of care

will result in better outcomes for all stakeholders. Using the PDSA cycle, strategies such as

TeamSTEPPS, and the SBAR communication model will enhance the interaction and efficiency

of the interprofessional team leading to quality improvement and better health outcomes.


Busari, J. O., Moll, F. M., & Duits, A. J. (2017). Understanding the impact of interprofessional

collaboration on the quality of care: a case report from a small-scale resource limited

health care environment. Journal of Multidisciplinary Healthcare, 10, 227. doi:

Cea, M. E., Reid, M. C., Inturrisi, C., Witkin, L. R., Prigerson, H. G., & Bao, Y. (2016). Pain

assessment, management, and control among patients 65 years or older receiving hospice

care in the US. Journal of Pain and Symptom Management, 52(5), 663-672. doi:

Keller, K. B., Eggenberger, T. L., Belkowitz, J., Sarsekeyeva, M., & Zito, A. R. (2013).

Implementing successful interprofessional communication opportunities in health care

education: a qualitative analysis. International Journal of Medical Education, 4, 253. doi:

Khouri, R. K., Hou, H., Dhir, A., Andino, J. J., Dupree, J. M., Miller, D. C., & Ellimoottil, C.

(2017). What is the impact of a clinically related readmission measure on the assessment

of hospital performance? BMC Health Services Research, 17(1), 781. doi:

Nowrouzi, B., Giddens, E., Gohar, B., Schoenenberger, S., Bautista, M. C., & Casole, J. (2016).

The quality of work life of registered nurses in Canada and the United States: a

comprehensive literature review. International Journal of Occupational and

Environmental Health, 22(4), 341-358. doi: [10.1080/10773525.2016.1241920]
Sfantou, D. F., Laliotis, A., Patelarou, A. E., Sifaki-Pistolla, D., Matalliotakis, M., & Patelarou,

E. (2017, October). Importance of leadership style towards quality of care measures in

healthcare settings: a systematic review. Healthcare 5(4), 73. doi:

Sud, M., Yu, B., Wijeysundera, H. C., Austin, P. C., Ko, D. T., Braga, J., … & Lee, D. S. (2017).

Associations between short or long length of stay and 30-day readmission and mortality


in hospitalized patients with heart failure. JACC: Heart Failure, 5(8), 578-588.



Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

Data Analysis and Quality Improvement Initiative Proposal

Learner’s Name

Capella University

Quality Improvement for Interprofessional Care

Data Analysis and Quality Improvement Initiative Proposal

Month, Year

Comment [JS1]: Good job with the
submission. It follows the rubric. For

the most part is written in scholarly

voice. The submission is clear and

concise. References and citations are

used to support your opinion and

position with relevant evidence.

Please see my tracked changes for

areas of revision.


Data Analysis and Quality Improvement Initiative Proposal

I. Introduction

Health care professionals are constantly striving to improve the quality of care and safety

provided to their patients. The culture of care quality and patient safety depends on a strong and

supportive work environment that promotes leadership, evidence-based practice, effective

communication, and interprofessionalism. Nurse leaders play a crucial role in establishing this

culture and directly influence quality outcomes across an organization.

II. Problems and Needs

The role of nurse leaders in maintaining the quality in the nursing and clinical

departments is discussed using the example of TrueWill General Hospital (TGH), a

multispecialty hospital in the United States. As part of an annual assessment of organizational

quality, the hospital’s quality management office completed its analysis of dashboard metrics for

the surgical units for the year 2016–2017. The office released the data in its Quality and Safety

Report 2016–2017. The surgical units’ data included adverse events and near misses and used

four quality indicators: length of stay (LOS) exceeding 7 days, patient readmission rates, pain

level between 7 and 10 for more than 24 hours, and patients with pressure ulcers.

III. Proposed Solution

The results of the analysis showed that three quality indicators—pain levels, readmission

rates, and pressure ulcers—performed below the hospital’s benchmarks (see Table 1 and

Appendix for data and descriptions of indicators and benchmarks). The connection between these

indicators and the services of the surgical units’ nurses will be discussed in this proposal for a

quality improvement initiative. The proposal will analyze the relational patterns between the

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.


indicators and the data, identify assumptions governing health care quality and nursing

characteristics, determine methods to discover the root causes of quality issues, and recommend

a framework as well as strategies to improve quality outcomes in the surgical units.

Analysis of Dashboard Metrics to Identify Quality Issues

The patients who require round-the-clock perioperative care are admitted to TGH’s

surgical units, which are equipped for general, orthopedic, urologic, and ambulatory surgery. The

critical nature of patients admitted to these units makes quality and safety the units’ highest

goals. Quality and safety outcomes are regularly evaluated. The units are staffed by teams of

interdisciplinary professionals: physicians, nurses, therapists, dieticians, pharmacists, and

ancillary medical staff.

Table 1

Quality and Safety Report 2016–2017

Unit – Year


exceeding 7




Pain level

between 7 and

10 for more

than 24 hours

Patients with





43 29 15 14 101


31 43 30 25 129

The data available from the Quality and Safety Report in Table 1 revealed that the

annual patient readmission rates increased from 29 incidents in 2016 to 43 in 2017. Similarly,

the number of patients who experienced pain for more than 24 hours without relief doubled

from 15 in 2016 to 30 in 2017. Pressure ulcers, a common quality and safety issue in surgical

patients, also increased to 25 from 14 in 2016. Conversely, the units reported a drop in the

number of patients whose LOS exceeded 7 days—from 43 in 2016 to 31 in 2017.

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.


The outcomes are a cause for concern because they can affect the hospital’s

stakeholders—the patients, health care professionals, and the organization—in various ways.

Patient readmissions are a costly outcome for TGH because the Patient Protection and Affordable

Care Act, through its Hospitals Readmissions Reductions Program, financially penalizes

hospitals with higher than expected readmissions (Bartel, Chan, & Kim, 2014). Hefty penalties

are enforced because readmissions are thought to be the result of poor follow-up care (Abelson,


Furthermore, studies have found an association between LOS and the risk of

readmissions. Bartel et al. (2014) reviewed prior literature on the impact of decreasing patient

LOS and increasing readmission rates and concluded that a patient who stays for an additional

day may reach a higher level of stability. At TGH, health care professionals may have faced

immense pressure to reduce patient LOS to control per capita health costs. The pressure could

have forced the units’ nurses and doctors to rush through patient care plans and hasten the

process of educating patients regarding post-discharge behavior. Furthermore, patients who are

readmitted may lose trust in the ability of their health care providers to provide complete and

quality care.

Just as readmissions are a quality issue that affects all stakeholders, high pain levels and

pressure ulcers affect the surgical units’ nurses and patients. This inference is based on the theory

of nurse-sensitive patient outcomes, which explains that pain and pressure ulcers are patient

outcomes that depend on the quantity and quality of nursing (Stalpers, de Brouwer, Kaljouw, &

Schuurmans, 2015). Based on this inference, it can be assumed that there could be issues in the

performance and quality of nursing in TGH’s surgical units.

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.


Moreover, there is evidence linking pressure ulcers and postoperative pain to a higher

risk of readmissions (Kirkner, 2017; Lyder et al., 2012). While TGH’s data do not directly link

pressure ulcers and pain to readmission rates, it is possible to theorize that reducing pressure

ulcers and pain in patients will also reduce readmissions. Therefore, the surgical units’ nurses can

help prevent readmissions by preventing ulcers and managing pain in patients more efficiently.

The standard of nursing quality is an important predictor of favorable quality outcomes.

Based on the analysis of the data in the report, TGH’s nurse leaders met with the units’ nurses to

examine the nursing factors that contributed to the unfavorable outcomes. The nurse leaders

identified the problem to be the transactional leadership style practiced by the perioperative

charge nurses. Transactional leadership is defined as an exchange relationship that clearly

distinguishes the follower from the leader and is focused on the contingent reward system with

individuals being rewarded or punished based on their performance (Thomas, 2016).

Transactional leadership may have become the dominant style of leadership in TGH’s surgical

units because of the lack of training and incompetence among nurses. The nurse leaders decided

to change the leadership style of charge nurses with a quality improvement (QI) initiative based

on the data analysis. The proposal for the QI initiative will identify an ideal leadership style and

propose strategies to implement the style. Knowledge gaps or areas of uncertainty that require

further evaluation will also be discussed in the proposal.

Outline for the Quality Improvement Initiative Proposal

Charge nurses occupy a frontline position in influencing the staff engaged in patient care

(Thomas, 2016). They are responsible for functions such as coordinating and evaluating nurse

staffing plans, balancing unit budgets, and making patient assignments. However, the

transactional leadership at TGH was ineffective because the charge nurses were not skilled

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

Comment [JS2]: This reference is
too old to be viable for relevant
evidence-based practice. In health
care, it is important to use up-to-date
references that are not more than 5

years old. I might suggest finding a

more recent reference.


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

enough to notice nurse dissatisfaction, prevent conflicts and competition among the nurses, or

establish effective communication channels. The surgical units’ nurses were not given any

guidance by the charge nurses on accomplishing quality improvement tasks or participating in

collaborative and interprofessional efforts. Because of the transactional leadership’s tendency to

reward or punish staff based on performance (Thomas, 2016), the nursing staff paid more

attention to accomplishing tasks such as discharging patients quickly than to ensuring patient


The QI initiative will provide strategies that support the transition from transactional to

transformational leadership. Transformational leaders focus on internalizing ethical and

professional values in their team members and assist in aligning those values with organizational

goals. A transformational leader’s optimism, selfless service, and creativity motivate and

encourage teams. It is worth noting that the motivational and inspirational aspects of

transformational leadership will significantly change the work environment and the nurses’

commitment to the organization (Thomas, 2016).

The quality improvement model that is best suited to introduce and implement

transformational leadership is the Plan-Do-Study-Act (PDSA) model. Hence, the model will

serve as the framework for the QI initiative. The model is effective when there is a need for

accelerated change, as in TGH’s case. The four steps of the framework can effect systemic

change that will promote long-term improvement and implementation of the initiative on a larger

scale. Various strategies incorporated into the PDSA steps will be discussed briefly (Thomas,

2016). 1. Plan: This step involves setting up an interdisciplinary team. While the nurse

leaders already identified the problem to be transactional leadership through

discussions and the analysis, the interprofessional team will validate the previous


Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

results using a Multifactor Leadership Questionnaire survey. The survey will be

distributed to the nurses as well as other perioperative health care professionals.

After the results of the survey are analyzed, the team will define achievable goals

such as establishing a transformational leadership style and improving the

affected quality indicators.

2. Do: In this step, the team, with support from the organization, will create a

strategic plan to achieve the defined goals. Examples of strategies include

introducing training modules for leadership development and quality and safety


3. Study: The results from the implementation of strategies devised in the previous

steps are analyzed. Observations are based on different interprofessional

perspectives and are set against the performances of TGH’s surgical units, not just


4. Act: In the final step of the PDSA model, the goals set in step one are reevaluated

to determine whether the strategies were effective. TGH can carry out the step by

calculating data on the four quality indicators and noting increases or decreases in

the quality outcomes. Based on that evaluation, the PDSA cycle is deemed

complete or renewed with new goals and strategies.

Despite the effectiveness of the PDSA model, knowledge gaps and areas of uncertainty

may still affect the QI process. First, the use of just four indicators to measure quality outcomes

in the surgical units can give a partial or narrow understanding of the issues. Further evaluation

should be done using indicators such as mortality and patient satisfaction and nurse-sensitive

indicators such as nurse perception of job and level of nursing education.


Secondly, the data only shows problems affecting the hospital’s surgical units.

Foundational theories such as systems theory explain how problems in one part of the

organization affect performance and quality outcomes in other parts. However, there is a lack of

data on quality issues from other departments at TGH that could be connected to the issues seen

in the surgical unit. Therefore, the team spearheading the QI efforts can take steps to include data

from other units and departments to create a comprehensive QI initiative. Another area of

uncertainty is the studies connecting nursing leadership and patient outcomes. Most studies do

not test whether nursing leadership directly improves patient outcomes; they merely analyze the

connection conceptually. Understanding the relationship between leaders and patient outcomes

requires interventions and longitudinal studies with continuous observations (Wong, 2015).

To achieve better patient outcomes by changing the nursing leadership, the proposed QI

initiative will be guided by various interprofessional perspectives. The perspectives will support

patient safety, cost-effectiveness, and work-life quality for nurses and other units’ staff. Each

perspective will address an aspect relevant to TGH, such as leadership and teamwork. The

discussion will also identify assumptions that highlight the importance of these perspectives.

Integration of Interprofessional Perspectives That Support Quality Improvement

Over the years, efforts to improve health care quality and safety drew inspiration from

various interprofessional perspectives. The perspectives important to TGH are leadership theory,

systems theory, and collaborative relationships. The identification of these specific perspectives

and their integration into the hospital’s QI initiative are based on assumptions made on the

factors that influence patient outcomes.

One assumption is that health care systems are interconnected and problems in one unit

or department can affect other parts of the system (Huber, 2017); problems in the surgical units

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can affect the quality of other hospital departments. When quality is compromised in multiple

departments, the organization will be unable to function properly and achieve its goals of

providing quality and safe care for patients. Poor nursing performance and quality also affect the

performance of doctors, therapists, pharmacists, dieticians, and other interdisciplinary

professionals working in the surgical unit. These health care professionals work alongside nurses

and depend on them to carry out care plans effectively, quickly, and cost-effectively.

Another assumption is that nurse leaders such as charge nurses can learn and develop

leadership attributes (Thomas, 2016) that will help them improve their leadership style.

However, leadership development can only take place if the organization is supportive and

allocates appropriate resources and facilities. The third and last assumption guiding the

conceptual basis of the initiative is that anyone—not just executives or managers—can practice

leadership (Smith-Trudeau, 2016).

The main theme explored in these assumptions is leadership; it is an important systems

theory factor and collaborative relationships are influenced by leadership styles. Although the

connection between leadership and patient safety needs to be further evaluated, experts agree that

certain leadership styles obtain better results than others do. In particular, experts have compared

the effectiveness of transactional leadership to transformational leadership in achieving patient

safety. Transactional leadership, as was observed in TGH, is ineffective, as it focuses on rewards

rather than outcomes. Conversely, transformational leadership engenders a higher level of

competence that helps in guiding and motivating team members to follow a higher level of ethics

and evidence-based care, thereby improving the outcomes for patients (Thomas, 2016).

Transformational leaders are also more competent when introducing cost-reduction plans while

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maintaining quality in their units. They are more skilled than transactional leaders at

organizational and administrative management, which is an essential skill for budgeting.

Transformational leadership is also the preferred leadership strategy in implementing

systems theory approaches. Systems theory is important in QI, as it focuses on understanding

root causes and symptoms of quality and performance problems (Huber, 2017). By

understanding latent causes of quality issues, TGH can focus on proactive quality measures that

prevent quality and safety issues in the long term. Such approaches are known to be cost-

effective and sustainable.

Transformational leadership’s focus on people through effective interpersonal

relationships and charismatic influence is also beneficial for establishing collaborations among

teams and developing optimum work-life quality for staff. The surgical units at TGH, consisting

of interprofessional staff, depend on a sense of shared goals among staff. The nurses are the

largest staff group in the surgical units and issues within their workforce such as nonalignment

of goals affect other units’ staff. Transformational leaders are capable of guiding nurses in

building respectful and positive relationships with their colleagues.

These interprofessional perspectives will act as guides for the QI team as they implement

the PDSA steps. The perspectives are especially useful in facilitating open and transparent

communication. The QI proposal will suggest communication strategies that are imperative

when expanding the proposal into a full-fledged QI program. The proposal will also provide

assumptions that will guide those suggestions.

Effective Communication Strategies to Promote Quality Improvement

Communication is a key leadership duty and facilitates the smooth functioning of different

organizational systems (Huber, 2017). Without effective communication methods,

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leaders will not be able to convey organizational goals and decisions or implement QI changes.

At TGH, the charge nurses could not communicate care plans to their nursing staff or coordinate

with other units’ leaders and interdisciplinary professionals to achieve ideal outcomes. Their

ineffective communication methods also set a bad example for the nursing staff, who look to

their leaders for guidance and instruction.

Therefore, it is important to develop communication strategies before the QI strategies

are implemented. Well-defined communication channels will promote interprofessional efforts in

patient care and quality improvement. The assumptions guiding the strategies are as follows: (a)

Leaders facilitate and mediate effective interprofessional collaborations in care delivery, which

can only happen if the leaders are competent in communication skills; (b) Quality improvement

is a resource-intensive effort, but coordinating and utilizing those resources requires open and

honest communication among organization, patients, and interprofessional staff; (c) Nursing

autonomy in decision making is important for improving the performance of nursing staff, but

autonomy is a product of mutual respect and effective communication among all

interprofessional staff, including management and administrative staff.

Based on these assumptions, a few communication strategies to implement the QI

initiative and promote interprofessional care or teamwork are recommended. The strategies are

as follows: (a) training the QI team in verbal, nonverbal, written, and electronic means of

communication, which will improve relations within the team and will be useful during

interprofessional collaborations; (b) setting up team documentation, where all team members

will enter details of ideas, meeting minutes, and QI-related data; during the Do stage of the

PDSA, team documentation will be implemented at the unit level and all staff present during a

patient visit will enter details into the patient record, assist with order entry, and

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process prescriptions (Bodenheimer & Sinsky, 2014); (c) setting up a weekly QI team meeting

where team members will receive a copy of the agenda in advance and provide feedback on

meeting goals; post-meeting, members will be sent copies of all communication via e-mail to

maintain transparency (Thomas, 2016); and (d) briefing units’ staff on decisions made in these

meetings and, when needed, e-mailing summaries of the meeting minutes to all staff members so

specific groups or individuals will not feel excluded from the QI efforts.

As the QI process progresses, the team can add more communication strategies into the

PDSA model or make improvements to the existing strategies. After all, the PDSA model for

quality improvement was selected because it allows experimentation, quick pilot testing of plans,

and implementing the plans on a larger scale after analyzing the results (Thomas, 2016). The

onus of organizing and coordinating the QI efforts falls on the nurse leaders heading the team.

They must develop their leadership competency to inspire similar changes in the charge nurses.

IV. Conclusion

Data- and outcome-driven organizations must constantly analyze their quality indicators

and implement changes that improve all clinical and organizational outcomes. Quality and safety

evaluations, such as the one conducted at TGH, often reveal hidden issues that are influencing

patient outcome negatively, such as ineffective leadership styles. Leadership is important in

uncovering the latent problems and implementing changes that improve quality and safety.

However, as displayed at TGH, leadership itself depends on factors such as interprofessional

care and teamwork, communication, and highly qualified health care professionals. The absence

of these factors can affect patient outcomes drastically. Understanding this interdependence

among organization, leadership, and staff is key to high-quality performance and patient safety.

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Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.


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Comment [JS3]: I would suggest
locating a more recent reference.


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Stalpers, D., de Brouwer, B. J. M., Kaljouw, M. J., & Schuurmans, M. J. (2015). Associations

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Description of Quality and Safety Report 2015–2016

The Quality and Safety Report data for the year 2015–2016 represents four recognized

quality indicators in health care. The calculations are based on the total number of adverse events

and issues, differentiated by type, documented in TGH’s surgical units for 2015–2016. The

length of stay is calculated for patients who are admitted for more than 7 days. Patient

readmissions describe revisits by former surgical patients to the emergency department or

surgical units within 30 days of their discharge. The revisiting patients may sometimes require

additional hospital stay, which might be related to their surgical procedures.

The third indicator is based on medical pain where pain is rated on a scale of one to 10—

one being the mildest pain and 10 the most severe. TGH chose numbers between 7 and 10 on the

scale because a pain level between 7 and 10 that lasts for more than 24 hours is considered a

patient safety issue. The final indicator denotes pressure ulcers, which are injuries caused to skin

tissue resulting from prolonged pressure on the area. Patients bed-ridden after medical

procedures are at high-risk of pressure ulcers. The ideal benchmark for each indicator is zero,

which means that the goal of TGH is to prevent extended stays, readmissions, prolonged pain

without relief, and pressure ulcers in surgical patients.


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