Data Analysis and Quality Improvement Proposal.

Prepare an 8–10-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.Data Analysis and Quality Improvement Proposal.

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\”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.Data Analysis and Quality Improvement Proposal.

In this assessment, you will propose a quality improvement (QI) initiative proposal based on a health issue of professional interest to you. The QI initiative proposal will be based on an analysis of dashboard metrics from a health care facility. You have one of two options:

Option 1

If you have access to dashboard metrics related to a QI initiative proposal of interest to you:

Analyze data from the health care facility to identify a health care issue or area of concern. You will need access to reports and data related to care quality and patient safety. If you work in hospital setting, contact the quality management department to obtain the data you need.
You will need to identify basic information about the health care setting, size, and specific type of care delivery related to the topic that you identify. You are expected to abide by HIPAA compliance standards.
Option 2

If you do not have access to a dashboard or metrics related to a QI initiative proposal:Data Analysis and Quality Improvement Proposal.

You may use the hospital data set provided in the media piece titled Vila Health: Data Analysis. You will analyze the data to identify a health care issue or area of concern.
You will follow the same instructions and provide the same deliverables as your peers who select Option 1.
Instructions
Analyze dashboard metrics related to the selected issue.

Provide the selected data set in the proposal.
Assess the stability of processes or outcomes.
Delineate any problematic variations or performance failures.
Evaluate QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and non-governmental bodies on quality improvement.Data Analysis and Quality Improvement Proposal.
Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization and the interprofessional team.
Outline a QI initiative proposal based on the selected health issue and data analysis.
Identify target areas for improvement.
Define what processes can be modified to improve outcomes.
Propose strategies to improve quality.
Define interprofessional roles and responsibilities as they relate to the QI initiative.
Provide recommendations for effective communication strategies for the interprofessional team to ensure the success of the QI initiative. Briefly reflect on the impact of the proposed initiative on work-life quality of the nursing staff and interprofessional team.
Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
The numbered points below 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 Quality Improvement Initiative Evaluation addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion.Data Analysis and Quality Improvement Proposal.

Address #1-4 in the paper

Analyze data to identify a health care issue or area of concern, and evaluates the quality of the data.
Identify the type of data you are analyzing (from your institution or from the media piece).
Discuss why the data matters, what it is telling you, and what is missing.
Analyze dashboard metrics and provide the data set in the proposal.
Present dashboard metrics related to the selected issue.
Delineate any problematic variations or performance failures.
Assess the stability of processes or outcomes.
Evaluate the quality of the data and what can be learned from it.
Identify trends, outcome measures and information needed to calculate specific rates.
Analyze what metrics indicate opportunities for quality improvement.
Outline a QI initiative proposal based on a selected health issue and supporting data analysis, and identifies knowledge gaps, unknowns, missing information, unanswered questions, or areas of uncertainty.
Identify benchmarks aligned to existing QI initiatives set by local, state, or federal health care policies or laws.
Identify existing QI initiatives related to the selected issue, and explain why they are insufficient.Data Analysis and Quality Improvement Proposal.
Identify target areas for improvement, and define what processes can be modified to improve outcomes.
Propose evidence-based strategies to improve quality.
Evaluate QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and non-governmental bodies on quality improvement.
Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization and the interprofessional team.
Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality, and identifies assumptions on which the suggestions are based.
Define interprofessional roles and responsibilities as they relate to the data and the QI initiative.
Explain how you would you make sure that all relevant roles are fully engaged in this effort.Data Analysis and Quality Improvement Proposal.
Explain what non-nursing concepts would you incorporate into the initiative?
Identify how outcomes to measure the effect of the intervention affect the interprofessional team.
Briefly reflect on the impact of the proposed initiative on work-life quality of the nursing staff and interprofessional team. Describe how work-life quality is improved or enriched by the initiative.
Apply effective communication strategies to promote quality improvement of interprofessional care, and identifies assumptions on which the suggestions are based.
Identify the kind of interprofessional communication strategies that will be effective to promote and ensure the success of this performance improvement plan or quality improvement initiative.
In addition to writing, identify communication models (like CUS, SBAR) that you would include in your initiative proposal.
Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.Data Analysis and Quality Improvement Proposal.
Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.
Submission Requirements
Length of submission: 8–10 double-spaced, typed pages, not including title and reference page.
Number of references: Cite a minimum of five sources (no older than seven years, unless seminal work) of scholarly, peer-reviewed, or professional evidence that support your evaluation, recommendations, and plans.
Attached is the paper direction, scoring guide, and suggested but not required resources.Data Analysis and Quality Improvement Proposal.

Data Analysis and Quality Improvement Proposal

A Hospital-acquired infection (HAI) is a nosocomial infection that patients contract because of the present to toxins or infection in the hospital environment. As the name suggests, these are infections that are either incubating or not present at the time of admission. Some of the more common HAI’s include Clostridium difficile infections, ventilator-associated pneumonia, hospital-acquired pneumonia, surgical site infection, catheter-associated urinary tract infections, and central line-associated bloodstream infections (Wattal&Khardori, 2013). The risk of HAI is typically dependent on the prevalence of various pathogens, infection control practices, and the patient’s immune status. The risk factors for HAI include stay in critical care, indwelling devices, mechanical ventilator support, recent invasive procedures, frequent encounters with health care facilities, multiple underlying chronic ailments, longer hospital stays, immunosuppression, and older age (Jarvis, 2015). The present proposal presents the reality of HAI at Montefiore Medical Center: Einstein Campus (MMC), located in The Bronx – New York City, and suggests strategies for reducing HAI rates.Data Analysis and Quality Improvement Proposal.

Established in 1884, MMC is the academic medical center and university hospital for Albert Einstein College of Medicine (Montefiore Medical Center, 2020). HAI is a source of concern for MMC because it presents a paradox since patients go to the facility to get well, yet some of them end up contracting HAIs with deadly consequences. Patients who contract HAIs stay in the facility for longer and spend more on health care. In fact, HAIs are a significant cause of death and illness, and have serious medical, financial, and emotional consequences. The presence of HAI in MMC makes sense the facility handles a large number of persons who are sick: many with compromised immune systems and some with communicable diseases.Data Analysis and Quality Improvement Proposal. Surgical procedures and medical devices (such as catheters) provide easy routs for pathogens to gain entry into the body. Most importantly, the activities that occur in the facility and movement of personnel offer a plethora of ways for pathogens to spread. Although the presence of HAIs makes sense, most of them can be prevented through implementing quality improvement procedures. Many facilities have demonstrated dramatic reductions in HAI rates following the implementation of quality improvement plans (Jarvis, 2015). As such, it is prudent for MMC to implement quality improvement strategies that address HAIs.Data Analysis and Quality Improvement Proposal.

Data analysis

The data presented compares MMC performance to New York State performance in 2017 and 2018 based on a risk adjustment model. The comparison is conducted separately for type of HAI. The comparison takes into accounts the population of patients are they relate to risk factors for HAI development such as complex procedures that would increase risk of infection.Data Analysis and Quality Improvement Proposal. A standardized infection ratio (SIR) figure exceeding 1.0 implies that MMC HAI rate is worse than the New York State average after applying the risk adjustment model to account for differences in patient population. The figure above 1.0 is the percentage by which MMC HAI rate exceeds the state average. On the other hand, an SIR figure below 1.0 implies that MMC HAI rate is better than the state average after adjusting for differences in patient population. The figure below 1.0 is the percentage by which MMC HAI rate is less than the state average. For colon SSI, MMC rate was less than the state average by 27% in 2017 and exceeded the state average by 85% in 2018 to imply a worsening trend. For CABG chest SSI, MMC rates exceeded the state average by 219% in 2017 and 7% in 2018 to imply an improving trend. For hysterectomy SSI, MMC rates exceeded the state average by 23% in 2017 and 126% in 2018 to imply a worsening trend. For CLABSI, MMC rates exceeded the state average by 5% in 2017 and 61% in 2018 to imply a worsening trend. For CDI, MMC rates exceeded the state average by 35% in 2017 and 93% in 2018 to imply a worsening trend. The performance data indicates a worsening performance in all indicators except for CABG chest SSI where significant improvement was reported. Still, the figures reported for MMC exceed the state averages thus indicating that the facility is performing worse than most other facilities operating in the state (see Table 1; New York State – Department of Health, 2019). Based on the data analysis, there is a need for quality improvement initiatives that target the evaluated performance indicators to be implemented in order to reduce HAI rates at MMC.Data Analysis and Quality Improvement Proposal.

Table 1. MMC performance compared against New York State average performance in 2017 and 2018 (Source:New York State – Department of Health, 2019)

Quality improvement initiative proposal

It is evident that the risk for HAI is especially high for patients in MMC. To address this concern, there is a need for infection prevention, surveillance and response, as well as ensuring quality in care delivery. Through ensuring that operations in the facility comply with evidence-based best practices in care delivery, the quality improvement initiative can act as a prevention mechanism against HAI. In fact, quality improve address HAI as a concern through placing quality at the core of care delivery with a focus on how to reorganize care delivery process to ensure that every patients gets the required care in a timely manner (Wattal&Khardori, 2013). The existence of HAIs in MMC (when compared to New York State averages) is an indication that health care processes in the facility are not functioning in a manner that is compliant with evidence-based best practices.Data Analysis and Quality Improvement Proposal. Given this awareness, the quality improvement initiative proposes that HAI concern in MMC be address through: prevention using delivery of high quality care; surveillance and monitoring of incidences; and continuous improvement to properly respond to incidences and build resilience. The three measures ensure that quality improvement is offered as a simple methodology that reorganizes processes already being conducted in the facility in a manner that ensures best guidelines and evidence-based practices are followed. The practiced and established surveillance systems and standards, when paired with quality improvement, is anticipated to increase MMC’s resilience to HAI through their ability to monitor and manage outbreaks while increasing care delivery quality (Graban, 2018).Data Analysis and Quality Improvement Proposal.

Prevention

The facility should implement infection control practices and guidelines since they are targeted at standardizing the delivery of health care to ensure that pathogens are not transmitted in the delivery processes. Adherence to these practices and guidelines is of principal significance in preventing HAIs. It is equally imperative to continuously monitor how the practice and guidelines are implements as well as their outcomes through surveillance to determine areas of weaknesses and failings (Graban, 2018).Data Analysis and Quality Improvement Proposal.

The general prevention measures against HAIs are fairly straightforward. They include and not limited to (Jarvis, 2015):

• Ensuring that rooms are well ventilated.
• Properly cleaning surfaces with the recommended frequency.
• Wearing personal protecting equipment in appropriate circumstances to include face protection, gowns, and gloves.
• Observing hand hygiene that involves handwashing and using alcohol rubs before and after touching each person.
• Identifying the isolation type needed for each patient to help protect others and reduce opportunities for additional infection.
• Screening patients at admission to identify the risk of HAI and the need for isolation.Data Analysis and Quality Improvement Proposal.
• Following aseptic insertion techniques when using medical devices and instruments to minimize infection.
• Using a closed drainage and waste management system.
• Changing medical devices when medically indicated.
• Inserting medical devices only when needed and removing them when no longer needed.
• Thoroughly cleaning the environment.
• Proper sterilization techniques for all instruments.
• Careful use of anti-microbial agents with a focus on preventing resistance, and using the right medication when required.Data Analysis and Quality Improvement Proposal.

Surveillance and monitoring

There is a need to recognize that HAIs can occur even when the facility provides high quality care. In fact, quality improvement exceeds health care delivery processes and places emphasis on the establishment and continuous improvement of standards for preventing pathogens transmission. Through establishing a surveillance system for HAI incidences, MMC can monitor HAIs and infection outbreaks to facilitate quality improvement with a focus on identifying shortcomings in the current approaches and suggesting informed improvements (Graban, 2018).Data Analysis and Quality Improvement Proposal.

Continuous improvement

Given that health care delivery processes are inherently imperfect, whether at MMC or any other medical facility, continuous improvement is necessary to ensure that they approach perfection. Beyond establishing surveillance and monitoring, applying continuous improvement provides the means through which the facility can review and appropriately respond to the collected surveillance data. To review and respond to surveillance data is a necessary measure for controlling and responding to HAI incidences. Also, it makes the facility aware of existing issues that contribute to HAI incidences in its health care delivery processes. Through using improvement methods, MMC gains the ability to not only respond to HAI outbreaks, but can also build resilience to outbreaks by continuously improving the safety and quality of health care delivery process to prevent and reduce HAI occurrence (Graban, 2018).Data Analysis and Quality Improvement Proposal.

Inter-professional perspectives

HAI has serious implications for MMC, not to talk of the high mortality and morbidity as well as the increased cost of care. While the previously discussed quality improvement measures are well intentions with regards to reducing and eliminating HAI incidences, only a concerted effort by the health care team would realize the desired impact. The primary strategy for the present plan is to prevent the transmission of pathogens among patients.Data Analysis and Quality Improvement Proposal. Towards this end, nurse personnel play an important role in the prevention strategy as they are the first members of the inter-professional team who encounter HAI incidences. For them, washing hands are recommended and following the established hygiene standards for HAI prevention is key (Vince &Amalberti, 2016). Other than nurses, other medical and support staff who are in the hospital environment on a regular basis should be subjected to education on how to clean surfaces, secure catheters and other medical devices, use aseptic techniques when performing invasive procedures, handwashing, and infection control procedures. In addition, decreasing environmental contamination and disinfecting hospital rooms should be encouraged. Besides that, there is a need for the facility to acknowledge that antibiotic resistance is a concern, in which case a hospital committee (consisting of pharmacists, nurses, physicians and other primary care providers) should be established. This inter-professional committee would ensure that the empirical use of antibiotics does not turn routine, and that the available antibiotics are categorized with some of them being subjected to controlled use with individual case use requiring prior approval of the committee (Healey & Marchese, 2012). Overall, there is a need for all members in all disciplines of the inter-professional health care teams to be involved in the quality improvement process.Data Analysis and Quality Improvement Proposal.

Communication strategies

This proposal acknowledges that engaging patients and medical personnel in quality improvement can led to measurable quality and safety improvements. In fact, communication between medical personnel, patients, and family is a critical component of safe and high-quality care, and acts as the foundation of partnerships. The communication strategy will make use of six tools. The first tool is ensuring that the patient is a partner in the care process by informing the patient and family members of the scheduled communication opportunities when they can interact with medical personnel. It makes use of a handout that highlights routine events in which the facility holds conversations with patients and family.Data Analysis and Quality Improvement Proposal. The second tool ensuring that the patient knows how to be a partner in the care process through helping the patient and family to know how to interact with the medical personnel. This requires that the patient informs the medical personnel of the family members and friends who should be involved in the care, ask questions until they understand the care process, check to see if they understand what the medical personnel say, and tell medical personnel about their health. It makes use of a handout that describes tips for patients to be partners in their care (Perry, Potter &Ostendorf, 2016).Data Analysis and Quality Improvement Proposal.

The third tool is enabling patients and family members to understand the roles of the different medical personnel, patient and family. It makes use of a handout that details the roles of the different members of the health care team to include hospital staff, clinicians, family and patient. The fourth tool is helping the patient to understand that they are part of the care team through reminding them of the importance of being partners and how they can contribute. It makes use of a poster and flyer that summarizes the main action points.Data Analysis and Quality Improvement Proposal. The fifth tool is communicating the clinicians’ competencies through establishing the sets of behavior that invite support from patients and family as members of the care team. It makes use of a handout and verbal descriptions to highlight behaviors that invite and support the patient and family to engage in care. The final tool is communication training that prepares medical personnel to support efforts to engage patients and family in communication. It makes use of training materials (Perry, Potter &Ostendorf, 2016).Data Analysis and Quality Improvement Proposal.

In addition, the communication will be facilitated using SBAR, an acronym for situation, background, assessment and recommendation. It offers medical personnel a standard framework for their communication needs in the professional environment. To be more precise, SBAR is a communication tool that puts every participant in the same mind frame so that the message delivered is the message received. It is particularly useful for transitions and handoff.Data Analysis and Quality Improvement Proposal. It applies four steps. The first step is to describe the situation in a manner that prepares the listener for the upcoming background, assessment and recommendation. For instance, the situation would be a description of the patient’s demographic information and that he/she is running a fever and bad cough. The second step is to present the background information on the situation and put it into context in terms of what is happening at the time. For instance, the background would be that a patient suffers from diabetes. The third step is an assessment that interprets the background information in terms of implications for medical personnel. For example, the assessment would be that the patient is lethargic but responsive. The final step is recommendation that suggests how the medical personnel can address the situation. For instance, the recommendation would be that the patient might be suffering from a respiratory infection and requires laboratory tests to ascertain the presence and cause of the infection (Slusser et al., 2019). The rationale for this communication strategy is that allows for patient and family engagement thereby creating an environment in which medical personnel, families and patients work partner to improve health care safety and quality in the facility.Data Analysis and Quality Improvement Proposal.