Quality Improvement Initiative: Part 1

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Prior to beginning work on this assignment, read the following:

For this first part of the quality improvement (QI) initiative, you will write a three- to five-page paper that details the information you find in your research about your team’s selected hospital. Recall from the Project Brief: Quality Improvement Initiatives that your team is to select a hospital from the Medicare.gov Providers & Services: Find Care ProvidersLinks to an external site. webpage.

In order to fulfill the CEO’s request to identify the low performing quality and patient safety issues in the hospital, browse through the following categories listed on the webpage for your team’s selected hospital:

  • General Information
  • Survey of Patients’ Experiences
  • Timely and Effective Care
  • Readmissions
  • Complications and Deaths
  • Use of Medical Imaging, Medicare Payment
  • Number of Medicare Patients

Note: No two team members can research the same initiative. Each team member will be working independently on their chosen initiative. If you feel you need support, reach out to your team members.

After your team selects a hospital, explore the categories listed on your chosen hospital’s webpage to get an understanding of how it scores. Be sure to scroll down and expand each category to see the measures nested within the category. For example, for one particular hospital, under the category “Timely and Effective Care for Sepsis Care,” the hospital scored 53% for this measure. This is the percentage of patients who received appropriate care for severe sepsis and septic shock. The national average was 60%, and the state average was 55%. This is a low performing quality and patient safety issue that could be explored. Here is another example: Under the category “Timely and Effective Care for Emergency Department Care,” this hospital had 146 minutes for the measure, “average (median) time patients spent in the emergency department before leaving from the visit.” The national average had 172 minutes, and the state average had 158 minutes. But another hospital in the same area had 125 minutes. This measure could be explored as well.

In your paper,

  • Describe the nature of the business, services or products, and customers served by your chosen hospital.
  • Evaluate one measure of your choice.
  • Remember that each team member must have a unique measure.
  • Discuss the importance of your selected measure (e.g., accreditation status, patient safety, and/or financial status of the hospital).
  • Define two to three SMART goals for your selected measure to improve. 
  • Be sure to include all five elements—specific, measurable, attainable, relevant, and time-bound—in each goal. 
  • For example: To implement an up-and-running emergency department tracking system by 12/31/2022. To hire and train additional five nurses to meet the staff-to-patient ratio during peak times by 12/31/2022.  To reduce the turnaround time at 10% for lactic acid/lactate levels laboratory testing by 12/31/2022.
  • Analyze specific local, state, or national policies (e.g., The Joint Commission Standards) that have been developed to improve your selected measure based on evidence-based practice research.

The Quality Improvement Initiative: Part 1

  • Must be three to five double-spaced pages in length (not including title and references pages) and formatted according to APA StyleLinks to an external site. as outlined in the Writing Center’s APA Formatting for Microsoft WordLinks to an external site. resource.
  • Must include a separate title page with the following:
  • Title of paper in bold font
  • Space should appear between the title and the rest of the information on the title page.
  • Student’s name
  • Name of institution (The University of Arizona Global Campus)
  • Course name and number
  • Instructor’s name
  • Due dateQuality Improvement Initiative: Part 1 [WLOs: 2, 5, 6] [CLOs: 3, 5, 6] Prior to beginning work on this assignment, read the following:
  • An Evaluation of Medicare’s Hospital Compare as a Decision-Making Tool for Patients and Hospitals.
  • U.S. Hospital Performance Methodologies: A Scoping Review to Identify Opportunities for Crossing the Quality ChasmDownload U.S. Hospital Performance Methodologies: A Scoping Review to Identify Opportunities for Crossing the Quality Chasm
  • Impact of Teaching Intensity and Sociodemographic Characteristics on CMS Hospital Compare Quality Rating Download Impact of Teaching Intensity and Sociodemographic Characteristics on CMS Hospital Compare Quality Rating
  • For this first part of the quality improvement (QI) initiative, you will write a three- to five-page paper that details the information you find in your research about your team’s selected hospital. Recall from the Project Brief: Quality Improvement Initiatives that your team is to select a hospital from the Medicare.gov Providers & Services: Find Care ProvidersLinks to an external site. webpage. In order to fulfill the CEO’s request to identify the low performing quality and patient safety issues in the hospital, browse through the following categories listed on the webpage for your team’s selected hospital:
  • General Information
  • Survey of Patients’ Experiences
  • Timely and Effective Care
  • Readmissions
  • Complications and Deaths
  • Use of Medical Imaging, Medicare Payment
  • Number of Medicare Patients
  • Note: No two team members can research the same initiative. Each team member will be working independently on their chosen initiative. If you feel you need support, reach out to your team members. After your team selects a hospital, explore the categories listed on your chosen hospital’s webpage to get an understanding of how it scores. Be sure to scroll down and expand each category to see the measures nested within the category. For example, for one particular hospital, under the category “Timely and Effective Care for Sepsis Care,” the hospital scored 53% for this measure. This is the percentage of patients who received appropriate care for severe sepsis and septic shock. The national average was 60%, and the state average was 55%. This is a low performing quality and patient safety issue that could be explored. Here is another example: Under the category “Timely and Effective Care for Emergency Department Care,” this hospital had 146 minutes for the measure, “average (median) time patients spent in the emergency department before leaving from the visit.” The national average had 172 minutes, and the state average had 158 minutes. But another hospital in the same area had 125 minutes. This measure could be explored as well. In your paper,
  • Describe the nature of the business, services or products, and customers served by your chosen hospital.
  • Evaluate one measure of your choice.
  • Remember that each team member must have a unique measure.
  • Discuss the importance of your selected measure (e.g., accreditation status, patient safety, and/or financial status of the hospital).
  • Define two to three SMART goals for your selected measure to improve. 
  • Be sure to include all five elements—specific, measurable, attainable, relevant, and time-bound—in each goal. 
  • For example: To implement an up-and-running emergency department tracking system by 12/31/2022. To hire and train additional five nurses to meet the staff-to-patient ratio during peak times by 12/31/2022.  To reduce the turnaround time at 10% for lactic acid/lactate levels laboratory testing by 12/31/2022.
  • Analyze specific local, state, or national policies (e.g., The Joint Commission Standards) that have been developed to improve your selected measure based on evidence-based practice research.
  • The Quality Improvement Initiative: Part 1
  • Must be three to five double-spaced pages in length (not including title and references pages) and formatted according to APA StyleLinks to an external site. as outlined in the Writing Center’s APA Formatting for Microsoft WordLinks to an external site. resource.
  • Must include a separate title page with the following:
  • Title of paper in bold font
  • Space should appear between the title and the rest of the information on the title page.
  • Student’s name
  • Name of institution (The University of Arizona Global Campus)
  • Course name and number
  • Instructor’s name
  • Due date