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Quality improvement (QI) can be defined as the effort to better patient outcomes, system
performance, and professional development (Batalden & Davidoff, 2007). The Institute of
Medicine (IOM) has challenged professionals to improve healthcare quality, with quality
described using the following six domains: safety, timeliness, effectiveness, efficiency, equity
and patient-centeredness. These quality aims provide a framework for focusing improvement
efforts. The unrelenting engagement of all providers is required to transform healthcare. APNs
are well positioned to lead quality initiatives by virtue of their advanced knowledge and
preparation. To effectively lead quality improvement requires understanding that organizations
are complex adaptive systems; dynamic, unpredictable, and are composed of moving parts.
Knowledge of theoretical underpinnings of change (theory explicating the phenomenon of
human behavioral change) is foundational to successful improvement. A wide variety of QI
models, tools, and methods are available to guide the APN in facilitating improvement.
In his book, The Seven Habits of Highly Effective People, Stephen Covey reminds us to
“begin with the end in mind”. Dr. Covey is talking about people’s personal quest for
improvement. However, wouldn’t the same apply to quality improvement matters? The
question is rhetorical and the answer, of course, is “yes”. Before we decide what to do, we must
decide where we are going. If you have not determined where you are going, then how do you
know when you have arrived, or how close you are to getting to your destination?
In quality improvement, we refer to our destination as outcome measures. Most
outcome measures are downstream, meaning changes in outcomes are achieved over time and
confounded by multiple variables. Process measures are a means to an end. In other words,
processes are the activities that affect the outcome measure. For instance, if one wanted to
improve patient satisfaction (an outcome measure) the variables affecting patient satisfaction
would be examined. One such variable may be the process of communication from the patient to
the nurse for patient calls. Perhaps, the first thing the change agent would do is to assess the
nurse response time to patient calls (process measure). It may be important to correlate the
response time to the hour of the day or the day of the week. The investigator would look for
variability (how wide the range) in response times and understand the more variability in the
process, the more complex and the more unpredictable the outcome. Standardization of
processes decreases the variability of process outcomes and promotes the likeliness of
improving downstream outcomes.
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I suspect that you already understood all of this, right? It makes perfect sense.  Before
we move forward, I want to emphasize a few essential points. First, when facilitating process
improvement, it is essential to understand the complexity of a practice concern and the processes
influencing outcomes. We often use tools to help us understand the problem, such as a fishbone
diagram, a flowchart, a root cause analysis, a failure mode effect analysis or other similar
tools. If one doesn’t take the time to understand the issue, improvement strategies, regardless of
their evidence-base, do not have a chance of success.
Facilitating process improvement requires a “systems thinker”, one who focuses on the
system and processes and not the person. A systems thinker recognizes that to err is human, so
he/she attempts to build safeguards into processes to reduce variability of outcomes. Once
serving as a legal nurse expert I reviewed a case where a nurse mistakenly gave four times the
prescribed dose of digoxin. Subsequently, the patient experienced a cardiac arrest and although
revived suffered long term consequences. It is easy to look at a situation and criticize the nurse
for the error. Why everyone knows the toxicity of digoxin. How could anyone be so
careless? A systems thinker looks differently at the error. The system thinker looks for system
breakdowns. For instance, why was this large dosage of digoxin available to the nurse? What
was the procedure for pharmacy to check physician orders for drugs before administration? Was
there a nurse double check system in place to reduce nurse administration errors? If yes, was it
being used? If the double check policy was not being practiced, were there obstacles preventing
use of this safeguard? Were alerts available to warn nurses against this dosage of medication? In
other words, where were the safeguards to protect against human error? What process failures
contributed to the medication error?
Lastly, when selecting the process measures, consider the logistics and difficulty of data
collection. Nursing occurs in real time with real people. Human resources are limited. Asking
nurses to do one more thing will probably get someone tarred and feathered. Look for
measurements already in place so data can be easily obtained.
Rev 5.21

Rev 5.21
Assignment Instructions:

For this assignment select a practice improvement issue within your organizational system and
within the realm of your practice area. Using the grading rubric as a guide, develop a quality
improvement plan to address the identified issue.
The purpose of this paper is to demonstrate knowledge of the essential elements of quality
improvement, with change theory as an underpinning for the process.
Do not use a quality intervention plan that has already been implemented for
this assignment; this should be a new plan for the organization with a clear measurable problem
statement and a planned evidence-based intervention.
Students are not expected to implement the plan; however, the process for implementation and
evaluation is addressed as part of the planning process.
The paper should be carefully written in a formal style, based on primary sources, provide an
integration of ideas, and be 6 to 7 pages in length, excluding title page, appendices & reference
list. Organized flow, logical progression of ideas, and clarity in thought are essential.
Please use headings consistent with the topic areas of the rubric to separate content. References
must be timely; published within the previous five (5) years. Liberal number of primary and
peer reviewed references  (minimum of 10). This paper will be automatically submitted to
Turnitin when you submit your assignment. You will be allowed to view the Turnitin report and
resubmit the paper until the due date. Any papers submitted OR resubmitted after the due date
will have a late penalty applied consistent with the syllabus unless prior arrangements were
approved by the primary faculty.
Scholarship Expectations: The assignment will be formatted based on the APA 7th edition.
There will be a title page and headings used appropriately.  Clarity and conciseness in writing,
grammar and spelling will be consistent with graduate level work. The points allocated for
scholarship will be at the discretion of the faculty member.
You are clinical nurse scholars in the making. You are the nurses with advanced education/
DNPs and members of the highly literate profession of advanced practice nursing who will
chart the future of health care. Good writing ability is as much a required skill for nurses in
advanced practice as performing clinical functions. Therefore, precision and scholarship is
expected in all assignments.

Rev 5.21
Grading Rubric

Name: Grade Points
Introduction paragraph (one paragraph).

Introduce a practice issue
appropriate for a quality improvement project facilitated by a MSN or DNP
prepared nurse. The practice issue should be stated as a clear problem
statement. There must be a thesis statement at the end of the paragraph
that tells the reader the purpose of paper and what will be discussed.



Background and problem

Describe background/context of the identified local measurable practice issue. Quantify
(measure) the local practice concern (the local problem) to establish a baseline for your
work. State the problem in one measurable sentence.  State a project aim in a single
sentence. Use evidence to further support the problem/concern. Note: Do not describe the intervention
in this section. The next steps will focus solely on the problem.

Change Theory
Discuss and apply one theoretical underpinning of change (Lewin, Rogers,
Kotter, Havelock, Prochaska & Diclemente, Bandura) for the proposed
quality initiative. Using the selected change theory, describe the profound
importance of staff engagement, empowerment, commitment, and ownership
of practice improvement initiatives/projects.

Quality Improvement Tool

Describe how at least one improvement tool (root cause analysis, fishbone
cause and effect diagram, FMEA, etc.) can be used to better understand your identified practice issue. Describe how to apply the tool to the identified
practice issue to understand and assess the concern before planning an
intervention. Do not describe the solution, describe how you will investigate the problem using this tool.

Quality Improvement Model
Select a model (e.g., PDSA, FADE, Six Sigma, TCAB, TeamSTEPPs) for the
quality improvement project. Describe the model and summarize the practice
improvement initiative/intervention(s) using the steps of the model. This is
the point in the paper where you describe the evidence based intervention
(with citation) based on the problem, background and investigation of the

Quality Improvement Budget
Budget:  Discuss briefly the revenue or savings associated with the project,
expenses and identify if there will be a return on the investment.
Use the budget template provided with the assignment link to prepare a
brief budget. 10.22.20 Clarification: Do not attach the budget template to the paper

Process and Outcome Measures
Based on Donabedian’s work, identify and describe (a) the structure measures,
(b) the process measures, and (c) the outcomes measures for the quality
improvement intervention(s) for this project.

Qualitative and Quantitative Measures
What qualitative and quantitative measures will be identified to determine
effectiveness of quality initiative? How would qualitative findings contribute
to the evaluation of your specific quality initiative?

Quality Improvement Visual Display
Identify and briefly describe at least two visual displays for reporting
outcome data for your selected practice issue (e.g. histogram, run chart, pie chart, bar graph, etc.).  1.5


Conclusions: Summarize the essential points of paper (one paragraph).


Demonstrate Graduate Level Scholarship.

1. Formal, scholarly writing style; no first-
person language.

2. Writing should be clear and concise.

3. Organize work by headings.

4. Writing should be free of APA errors.

5. Full paper (except reference page, appendices, and
attachments) submitted to Turnitin, with minimal similarity.

6. CON approved format for a title page, running head, introduction, and page numbers.

7. Paper to include a minimum of 10 peer- reviewed or scholarly

8. Citations and references follow APA

9. Writing should be free of grammatical and
spelling errors.

10. Paper not to exceed six (6) to seven (7) pages
(excluding title page, reference page, and any appendices).

11. Follow all assignment instructions.

Additional deductions may apply for late submissions, plagiarism or lack of scholarship and professionalism in the assignment.

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