Final project

IHP 430 Final Project Guidelines and RubricOverview
As a student of healthcare quality management, it is vital that you are able to identify problems that arise in healthcare organizations and propose strategies for
their improvement. A critical part of this process requires you to be familiar with quality and accreditation standards and navigate the communication channels
of the organization.
For your summative assignment, you will identify a departmental problem within a healthcare organization and develop a collaborative performance
improvement initiative to address it. Ideally, the proposed evidence-based solution will serve to improve the departmental problem, thus contributing to the
overall success of the healthcare organization. The project is divided into three milestones, which will be submitted at various points throughout the course to
scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Two, Four, and Six. The final product will be submitted in
Module Seven.
In this assignment, you will demonstrate your mastery of the following course outcomes:
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Evaluate appropriate methods of healthcare data collection and interpretation for informing organizational decision making
Assess healthcare performance improvement initiatives for addressing gaps in organizational performance
Evaluate requirements of current quality and safety initiatives for how they promote the culture of safety in healthcare organizations
Formulate communication and teamwork strategies in quality management that engage diverse stakeholders within healthcare organizations
Evaluate information management systems and patient care technologies that promote healthcare quality
Prompt
Begin by identifying an organizational problem within your own workplace healthcare setting or a hypothetical healthcare organization. Propose an initiative that
addresses this chosen problem, utilizing evidence-based literature and quality standards. If you choose a problem in your workplace, be sure to utilize data from
that healthcare organization; if you have created a hypothetical healthcare organization, you may use a public domain database with instructor permission. As
this is a scholarly initiative, this assignment must adhere to all APA requirements and formatting and include peer-reviewed and evidence-based sources to
support any and all claims.
Specifically, the following critical elements must be addressed:
I.
What Is the Organizational Problem?
a) Provide the organizational problem that you have chosen. How does this problem fail to meet quality or other regulatory requirements?
b) Articulate organizational challenges posed by the problem (e.g., interdepartmental conflicts, communication failure, budgeting issues).
II. Evidence-Based Support
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a) Provide data that supports the existence of the problem. You may utilize public sources to find data related to your selected problem.
b) How has this problem been addressed in the past? What information management systems or patient care technologies have been utilized when
addressing this problem? Be sure to use peer-reviewed literature to support your answer.
c) Discuss relevant accreditation standards, safety standards, compliance standards, and quality initiatives. How do these standards promote a
culture of safety within the department? Be sure to cite the appropriate standards within your answer.
III. Performance Improvement Initiative
a) Propose an initiative that will address this problem within the department of your chosen healthcare organization. What specific relevant quality
standard will this quality initiative address?
b) Describe the type of data that will reveal a quality outcome.
IV. Implementation of the Plan in the Organization
a) How will this implementation plan be communicated among departments?
b) How will the data be displayed and shared with the organization?
c) If the plan for this initiative was implemented, what do you believe would be the hypothetical effect(s) on patient care outcomes? How will
health information systems support those improvements in patient care?
d) What do you think the hypothetical effect of the quality or performance plan would be on the culture of safety within the organization?
V. Success of the Performance Improvement Plan
a) If this initiative is successful, how would the organization monitor the financial implications?
b) How would the current information management systems contribute to the success of your plan?
c) What current organizational processes will help the plan be successful?
d) How will the plan be communicated among departments? How will this communication help team members commit to the performance
improvement plan?
Milestones
Milestone One: Identify Organizational Problem
In Module Two, first, you will identify a problem in a healthcare organization. You may use a problem from your organization or a problem from a fictional
organization. This milestone is graded with the Milestone One Rubric.
Milestone Two: Initiative Proposal
In Module Four, you will build upon the work you completed on milestone one. In this milestone, you will propose an improvement plan that focuses on the
problem you selected in Milestone One. If you chose a problem in your workplace, be sure to use data from that healthcare organization; if you created a
hypothetical healthcare organization, you might use a public domain database with instructor permission. Next, you will develop an implementation plan for the
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problem that you are focusing on. Then, you will discuss the predicted success of the performance improvement plan after implementation. This milestone is
graded with the Milestone Two Rubric.
Milestone Three: Implementation of Performance Initiative
In Module Six, you will implement your performance improvement plan. Also, you will discuss what success of the performance improvement plan will look like.
If you choose a problem in your workplace, be sure to use data from that healthcare organization. If you created a hypothetical healthcare organization, you
might use a public domain database with instructor permission. This milestone is graded with the Milestone Three Rubric.
Final Submission: Organizational Performance Initiative
In Module Seven, you will submit your final project. The final project should be a complete, polished paper containing all of the items listed on the grading rubric.
Your paper should show that you have applied all of the instructor feedback. This submission is graded with the Final Project Rubric.
Deliverables
Milestone
Deliverable
Module Due
Grading
One
Identify Organizational Problem
Two
Graded separately; Milestone One Rubric
Two
Initiative Proposal
Four
Graded separately; Milestone Two Rubric
Three
Implementation of Performance Initiative
Six
Graded separately; Milestone Three Rubric
Final Submission: Organizational Performance
Initiative
Seven
Graded separately; Final Project Rubric
Final Project Rubric
Guidelines for Submission: Your organizational performance initiative should be 8–10 pages in length; however, the quality of this submission is much more
important than the length. All resources must be appropriately cited in APA format.
Critical Elements
Problem: Provide
Exemplary (100%)
Meets “Proficient” criteria and
includes insightful detail about
how the problem fails to meet
quality or regulatory
requirements
Proficient (85%)
Comprehensively provides
details about how the problem
fails to meet quality or
regulatory requirements
3
Needs Improvement (55%)
Provides details about how the
problem fails to meet quality
or regulatory requirements but
with gaps in detail or logic
Not Evident (0%)
Does not provide details about
how the problem fails to meet
quality or regulatory
requirements
Value
4.5
Critical Elements
Problem: State
Support: Provide
Support: Addressed
Exemplary (100%)
Meets “Proficient” criteria and
offers greater depth of
information regarding the
organizational challenges
posed by the problem
Meets “Proficient” criteria and
data provided demonstrates
nuanced understanding of the
problem
Meets “Proficient” criteria and
description includes insightful
detail regarding how this
problem has been addressed in
the past
Support: Discuss
Meets “Proficient” criteria and
offers professional insights
concerning how accreditation,
safety, compliance, and quality
standards promote a culture of
safety
Performance:
Propose
Meets “Proficient” criteria and
proposal demonstrates a
nuanced insight into the
relationship between the
performance improvement
plan and the quality standard
being addressed
Meets “Proficient” criteria and
demonstrates great insight into
the type of data that will reveal
a quality outcome
Performance:
Describe
Proficient (85%)
Clearly states organizational
challenges posed by the
problem
Needs Improvement (55%)
States organizational
challenges posed by the
problem, but articulation is not
clear
Not Evident (0%)
Does not state organizational
challenges posed by the
problem
Value
6
Provides data that supports the
existence of the problem
Provides data but data does
not fully support existence of
the problem
Does not provide data or data
provided does not support
existence of the problem
6
Thoroughly describes how this
problem has been addressed in
the past, including the
information management
systems or patient care
technologies utilized, and
supports answer with peerreviewed literature
Clearly discusses relevant
accreditation, safety, and
compliance standards, as well
as quality initiatives, including
how these standards promote
a culture of safety within the
department, and cites
appropriate standards
Proposes a performance
improvement plan to address
the chosen problem, including
the quality standard being
addressed
Describes how this problem
has been addressed in the past
but with gaps in detail, and
supports answer but support
does not include peerreviewed literature or is
irrelevant
Does not describe how the
problem has been addressed in
the past or does not support
answer
6
Discusses accreditation, safety,
and compliance standards, as
well as quality initiatives, but
with gaps in detail or clarity,
and cites standards but
citations are irrelevant or
inappropriate
Does not discuss accreditation,
safety, compliance, and quality
standards and does not cite
standards
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Proposes a performance
improvement plan to address
the chosen problem but
proposal has gaps in detail or
logic
Does not propose a
performance improvement
plan
4.5
Accurately describes the type
of data that will reveal a quality
outcome
Describes the type of data that
will reveal a quality outcome
Does not describe the type of
data that will reveal a quality
outcome
6
4
Critical Elements
Implementation:
Communication
Implementation:
Data
Implementation:
Initiative
Implementation:
Effect
Success: Financial
Success: Information
Exemplary (100%)
Meets “Proficient” criteria and
description is exceptionally
clear in how the
implementation plan will be
communicated among
departments
Meets “Proficient” criteria and
choices of how the data will be
displayed and shared with the
organization demonstrate
nuanced insight into
communication within the
chosen healthcare organization
Meets “Proficient” criteria and
offers reasoning concerning
the hypothetical effects of the
initiative on patient care
outcomes
Meets “Proficient” criteria and
offers reasoning concerning
the hypothetical effect of the
quality plan on the culture of
safety within the organization
Meets “Proficient” criteria and
offers reasoning pertaining to
how the organization will
monitor the financial
implications if this initiative is
successful
Meets “Proficient” criteria and
hypothesis demonstrates
nuanced insight into the
relationship between
information management
systems and performance
improvement initiatives
Proficient (85%)
Thoroughly describes how the
implementation plan will be
communicated among
departments
Needs Improvement (55%)
Describes how the
implementation plan will be
communicated among
departments but description
has gaps in detail
Not Evident (0%)
Does not describe how the
implementation plan will be
communicated among
departments
Value
6
Accurately describes how
the data will be displayed and
shared with the organization
Describes how the data will be
displayed and shared with the
organization but description is
inaccurate
Does not describe how
the data will be displayed and
shared with the organization
6
Comprehensively describes the
hypothetical effects of this
initiative on patient care
outcomes, including how
health information systems
support improvements in
patient care
Comprehensively describes the
hypothetical effect of the
quality plan on the culture of
safety within the organization
Describes the hypothetical
effects of this initiative on
patient care outcomes but
description is cursory
Does not describe the
hypothetical effects of the
initiative on patient care
outcomes
6
Does not describe the
hypothetical effect of the
quality plan on the culture of
safety within the organization
9
Comprehensively describes the
how the organization will
monitor the financial
implications if this initiative is
successful
Describes the hypothetical
effect of the quality plan on
the culture of safety within the
organization but description is
cursory
Describes how the organization
will monitor the financial
implications if this initiative is
successful but description is
cursory
Does not describe how the
organization will monitor the
financial implications if this
initiative is successful
4.5
Logically hypothesizes how the
current information
management systems would
contribute to the success of
this plan
Hypothesizes how the current
information management
systems would contribute to
the success of this plan but
hypothesis is illogical
Does not hypothesize how the
current information
management systems would
contribute to the success of
this plan
6
5
Critical Elements
Success: Processes
Success:
Communication
Articulation of
Response
Exemplary (100%)
Meets “Proficient” criteria and
provides nuanced insight into
the organizational processes
that will help the plan be
successful
Meets “Proficient” criteria and
provides keen insight into how
communication will help team
members commit to the
performance improvement
plan
Proficient (85%)
Accurately describes the
organizational processes that
will help the plan be successful
Needs Improvement (55%)
Describes what organizational
processes will help the plan be
successful but description is
inaccurate
Not Evident (0%)
Does not describe what
organizational processes will
help the plan be successful
Value
4.5
Comprehensively explains how
the plan will be communicated
among departments and
analyzes how that
communication will help team
members commit to the
performance improvement
plan
Does not explain how the plan
will be communicated among
departments or analyze how
that communication will help
team members commit to the
performance improvement
plan
6
Submission is free of errors
related to citations, grammar,
spelling, syntax, and
organization and is presented
in a professional and easy-toread format
Submission has no major errors
related to citations, grammar,
spelling, syntax, or organization
Explains how the plan will be
communicated among
departments and analyzes how
that communication will help
team members commit to the
performance improvement
plan but patterns are not
interdepartmental or analysis is
cursory
Submission has major errors
related to citations, grammar,
spelling, syntax, or organization
that negatively impact
readability and articulation of
main ideas
Submission has critical errors
related to citations, grammar,
spelling, syntax, or organization
that prevent understanding of
ideas
10
Total
100%
6
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IHP 430 Milestone One
Denise Vazquez
Southern New Hampshire University
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I.
What is the Organizational Problem?
A. Provide
Medical errors are a public health care concern because every patient is
vulnerable to their incidence and prevalence. In New Vale Clinic, physicians have
been covering up errors that occur in medicine prescription, administration, and
healthcare complications resulting from such errors. This goes against the report
by the Agency for Healthcare Research and Quality on error prevention and
quality improvement in healthcare (Rodziewicz et al, 2022). Medical error is a
quality indicator, and failure to report cases of medical error is among the root
causes of preventable cases of health complications due to wrong prescriptions
and medication.
B. State
Leadership dynamics in the organization are a contributing factor to medication
errors. Teams perceive the impact of leadership as a determining factor in their
success in delivering quality care. When leadership dynamics are factored in,
tension, frustration, and burnout become negative mitigating elements that lead to
poor patient care delivery, characterized by several medical errors in the
institution (Roberts, 2020).
II.
Evidence-Based Support
A. Errors that occur either do or do not harm patients. Medical errors are the third
leading cause of death in the United States following heart disease and cancer. A
study by Johns Hopkins indicated that almost 250,000 Americans lose their lives
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yearly because of a medical error. This is a crude approximation because of the
wide range of medical errors that can occur.
B. Prevention measures have been implemented in the past to address medical errors.
These measures took a significant turn after the publication of the Institute of
Medicine’s (IOM) report To Err Is Human: Building a Safer Health System
(Ackley et al., 2019). Guidelines on how to avoid medical errors by AHRQ, and
bar code readers to promote correct medication have been used in the past to
reduce the incidence and prevalence of medical errors (Sorrell, 2017).
C. Agency for Healthcare Research and Quality, AHRQ has been at the forefront of
pushing quality initiatives, including sponsoring hundreds of patient safety
research and implementation projects to prevent and reduce medical errors
(Rodziewicz et al, 2022).
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References
Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M.
(2019). Nursing diagnosis handbook E-book: An evidence-based guide to planning care.
Elsevier Health Sciences.
Roberts, R. (2020). How Leadership Dynamics in Health Care Can Contribute to Medical
Errors. Ohiostate.pressbooks.pub. Retrieved 11 September 2022, from
https://ohiostate.pressbooks.pub/pubhhmp6615/chapter/how-leadership-dynamics-inhealth-care-can-contribute-to-medical-errors/.
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical error reduction and
prevention. In StatPearls [Internet]. StatPearls Publishing.
IHP 430 Milestone Two
Denise Vazquez
Southern New Hampshire University
Performance: Propose an Initiative
First, teach on-duty physicians and nurses to reduce medical errors. Then-posted health
staff will be separated into two groups and taught in hour-long interactive sessions, two in
consecutive weeks. Using multimedia aids, they will learn pharmacological characteristics,
doses, suitable preparations, intervals, and routes of administration of numerous newborn
medicines. During training, they will get a typical medication list drawn from pharmacology
textbooks. This will be presented at physicians’ and nurses’ workstations for medicine
prescription and administration.
The second strategy is to emphasize accountability. Physicians will sign prescriptions and
nurses monitoring sheets. The QI team will double-check medications weekly following morning
rounds using the same checklist. The initial challenge will be convincing residents and nursing
staff to sign fully.
Performance: Discuss Data Determinants of Success
This program will enhance statistics like an organization’s annual money loss. When a
claim is lacking information or the coding is erroneous, the organization loses money, which is
bad for its success. If we look at the number of medical mistakes that occur each year and how
much they cost organizations like Medicare, we can see the economic effects of medical errors
on organization performance (Council For Medicare Integrity, 2018).
The question; How will medical mistakes reduce after 3 months of software
implementation? will inform us how successful the effort is and whether any adjustments are
needed to make it work. This investigation’s results may be incorporated into the software to help
hospitals reduce medical errors. Another data determinant is comparing before and after my
initiative’s implementation. Thus, the outcomes and data may be more accurate.
Implementation: Describe Interdepartmental Communication Channels
A complete staff meeting is one technique to explain my idea to the team. The
medical/coding section fills and sends out claims, but everything is a collaborative effort. If a
patient enters the institution with erroneous or missing information, someone at the front desk
committed a mistake that was unnoticed by other departments.
Implementation: Describe the Manner of Data Interpretation
I’ll use a bar graph to compare data before and after implementing my project. Since I’m
comparing two items over a year, a bar graph is preferable. “Bar graphs compare groupings or
follow changes over time. Bar graphs are ideal for measuring major changes over time (National
Center for Education Statistics, n.d.). secondly, line graph will be used to show the annual loss of
money and the reduction in medical mistakes after 3 months of initiative execution. Line graphs
show short- and long-term changes. Line graphs are preferable for these determinants since the
change is over a shorter time frame.
Implementation: Effects of Initiative on Patient Care Outcomes
My effort will improve patient treatment. Patients are happier with services as medical
mistakes are declining. Medical mistakes may affect how patients feel about the hospital, which
is bad since they aren’t happy with the services. Front-office concerns like medical and
scheduling may affect how patients see medical interactions and rate them online. Providers
should take note (Bryant, 2018). Non-insured individuals must pay out of pocket for treatments,
therefore medical mistakes might cost them hundreds of dollars to resolve.
Implementation: Effect of Quality Initiatives on Culture of Safety
My idea will assist the organization’s safety culture by increasing patient care. Since
medical errors have been reduced, professionals are more cautious about patients and prioritize
them more since they no longer need to worry about making mistakes. This helped the institution
boost patient satisfaction, which is positive. In a medical institution, one department’s
dysfunction might affect the whole complex. This program will change things in a favorable
direction, which is good for a facility.
References
Bryant, M. (2018, October 10). Patient satisfaction is up, but billing woes can hurt online
reviews, survey shows. Healthcare Dive.
https://www.healthcaredive.com/news/patientsatisfaction-is-up-but-billing-woes-canhurt-online-reviews-surve/539300/
Council For Medicare Integrity. (2018). Error Rate Drops, but Medicare Still Lost $31.6 Billion
to Preventable Billing Errors in FY2018 | Council for Medicare Integrity.
Medicareintegrity.Org. http://medicareintegrity.org/error-rate-drops-but-medicarestilllost-31-6-billion-to-preventable-billing-errors-in-fy2018/
National Center for Education Statistics. (n.d.). How Do I Choose Which Type of Graph to Use?
– NCES Kids’ Zone. Nces.Ed.Gov. Retrieved 2020, from
https://nces.ed.gov/nceskids/help/user_guide/graph/whentouse.asp
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Success of the Performance Improvement Plan
Denise Vazquez
Southern New Hampshire University
2
The success of the Performance Improvement Plan
Financial
Preventable medical errors cost healthcare organizations a lot of money in terms of
capitated payment arrangements. That’s because errors may increase the total cost of care so that
it ultimately exceeds the fixed payment the organization will receive (Ahsani-Estahbanati et al.,
2021). Additionally, for value-based care, failure to meet some quality expectations leads to
compensated care needs (Ahsani-Estahbanati et al., 2021). With the proposed initiative to
eliminate the onset and prevalence of medical errors. As a result, the expectation is that the cost
associated with medical errors will reduce significantly.
Information Management Systems
Patient safety is a primary concern for all healthcare organizations. As part of achieving
that goal, health information management systems are used to collect and analyze data on safe
patient care delivery progress to facilitate information-based quality improvement metrics
(Hutton et al., 2017). In the same way, the information management systems will be used to
collect data on previous initiatives on preventing medical errors and compare them with other
organizations to determine the chances of achieving the goal of the current initiative.
Current Organizational Processes
The organization is guided by the mission to uphold patient safety through the provision
of resources. Resource availability is critical in determining the success rate of key initiatives.
Nurses have access to patient information and can request the resources they need to identify atrisk patients and the strategies they can implement at the individual or organizational level to
deliver safe care.
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Communication of the Plan
The teams will be notified through memos and the organization’s official communication
platform. Most healthcare organizations still rely on memos to pass out key messages for official
purposes. Apart from that, messages will be communicated through the company’s email address
to reach out to those unable to access the memos. In other cases, short messages will be sent to
specific teams through WhatsApp and other compatible media.
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References
Ahsani-Estahbanati, E., Doshmangir, L., Najafi, B., Akbari Sari, A., & Sergeevich Gordeev, V.
(2021). Incidence rate and financial burden of medical errors and policy interventions to
address them: a multi-method study protocol. Health Services and Outcomes Research
Methodology, 22(2), 244-252. https://doi.org/10.1007/s10742-021-00261-9
Hutton, K., Ding, Q., & Wellman, G. (2017). The Effects of Bar-coding Technology on
Medication Errors: A Systematic Literature Review. Journal Of Patient Safety, 17(3),
e192-e206. https://doi.org/10.1097/pts.0000000000000366