NURS FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

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Data Analysis and Quality Improvement Initiative Proposal

Student name

Capella University

NURS-FPX6016 Quality Improvement of Interprofessional Care

Professor Name

Submission Date

Data Analysis and Quality Improvement Initiative Proposal

Slide 1:

Hi, my name is ______. This presentation aims to discuss the data from Howard University Hospital and identify more harmful events than the national average.

Slide 2 (objectives):

Patient safety is a natural health concern that aims at avoiding injuries as well as minimizing mistakes in the process of care delivery. In this evaluation, the performance statistics of Howard University Hospital are juxtaposed, and this is far better in terms of harmful event scores compared to the national standards. To rectify the problems, the presentation will compare various safety indicators, identify the areas where the system is vulnerable globally, as well as give a quality improvement project to improve globally. Thus, the presentation seeks to discuss how an interprofessional safety program must be organized to avoid preventable injuries and comply with national quality standards.

Slide 3

Data Analysis and Identification of Healthcare Concern

The Leapfrog Hospital Safety Grade shows that the performance of Howard University Hospital indicates a discouraging trend in patient safety measures. The hospital has 1.92 on unhelpful events, which is approximately double the national level of 1.00 and 3 times higher than the highest performing hospitals (0.53) (Leapfrog Hospital Safety Grade, 2025). The results of a scale that indicated the amount of unhelpful events (such as infections, falls, pressure ulcers, and medication errors) reveal that Howard University Hospital is in the lowest quartile in the United States and far above the inclusion criterion of safety performance. The information availed is comparison benchmark scores, not specific details such as what type of events, how often, and what causes. Nevertheless, the composite score is a warning sign of vulnerable patients in safety practices and care processes within the system.

The quality of the data in the Leapfrog is that they use the national standards and reporting practices. It rests on the accredited sources like CMS Hospital Compare and the state’s compulsory performance on safety. It is not cumulative information, and thus, one cannot tell what types of harmful events are the most widespread. They are also unable to determine whether the high figures are a result of infections, drug matters, surgery, or another factor. It is impossible to determine specific areas of breakdown without unit-level dashboards, root cause analysis, or internal reporting of incidents. They have the option of analyzing the information by disaggregating it according to patient condition, shifts, staffing, and type of service. These measures can not be made with the current dataset, and they are significant to make targeted improvements.

Slide 4

Key Metrics

The lack of correlation to national standards in terms of hospital variation and the overall performance gap between Howard University Hospital and the leaders of the benchmark are the main indicators that can be identified as a chance for quality improvement. Although the trend has not changed yet and thus cannot be regarded as a spike, the underperformance is chronic, which implies that there is a fundamental failure of process. Target measurements would be required to include such outcome measurements as central line-associated bloodstream infection (CLABSI) rates, catheter-associated urinary tract infection (CAUTI) rates, and preventable hypoglycemic episode rate, and would require numerator (number of events) and denominator (patient days or device days) data (Buetti, 2022). The degree of stability in the processes is low, which is indicated by a large harmful events score, and indicates an uneven delivery of care and inconsistent adherence to safety measures among units.

Slide 5

Suggested Quality Improvement Initiative

Based on the high score in the harmful events, a hospital-wide zero-harm initiative is proposed in accordance with the Triple Aim model of the Institute of Healthcare Improvement and facilitated by the Plan-Do-Study-Act (PDSA) cycle. This program is based on national programs, including The Joint Commission National Patient Safety Goals, the CMS Hospital-Acquired Condition Reduction Program (HACRP), and the safety standards established by Leapfrog. Since the infection prevention and medication safety measures would have been established in Howard University Hospital, they must be suboptimal, given the ongoing disparity in outcome (Leapfrog Hospital Safety Grade, 2025). The project will aim at high-frequency and high-severity events of harm, including medication errors (e.g., insulin-associated hypoglycemia), falls with harm, and healthcare-related infections.

Standardization of high-reliability practices (activation of real-time clinical decision support (CDS) alerts on high-alert drugs, frequent interprofessional safety huddles with the use of SBAR, universal assessment of the risk of falls and customized interventions, and daily audits of the use of devices is the foundation of the plan (ex, urinary catheters). The adaptations of evidence-based practices at high-performing facilities, including Johns Hopkins Comprehensive Unit-based Safety Program and glycemic control bundles at Kaiser Permanente, will be introduced into the safety-net, urban environment of the hospital (Santos et al., 2022). Barriers to benchmark achievement are limited resources, EHR interoperability problems, and possible reluctance to standardized procedures in a high-acuity heterogeneous environment.

Slide 6

Knowledge Gaps/Areas of Uncertainty 

Critical unknowns restrict the particularity of this proposal. The concrete report on the adverse events in Howard University Hospital, e.g., medication errors vs. infections, is not made available publicly in the Leapfrog report. They also fail to post in-house statistics on staffing ratio, nurse turnover rate, and EHR ease of use and patient socioeconomic status (that affect readmission and complication rates) (Li et al., 2024). Also, it is not clear why earlier studies of QI had not been performed, as the efforts were poorly implemented, the implementation was not optimal, or the efforts were not supported by the leadership. Further information provided by hospital dashboards, staff surveys, and logs on patient safety events would enhance more informed intervention and attainable goal setting.

Slide 7

Interprofessional Integration and Action Plan

Implementation of the Zero Harm Initiative needs to have clear interprofessional roles. Nurses will arrange bedside safety huddles and safety rounds, pharmacists will recheck high-alert medication orders twice, doctors will be the champions of compliance with protocols during rounds, and IT specialists will enhance the CDS rules to minimize alert fatigue. The staff of environmental services will help avoid falls, as they will eliminate clutter, and the timely discharge planning will be verified by the case managers to ensure that devices are not used improperly (Clemson et al., 2023). Full engagement will be guaranteed by the means of unit-based safety councils, common performance dashboards, and participation in PDSA test teams, where the frontline will be considered in the development of solutions. In a larger systems view, interprofessional collaboration can also lead to cost-efficiency and staff health through the efficient utilization of resources and the minimization of avoidable harm-related costs. With the synergistic working of all professional groups, the duplication of work will be minimized, the workflow inefficiency will be decreased, and the staff will be able to pay more attention to direct patient care. In addition, engaging frontline staff in safety enhancement programs will enable them to give their solutions, which enhances morale and quality of life.

Such non-nurse concepts as human factors engineering (to redesign work processes), behavioral economics (to nudge behavior to conformity), and health equity models (to cope with differences in the occurrence of harm) will be incorporated. Of special significance is that the program aims to address work-life improvement by lowering crisis-care (e.g., reducing the number of fast responses), role clarification, and empowerment to speak up without the fear of repercussions, which has been demonstrated to reduce burnout and improve retention (Razai et al., 2023). The outcome measures (e.g., the rates of harmful events per month, the results of the survey of staff safety culture, and patient satisfaction) will be made openly available to all team members, which will promote the feeling of collective responsibility.

Slide 8

Assumptions 

The assumption made in this plan is that the leadership at the Howard University Hospital is dedicated to the process of investing in the QI infrastructure, including the concept of safeguarded staff time to conduct the safety activities and the advancement of EHR. It is founded upon a preliminary assumption of psychological security in which it is secure to report mistakes, and a fair culture. It further supposes interprofessional teams are ready to operate beyond the traditional silos and the outside criteria (e.g., Leapfrog) are not unsuitable substitutes to local performance in the unfavorable patient demographic context, which aligns with the findings of Jones et al. (2024). It is also based on the assumption that the reduced number of bad events will result in increased levels of trust, reduced costs, and morale among the staff. Such benefits must extend countrywide, but must be monitored on a local basis.

Slide 9

Collaboration Strategies

Efficient communication is the key to the Zero Harm Initiative. Formal communication tools like SBAR (Situation-Background-Assessment-Recommendation) and CUS (Concerned-Unsafe-Safety issue) will be involved in the training and daily workflow, and procedures associated with handovers and concerns will be introduced (Etemadifar et al., 2021). The initiative will not just be used to implement safety with the help of written policies. It is performed through team huddles with the help of whiteboards, text notices in the case of an emergency, and monthly training in the real-life cases of the patients. The communication in a closed loop would be made with the assistance of the practice drills that were received during the simulation. Standardized safety rounds that leaders make with the help of a standard safety checklist will show leadership commitment and will open a channel of immediate feedback. The establishment of a timely response to the safety issues will be supported with the help of confidential communication tools (e.g., secure messaging by EHR to enable the response to safety concerns in a shift-to-shift and discipline-to-discipline manner) (Ferreira et al., 2024). They enable psychological safety, reduce ambiguity, and accelerate problem-solving, which are some of the high-reliability organization drivers.

Slide 10

Assumptions

These strategies will work provided that the entire team is trained on the usage of the communication tools regularly and their usage is promoted by the leaders. It presupposes that the technology platforms are cost-effective and accessible between the positions (i.e., pharmacists can easily send messages to nurses via EHR), as McGrow (2025) presupposes. It presupposes the presence of time and huddles and debriefs during the clinical pressure, which should be changed by the executives. Even the most effective ways of communication may appear like a performance rather than a change when the major supports are absent.

Slide 11

Conclusion

The presentation demonstrates that Howard University Hospital is full of detrimental incidents. The reason is that there exist serious safety issues that should be resolved. The Zero Harm Initiative applications include direct protocols, enhancement of communication, and inter-professional collaboration. Such an approach offers a sensible strategy of patient safety improvement to an amazing extent. Despite these few issues, the strategies can still significantly minimize preventable harm. A combination of well-supported frontline employees and leadership is the key to success.