Assessment 3: Data Analysis and Quality Improvement Initiative Proposal

Assessment 3: Data Analysis and Quality Improvement Initiative Proposal

Assessment 3: Data Analysis and Quality Improvement Initiative Proposal

Health care delivery is multifaceted. Health care organizations and providers should play their role diligently, and the government should support them as required. As time progresses, health care organizations should assess their progress to determine whether their performance matches the required level of patient safety and care quality. The possibility of adverse events should be evaluated, and necessary interventions put in place to avoid adverse outcomes. Technology should be a critical part of the health delivery process too. This paper is a data analysis and quality improvement proposal based on the performance of Mercy Medical Center; a Vila Health affiliated Hospital.

Data Analysis

The data analyzed in this report has been generated from the Vila Health activity. Concentrating on one of the affiliated hospitals, Mercy Medical Center, the data provides some underperformance areas at the facility that require a close assessment. One of the areas of underperformance is eye exam rates. The data also shows a huge racial discrepancy considering that whites dominate the proportion of visits, with American Indians with the worst performance. However, the area of concern is the low number of diabetes foot exams, particularly in the last quarter of 2019. It will be the focus of the analysis while showing its connection to patient safety and care quality.

Data is crucial in all health care processes. A health care organization cannot effectively determine whether it meets the desired performance level without using data. Norris et al. (2017) surmised that health care data encourages communication between health care stakeholders. It is also the basis of improving the overall quality of care since it gives deeper insights into the progress of specific conditions in the population. The same case applies to Vila health data. A close analysis shows where Mercy Medical Center should improve to avoid adverse events and improve its overall performance.

Dashboard Metrics

From an operation perspective, health care organizations improve performance by interpreting dashboard information. Dashboard metrics provide information on care metrics and outcome areas where an organization performs as required or underperforms and interventions are required. From the information presented in the Vila Health dashboard, the central area of concern is diabetes. It is among the lifestyle diseases affecting the productivity of many Americans. To enhance knowledge, Mercy Medical Center should measure the variation in the causes. It is crucial to determine whether the problem is genetic or stemming from lifestyle challenges besides the data according to age, gender, and race.

Concerning diabetes (the issue of concern), the main dashboard metric is the low foot exam rates. The total number of foot exams at Mercy Medical Center in 2019 was 145 out of the total visits (543). According to MedlinePlus (2021), a diabetic patient should have at least one diabetes foot exam per year. Unfortunately, the average of foot exams in 2019 shows a great underperformance, implying that a huge proportion is at risk of developing foot-related complications. Such outcomes lower people’s productivity and are a public health concern that deserves serious attention.

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Solving a health care concern depends on the institutional ability to sustain processes and outcomes. One of the critical indicators of a

Assessment 3 Data Analysis and Quality Improvement Initiative Proposal
Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

health care facility’s to sustain processes is resources. The type of patients served is another indicator. Mercy Medical Center is in Shakopee. It is a high-resource setting where the community is highly educated. In such situations, interventions to improve outcomes such as patient education and tech-based communication can be sustained. Regarding data quality, the metrics provided are clear that the facility needs to do more and act on time to address the issue of low foot exams. If that is not the case, the quality of health care is likely to decline as complications related to diabetes foot increase.

Adverse Events Data

Adverse events have huge implications on a health care facility’s performance. Risking patients’ lives affects an organization’s reputation and can lead to costly litigations. It is vital to factor adverse events in the outcomes and recommendations. For instance, the number of deaths that occur due to medication errors should be factored. Such data helps the organization keep improving and using the proper procedures to keep patients safe.

When assessing adverse outcomes, health care organizations should be adequately aware of the various sources of such events. A nursing process likely to cause an adverse event or a near-miss outcome is the lack of interprofessional collaboration. For instance, it is possible to give a patient the wrong medication if nurses do not collaborate to confirm and reconfirm medications. Another process issue is the failure to use the right technologies. Thompson et al. (2018) noted that technologies such as barcode scanning prevent medication errors by preventing prescribing and transcribing errors. Such factors should be noted when determining the probability of adverse events and their outcomes.

When measuring outcomes, nurses should pay close attention to trends, measures, and information. Concerning adverse events, the key indicator is a health care facility’s improvement in the rate of medication errors over time. Health care providers’ level of knowledge and how a facility uses technology are some of the measures and information need. When preventing adverse events and near misses, desired outcomes include an increased patient safety level, errors that match the required benchmark, and the ability of the health care facility to respond to prevent permanent injuries or deaths. For quality improvement, increased rate of hospital visits for diabetes foot exams is a suitable example of a future quality improvement opportunity.

Quality Initiative Proposal

In the current scenario, the quality improvement area that needs to be addressed is the low rate of diabetes foot exams. According to Boulton et al. (2019), diabetes foot exams are vital for checking infections, injuries, and bone abnormalities. In most cases, diabetes foot problems develop due to neuropathy and poor blood flow. To increase the rate of foot exams, Mercy Medical Center should engage patients better and more conveniently. The best way to improve engagement is by developing a tracking system with a database of all diabetes patients that also sends them (patients) reminders of routine diabetes exams. The system should also send frequent messages on the benefits of a foot exam and how to manage diabetes better. Such initiates will help the facility perform better in terms of annual visits for diabetes foot exams which should be once or more annually (MedlinePlus, 2021). Current data shows that about a third of the patients visit the facility for the exam, which is a huge risk for individual and community health.

Organizations use different interventions to address health care problems. A close review of Mercy Medical Center shows that it readily takes care of diabetic patients when they visit the facility for medical help. Data classified according to gender, race, and age reveals that the medical center is concerned about the rates of diabetes in Shapiro and would like to do better by educating patients and attending to all their health needs. However, improving care at the center is not adequate. Patients should be tracked even when at home and advised what to do to improve their health. With a tracking system, Mercy Medical Center can get patients’ data as shown in glucometers and can get information regarding medication routines and challenges hindering the recovery process. A holistic process is vital.

Concerning diabetes foot exams, organizations also consider the use of telehealth. It is among the quality improvement initiatives where technology plays an instrumental role in enhancing outcomes. Through telehealth, health care providers assess how patients are progressing remotely. They can receive photos of patients’ feet, health routines, and medication procedures and advise patients accordingly. Based on the data that health care providers receive, patients receive advice on keeping their feet healthy without the need for a physical hospital visit.

Target Areas for Improvement

A quality improvement practice should strive to improve outcomes in all areas. One target area of improvement is patients’ knowledge on the need for diabetes foot exams. It is irrational to expect patients to visit the health facility as required if they are not adequately informed about the benefits. The other target area is patients’ use of technology. For instance, patients cannot use glucometers and other devices and report their progress if they do not understand how to use such devices. The communication process should be modified to improve outcomes. Instead of routine physical communication when a patient visits the health facility, online communication should dominate the communication process.

To improve quality, patient education is essential. One way of educating patients is by giving them information brochures when they visit the facility for medical assistance. Such pamphlets should have adequate data on the benefits of a diabetes foot exam, causes of foot health problems in diabetic patients, and when to visit the hospital for an exam. Patient education is vital to change patients’ attitudes towards health intervention strategies and make them agents of change (Paterick et al., 2017). Besides patient education, the facility can also liaise with community health workers to improve patient monitoring at homes.


Challenges are common in change-based initiatives. The current objective is to increase the rate of diabetes foot exams from 145/543 annually to a minimum of 543/543 annually, as the 2019 data indicates. In this case, each patient must have at least one foot exam annually. In such situations, resources pose a significant challenge. For instance, patient education requires a lot of financial capital to facilitate the process, which may not be part of the hospital’s budget at all times. The other possible challenge is resistance to change. Ginex (2018) noted that resistance to change is among the leading barriers to change in organizations. Some health care workers are usually comfortable with the status quo and may be unwilling to support the new process. Patients may fail to cooperate and provide their data as required to facilitate their tracking.

As part of the quality improvement initiatives, in-service training for the interdisciplinary team is crucial. In such training, the interdisciplinary team can communicate about their worries and perceptions about the proposed change. The implementers of the change interact with the interdisciplinary team to ensure that every team member understands the benefits of helping patients improve the yearly foot exams. In this case, changing the interdisciplinary team’s attitude towards the initiative is vital to earning their support and cooperation.

Interprofessional Roles

Improving the rate from 145/543 to a better performance requires the interprofessional team to plays its role diligently and responsibly. One of the team’s roles and responsibilities relating to data and the QI initiative is communicating with patients. Besides the general care, patients will be counseled to understand the process and their new roles where a lot of commitment is required. The interprofessional team will also be involved in data management and analysis. Responding to patients’ progress based on the information in the tracking system will be part of roles and responsibilities. Clear job specification is necessary to ensure that all interprofessional roles are fully engaged in this effort. Accordingly, each team member will execute a specific role to make work easier and avoid role conflicts. The in-service training will help to clear any area of ambiguity.

Measuring Outcomes

The only way of ensuring that a change project has achieved the desired outcomes is through evaluation. Process and outcome evaluations will be used to measure outcomes and advise whether improvements are necessary. Data points to inform interprofessional team performance include patients’ rates of progress reports. They [patients] should provide monthly reports about their performance. The rate of visits for foot exams should be another data point. Data on the first and second quarter are examples of process outcomes, while the cumulative yearly data will be the primary reference outcome measure.

Work-Life Quality

Change initiatives usually affect health care providers’ work-life balance. Health care providers can be mentally and physically drained to engage in hobbies if their new roles become highly demanding. However, the proposed initiate enhances interprofessional collaboration. It makes the entire health team at Mercy Medical Center come together and change the hospital’s overall performance. In-service training and technology use in the change initiative give the interprofessional team a chance to learn new skills and improve productivity. Overall, the initiative is not draining to affect work-life balance in any negative way.


Communication is critical in change initiatives. It is challenging to achieve the desired outcomes without proper and clear communication. The best strategy in this scenario is to use the CUS model. Using the model implies that I am Concerned about the patients’ health conditions, I am Uncomfortable with their conditions [low foot exam rate], and I believe that the Safety of the patients is at risk. Accordingly, every member of the organization should understand why a new approach is necessary. The proposed change can be delivered to the stakeholders as a proposal document explaining the current situation and the vision for change. It should clearly show the performance gaps at Mercy Medical Center compared to the required benchmarks and how the proposed change will transform the situation.

In conclusion, health care organizations work to achieve several local, state, and federal benchmarks. The situation at Mercy Medical Center shows that the facility should improve the rates of foot exams annually to achieve the nationally required level of one exam per person yearly. To achieve this, it is crucial to engage the patient better than what happens currently. As a result, a tracking system that collects and analyzes patients’ data is crucial. Supported by telehealth and patient education, the initiative is expected to make patients more informed about the need for foot exams and when to undergo a test.


Boulton, A. J. M., Armstrong, D. G., Kirsner, R. S., Attinger, C. E., Lavery, L. A., Lipsky, B. A., … & Steinberg, J. S. (2019). Diagnosis and management of diabetic foot complications. Europe PMC.

Ginex, P. K. (2018, May 30). Overcome barriers to applying an evidence-based process for practice change. ONSVOICE.

MedlinePlus. (2021, Mar 3). Diabetic foot exam.

Norris, J. M., White, D. E., Nowell, L., Mrklas, K., & Stelfox, H. T. (2017). How do stakeholders from multiple hierarchical levels of a large provincial health system define engagement? A qualitative study. Implementation Science12(1), 1-13.

Paterick, T. E., Patel, N., Tajik, A. J., & Chandrasekaran, K. (2017). Improving health outcomes through patient education and partnerships with patients. Proceedings (Baylor University. Medical Center)30(1), 112–113.

Thompson, K. M., Swanson, K. M., Cox, D. L., Kirchner, R. B., Russell, J. J., Wermers, R. A., … & Naessens, J. M. (2018). Implementation of bar-code medication administration to reduce patient harm. Mayo Clinic Proceedings: Innovations, Quality & Outcomes2(4), 342-351.