HLT-362V Quality Improvement Proposal Solved

In a 1,250-1,500 word paper, describe the problem or issue and propose a quality improvement initiative based on evidence-based practice. Apply \”The Road to Evidence-Based Practice\” process, illustrated in Chapter 4 of your textbook, to create your proposal.

Include the following:

Provide an overview of the problem and the setting in which the problem or issue occurs.
Explain why a quality improvement initiative is needed in this area and the expected outcome.
Discuss how the results of previous research demonstrate support for the quality improvement initiative and its projected outcomes. Include a minimum of three peer-reviewed sources published within the last 5 years, not included in the course materials or textbook, that establish evidence in support of the quality improvement proposed.
Discuss steps necessary to implement the quality improvement initiative. Provide evidence and rationale to support your answer.
Explain how the quality improvement initiative will be evaluated to determine whether there was improvement.
Support your explanation by identifying the variables, hypothesis test, and statistical test that you would need to prove that the quality improvement initiative succeeded.

Nurses strive to provide the best possible care to diverse clients under consistently changing conditions. From the medications administered to the type of dressing used to heal a wound, nurses apply procedures that have been tested through research and deemed appropriate according to evidence-based standards of practice. Through foundational knowledge related to research methods, translation of research data is used to improve nursing practice and, ultimately, patient outcomes. Therefore, nurses must become familiar with the specific language of scientific research and the research process. As health care professionals, nurses seek to provide their patients with the best possible health care. To determine which approaches to care result in the best possible care, the effectiveness of each approach specific to a chosen population must be investigated. The pursuit of knowledge is the basis for research. Researchers seek to find answers to various scientific questions, but there are the boundaries associated with the pursuit of knowledge (Helbig, 2018).

Quality Improvement Proposal

The need for medical and healthcare facilities like Kaiser South Sacramento Medical Center, to improve the quality of services implores them to discover initiatives and reforms focused on facilitating the realization of these goals and objectives. According to Finn et al. (2018), quality improvement is a critical process that enables providers to enhance their services to patients and attain better satisfaction levels. Quality improvement initiatives allow healthcare entities to reduce cost of care, improve patient outcomes, enhance the performance and the effectiveness of their services. Quality i

HLT 362V Quality Improvement Proposal Solved
HLT 362V Quality Improvement Proposal Solved

mprovement also enhances patient and provider safety and ensures that healthcare settings and systems meet regulatory requirements (Johnson & Sollecito, 2020). Using the “The Road to Evidence-based practice” process model, this essay identifies a quality improvement opportunity at Kaiser South Sacramento Medical Center and proposes an initiative to address the challenge.

Overview of the Issue and Setting

The need for patient safety measures is a critical part of reducing medical errors and ensuring that patients and their families using the medical center are not impacted negative, especially through hospital acquired infections like contracting the novel Coronavirus disease 2019 (COVID-19) (Finn et al., 2018). At Kaiser Permanente and Kaiser South open facilities that were temporarily closed due to the COVID-19 pandemic, it is essential to enhance patient safety measures to reduce the spread of the condition. Safety protocols like mandatory hygiene measures that include wearing of face covers, washing of hands, and use of sanitizers are essential measures to ensure the safety of patients, their families, and providers using the facilities.

The Agency for Healthcare Research and Quality (AHRQ) (2020) asserts that the spread of COVID-19 and its related fatalities place health and nursing practitioners at increased risk of contracting the disease despite the availability of vaccines, especially with new variants like the Delta variant, that prove more lethal and fast spreading. The implication is that consideration of the humanness of care in the wider context of patient safety raises awareness of how human limitation impact individual clinicians and care teams and lower safety levels and quality of care. These weaknesses also increase the risk for both patients with COVID-19 and the staff caring for them. As such, the facilities must develop strict protocols to continue protecting its employees, patients and their families, and other stakeholders. The risk of exposure to infections reduces performance and contributes to failures like adverse events and misdiagnoses that lead to poor patient outcomes.

Reason for Quality Improvement Initiative and Expected Outcomes

Patient safety is a critical quality measure in any healthcare setting or organization as it indicates quality and ensures that individuals are safe while getting treatment interventions. Quality improvement initiatives are essential in enhancing overall quality of care and ascertaining that patients are not harmed, especially at this pandemic time when many are contracting COVID-19 and dying from its associated complications. In their study, Galvao et al. (2018) assert that hospitals and providers should establish a patient safety culture by developing values and behaviors through a collective and institutional approach for better outcomes. Institutions with patient safety have the ability to offer safe care of better quality to their patients. A safety culture has different dimensions that include reduced incidences of surgical site infections, reduction in injuries and critical adverse events and risk-adjusted mortality. A patient safety culture is an essential part of reducing medical errors among patients in the facilities and ensuring that providers offer optimal care.

The quality improvement initiative will allow the facility to offer quality care and ensure that patients’ satisfaction levels are higher than the current ratings. Patient safety is a regulatory requirement based on both state and federal laws and policies. Patient safety is a component of high reliability organizations as these entities are considered effective by consistently minimizing adverse events despite conducting intrinsically complicated and hazardous tasks, processes, and medical procedures. High reliability organizations have a commitment to maintaining safety at all level, right from frontline providers to managers and executives (Chegini et al., 2020). Such a commitment establishes a “culture of safety” that entails critical features like a blame-free environment where individuals can report error or near misses with no fear of punishment, reprimand, and reprisal.

Previous Research Studies

Results from previous research show support for the quality improvement initiatives and the anticipated outcomes. In their study, Reis et al. (2018) carry out a systematic review using hospital survey features to understand a patient safety culture and its dimensions. Their findings show that hospital organizational cultures are critical in enhancing patient safety. The authors also emphasize the need for effective safety culture evaluation based on strategies designed to enhance hospital-wide interventions for better patient outcomes.

In its article, the Agency for Healthcare Research and Quality (AHRQ) observes that a culture of safety is critical in overall care delivery and attaining the status of high reliability organization. Kaiser South medical Center is one of leading healthcare providers in Sacramento, California and ensuring that is a high reliability organization is essential to its ability to offer better care for patients. The AHRQ notes that a safety culture encourages collaboration across ranks and disciplines as individuals seek solutions to patient safety issues that emerge. Quality improvement initiative also ensures that there is organizational commitment of resources in addressing safety concerns.

In their study, Campione and Famalaro (2018) identify promising practices that can allow hospitals to improve patient safety. The authors note that patient safety culture has a positive impact on the effectiveness of quality improvement interventions. The article identifies common practices that lead to patient safety culture improvement. These include setting of goals and robust action planning for quality improvement, implementing evidence-based practice and well-known safety initiative and programs and rigorous survey administration approaches. The implication is that patient safety is an essential component of improving overall care delivery in healthcare settings like the Kaiser South Medical Center in Sacramento.

The implementation of a patient safety culture will allow the organization to mitigate potential infections acquired in the hospital, reduce exposure to COVID-19 by all stakeholders, and ensure that it offers increased patient satisfaction. This critical process will allow for the improvement of teamwork process among the professionals. In turn, this will enable the reduction in infection rates, lead to adherence to COVID-19 protocols and ensure that the organization becomes a high reliability entity in care provision.

Steps Necessary in Implementing the Quality Improvement Initiative

The implementation of this quality improvement initiative will entail following a determined process based on utilization of change models. These models include Lewin’s three step and plan-do-study-assess (PDSA). At the start of the implementation, change agents must create the urgency for change and ensure that they follow the three step process of Lewin’s approach that entail unfreezing, change implementation, and refreezing to ensure that the reforms are part of the organizational culture. The PDSA model would be instrumental in generating feedback from the users of the new approaches in the facility (Abd El-Shafy et al., 2019). With these models in mind, the initial step would be to communicate about the initiative and its significance to enhancing quality outcomes and reducing adverse events, including medical errors. Communication will ensure that stakeholders understand the need and urgency for change.

The next step will be training staff on the communication process and enhancement of a collaborative approach to the issue. Through the training, the quality improvement initiative will eliminate doubts among the providers and ensure that they attain a buy-in to support the changes. The organization would them move to implement the proposed interventions using Lewin’s model and evaluate if there is need for changes through the PDSA model. Implementation of the project may face resistance which the organization can mitigate through effective communication and ensuring that all people have equal opportunities to express their concerns.

Evaluation of the Quality Improvement Initiative

The evaluation process of the quality improvement initiative should be prudent for stakeholders to determine its overall success in enhancing patient safety and developing a safety culture within the setting. The evaluation process will be conducted through assessing success that will be attained by the using the new measures by healthcare providers or the medical staff in the facility (Campione & Famolaro, 2017). These individuals will identify possible weak areas that can compromise overall safety culture in the facility. There will be an evaluation of the potential impacts of communication and teamwork approaches.

The team will develop relevant hypotheses to demonstrate effectiveness of the changes and the need to improve quality care for the patients visiting the facility at this pandemic time. The team will offer monthly reviews and feedback based on the principles of the PDSA model. Corrective measures will ensue to ensure that the intervention leads to the development of a robust patient safety culture in the facility.


Quality improvement initiatives are essential approaches to ensuring that organizations better service provision and allow patients to experience better outcomes. In this case, the medical center needs to ensure that it develops a safety patient culture due to the ravaging COVID-19 pandemic with the aim of reducing exposure and susceptibility to the condition. The quality improvement initiative will lead to better patient outcomes and help the facility to attain the “high reliability organization” status.













Abd El-Shafy, I., Zapke, J., Sargeant, D., Prince, J. M., & Christopherson, N. A. (2019).

Decreased pediatric trauma length of stay and improved disposition with implementation of Lewin’s change model. Journal of Trauma Nursing| JTN, 26(2), 84-88.

Agency for Healthcare Research and Quality (AHRQ) (2019). Culture of Safety.

Agency for Healthcare Research and Quality (AHRQ) (2020). COVID-19: Team and Human

Factors to Improve Safety.

Campione, J. & Famolaro, T. (2017). Promising Practices for Improving Hospital Patient Safety

Culture. Safety Culture, 44(1):23-32. DOI:

Chegini, Z., Janati, A., Afkhami, M., Behjat, M., & Shariful Islam, S. M. (2020). A comparative

study on patient safety culture among emergency nurses in the public and private hospitals of Tabriz, Iran. Nursing open, 7(3), 768-775. doi: 10.1002/nop2.449

Finn, K. M., Metlay, J. P., Chang, Y., Nagarur, A., Yang, S., Landrigan, C. P., & Iyasere,

  1. (2018). Effect of Increased Inpatient Attending Physician Supervision on

Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical

Trial. JAMA Internal Medicine, 178(7), 952–959. doi:10.1001/jamainternmed.2018.1244

Galvão, T. F., Lopes, M. C. C., Oliva, C. C. C., Araújo, M. E. D. A., & Silva, M. T. (2018).

Patient safety culture in a university hospital. Revista latino-americana de enfermagem, 26. doi: 10.1590/1518-8345.2257.3014

Johnson, J. K., & Sollecito, W. A. (2020). McLaughlin & Kaluzny’s Continuous Quality

Improvement in Health Care (5th ed.). Burlington, MA: Jones & Bartlett


Reis, C. T., Paiva, S. G., & Sousa, P. (2018). The patient safety culture: a systematic review by

characteristics of hospital survey on patient safety culture dimensions. International Journal for Quality in Health Care, 30(9): 660-677.

One quality improvement opportunity that our organization has identified is in the area of patient data management. In particular, the management have identified ways to improve how employees collect, store, and retrieve patient data. Acme Healthcare System currently contracts with a third-party vendor for the electronic health records (EHR) systems. One of the recommendations from our quality improvement team was to invest in a new EHR system that would better suit the needs of the organization. Another recommendation was to develop a comprehensive patient data governance policy. This policy would set forth how patient data should be collected, stored, and accessed by employees across the organization. The purpose of this assignment is to identify a quality improvement opportunity in my healthcare organization describe the problem or issue and propose a quality improvement initiative based on evidence-based practice.

Overview Of the Problem and The Setting in Which the Problem or Issue Occurs

The problem of patient data management in my healthcare organization is that we have a lot of data, and we not sure what to do with it. The healthcare organization have data from patients’ electronic health records (EHRs), from the billing system, from the laboratory information system, and from other sources. The organization need to find a way to use this data to improve the quality of care given to patients. One idea is to use big-data analytics tools to analyze the data and find patterns that can help us improve approaches for caring for patients. Another idea is to use the data to identify high-risk patients and develop interventions specifically for them. The management is still trying to figure out the best way to use EHR system to enhance patient’s data management.

The problem of patient data management occurs in healthcare settings where accurate and up-to-date patient information is essential for providing quality care. This may include hospitals, clinics, and private practices. The problem arises when there is a lack of communication and coordination between different medical staff members who are responsible for managing different aspects of a patient’s care. This can lead to duplication of records, missed appointments, and even incorrect diagnoses. To solve this problem, healthcare organizations need to put systems in place that allow for better communication and collaboration between all medical staff members involved in a patient’s care.

Why A Quality Improvement Initiative is Needed in This

Area and The Expected Outcome

A quality improvement initiative is needed for patient data management in order to enhance the quality of patient outcomes and to reduce the cost of healthcare. Healthcare providers are collecting more data than ever before on patients, but much of this data is not being used effectively to improve patient care. By improving the way that data is collected, tracked, and analyzed, healthcare providers can make better decisions about how to treat patients and improve their quality of life. In addition, reducing the cost of healthcare will be critical in order to make it affordable for everyone. By improving patient data management, we can reduce waste and ensure that our resources are being used most effectively.

A quality improvement initiative is also needed for patient data management to reduce patient’s data loss. A recent study found that nearly one-third of patients reported they had experienced a loss of health information, largely due to human error. Incidents of lost or corrupted patient data can have significant consequences for both individuals and the healthcare system as a whole. For example, patients may experience delays in receiving care or incorrect treatment as a result of missing medical records. In addition, organizations may face financial penalties and reputational damage when data breaches occur. A quality improvement initiative can help to prevent such incidents by improving the accuracy and consistency of patient data handling processes across all areas of the healthcare system.

How The Results of Previous Research Demonstrate Support for The Quality Improvement Initiative and Its Projected Outcomes

In order to quality assure patient data, health information technicians use a variety of methods which have been found through research to improve the quality of data. The systematic application of these methods is what is referred to as a Quality Improvement Initiative or QI initiative. A recent study (conducted in Canada) set out to determine the effectiveness of a QI initiative on patient data management (Coles et al., 2020). The study found that the introduction of a QI initiative led to an increase in the accuracy and completeness of patient data. Furthermore, it was also found that there was an improvement in other key performance indicators such as turnaround time, staff satisfaction, and patient satisfaction. These findings demonstrate that a QI initiative can lead to significant improvements in data quality.

The results of previous research provide strong support to the Quality Improvement Initiative and its projected outcomes in patient data management. A study by Silver et al. (2017) found that a multifaceted quality improvement intervention was effective in reducing preventable harm events, including readmissions, mortality, lengths of stay, and costs. Moreover, the study also found that the overall quality of care improved following the intervention. This indicates that hospitals which undergo a quality improvement initiative can expect to see tangible improvements in patient safety and outcomes. Such findings underscore the importance of investing in such initiatives and point to the significant potential benefits they offer healthcare organizations.

A recent study published in the journal “Health Affairs” found that the Quality Improvement Initiative (QII) – which is a national effort to improve the quality and safety of healthcare – is projected to result in significant reductions in adverse events, including deaths, hospital readmissions, and costs (Main et al., 2018). The study used computer simulations to estimate the impact of QII on patient data management. The results showed that by 2020, QII could prevent: – Nearly 2 million adverse events, including more than 190,000 deaths, – More than 9 million hospital readmissions, and – More than $150 billion in costs (Main et al., 2018). These outcomes would be achieved through improvements in care coordination and patient engagement.

Steps Necessary to Implement the Quality Improvement Initiative

There are a few key steps necessary for the implementation of an EHR system for the effective management of patient data. First, it is important to consult with experts in the field to get a sense of what system would best fit the needs of your organization. Second, once a system has been selected, it is critical to have a dedicated team to manage its implementation and ensure that all staff are properly trained on how to use it. Third, ongoing communication and feedback from all stakeholders – including patients – is essential to monitor the effectiveness of the EHR system and make necessary adjustments. Finally, it is also important to have a robust back-up plan in place in case of technical difficulties or other issues that may arise. By following these

Discuss steps necessary to implement the quality improvement initiative.



How The Quality Improvement Initiative Will Be Evaluated to

Determine Whether There Was Improvement

When evaluating a quality improvement initiative on the implementation of an EHR system, it is important to collect data around patient management and quality. This can help determine whether there has been an improvement since the EHR system was put in place. The gathered data should be compared against benchmarks or standards to make sure that improvement has actually occurred. Additionally, it is important to get feedback from clinicians who are using the EHR system to see how well it is working for them in their daily workflows. By collecting all of this data and information, the management can create a well-rounded picture of how successful the quality improvement initiative has been.

There are many factors to consider when evaluating the success of an EHR system, but one of the most important is whether or not it leads to improvements in patient data management and quality. When implemented properly, an EHR system can help streamline clinical workflows and make it easier for staff to access and enter accurate patient data. This can ultimately improve patient care by reducing errors and providing more timely and relevant information to clinicians. Additionally, better data management can help support population health initiatives by providing analysts with cleaner and more complete datasets. That said, it is important to keep in mind that improvement in patient data management is just one piece of the puzzle when it comes to assessing EHR success.

The variables to be tested to determine effectiveness of the EHR system include clinical workflows, safety of patient data management, and reduction in errors in the patient data management. The hypothesis tests include: The application of EHR system leads to quality patient outcomes, EHR system leads to the reduction in erroneous patient’s data and leads to effective patient outcomes. The statistical tests needed to prove that the quality improvement initiative has succeeded include student t-test, ANOVA, and Z-test.


Open data initiatives are vital in improving patient data management quality because they allow for interoperability between systems. When stakeholder resource development organizations (healthcare facilities, employer groups, and health plans) standardize on a specific platform or application such as an EHR system, it becomes difficult to manage care coordination. Different forms of electronic patient data platforms used by these organizations compound this problem. One way to improve patient care coordination is to use a system that can connect various types of electronic patient records. Another solution is for developers of EHR software solutions to provide the capability for their systems to exchange information with each other through application programming interfaces or “APIs.”














Coles, E., Anderson, J., Maxwell, M., Harris, F. M., Gray, N. M., Milner, G., & MacGillivray, S. (2020). The influence of contextual factors on healthcare quality improvement initiatives: a realist review. Systematic Reviews9(1), 1-22.

Main, E. K., Markow, C., & Gould, J. (2018). Addressing maternal mortality and morbidity in California through public-private partnerships. Health Affairs37(9), 1484-1493.

Silver, S. A., Bell, C. M., Chertow, G. M., Shah, P. S., Shojania, K., Wald, R., & Harel, Z. (2017). Effectiveness of quality improvement strategies for the management of CKD: a meta-analysis. Clinical Journal of the American Society of Nephrology12(10), 1601-1614.