NURS FPX 6085 Assessment 6 Final Project Submission

Abstract

The capstone project will help overcome the serious issue of insufficient and timely documentation of pressure injury risks in adult patients in inpatient medical-surgical units within 24 hours. The intervention strategy involves a multifaceted audit and feedback scheme along with staff training, electronic health record optimization, and leadership involvement to improve the levels of documentation compliance.

The 12-week intervention uses weekly audits, biweekly feedback, EHR prompts, and interprofessional collaboration in order to resolve the deficiencies. The evidence-based approach is assisted by healthcare policies, such as the CMS Hospital-Acquired Condition Reduction Programs and Joint Commission National Patient Safety Goals. The evaluation plan adopts a mixed-methodology, which is composed of quantitative measures of compliance changes and qualitative variables of staff satisfaction.

The anticipated results are the minimization of hospital-acquired pressure injuries, the increase of compliance levels, enhanced patient safety, and a cut in healthcare costs in healthcare. The transferable framework could be versatile to quite a wide variety of clinical environments to push sustainable quality improvement programs and promote nursing practice by means of systematizing documentation improvement and interprofessional teamwork.

Introduction

The capstone project concerns the acute and extremely significant practice of documenting the risk of pressure injury in the first 24 hours after the admission of adult patients in the inpatient medical-surgical unit appropriately and correctly. The intended population, adult patients in the medical-surgical unit, consists of the highly acute level, mixed levels of care, and multidisciplinary care, among others, and it is very hard to be consistent with documentation standards.

The type of clinical work is a clinical practice where the nursing and clinical workforce is involved in patient intake and assessment; therefore, the standardization of the processes is essential to implement the quality improvement initiatives. The intervention strategy presents the systematic audit and feedback loop that implies training the whole staff, streamlining the electronic health records, and the use of automated prompts and checklists, and the proactive participation of the leader in the improvement of the documentation rates (Li et al., 2021).

The intervention is critical because inadequate reporting of the risk of pressure injuries will result in preventable nosocomial pressure injuries, excessive health spending in the form of prolonged hospital stays, and failure to meet the requirements of the Centers of Medicare and Medicaid Services (Roderman et al., 2024). In the implementation plan, there is a progressive implementation of 12 weeks that entails stakeholder involvement, thorough staff training, EHR system integration, and implementation of monitoring, which is in the form of weekly audits and fortnightly feedback.

The evaluation plan will involve an effective mixed-method approach to measure the quantitative outcomes, such as the rates of documentation compliance and the incidence of hospital-acquired pressure injuries, and the qualitative data, such as the staff satisfaction surveys and the focus groups, to determine the effectiveness, usability, and long-term sustainability of interventions.

Problem Statement

• Need Statement

The quality improvement and patient safety concern that will be mitigated by the project is the aspect of the documentation of the risk of a pressure injury in a time-sensitive manner, 24 hours after admission. The need should be addressed because pressure injuries are a considerable complication that may be prevented by patients who spend more time at the inpatient facility, which increases morbidity and higher healthcare costs.

Among the key facts that suggest the urgency, the results of Rose et al. (2022) that nurses only do documentation on manual repositioning adequately in 31.01 of cases deserve to be mentioned, which testifies to the necessity to change the existing practices. Moreover, the traditional assessment tools cannot determine any changes in the patient clinically, which makes it impossible to provide the required interventions and puts pressure injuries at risk, unless the assessment tool is updated regularly (Tomas & Mandume, 2024). Lapses in documentation impair the continuity of care and is not benefiting the much in risk-stratifying the vulnerable profiling of the patients populations.

• Population and Setting

The target population is represented by adult patients staying in the inpatient medical-surgical unit that is a heterogeneous population, and the assessment of risk factors is required in terms of different levels of acuity and clinical conditions. The timely pressure injury risk documentation in the population is essential and should be addressed since the patients are usually vulnerable to pressure injuries due to various risk factors, such as limited mobility, comorbidities, and extended hospital stays (Peterson et al., 2025).

The medical surgical unit is a high-turnover (patient) unit with multidisciplinary teams of care, and fast-paced work with market demand that is likely to compromise documentation consistency. The setting is favorable to a well-organized audit and feedback system because it fits the level of activity and access to unit-based educators and quality improvement staff to train and follow up. The environment has an appropriate infrastructure that supports the scaling up of efficient interventions within the hospital.

• Intervention Overview

The intervention suggested consists of an organized audit and feedback activity with the support of employee education, optimization of electronic health records, and involvement of leaders to increase the rate of compliance with the pressure injury risk documentation in the first 24 hours after admission (Picoito et al., 2025). The multi-component approach is well adapted to the adult medical-surgery demographic because it is able to address the extent of risk factors that the patient population poses and the magnitude of clinical demands that the patient population imposes on the nursing staff’s capacity to deliver a holistic assessment.

The medical-surgical unit is an easy location to apply the evidence-based intervention, as an existing infrastructure, like the unit-based educators, quality improvement specialists, or EHR systems, will guarantee the effective implementation of the proposed intervention in the unit. The structured audit component satisfies this need identified directly, as the component is observed to monitor the documentation lapses in a systematic way, but the feedback is to be employed to develop accountability and to make sure of the continuous enhancement of the quality of the work carried out by the nursing staff.

In addition, automated EHR alerts and training courses instill into practice the timely and precise risk assessment mode and eventually reduce the likelihood of possible hospital-acquired pressure injuries that can be prevented and have a beneficial impact on patient safety outcomes on a large scale (Rose et al., 2022).

• Potential Interprofessional Alternatives

Another interprofessional strategy would be introducing pressure injury risk assessment and documentation compliance, real-time multidisciplinary rounds with wound care specialists, unit-based educators, and nursing leadership (Gu et al., 2022). The alternative promotes a greater level of interprofessional collaboration than the audit-and-feedback model because it promotes shared decision-making and immediate problem-solving between various healthcare professionals (Sultan et al., 2022).

The same strategy can be implemented with the adult medical-surgical population, and makes a complete risk assessment with the help of a wide range of clinical knowledge. However, this alternative may be less relevant when it comes to the hectic time-streaked medical-surgery unit and in an inter-professional sense. Although it can be less sustainable than the systematic audit-and-feedback intervention, managing the documentation requirement through shared supervision can be less sustainable.

• Outcome

The ultimate goal is to attain a statistically significant change in the rates of pressure injury risk documentation adherence among adult patients in the medical-surgical unit in the 12-week period of intervention in 24 hours of admission. The result is a direct indication of the objective of the intervention to have systematic accountability and standardized documentation practices by way of structured audit and feedback.

The achievement indicates the accomplishment of the project goal of reducing the cases of preventable pressure injuries in hospitals as well as guaranteeing compliance with the regulations of the Centers for Medicare and Medicaid Services (Centers for Medicare and Medicaid Services, 2024).

The quantifiable result puts a clear structure of quality improvement wherein the measurable standards that can be tracked down, assessed, and maintained over time are established. The success of the outcome will result in better patient safety, lower cost of healthcare, and continuity of care through timely risk intervention and identification.

• Knowledge Gaps and Areas of Uncertainty

There are multiple gaps in the knowledge related to the structured audit and feedback implementation of pressure injury documentation. There is a paucity of information regarding long term sustainability when implemented over extended durations, especially in high-turnover medical-surgical settings. The relationship between the cultural and linguistic diversity in patients and documentation accuracy is not well understood.

The economic cost-effectiveness studies comparing the audit and feedback with other methods are limited and impede the process of making the best decisions regarding the allocation of resources. Also, the inconsistency in the engagement and feedback response of the staff in various team shifts and shifts leaves doubt regarding the consistency of the effectiveness of the intervention.

• Time Frame

The stage of development of the intervention will take about 4 weeks of stakeholder meetings, developing and training audit tools, and integrating the EHR system to track documentation. The time frame is not ideal because there are unit-based educators and staff on quality improvements to assist in the planning activities. Possible issues that may affect the development are delays in changing the EHR system and the staff’s inconsistency in being included in the first training sessions (Tsai et al., 2020).

The implementation phase will take 8 weeks (weeks 5-12 out of 12-weeks project) as the full implementation of organized audit and feedback mechanisms with ongoing staff training and data gathering. The timeframe of implementation is also realistic since it will be possible to conduct audits and provide feedback on the implementation after every week, and adjust the strategies when needed.

Staffing shortages not predicted, conflicting unit priorities, or irregular data entry practices may make the audit process more complex and lengthen the schedule, however (Robinson, 2023). Secondly, there may not be sufficient baseline data on the present documentation processes, which may need additional preceding evaluation time.

Literature Review

As the existing sources confirm, the specified necessity concerning the enhancement of the risk of pressure injuries documentation, as well as the applicability of the proposed tool to the adult medical-surgical population and the environment, has been proven successfully. There was a considerable gap in documentation, as Rose et al. (2022) revealed that the use of manual repositioning documentation in nurses was only done thirty-one percent of the time, whereas wearable sensor technology was done eighty-two percent of the time, indicating that preventive care interventions were under-documented to a great extent.

The necessity was also proven by McEvoy et al. (2024), who found that the Braden scale scores did not change during several days in the ICU, whereas the sub-epidermal moisture measurements indicated the declining skin condition, which demonstrated that conventional assessment instruments are not effective at capturing clinical shifts unless updated regularly. Andersson et al. (2022) supported the results with a retrospective audit according to which the level of pressure ulcer documentation was insufficient, and the analysis did not involve the key information on location, stage, and interventions, which undermined the continuity of care.

Righi et al. (2020) showed that structured audit programs at long-term care centers had significant adverse effects on the prevalence of pressure ulcers because of a higher adherence rate to risk assessment and documentation. Shuldiner et al. (2023) confirmed the efficacy of audit and feedback, demonstrating a significant yet insignificant 4.3% positive change in compliance when presented timely and compared with colleagues.

The results of the assessment conducted by Sarkies et al. (2023) on audit-and-feedback tools in nursing are mixed because the improvement in documentation is reported. The critical result documentation employed by Glass et al. (2025) was peer audit and feedback, which boosted compliance and satisfaction among nurses. As pointed out by Gould et al. (2023), there has been a difference in reporting the pressure ulcer across systems, and that one should adopt uniform classification schemes.

Padula et al. (2024) redesigned electronic health record interfaces with standardized pressure injury documentation fields, which enhanced the ease and consistency of nursing documentation and ensured low pressure injury rates across departments.

• Evaluation of Relevance and Currency

The sources are very relevant and up-to-date due to the direct emphasis on the documentation of pressure injuries, audit and feedback intervention, and nursing compliance in a healthcare environment. The year of publication is within the range of 2020-2025, which means that the evidence is up-to-date and presents current clinical practice and technological possibilities.

Nurse scientists, clinical specialists, and quality improvement experts are also the authors; they offer authoritative opinions on the issues of documentation and intervention success. The studies are dealing with pertinent issues such as nursing compliance, electronic health record maximization, and audit execution in the different healthcare setups. Research methods are systematic, using reviews that are peer-reviewed and data-based, which directly impact the clinical practice improvement and quality improvement initiatives in the medical-surgical settings.

• Existing Health Policies Impacting the Approach

A number of healthcare policies have a direct implication on how pressure injury risk documentation compliance should be handled in the medical-surgical units. Hospital-acquired pressure injuries (HAPIs) are defined as never events by the Centers for Medicare and Medicaid Services (CMS) and are subject to financial fines and penalties in the form of value-based purchasing and hospital-acquired condition (HAC) reduction programs to promote accountability and initiatives of early risk assessment and documentation (Centers for Medicare and Medicaid Services, 2024).

AHRQ recommends the best practices of preventing pressure injuries using structured tools, audits, and performance feedback, which is consistent with an evidence-based intervention approach (Agency for Healthcare Research and Quality, 2024). National Patient Safety Goals provided by the Joint Commission focus on the necessity to document the information in a timely and correct manner to identify the risks of patients in the first place, allowing systematic audit procedures (Joint Commission, 2025).

The policies establish a regulatory framework where hospitals ought to show pressure injury prevention by having measurable, auditable outcomes. As a result, the intervention should entail compliance monitoring systems, streamlined documentation guidelines, and monitoring metrics that meet the regulatory standards. Furthermore, HIPAA policies require safe data management in audit operations and feedback with the staff (Edemekong et al., 2024). The intervention strategy should provide the objectives of being consistent with professional standards of nursing without infringing on the privacy and confidentiality of the patients during the implementation process.

• Missing Information

The lack of information comprises certain implementation schedules on compliance requirements of policy and elaborate financial penalty frameworks within CMS value-based purchasing schemes. There is scant information on the meaning of Joint Commission documentation standards to healthcare organizations with different units. The state-level policies, which are additional to the federal policies, introduce different compliance requirements that are still vague.

The communication between HIPAA requirements and audit procedures is not clear in terms of interprofessional data sharing procedures. Certain recommendations on how to align policy needs with the current electronic health record systems have not been sufficiently discussed.

Intervention Plan

• Intervention Plan Components

The intervention plan will consist of four significant elements aimed at improving the level of pressure injury risk documentation adherence of adult medical-surgical patients during the first 24 hours of admission. The formal audit and feedback process includes weekly audits with the use of predetermined measures, such as the Braden Scale, to determine the accuracy and completeness of documentation and biweekly performance reports, which define areas of improvement and trends in performance (Kennerly et al., 2022).

Employee training programs include practical simulation as a method of competency and consistency in risk assessment practices, and the optimization of electronic health records incorporates prompts and checklists into nursing work processes to enable timely documentation (Altmiller and Pepe, 2022). Accountability and support of expectations during the implementation process are achieved through engagement of leaders in the form of nurse managers and peer champions.

The elements result in improvements through the establishment of systematic accountability mechanisms, clinical knowledge improvement, documentation process simplification, and supporting organizational structure in the behavior change process. The combination is the optimal choice since it will help to overcome several obstacles at once: knowledge gaps by means of education, workflow inefficiencies by means of technology integration, and compliance issues by means of organized monitoring and feedback.

The heterogeneous adult medical-surgical population poses an important challenge in terms of cultural needs that directly influence the development of interventions. There is a relationship between patient beliefs, language barriers, and different levels of their health literacy, and the assessment validity and the communication effectiveness that need to be supported by culturally competent documentation practices (Gerchow et al., 2021).

The educational component of the intervention should include culturally sensitive communication skills, services of interpreters, and translated materials in order to provide all groups of patients with equal care delivery. Audit tools should be updated to accommodate the inclusive care strategy, and patients of all cultural affiliations should have the same quality of assessment and documentation (Muller et al., 2024).

The patient turnover, multidisciplinary care teams, and the rapid pace of work at the medical-surgical unit precondition the high level of organizational culture in this field that requires a smooth flow of interventions. The environment has to be provided with interventions that are flexible to the different shift schedules, different staff profiles, and competing interests without interfering with the routine of care.

The culture of continuous improvement and the developed infrastructure of the unit, the unit-based educators, and the quality improvement staff, encourage the systematic implementation but promote the sense of collective ownership of documentation standards and patient safety outcomes.

• Theoretical Foundation

The self-care deficit theory by Dorothea Orem is a suitable theoretical framework to be used as it conceptualizes patient vulnerability in the context of being unable to change positions or negotiate with others, and highlights the role of nurses in identifying and responding to self-care deficits. The model has a direct influence on the intervention design in that it aims at risk assessment that is patient-centered and timely recorded to enable early detection of the risk of pressure injury.

The main weakness of the model, however, is that it concentrates on individual patient care as opposed to system-based documentation processes. Other applicable models are the novice-to-expert theory by Patricia Benner that advocates the educational aspect by recognizing clinical expertise levels to different degrees in nursing personnel (Sterner et al., 2021). The theory promoted by Orem is the one that will have the most significant contribution to the intervention design, as it will reinforce the ethical requirement of holistic, timely risk assessment and documentation.

• Strategies from Other Disciplines and Quality Improvement

Quality improvement disciplines such as Lean Six Sigma methodology and Plan-Do-Study-Act (PDSA) can be used to offer strategic frameworks of intervention rollout and optimization of processes. The strategies will have a tremendous influence on design as they will focus on a gradual change, quantifiable results, and continuous process improvement during the 12-week implementation process.

Lean principles assist in streamlining the workflow and removing documentation barriers, whereas Six Sigma is aimed at minimizing variability in the nursing assessment practices (Barr & Brannan, 2024). With the help of PDSA cycles, real-time monitoring and alteration of strategies can be done according to the weekly audit outcomes and feedback provided by personnel (Singer et al., 2021). Recent quality improvement plans will have the greatest influence on the design of interventions by offering a systemized approach to the methodology of intervention, evaluation, and behavioral change maintenance.

• Health Care Technologies

The most applicable health technology, in relation to the intervention, would be electronic health record systems that have inbuilt prompts, smart forms, and automated reminders. The technologies will have a serious influence on design as they will enable capturing real-time documentation and mitigate the rate of omission, besides fitting into the current nursing protocols quite seamlessly.

EHR features allow to produce automated audit reports, the creation of a performance dashboard, and the tracking of compliance between shifts and members of staff (Zheng et al., 2020). Possible constraints are, however, the risk of disruption of workflow, resistance by users, and variability of system design across institutions. The intervention design will be affected the most by EHR optimization since it will offer the technological base needed to improve documentation sustainably and make it a continuous process.

• Justification

The self-care deficit theory of Orem explains the relevance of the systematic risk assessment and documentation in the intervention to develop the concept of nurse responsibility to identify the patient vulnerability and take precautionary measures in situations when patients are unable to represent themselves (Khademian et al., 2020). The systematic audit and feedback elements can be supported by Lean Six Sigma and PDSA approaches, which offer the evidence-based frameworks of process enhancement, variability elimination, and progressive refinement to ensure the sustainability of behavior change (Barr and Brannan, 2024).

The 12-week implementation plan is justified by the quality improvement plans that would be reviewed weekly and revised in case of underperformance every half year, as the performance data would be assessed. Electronic health record technologies that have prompts and automated reminders warrant the workflow integration approach because they offer real-time decision support to minimize human error and documentation omissions (Zheng et al., 2020).

The integration of theoretical nursing underpinnings, quality improvement initiatives, and healthcare technologies provides an all-inclusive rationale as to multi-component intervention design that focuses on individual nurse responsibility, process systematic enhancement, and workflow optimization to foster long-term documentation compliance enhancement.

• Stakeholder Needs, Health Care Policy, Regulations, and Governing Bodies

The nursing staff that needs a workflow-based, practical intervention to improve but not to overload the daily work, the patients who need to receive timely risk assessment and prevention interventions, the clinical leaders who need to report the quality in measurable outcomes, and the administrators who need to obtain regulatory compliance and cost-cutting measures are relevant stakeholders.

The policies in healthcare, like CMS Hospital- Acquired Condition Reduction Program, provide financial incentives to decrease pressure injuries, directly affecting the design of interventions by necessitating auditable documentation and quantifiable results (Centers for Medicare and Medicaid Services, 2024). The Joint Commission National Patient Safety Goals require that the risks be assessed and documented in time, which impacts the elements of interventions with a standardized assessment tool and a tracking system of compliance (Joint Commission, 2025).

CMS and The Joint Commission act as the key controlling bodies that provide the quality standards and the accreditation requirements that determine the design of interventions via obligatory reporting frameworks, performance measures, and evidence-based practice guidelines. The needs of stakeholders, policies, regulations, and the governing bodies, in turn, demand the intervention elements that will reflect quantifiable savings in compliance, cost-effectiveness, and improvement in patient safety, and sustainable implementation among current healthcare delivery systems.

• Ethical and Legal Issues

The main ethical considerations that are applicable in this case relate to the principles of beneficence and non-maleficence in nursing practice, as healthcare professionals need to guarantee patient safety and avoid harm by performing a timely pressure injury risk assessment and recording. The ethical requirements have an impact on the healthcare practice in terms of the obligatory risk assessment and preventive measures, organizational change due to the development of the accountability culture, and the educational needs of the staff.

Ethical aspects influence the elements of intervention by requiring positive feedback to foster learning and avoid punitive responses, which do not harm the staff psychologically when they undergo audit procedures (Andersson et al., 2022). Such legal implications involve documentation as formal clinical care records; incomplete or missing pressure injury risk assessment exposes the organization to liability due to avoidable injuries and malpractice suits (Demsash et al., 2023).

Healthcare practice is impacted by legal requirements because it enforces regulatory standards as stipulated by the CMS and The Joint Commission, which influence organizational change through policy formulation and staff training guidelines. Legality has an influence on the design of the intervention since it necessitates the use of HIPAA-conformant audit procedures, data security when conducting feedback, and documentation that would meet the standards of professional nursing and institutional liability coverage (Edemekong et al., 2024).

• Assumptions

The intervention presupposes that the current documentation practices are not consistent and optimal, and they need to be improved methodically in a systematic way. It assumes that structured audit and feedback interventions would increase compliance and that timely documentation has a direct effect on pressure injury prevention outcomes.

The plan presupposes that the staff will have a positive reaction to constructive feedback and change their behavior as well. It also presupposes the sufficiency of EHR infrastructure, administrative support, and stakeholder dedication to the effective implementation and the sustained introduction of new documentation guidelines.

Implementation Plan

• Management and Leadership

Transformational leadership, which will involve nurse managers and peer champions, will inspire teams because of a collective vision and dedication to patient safety, which will promote interprofessional teamwork by developing psychological safety to receive feedback and accountability. Daily huddles and interdisciplinary rounds are part of the management strategies, offering a platform to enable real-time dialogue on documentation expectations and performance updates between nurses, quality improvement teams, and wound care specialists (Lin et al., 2022).

Defining roles and having common responsibility frameworks will make sure that all the team members know what they should contribute to documentation compliance and patient outcomes. Evidence-based care, ongoing learning, and professional accountability in professional nursing practices will inform the staff interactions with audit feedback and learning aspects. The practices encourage interprofessionalism by harmonizing communication procedures and establishing respect among the healthcare professions.

The performance checking and the provision of constructive feedback will frequently keep the staff motivated and handle obstacles in a cooperative manner (Abraham and Singaram, 2024). The combined leadership, management, and professional approaches establish a combined approach that aids in maintaining behavior change and enhancing quality across time.

• Implications

Transformational leadership techniques will ensure the establishment of accountability and shared responsibility in the medical-surgical unit, which will positively impact the quality of care by means of preventing pressure injuries more effectively, detecting risks in time, and providing patients with more proactive and preventive care experiences.

The daily huddles and interdisciplinary rounds used in management strategies will provide systematic communication protocols aimed at enhancing the and improving care coordination and patient safety events and boost family confidence due to the visible teamwork and regular communication (Lin et al., 2022). Evidence-based documentation and lifelong learning in professional nursing practices will result in standardized assessment practices, which will minimize the variability of practice and enhance the accuracy of clinical decision-making (Mohamed et al., 2024).

The overall improvements will lead to control of costs by aiding in the prevention of hospital-acquired pressure injuries, lowering treatment costs, avoiding CMS monetary fines, and leaving the hospital sooner by utilizing better risk control and early intervention measures.

• Delivery and Technology

The most suitable modes of intervention delivery are face-to-face educational activities, integration of electronic health records, provision of audit feedback on the digital dashboard, and structured interprofessional communication guidelines during shift-to-shift and daily huddles (Pimentel et al., 2021). The reason is that the methods are suitable since they can accommodate a variety of learning styles when they are integrated into current workflows, and when the solutions can give instant access to performance information and feedback systems.

The suggested approaches enhance the quality of project implementation by making the staff interaction uniform, documenting the process standardized, and allowing constant monitoring and correction of it during the 12 weeks of implementation term. The latest technological features are EHR-based prompts and alerts, automated audit report generation, performance dashboard with real-time compliance monitoring, and secure message boards to deliver feedback to nursing personnel in time (Zheng et al., 2020).

The technologies improve the effectiveness of delivery, as it minimizes the error in documentation, enable instant performance visibility, and help the interprofessional team members to communicate quickly. Integration of EHR is expected to positively influence the largest impact as it will help to include risk assessment prompts in the daily routine of nurses (Johnston et al., 2022).

Some of the new technologies under development are the use of artificial intelligence in predictive analytics to identify pressure injury risks early, wearable pressure sensors to monitor pressure injuries continuously, and mobile health apps to provide bedside education materials and reminders.

• Stakeholders, Policy, and Regulations

Applicable stakeholders are nursing staff who need workflow-integrated solutions, patients who need to have timely risk assessment, clinical leaders who need to have measurable outcomes, and administrators who need to achieve regulatory compliance and cost reduction, whose needs as a group result in pragmatic and evidence-based intervention components that show clear value.

The legislation, such as the CMS Hospital-Acquired Condition Reduction Program and the Joint Commission National Patient Safety Goals, imposes systematic pressure injury prevention and documentation that has a beneficial effect on implementation by offering regulatory assistance and financial incentives to improve compliance (Centers for Medicare and Medicaid Services, 2024; Joint Commission, 2025).

Other aspects of support can be regarded as proper staffing, the capacity of the EHR infrastructure, and continuous quality improvement resources that will guarantee sustained implementation success (Zheng et al., 2020). The current policies that facilitate the implementation encompass the AHRQ pressure injury prevention regulations and the evidence-based practice requirements that substantiate the structured audit and feedback methods (AHRQ, n.d.).

New policy implications may consist of the obligatory risk documentation period of pressure injuries within the institutional policy and the standardized interprofessional communication guidelines that would enhance accountability mechanisms. The new policies would have positive effects on the implementation process by establishing clarity of expectations, improving interprofessional collaboration, and organizational support of the long-term behavior change among healthcare teams.

• Timeline

The period of implementation of the intervention is 12 weeks, the first 4 weeks of which are allocated to development, including stakeholder meetings, the development of audit tools, and training materials, and the active implementation of EHR with weekly audits and a biweekly feedback meeting. The time-period is practical based on the availability of unit infrastructure, such as teachers and quality improvement personnel support.

The timing is affected by certain factors, such as the availability of staff to train, possible delay of EHR modifications, unstable data entry practices that increase the difficulty of the audit process, unforeseen staffing shortages, conflicting priorities in the unit, and limited data on baseline documentation that needs prior evaluation (Tsai et al., 2020). The considerations can have a moderate impact on extending the timeline to 2-4 weeks in case several setbacks arise at the same time.

• Assumptions

The schedule is based on the assumption that there is sufficient administrative support and institutional follow-up on quality improvement programs during the implementation process. It assumes that the changes in the EHR system may be made within the available time of development without any serious technical issues.

The analysis presupposes that nursing personnel will be present and eager to get engaged in the process of education and feedback. It will also require that there is baseline documentation data available and that can be compared, and that rival clinical priorities will not cause a serious impediment to the intervention timeline.

Evaluation of the Plan

The first outcome is the attainment of a statistically significant change in the rates of pressure injury risk documentation compliance in adult patients of the medical-surgical unit upon admission in the 24 hours during the 12-week intervention. Secondary outcomes are reduced hospital-acquired pressure injury rate, improved interprofessional collaboration in terms of patient risk condition, better continuity of care, and improved staff satisfaction with documentation procedures (Roderman et al., 2024).

The results directly depict the intent of the intervention, which is the creation of systematic accountability and standardized documentation practices, through systematic audit and feedback mechanisms. The results show the achievement objectives of decreasing preventable pressure injuries as well as the regulatory adherence to CMS standards and Joint Commission requirements (Centers for Medicare and Medicaid Services, 2024).

The evaluation plan is based on the mixed-methods design, quantifying such indicators as pre- and post-intervention compliance rates that are examined by EHR reports, hospital-acquired pressure injuries, audit accuracy scores, and documentation completion times. The automated EHR reporting systems, standardized audit tools, and compliance tracking dashboards will be used to collect data weekly during implementation (Lewis et al., 2023).

Qualitative measures will be in the form of staff feedback by post implementation survey and focus groups on perceived usability, impact of workload, and effectiveness of intervention. The process evaluation will involve monitoring the attendance of education sessions, the rate of EHR prompt use, and timely feedback based on electronic monitoring systems and attendance records.

Strategies of data analysis will be statistical comparison of pre- and post-intervention compliance rates, trend analysis of weekly performance data, and thematic analysis of qualitative feedback data through the use of survey software and focus group transcription tools.

The evaluation plan will report the impact of intervention with a holistic report of both quantitative and qualitative indicators of improvements in documentation measures and staff satisfaction, and both clinical and feasibility of implementation to scale-up and sustainability of the intervention in the long term in the healthcare organization (Bobini and Cicchetti, 2025).

• Assumption

The evaluation plan presupposes that the baseline documentation data should be properly documented and available for comparison. It assumes that the staff will be honest during surveys and focus groups, and the resulting feedback will be qualitative. The plan presupposes that EHR systems will be able to produce effective compliance reports, and the quality of documentation will always be appraised with the use of audit tools.

Discussion

• Advocacy

Nurses are the driving force in change in the field of professional practice and interprofessional teams by acting as direct care agents, facilitating evidence-based practices, and modeling adherence to documentation regulations by utilizing transformational leadership strategies that build shared commitment to patient safety outcomes (Flaubert et al., 2021).

The intervention plan influences nursing in that it instills systematic accountability measures, clinical knowledge gained through education, and technological support that simplifies the documentation processes at the expense of the administrative burden. The process of interprofessional collaboration is enhanced by well-established communication procedures, such as daily huddles and feedback loops that encourage the growth of shared responsibility between the nurses and wound care specialists, as well as quality improvement teams (Ominyi & Alabi, 2025).

The benefits of the healthcare sector include reduced pressure injuries related to hospitalization, lowering the cost of the treatment, higher compliance of the regulatory measures with the CMS and Joint Commission regulations, higher quality of data used in the outcomes reporting, and creation of the frameworks of quality improvement that can be scaled to a variety of care environments and clinical patient groups.

• Future Step

The intervention may be optimized by increasing the scope of current documentation compliance to proactive reduction of risks with the introduction of predictive analytics to allow the risk to be detected earlier by cross-referencing Braden scores with such clinical indicators as mobility, nutrition status, and comorbidities (Kennerly et al., 2022).

New technologies, such as wearable sensors that track the pressure on the skin in real-time and sub-epidermal moisture sensors, mobile health applications, etc., have the potential to offer real-time measurements of the skin integrity and provide bedside educational tools to keep the staff constantly engaged (El-Rashidy et al., 2021).

Such innovative care approaches as interdisciplinary team rounds with wound care professionals and quality improvement leaders would make sure that risk prevention strategies are incorporated into routine processes and set in stone patient and family engagement through repositioning education and skin assessments.

The improvements would significantly increase patient outcomes by allowing technology-supported early detection, effective interprofessional coordination of care, and shared responsibility of preventing hospital-acquired injuries and promoting long-term culture changes that promote a healthy and sustained safety culture.

• Reflection on Leading Change and Improvement

The capstone project has contributed greatly to changing leadership capacity through its refined knowledge on how evidence-based and structured interventions with structure can deliver quantifiable change in care quality and patient safety. The construction of the audit and feedback framework on documenting pressure injury risk enhanced the significance of integrating both data-driven decision-making and collaborative and enabling methods of leadership (Li et al., 2022).

It was a practical experience in terms of competencies in stakeholder engagement, aligning interventions with organizational priorities, and using technology to enhance the efficiency of the working process. The project helped to learn to expect resistance through the creation of psychological safety, positive feedback, and shared ownership of results. The experience showed the importance of being flexible and implementing real-time data to optimize strategies without losing sight of the long term goals.

It will be possible to lead quality improvement efforts that demand both clinical acumen and interprofessional collaborations more effectively in the future, realizing that sustainable changes will occur upon gaining cultures in which team members feel empowered, educated, and invested in providing safer and higher-quality care (Bornman and Louw, 2023).

The final intervention, implementation, and evaluation plans have a transferable framework that can be used in different quality improvement projects in nursing practice. Targeted education and integrating EHRs with the systematic audit-and-feedback model can provide a reproducible compliance improvement mechanism across a variety of clinical settings, such as medication safety, infection prevention, and discharge planning (Zheng et al., 2020).

Lessons learned in the implementation concerning the involvement of stakeholders, a gradual rollout, and integration of workflow can inform future implementation, and the mixed-methods evaluation methodology can be used as a blueprint to measure both quantitative and qualitative results and provide meaningful and sustainable change across various care environments.

Conclusion

The overall capstone project proves the efficiency of the employment of the organized audit and feedback procedures to improve compliance in the medical-surgery units in terms of pressure injury risks documentation. The project approaches the key patient safety requirements through evidence-based intervention development, stakeholder involvement, and planning of systematic evaluation, and contributes to regulatory adherence and cost savings.

A combination of leadership plans, interprofessional cooperation, and new technologies will establish a sustainable model of quality improvement that can be reproduced in various healthcare facilities and, eventually, develop nursing practice and enhance the outcomes of patients with the help of systematic documentation improvement and preventive care procedures.

Explore Previous Assessment: NURS FPX 6085 Assessment 5

Need help with NURS FPX 6085 Assessment 6? Get step-by-step guidance and expert support to improve grades and succeed confidently.