NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

NURS FPX 6016 Assessment 2

NURS FPX 6016 Assessment 2

Quality Improvement Initiative Evaluation

It is important to know that quality improvement is vital for the development of healthcare and the improvement of patient’s health, as well as for increasing the efficiency of work. Therefore, in the healthcare system, which is a relatively highly competitive and evolving industry, there is a constant need for fresh evaluations and improvements in response to the varying requirements of society. Unlike other evaluations, this evaluation concerns a present-day QI project in a healthcare organization, reviewing its development, outcomes, and possible improvements (Smith, 2020; Johnson et al., 2021).

This assessment of the initiative on patient care can therefore present a general view of the initiative’s effectiveness, the prospects for further expansion, the practices generated by outside professional bodies, and the recommendations for further enhancements drawn from the input of professionals from different fields. Both internal and external factors stimulated the selected QI initiative; and performance analysis and thus was planned to resolve some of the issues within the organization.

Hence, this evaluation will employ a qualitative and quantitative analysis approach to show the initial intended goals of the initiative, in addition to the subsequent problems left unaddressed or newly emerging ones. The initiative’s efficiency will be evaluated by comparing it with the set standards and indicators with a focus on successes and further development.

Current Quality Improvement Initiative

The subject of the selected quality improvement (QI) project revolves around hospital-acquired infections (HAIs) in a middle-sized urban hospital. This was occasioned by internal audits and patient safety reports that CCA had a relatively higher average rate of HAIs than was expected; a factor that worsened patient prognosis and ballooned the expenses of healthcare delivery.

By following them, the level of infections must be reduced, the level of patient safety increased, and the requirements of the national standards of healthcare adopted (Smith, 2020). The QI initiative targeted several key areas:

promoting and fostering healthcare workers to strictly observe hand washing procedures, increasing cleaning frequency and standard in the patients’ zones, establishing prudent antibiotic use to prevent the development of resistant strains, and educating patient caregivers about contagion protocols. These measures were designed to make the healthcare setting safer and substantially lower the incidence of HAIs.

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Some study’s limitations and open questions still exist as follows. A significant issue is the validity and representativeness of data on HAIs before the introduction of such an initiative. The initial erroneous data collection may mislead the result of the significance of the effort, thereby complicating means for identifying progress.

Also, there is doubt about the continuity of improved practices and the succeeding commitment of the staff to practice them. This means that without replicating efforts, it is possible to experience the deterioration of the improvement outcomes and the subsequent emergence of HAIs (Johnson et al., 2021).

The Success of a Current QI Initiative Through Recognized Benchmarks and Outcome Measures

Evaluating the success of mid-sized urban hospital’s QI initiative that focused on decreasing HAIs involves employing the established national, state, and accreditation standards and outcomes. Other parameters developed at the national level, including the ones from the CDC, help define the average HAI rates that a hospital should adhere to. Moreover, the state’s health departments may also establish their standards and monitor the HAI rates within different healthcare facilities.

In this regard, the hospital set its own HAI benchmark such that it would be able to achieve these set goals. For instance, the initiative was to address CLABSI; it was set with a SIR of less than 1. 0. The A hospital campaign reduced the CLABSI by 35% achieving an SIR of 0.

The total socio-demographic index of Lancaster is 85, however, it is below the national score. Likewise, for the CAUTI measure, the improvement initiative provided a 40% reduction, hence attaining a SIR of 0. 78; For BSI, there was a 39% reduction and for SSI 30%, the SIR obtained was 0. 92 (Johnson et al., 2021).

Entities such as The Joint Commission also have set regulations to ensure that different health facilities adhere to high standards of infection prevention and control. The Joint Commission mandates that hand hygiene compliance should be not less than 90 percent (Davis & Thompson, 2022).

The hospital management was able to increase hand hygiene compliance to 93% above the set accreditation standard. Also, it initiated a simple cleaning plan and standard solution which enhanced cleaning frequency as well as the audit scores of the places enhanced to 88% creating a standard for the Joint Commission for environmental cleaning (Davis & Thompson, 2022).

Interprofessional Perspectives Related to The Success of Actions Used in The QI Initiative

In both aspects, nurses were determinant of the compliance to the hand care protocol and to providing information and awareness for patients and relatives regarding infection prevention measures. We received contribution from physicians in a way that made sure that usage of antibiotics complied with the recommended policies to avoid spread of resistant strains.

Skilled infection control preceded surveillance of infection trends, evaluation of the results and constant feedback to the work team. Concerning the execution of the strategy, the pharmacists ensured that the use of antibiotics was as efficient as possible and acted as educators to the rest of the healthcare personnel on adhering to the current guidelines.

Cleaning and environmental management was performed by Environmental Services staff improving the level of cleanliness by implementing cleaning protocols and assuring cleanliness in patients’ areas (Davis & Thompson, 2022).

Perspectives and Impact

Communications with different kinds of interprofessional team members proved to be beneficial in the context of assessing the functionality of the initiative as well as the outcomes achieved. While speaking to the nurses in the hospital, most of them noted that the adoption of new hand hygiene policies made a massive difference in cutting the infection incidences in their working areas.

The total number of complications linked to HAIs was noted to be lesser by the physicians hence making the outcomes of the patients better. Some of the issues raised in the discourse were pulled from environmental services workers who noted that cleaning is vital for the initiative to work. Antibiotic stewardship was reported by pharmacists to improve patient safety as well as to help in the prevention of resistant infections.

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The employees’ views confirmed that all people in the team assumed equal responsibility and involved themselves in several tasks to respond to the initiative. Interprofessional practice meetings were conducted regularly to discuss and coordinate the best practice regarding the client’s care, as well as address emerging concerns.

The constructive and collaborative form of interaction and cooperation was essential for the success and continuation of the work on this given initiative (Brown & Patel, 2019).

Sources of Unknowns and Information Deficiencies

There are several research limitations that one has to consider when analyzing the outcomes of the initiative and the methodology used in the study. However, there are a couple of issues that remain ambiguous: the sustainability of the improved practices, for instance.

The preliminary outcomes are quite positive, nonetheless, daily compliance with the procedures by all employees is vital for improved outcomes (Smith, 2020). More studies should be conducted to establish why the rates of people providing quality services reduce after some time, and how to keep it up in the future.

NURS FPX 6016 Assessment 2

Additional Indicators and Protocols to Improve and Expand Outcomes of the Current

To boost and elongate the results of the enhancement and expansion of the quality improvement (QI) initiative about HAIs, additional indicators and protocols can be recommended. These recommendations are informed by the existing literature and new trends on applying quality improvement practices to the healthcare setting. Patient satisfaction and feedback as measurable variables (Davis & Thompson, 2022).

Questionnaires completed by the patients can also contain useful information about the patient’s view of the infection control practices in a certain facility. Such positive remarks from patients can help in creating a better reputation of the hospital and builds trust among the patients.

Nevertheless, gathering and analyzing data on patients’ experiences is time-consuming and may need to involve more personnel. Also, if patients can provide only positive feedback, this may lead to general bias in the feedback given.

Compliance monitoring is also another crucial protocol recommendation advanced by the scholars (Johnson, Lee, & Williams, 2021). These systems can provide data on the level of compliance with hand hygiene and environmental cleaning procedures in real-time and even alert for compliance issues.

This can make compliance higher and the necessary changes that need to be made quicker to identify as compared to a reactive approach. However, the first investment in using real-time monitoring of weaknesses is usually high, and resistance may be encountered from staff who may feel that they are overly scrutinized. Maintenance and technical support are also crucial for the continual efficiency of those systems to be achieved.


Several important observations can be made when analyzing the results of the QI initiative that targeted HAIs reduction From the above analysis one can conclude that the QI project is functioning successfully and there is still room for improvement.

The initiative based on the ideas of acciones, aimed at the strengthening of measures for the protection against new infections, had shown the effectiveness of the strategy by achieving the outcomes better than the national indicators and accreditation requirements in the field of CLABSI, CAUTI, and SSI rates.

These can be assigned to the following interprofessional team of the initiative that included nurses, physicians, infection control specialists, pharmacists, and environmental services staff. The active participation of each team member in the adopting and compliance to new protocols of infection prevention proved significant in the success of the team’s achievements within the hospital.

Such organizational interaction provided the means of communication of professional successes and maintenance of problem-solving when occurring in daily interprofessional meetings.

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