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NURS FPX 8020 Assessment 3

Quality Improvement Proposal

Student name

Capella University

NURS-FPX8020

Professor Name

Submission Date

Quality Improvement Proposal

Slide 1

Hello everyone! My name is [insert name], and the QI initiative I am going to propose concerns improving the patient experience in the Department of Medicine at the University of Alabama at Birmingham, to support the overall strategic goals and organizational excellence objectives of the institution.

Slide 2

Quality improvement programs are essential processes that facilitate the provision of high-quality healthcare services, enhance patient safety, and promote organizational effectiveness in dynamic medical settings. The programs address the major gaps in care delivery and facilitate the implementation of evidence-based practices and regulatory compliance requirements. Quality improvement initiatives aim to enhance patient outcomes, reduce clinical errors, and optimize resource efficiency in healthcare institutions (Bhati et al., 2023). The strategic quality programs help synchronize departmental objectives with the institution’s overall vision and also contribute to its financial viability. Positive quality improvement initiatives ultimately change the healthcare delivery models.

The Rationale for Establishing a Strategic Priority

Slide 3

Healthcare organizations are compelled to establish evidence-based strategic priorities that enhance and address key performance gaps and support the accomplishment of their institutional mission. One of the main quality improvement initiatives that would help address the identified gaps in healthcare communication and care coordination that are documented is the customer priority of the Department of Medicine at the University of Alabama at Birmingham to enhance patient experience through improving the scores on healthcare consumer assessment of healthcare providers and systems (HCAHPS) and clinician and group consumer assessment of healthcare providers and systems (CGCAHPS) satisfaction. It has been found that clinical outcomes, readmission rates, and financial performance of organizations are directly related to patient satisfaction scores, and prioritizing patient satisfaction is one of the keys to overall improvement in quality (Ferreira et al., 2023). As demonstrated, the adoption of formal communication practices and care coordination initiatives can increase patient satisfaction rates while simultaneously improving staff engagement and reducing turnover (Weller et al., 2024). The customer focus aligns with the pillar of patient care at UAB, as it is dedicated to delivering the best patient-centered, integrative care, contributing to the organizational goal of maintaining satisfaction scores above 90 percent among all health-related organizations (The University of Alabama at Birmingham, 2024). The strategic priorities must provide clear, evidence-based reasoning and tangible outcomes that can be successfully measured and implemented to encourage excellence in departmental and institutional strategic objectives.

SWOT Analysis

Slide 4

The strategic initiatives require a comprehensive development of the strengths, weaknesses, opportunities, and threats (SWOT) analysis, which will identify internal capabilities and external factors that influence the success of implementation and organizational performance. The Department of Medicine customer priority to enhance patient experience through an increase of HCAHPS and CGCAHPS scores has its strengths, including the built quality improvement infrastructure, the existence of electronic health record systems, and the fact that it ties to the strategic pillar of the patient care of the UAB that aims to achieve 90 percent satisfaction (The University of Alabama at Birmingham, 2024). However, the possible limitations of resources, resulting from competing priorities in eight strategic areas, and the need to make substantial investments in staff training to implement communication protocol improvements are also among the weaknesses (Canale et al., 2023). The political environment presents opportunities, including the institutional mission to deliver patient-centered care, financial stability with an Aa2/AA+ credit rating, and an increasing trend toward value-based healthcare delivery models that reward patient satisfaction outcomes (The University of Alabama at Birmingham, 2024). On the other hand, threats include high competition with other academic medical facilities, possible regulatory modifications related to reimbursement based on satisfaction scores, and workforce shortages that could constrain broad-scale staff development programs (Sommer et al., 2024). The customer’s priority should be to balance competing institutional needs and utilize existing strengths to address barriers to implementation. A good SWOT analysis would enable strategic leaders to devise targeted interventions that maximize organizational strength and mitigate the risks associated with threats to strategic priority realization.

Key Performance Indicators

Slide 5

Quality improvement programs must be actively supported by an elaborate measurement system, such as the Plan-Do-Study-Act (PDCA) cycle, which monitors achievement in various areas of the organization and the outcomes for stakeholders. The Department of Medicine’s customer priority is to improve the patient experience by increasing HCAHPS and CGCAHPS satisfaction scores, which requires strong key performance indicators that align with the UAB strategic objectives and the goals of the academic medical center (AMC21) (UAB Medicine, 2025). Some financial measures include earnings before interest, tax, depreciation, and amortization (EBITDA) performance and revenue per patient encounter, aiming to make it sustainable in line with the economic impact goals of UAB, which is $ 15 billion (The University of Alabama at Birmingham, 2024). Customer indicators revolve around HCAHPS and CGCAHPS satisfaction scores, where the aim is to achieve above 90 percent in line with the patient care pillar of UAB (The University of Alabama at Birmingham, 2024). Internal process measures include the UHC quality scorecard performance and chart documentation accuracy, which utilize available electronic health record systems to support AMC21 quality pillars. The learning and growth indicators monitor staff engagement ratings and communication competency ratings, which aid in the development of the workforce across different clinical divisions (The University of Alabama at Birmingham, 2024). The measures enable tracking the process of systematic advancement and, at the same time, ensure that it aligns with the patient care pillar and the standards of institutional quality excellence at UAB. Formal KPI systems ensure a form of accountability that can turn strategic priorities into measurable results and long-term organizational gains.

Table 1

Department of Medicine Key Performance Indicators

Balanced Scorecard Domain	KPI Category	Specific Metrics	Target Goals
Financial	Revenue Performance	EBITDA margin, Revenue per patient encounter, Operating efficiency ratios	Achieve positive EBITDA growth aligned with UAB’s 0.75 spendable cash ratio target, support $15 billion economic impact goal, and maintain Aa2/AA+ credit rating standards
Customer	Patient Experience	HCAHPS scores, CGCAHPS scores, and Patient satisfaction metrics across health entities	Achieve above 90% patient satisfaction consistent with UAB’s patient care targets, maintain top quartile performance among academic medical centers, and support 15% patient visit increase goals.
Internal Process	Clinical Quality	UHC Quality Scorecard performance, Chart documentation accuracy, Care coordination efficiency	Achieve top quartile UHC Quality performance, Maintain 95% documentation accuracy, Support UAB’s research integration and quality excellence goals.
Learning & Growth	Workforce Development	Staff engagement scores, Faculty engagement metrics, Communication competency assessments	Improve staff and faculty engagement in support of the AMC21 culture pillar, achieve 100% communication training completion, and Support UAB’s diverse faculty recruitment objectives.

Note. The data represent key performance indicators for the Department of Medicine’s customer priority enhancement initiative, aligned with the balanced scorecard domains. Target goals reflect UAB’s institutional benchmarks, including patient satisfaction targets of over 90%, financial sustainability objectives that maintain Aa2/AA+ credit ratings, and $15 billion in economic impact goals. Data was retrieved from The University of Alabama at Birmingham (2024) and UAB Medicine (2025).

Stakeholders Identification

Slide 6

The quality improvement campaigns in healthcare require the formal participation of stakeholders to realize sustainable implementation and transformational organizational performance in various areas of operation. The key players that will be critical to the patient experience improvement initiative at the Department of Medicine include the UAB President Ray Watts and the strategic planning council, which offers institutional leadership via the overall planning framework that involves 55 representatives across the university and health system networks (The University of Alabama at Birmingham, 2024). Clinical leadership: The department chairs, division directors, and faculty physicians all bring specialized expertise promoting HCAHPS and CGCAHPS performance goals that are consistent with AMC21 strategic pillars (UAB Medicine, 2025). Various stakeholder groups, including patients served by UAB health entities, nursing staff, medical students, and fellowship members, provide important information about care processes and satisfaction enhancements to inform strategic patient care priorities within the institution. The research teams and administrative support staff ensures the coordination of initiatives with the organizational mission of UAB and the maintenance of commitment to surpass patient satisfaction levels among diverse patient demographics.

Process for Collaborating with Stakeholders

The achievement of quality improvement should be systematic in gathering the opinions of stakeholders and employing interactive engagement methods that incorporate diverse perspectives and experiential knowledge. The feedback mechanism will utilize structured feedback, such as employee satisfaction surveys, patient experience assessments, and multidisciplinary team input, along with the UAB time-tested town hall and public comment process (Marcinow et al., 2022). Stakeholder sessions involving the Department of Medicine faculty, healthcare workers, and management units will ensure constant communication to support the implementation of HCAHPS improvement methods (Petkovic et al., 2020). The research-based approaches of the UAB, in collaboration with stakeholders, will be incorporated through joint planning meetings, thereby strengthening the overall strategic structure of the institution and enhancing the excellence standards of AMC21. Intentional stakeholder collaboration enhances the impact of initiatives and generates organizational commitment, ensuring a sustainable improvement in patient experiences that aligns with the university’s strategic objectives.

Leveraging Stakeholder Feedback

Healthcare organizations need to systematize the inclusion of stakeholder input to improve initiatives and attain sustainable quality improvements and excellence in patient care. The customer-oriented program of the Department of Medicine will implement systematic feedback strategies with clinical faculty and staff to address communication barriers and enhance the coordination of care within existing operational systems (Boehnke and Rutherford, 2021). Team-based insights and patient satisfaction data will be used to determine HCAHPS improvement strategies, based on UAB institutional excellence standards and the university’s $ 15 billion economic impact goals (The University of Alabama at Birmingham, 2024). The departmental heads will introduce common assessment activities with the clinical staff to measure satisfaction results and adjust communication strategies to serve organizational objectives (Restivo et al., 2022). The incorporation of continuous feedback enables the continuous enhancement of the initiative, while also maintaining consistency with the requirements of the UAB patient care strategic pillar and the AMC21 operational framework.

Role of Change Theory

Slide 7

Modern change theories provide systematic approaches to implementing quality improvement initiatives and managing organizational change in any healthcare setting. The three-stage change theory developed by Lewin can be utilized in a systematic manner to improve customer priority in the Department of Medicine, as the first phase of the change theory is unfreezing, during which the leadership can pinpoint the existing gaps in HCAHPS performance and generate urgency to improve communication protocols among clinical personnel (Sheehan et al., 2021). The changing stage is characterized by the adoption of new care coordination procedures, educating the staff on new and improved methods of communication with patients, and standardizing satisfaction improvement procedures in line with the AMC21 quality pillars (Albertson et al., 2021). The refreezing phase is a process that reinforces the changes, instilling new communication habits into regular work processes, creating regular monitoring systems, and strengthening behaviors that facilitate long-term patient satisfaction exceeding 90 percent (Hibbert et al., 2023). Theories of structured change enable the systematic transformation and guarantee sustainable organizational changes, as well as the involvement of stakeholders, during implementation processes.

Interpretation

Experimenting with organizational change can be facilitated by applying Lewin’s three-stage change theory, which systematically approaches human resistance to change, acknowledging that the implementation process occurs through distinct stages. The unfreezing level acknowledges the tendency of people and companies to resist change, and that motivation and preparedness can be created through effective communication and education (Barrow and Annamaraju, 2022). The changing stage acknowledges that change necessitates an active intervention that requires a sense of direction, support systems, and ongoing reinforcement for stakeholders as they adopt new behaviors and troubleshooting methods (Ahmed et al., 2022). The refreezing stage is made sustainable by the fact that the new practices are incorporated into the organizational culture and policies, and in day-to-day activities, there is no tendency to revert to old behaviors. The theory emphasizes that effective change must be well-prepared, executed systematically, and reinforced in a specific way to achieve the success of long-term organizational change.

Policy Recommendation

Slide 8

Healthcare organizations should implement a supportive policy framework to enable the implementation of quality improvement, bridging the gap toward organizational transformation at all levels of operation. The Department of Medicine should develop a strategy plan regarding patient communication and care coordination, whereby standard HCAHPS improvement policies would require clinical staff members to undergo patient communications training, and regular competence testing should be conducted to determine an improvement plan to achieve quality improvement objectives (Mrayyan et al., 2023). Additionally, updating the existing quality metrics reporting policies to incorporate real-time monitoring of the satisfaction dashboard will enable the provision of timely feedback on performance and the application of corrective measures to achieve patient satisfaction goals within the institution. The company must eliminate obsolete documentation policies that generate administrative overhead without providing a value advantage, simplifying work processes in favor of patient-focused communication and care coordination processes (Harbi et al., 2024). Lastly, patient experience incentive policies that tie staff performance ratings to increases in patient satisfaction scores will support behavioral change and ensure a long-term commitment to excellence in all clinical divisions (Marcinow et al., 2022). Strategic policy formulation is built on the sustainable pillars of organizational excellence and sustained quality improvement initiatives within healthcare settings.

Policy Implications and Justification

Slide 9

Policy implementation has significant organizational implications that should be taken into consideration, including resource allocation, the impact on stakeholders, and changes in the operations of the healthcare environment. The patient communication and care coordination policy provided will require a high level of investment in staff training and the allocation of personnel resources, along with improvements to the technology infrastructure that will help bring real-time HCAHPS monitoring systems into existence. One of the studies has revealed that the higher patient satisfaction, the lower readmission rates, and improved clinical outcomes (Ferreira et al., 2023). It has been demonstrated that well-structured communication training programs enhance patient satisfaction scores and improve staff engagement (Chen et al., 2025). A study indicates that performance-based incentive policies lead to long-lasting behavioral changes and encourage quality improvement efforts (Gadsden et al., 2021). The updated quality metrics reporting policy enables proactive intervention measures, and the patient experience incentive policy can tailor staff behavior to institutional goals, which is significant in developing accountability structures to support long-term performance improvement in clinical divisions. Strategic policy frameworks are crucial to achieving sustainable organizational change and enhancing the quality of healthcare delivery systems.

Conclusion

Slide 10

The key to strategic planning in healthcare organizations implies the general integration of evidence-based priorities, stakeholder involvement, and efficient change management procedures. The customer priority within the department of medicine indicates the efficiency of aligning patient satisfaction improvement strategies with institutional strategic programs within the balanced scorecard framework, utilizing robust key performance indicators. The keys to success are a supporting policy, effective stakeholder cooperation, and the structured application of change theory that addresses the challenges of organizational transformation. A good strategic plan offers a sustainable competitive advantage that has a measurable positive impact and continuous improvement in every functional area of operation.

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Step-By-Step Instructions To Write NURS FPX 8020 Assessment 3

Follow these steps to write NURS-FPX 8020 Assessment 3 Quality Improvement Proposal.

Objective: Develop an 8-10 minute multimedia proposal for a quality improvement (QI) initiative aligned with a strategic priority.

Step 1: Select a strategic priority.

Select a priority from your strategic plan for Assessment 1 (e.g., reducing HAIs, improving patient satisfaction).

Step 2: Develop presentation materials.

Address all criteria from the assessment guide in 8-10 slides:

Title slide: Your name, course, strategic priority.
Rationale: State the priority and support it with evidence (2-3 references).
SWOT analysis: Summarize strengths, weaknesses, opportunities, and threats.
KPIs: Define 3-4 measurable metrics (e.g., reducing the falls rate by 20%).
Stakeholders: Identify key groups and describe the plan for collaboration.
Theory of Change: Implement a theory (e.g., Kotter’s 8-Step Model).
Policy Recommendations: Propose and justify a policy change.
References: Sources in APA format.

Step 3: Draft and Record

Use PowerPoint, Google Slides, or Prezi for visual representations.
Record a voiceover or video (in Kaltura or MP4/MOV format).
Rehearse to ensure clarity and timing (8–10 minutes).

Step 4: Review and Submit.

Review audio, visuals, APA formatting, and the integration of instructor feedback.
Submit via Courseroom.

Writing Support

Use the “What, Why, How” framework:

“What: Our goal is to reduce healthcare-acquired infections. Why: Evidence shows that a reduction of X% improves safety (quote). How: Conduct hand hygiene audits.”

Use Capella’s Writing Center for support with APA formatting and writing.

Use the Tutors Academy for templates and examples.

Research Platforms

Capella Library: CINAHL, PubMed, and JBI for peer-reviewed articles.

QI Resources: IHI and AHRQ for tools and data.

Ethical use of resources for research and consultation.

References For NURS FPX 8020 Assessment 3

You can use these References for your assessment:

Ahmed, A., Kassem, A., & Sleem, W. (2022). Applying Lewin’s change management theory to improve patients’ discharge plan. Mansoura Nursing Journal (MNJ), 9(2), 335–348. https://mnj.journals.ekb.eg/article_295591_2e01c440a7769101b9fd53066f06f65c.pdf

Albertson, E. M., Chuang, E., O’Masta, B., Lye, I. M., Haley, L. A., & Pourat, N. (2021). Systematic review of care coordination interventions linking health and social services for high-utilizing patient populations. Population Health Management, 25(1), 73–85. https://doi.org/10.1089/pop.2021.0057

Barrow, J. M., & Annamaraju, P. (2022, September 18). Change management in health care. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459380/

Bhati, D., Deogade, M. S., & Kanyal, D. (2023). Improving patient outcomes through effective hospital administration: A comprehensive review. Cureus, 15(10), 1–12. https://doi.org/10.7759/cureus.47731

Boehnke, J. R., & Rutherford, C. (2021). Using feedback tools to enhance the quality and experience of care. Quality of Life Research, 30(11), 3007–3013. https://doi.org/10.1007/s11136-021-03008-8

Canale, A. A., Jeet, V., Bilgrami, A., Seil, E., Gu, Y., & Cutler, H. (2023). Barriers and facilitators to implementing priority setting and resource allocation tools in hospital decisions: A systematic review. Social Science & Medicine, 322, e115790. https://doi.org/10.1016/j.socscimed.2023.115790

Chen, X., Liu, C., Yan, P., Wang, H., Xu, J., & Yao, K. (2025). The Impact of Doctor-Patient Communication on Patient Satisfaction in Outpatient Settings: Implications for Medical Training and Practice. BioMed Central Medical Education, 25(1), 830. https://doi.org/10.1186/s12909-025-07433-y

Ferreira, D. C., Vieira, I., Pedro, M. I., Caldas, P., & Varela, M. (2023). Patient satisfaction with healthcare services and the techniques used for its assessment: A systematic literature review and a bibliometric analysis. Healthcare, 11(5), 639. https://doi.org/10.3390/healthcare11050639

Gadsden, T., Mabunda, S., Palagyi, A., Maharani, A., Sujarwoto, S., Baddeley, M., & Jan, S. (2021). Performance-based incentives and community health workers’ outputs: a systematic review. Bulletin of the World Health Organization, 99(11), 805–818. https://doi.org/10.2471/blt.20.285218

Harbi, S. A., Aljohani, B., Elmasry, L., Baldovino, F. L., Raviz, K. B., Altowairqi, L., & Alshlowi, S. (2024). Streamlining patient flow and enhancing operational efficiency through case management implementation. British Medical Journal Open Quality, 13(1), 1–18. https://doi.org/10.1136/bmjoq-2023-002484

Hibbert, P. D., Stewart, S., Wiles, L. K., Braithwaite, J., Runciman, W. B., & Thomas, M. J. W. (2023). Improving patient safety governance and systems through learning from successes and failures: Qualitative surveys and interviews with international experts. International Journal for Quality in Health Care, 35(4). https://doi.org/10.1093/intqhc/mzad088

Marcinow, M., Health, T., Harprit, P., Trillium, S., Partners, H., & Kuluski, K. (2022). The use of patient experience data for quality improvement in hospitals: A scoping review. Patient Experience Journal, 9(1), 174–188. https://pxjournal.org/journal/vol9/iss1/21

Mrayyan, M. T., Abunab, H. Y., Khait, A. A., Rababa, M., Al-Rawashdeh, S., Algunmeeyn, A., & Saraya, A. A. (2023). Competency in nursing practice: A concept analysis. BioMed Journal Open, 13(6), e067352. https://doi.org/10.1136/bmjopen-2022-067352

Petkovic, J., Riddle, A., Akl, E. A., Khabsa, J., Lytvyn, L., Atwere, P., Campbell, P., Chalkidou, K., Chang, S. M., Crowe, S., Dans, L., Jardali, F. E., Ghersi, D., Graham, I. D., Grant, S., Smith, R. G., Guise, J.-M., Hazlewood, G., Jull, J., & Katikireddi, S. V. (2020). Protocol for the development of guidance for stakeholder engagement in health and healthcare guideline development and implementation. Systematic Reviews, 9(21), 1–11. https://doi.org/10.1186/s13643-020-1272-5

Restivo, V., Minutolo, G., Battaglini, A., Carli, A., Capraro, M., Gaeta, M., Odone, A., Trucchi, C., Favaretti, C., Vitale, F., & Casuccio, A. (2022). Leadership effectiveness in healthcare settings: A systematic review and meta-analysis of cross-sectional and before-and-after studies. International Journal of Environmental Research and Public Health, 19(17), 1–13. NCBI. https://doi.org/10.3390/ijerph191710995

Sheehan, J., Laver, k, Bhopti, A., Rahja, M., Usherwood, T., Clemson, L., & Lannin, N. (2021). Methods and effectiveness of communication between hospital allied health and primary care practitioners: A systematic narrative review. Journal of Multidisciplinary Healthcare, 14(14), 493–511. https://doi.org/10.2147/JMDH.S295549

Sommer, D., Wilhelm, S., & Wahl, F. (2024). Nurses’ workplace perceptions in Southern Germany—Job satisfaction and self-intended retention towards nursing. Healthcare, 12(2), 172. https://doi.org/10.3390/healthcare12020172

The University of Alabama at Birmingham. (2024). University of Alabama at Birmingham strategic plan 2024-2028: forging ahead. In uab.edu. https://www.uab.edu/plan/images/2024-2028-plan/forging-ahead.pdf

UAB Medicine. (2025). Strategic plan – Department of Medicine. Uab.edu. https://www.uab.edu/medicine/dom/research?view=article&id=43:mission&catid=128

Weller, J. M., Mahajan, R., Williams, K. F., & Webster, C. S. (2024). Teamwork matters: Enhancing team situation awareness to build high-performing healthcare teams —a narrative review. British Journal of Anaesthesia, 132(4), 771–778. https://doi.org/10.1016/j.bja.2023.12.035

Best Professors To Choose From For 8020 Class

Michael Ruth, DNP, MSN.
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(FAQs) related to NURS-FPX 8020 Assessment 3

Question 1: Where can I get a free sample of the NURS-FPX8020 Assessment 3?

Answer 1: Free samples are available through educational platforms such as Tutors Academy.

Question 2: What is the NURS-FPX8020 Assessment 3?

Answer 2: It involves developing a strategically prioritized quality improvement proposal, presented in an 8- to 10-minute multimedia presentation.

Question 3: What examples of quality improvement proposals are available at Suncrest Home Health as part of the NURS-FPX 8020?

Answer 3: Examples include initiatives to reduce falls or improve medication adherence using an evidence-based approach.

Question 4: How can I improve stakeholder engagement with the NURS-FPX8020 Assessment 3?

Answer 4: Identify key groups, incorporate their feedback through surveys or meetings, and complement them with practices based on their needs and insights.

NURS FPX 8020 Assessment 3 Quality Improvement Proposal

NURS FPX 8020 Assessment 3 Sample FREE DOWNLOAD