Quality Improvement Initiatives

Quality Improvement Initiatives

You have been asked to prepare and deliver an analysis of an existing quality improvement initiative at your workplace. The QI initiative you choose to analyze should be related to a specific disease, condition, or public health issue of personal or professional interest to you. The purpose of the report is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics.

Your target audience consists of nurses and other health professionals with specializations or interest in your selected condition, disease, or issue. In your report, you will define the disease, analyze how the condition is managed, identify the core performance measurements used to treat or manage the condition, and evaluate the impact of the quality indicators on the health care facility:

Note: Remember, you can submit all, or a portion of, your draft to Smarthinking for feedback, before you submit the final version of your analysis for this assessment. However, be mindful of the turnaround time for receiving feedback, if you plan on using this free service.

The numbered points below correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your Quality Improvement Initiative Evaluation addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion.

  1. Analyze a current quality improvement initiative in a health care setting.
    • Evaluate a QI initiative and explain what prompted the implementation. Detail problems that were not addressed and any issues that arose from the initiative.
  2. Evaluate the success of a current quality improvement initiative through recognized benchmarks and outcome measures.
    • Analyze the benchmarks that were used to evaluate success. Detail what was the most successful, as well as what outcome measures are missing or could be added.
  3. Incorporate interprofessional perspectives related to initiative functionality and outcomes.
    • Integrate the perspectives of interprofessional team members involved in the initiative. Detail who you talked to, their professions, and the impact of their perspectives on your analysis.
  4. Recommend additional indicators and protocols to improve and expand quality outcomes of a quality initiative.
    • Recommend specific process or protocol changes as well as added technologies that would improve quality outcomes.
  5. Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling.
  6. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style.

Submission Requirements

  • Length of submission: A minimum of five but no more than seven double-spaced, typed pages.
  • Number of references: Cite a minimum of four sources (no older than seven years, unless seminal work) of scholarly peer reviewed or professional evidence that support your interpretation and analysis.
  • APA formatting: Resources and citations are formatted according to current APA style and formatting.



The purpose of the report is to assess whether specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Nurses and other health professionals with specializations and/or interest in the condition, disease, or the selected issue are your target audience.



As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

Reflect upon data use in your organization as it relates to adverse events and near-miss incidents.

  • How does your organization manage and report on adverse events or near-miss incidents?
  • What data from your organization’s dashboards help inform adverse events and near-miss incidents?
  • What additional metrics or technology are you aware of that would help ensure patient safety?
  • What changes would you like to see implemented to help the interprofessional team better understand data use and data trends as quality and safety improvement tools?



Quality Improvement Initiative Evaluation

            A Quality Improvement (QI) program is a set of activities designed to monitor, analyze and improve the quality of procedures in healthcare facilities in order to improve health outcomes for all stakeholders involved. Despite their proliferation, QI initiatives take place in the background and are incorporated in the organization’s day-to-day activities (Abrampah et al. 2018). Often times, patients never realize that a QI program is in effect. QI initiatives are critical because they strive to improve outcomes for patients, maintain staff efficiency and reduce waste due to process failures. Effective QI programs have set targets that focus on improving safety, effectiveness, access and are patient-centered (Abrampah et al. 2018). Additionally, effective QI programs always align their priorities with the organization’s strategic plan and provide detailed key performance indicators to track progress towards goal achievement.

In line with its goal of improving operations and reducing wastage, Bethany health center initiated the “no to tubes” program focused on reducing the use of catheters in the facility. After conducting an annual audit of the facility’s operations, the health center realized that catheters were being given to patients who did not need them. More alarming than that was the fact that these catheters were being left in for longer periods of time. In line with this realization, the facility developed the “no to tubes” program with the aim of reducing the increasing number of catheter-associated urinary tract infections (CAUTI) caused by catheters that are left in for too long. In addition, the QI program aimed at reducing resource wastage and improving overall operations at the facility. Using the “no to tubes” QI program as an example, the report will assess how specific quality indicators improve patient outcomes, reduce costs and improve organizational efficiency.

Analysis of the Quality Improvement Initiative

The “no to tubes” QI initiative was designed to reduce the occurrence of CAUTI at

Bethany Health Center. Over the following couple of months, the facility implemented a new system of nursing documentation and clinician orders. The nursing documentation system ensured that the patients who needed catheters received them and when the time came for them to be removed, the system would send alerts to nurses prompting them to remove the catheters. The initiative successfully reduced CAUTI rates in the facility from 3.2 per month to less than 1 per month. In addition to implementing the nursing documentation system, the nurses carried out regular and systemic check-ins. The check-ins further reduced infection rates and improved overall quality of care. To further reduce infection rates at the facility, the “no to tubes” initiative implemented an electronic health record catheter identification system, interdisciplinary training was also conducted and clinician education heightened. Measuring the rate of CAUTI is challenging and resource intensive. To mitigate the challenges, Bethany Health Center implemented an electronic CAUTI surveillance system. The system monitored the presence of urinary catheters and fever in patients and used natural language processing (NLP) to include subjective symptoms which were documented in clinical notes (Sanger et al. 2017).

Quality Improvement Initiatives

To evaluate the “no to tubes” initiative, the analysis will use benchmarks and outcome measures.

Evaluation of the QI Initiative through Recognized Benchmarks and Outcome Measures

Quality of healthcare initiatives is usually assessed by using processes and outcome measures. Measuring outcomes of QI initiatives facilitates the decision-making process and improves public accountability (Kampstra et al. 2018). The key feature of benchmarking is to integrate with comprehensive quality improvement policies. Additionally, benchmarking involves measuring results and comparing them to set standards to evaluate organizational performance. There are two key benchmarking activities that Bethany Health Center employed to measure the results of the “no to tubes” initiative. They include: internal benchmarking which identifies best practices in the organization and compares them to the current initiative; external or competitive benchmarking that involves the use of comparative data between healthcare facilities to gauge performance of the initiative and identify areas for improvement (Lovaglio, 2014). Patient quality has always been at the forefront of all the activities at Bethany Health Center. It is with this goal in mind that the facility has successfully implemented previous QI initiatives and used them to benchmark the “no to tubes” initiative.

Outcome measures are changes in the health of individuals, groups of people or populations that are attributed to interventions or series of interventions by the healthcare facility. Effectiveness of care outcome measures evaluate compliance with the best care practices and analyzes achieved outcomes (Kampstra et al. 2018). After implementing the nursing documentation system and the CAUTI surveillance system, Bethany Health Center experienced reduced rates of CAUTIs. Additionally, patient-reported outcome measures (PROMs) were used to measure patient experiences. The patient’s experiences and their perceptions about the care they received at the facility were analyzed. The results showed that patients were generally satisfied with the “no to tubes” initiative and the care they received from healthcare professionals at the facility.

Quality Improvement Initiatives

Interprofessional Perspective on Initiative Functionality and Outcomes

Interprofessional collaboration occurs when healthcare workers from different professional backgrounds unite and work together with patients, their families and the community to deliver high quality care (Garth et al. 2018). Interprofessional teamwork is a core clinical skill that identifies the benefits of collaboration to address the unmet needs of healthcare systems. With the goal of integrating quality improvement and maintaining patient safety efforts with graduate medical education, Scottsdale Healthcare facility participated in the Alliance of Independent Academic Medical Centers (AIAMC) National Initiative IV between 2013 and 2015. The AIAMC implemented several initiatives to reduce unnecessary use of urinary catheters in hospitals. The initiative focused on a multidisciplinary medical education conference that centered on CAUTI prevention (Bell, Alaestante & Finch, 2016). In addition, the facility embarked on the emergency department initiative that saw emergency department nurses and physicians receive intensive education on the reduction of urinary catheter use. Patient tracking was also involved in the initiative and the patients who had urinary catheters were tracked and the information uploaded in the nursing staff daily management system. The results of the initiative show that by incorporating all the stakeholders, Scottsdale Healthcare facility saw a dramatic decrease in urinary catheter insertions and an overall decline in CAUTI cases (Bell, Alaestante & Finch, 2016). The study results further prove that interdisciplinary interaction and collaboration in healthcare further improve patient outcomes and reduce the spread of infections.


The “no to tubes” initiative would benefit from analyzing staff perspectives towards CAUTI. According to an analysis carried out by Niederhauser at colleagues (2018), there are significant changes in staff perceptions after the implementation of evidence-based interventions. Efforts should therefore be directed towards sustaining the changes so that the intervention implemented becomes an integral part of the organization’s culture. To maintain this culture, staff knowledge about the intervention, their perception of current practices, self-reported responsibility and behavior determinants should be regularly assessed (Niederhauser et al. 2018). To further strengthen the “no to tubes” initiative and obtain the best results, Bethany Health Center should implement a multimodal bundle of interventions that incorporates an evidence-based intervention, daily re-evaluation of catheter use, training and education of all healthcare providers.

Additional Indicators and Protocols to Improve Quality Outcomes

By introducing a nursing documentation system and an electronic health record catheter identification system and encouraging a culture of interdisciplinary training and education, Bethany Health Center has successfully reduced the rate of CAUTI infections and has improved overall quality of care offered to patients. While both the internal and external benchmarking tools have been used to gauge success of the “no to tubes” initiative, additional indicators of quality can improve quality outcomes. The goal of healthcare systems is to improve the quality of care they offer to patients. Successful quality improvement might be challenging. However, by implementing key essentials of success quality improvement can be maintained.

Quality Improvement Initiatives

The first requirements is that health facilities should have a culture of adaptive leadership and governance. Individuals within the health system should have the aptitude to make continuous improvements. Likewise, staff members should be dedicated to the organization and its goals. However, individual efforts are not enough to sustain quality (Tinker & Hough, 2016). There needs to be senior leadership support, an adaptive learning culture and data-driven initiatives for quality improvement. Analytics is a crucial ingredient used to sustain quality in the quality improvement lifecycle. Analytics is incorporated into baseline measurements, problem descriptions and system implementation processes. Analytics should never be mistaken for measurements. The third and critical essential to improve quality is the adoption of evidence and consensus-based best practices. Evidence-based practices are the foundation upon which best practices that improve quality are built (Tinker & Hough, 2016). While the aforementioned practices are designed to improve quality, they will not be successful unless resources are dedicated to implement outcome initiatives. Bethany Health Center should set aside resources towards performance evaluation practices and organizational incentives.

The Lean Six Sigma model is a combined toolkit that provides a systemic approach to help organizations improve their problem-solving skills. The model is based on a scientific method that supports organizations that are looking to improve their problem-solving culture (Lighter, 2014). By adopting the Lean Six Sigma model, Bethany Health center will be able to streamline the “no to tubes” initiative results and improve patient satisfaction levels. Additionally, the model will help the facility engage staff members, improve staff morale and standardize processes. The model will also help the facility better understand the current state of affairs and remove barriers to success. The model focuses on eliminating defects, improving patient safety and maintaining quality. By using the Define-Measure-Analyze-Improve-Control five-step process improvement structure, the Lean Six Sigma model improves patient experiences and makes sure processes consistently deliver desired results (Lighter, 2014).

Quality Improvement Initiatives


Despite their importance and proliferation, quality improvement initiatives often go on in the background and are integrated into the day-to-day operations of healthcare facilities. Quality improvement initiatives are the primary means for improving operations and maintaining high quality care. QI initiatives like the “no to tubes” initiative designed to reduce the rate of CAUTIs set targets aimed at improving patient safety, access to care and guarantee delivery of effective and patient-centered care. To ensure success of QI initiatives, healthcare facilities must evaluate their effectives by using recognized internal and external benchmarks and outcome measures. To reduce the risk of failure, QI initiative must incorporate interprofessional perspectives and set protocols and indicators that are relevant to the implemented QI initiative. Lastly, evidence-based models like the Lean Six Sigma model will help healthcare facilities eliminate defects and maintain staff morale.




Abrampah, N.M. et al. (2018). Quality Improvement and Emerging Global Health Priorities. International Journal for Quality in Health Care, 30(suppl 1), 5-9. Doi: 10.1093/intqhc/mzy007

Bell, M.M., Alaestante, G. & Finch, C. (2016). A Multidisciplinary Intervention to Prevent Catheter-Associated Urinary Tract Infections using Education, Continuum of Care and System wide Buy-in.  The Ochsner Journal, 16(1), 96-100. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795513/

Garth, M., Millet, A., Shearer, E. et al. (2018). Interprofessional Collaboration: A Qualitative Study of Non-Physician Perspectives on Resident competency. Journal of General Internal Medicine, 33(4), 487-492. Doi: 10.1007/s11606-017-4238-0

Kampstra, N.A. et al. (2018). Health Outcomes Measurement and Organizational Readiness Support Quality Improvement: A Systematic Review. BMC Health Services Research, 18(1005). Doi: 10.1186/s12913-018-3828-9

Lovaglio, P.G. (2014). Benchmarking Strategies for Measuring the Quality of Healthcare: Problems and Prospects. The Scientific World Journal Volume, 13. Doi: 10.1100/2012/606154

Lighter, D.E. (2014). The Application of Lean Six Sigma to Provide High-Quality, Reliable Pediatric Care. International Journal of Pediatrics and Adolescent Medicine, 1(1), 8-10. Doi: 10.1016/j.ijpam.2014.09.009

Niederhauser, A., Zuillig, S., Marschall, J. et al. (2018). Change in Staff Perspectives on indwelling Urinary Catheter use after Implementation of an Intervention Bundle in Seven Swiss Acute Care Hospitals: Results of a before/after Survey Study. BMJ Open, 9(10). Doi: 10.1136/bmjopen-2018-028740

Sanger, P.C., Granich, M. et al. (2017). Electronic Surveillance for Catheter-Associated Urinary Tract Infection Using Natural Language Processing. AMIA Annual Symposium Proceedings, 1507-1516. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977673/

Tinker, A. & Hough, L. (2016). The Top Five Essentials for Outcomes Improvement. Health Catalyst. Retrieved from https://www.healthcatalyst.com/outcomes-improvement-five-essentials

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