Use the hospital data set provided in Vila Health: Data Analysis

Use the hospital data set provided in Vila Health: Data Analysis. to analyze data to identify a health care issue or area of concern.
Include basic information about the health care setting, size, and specific type of care delivery related to the identified topic.

Analyze data to identify a health care issue or area of concern.
    Identify the type of data you are analyzing from your institution or from the Vila Health activity.
    Explain why data matters. What does data show related to outcomes?
    Analyze the dashboard metrics. What else could the organization measure to enhance knowledge?
    Present dashboard metrics related to the selected issue that are critical to evaluating outcomes.
    Assess the institutional ability to sustain processes or outcomes.
    Evaluate data quality and its implications for outcomes.&
Determine whether any adverse event or near-miss data needs to be factored in to outcomes and recommendations.
    Examine the nursing process for variations or performance failures that could lead to an adverse event or near miss.
    Identify trends, measures, and information needed to critically analyze specific outcomes.
    Specify desired outcomes related to prevention of adverse events and near misses.
    Analyze which metrics indicate future quality improvement opportunities.
Develop a QI initiative proposal based on a selected health issue and supporting data analysis.
    Determine benchmarks aligned to existing QI initiatives set by local, state, or federal health care policies or laws.
    Identify any internal existing QI initiatives in your practice setting or organization related to the selected issue. Explain why they are insufficient.
    Evaluate external national or international QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and nongovernmental bodies on quality improvement.
    Define target areas for improvement and the processes to be modified to improve outcomes.
    Propose evidence-based strategies to improve quality.
    Analyze challenges that meeting prescribed benchmarks can pose for a health care organization and the interprofessional team.
Communicate QI initiative proposal based on interdisciplinary team input to improve patient safety and quality outcomes and work-life quality.
    Define interprofessional roles and responsibilities relating to data and the QI initiative.
    Explain how to ensure all relevant interprofessional roles are fully engaged in this effort.
    Identify how outcomes will be measured and data used to inform interprofessional team performance related to specific tasks.
    Reflect on the impact of the proposed initiative on work-life quality of the interprofessional team.
    Describe how the initiative enhances work-life quality due to improved strategies supporting efficiency.
Determine communication strategies to promote quality improvement of interprofessional care.
    Identify interprofessional communication strategies that will help to promote and ensure the success of the QI initiative.
    Identify communication models, such as SBAR and CUS, to include in your proposal. 
        SBAR stands for Situation, Background, Assessment, Recommendation.
        CUS stands for "I am Concerned about my resident's condition; I am Uncomfortable with my resident's condition; I believe the Safety of the resident is at risk."
    Consult this resource for additional information about these fundamental evidence-based tools to improve interprofessional team communication for patient handoffs: 
        Agency for Healthcare Research and Quality (AHRQ). (n.d.). Module 2: Communicating change in a resident’s condition.





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Data Analysis and Quality Improvement Initiative Proposal

Learner’s Name

Capella University

Quality Improvement for Interprofessional Care

Data Analysis and Quality Improvement Initiative Proposal

Month, Year

Comment [JS1]: Good job with the submission. It follows the rubric. For

the most part is written in scholarly

voice. The submission is clear and

concise. References and citations are

used to support your opinion and

position with relevant evidence.

Please see my tracked changes for

areas of revision.


Data Analysis and Quality Improvement Initiative Proposal

I. Introduction

Health care professionals are constantly striving to improve the quality of care and safety

provided to their patients. The culture of care quality and patient safety depends on a strong and

supportive work environment that promotes leadership, evidence-based practice, effective

communication, and interprofessionalism. Nurse leaders play a crucial role in establishing this

culture and directly influence quality outcomes across an organization.

II. Problems and Needs

The role of nurse leaders in maintaining the quality in the nursing and clinical

departments is discussed using the example of TrueWill General Hospital (TGH), a

multispecialty hospital in the United States. As part of an annual assessment of organizational

quality, the hospital’s quality management office completed its analysis of dashboard metrics for

the surgical units for the year 2016–2017. The office released the data in its Quality and Safety

Report 2016–2017. The surgical units’ data included adverse events and near misses and used

four quality indicators: length of stay (LOS) exceeding 7 days, patient readmission rates, pain

level between 7 and 10 for more than 24 hours, and patients with pressure ulcers.

III. Proposed Solution

The results of the analysis showed that three quality indicators—pain levels, readmission

rates, and pressure ulcers—performed below the hospital’s benchmarks (see Table 1 and

Appendix for data and descriptions of indicators and benchmarks). The connection between these

indicators and the services of the surgical units’ nurses will be discussed in this proposal for a

quality improvement initiative. The proposal will analyze the relational patterns between the

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indicators and the data, identify assumptions governing health care quality and nursing

characteristics, determine methods to discover the root causes of quality issues, and recommend

a framework as well as strategies to improve quality outcomes in the surgical units.

Analysis of Dashboard Metrics to Identify Quality Issues

The patients who require round-the-clock perioperative care are admitted to TGH’s

surgical units, which are equipped for general, orthopedic, urologic, and ambulatory surgery. The

critical nature of patients admitted to these units makes quality and safety the units’ highest

goals. Quality and safety outcomes are regularly evaluated. The units are staffed by teams of

interdisciplinary professionals: physicians, nurses, therapists, dieticians, pharmacists, and

ancillary medical staff.

Table 1

Quality and Safety Report 2016–2017

Unit – Year


exceeding 7




Pain level

between 7 and

10 for more

than 24 hours

Patients with





2015 43 29 15 14 101


2016 31 43 30 25 129

The data available from the Quality and Safety Report in Table 1 revealed that the

annual patient readmission rates increased from 29 incidents in 2016 to 43 in 2017. Similarly,

the number of patients who experienced pain for more than 24 hours without relief doubled

from 15 in 2016 to 30 in 2017. Pressure ulcers, a common quality and safety issue in surgical

patients, also increased to 25 from 14 in 2016. Conversely, the units reported a drop in the

number of patients whose LOS exceeded 7 days—from 43 in 2016 to 31 in 2017.

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.


The outcomes are a cause for concern because they can affect the hospital’s

stakeholders—the patients, health care professionals, and the organization—in various ways.

Patient readmissions are a costly outcome for TGH because the Patient Protection and Affordable

Care Act, through its Hospitals Readmissions Reductions Program, financially penalizes

hospitals with higher than expected readmissions (Bartel, Chan, & Kim, 2014). Hefty penalties

are enforced because readmissions are thought to be the result of poor follow-up care (Abelson,


Furthermore, studies have found an association between LOS and the risk of

readmissions. Bartel et al. (2014) reviewed prior literature on the impact of decreasing patient

LOS and increasing readmission rates and concluded that a patient who stays for an additional

day may reach a higher level of stability. At TGH, health care professionals may have faced

immense pressure to reduce patient LOS to control per capita health costs. The pressure could

have forced the units’ nurses and doctors to rush through patient care plans and hasten the

process of educating patients regarding post-discharge behavior. Furthermore, patients who are

readmitted may lose trust in the ability of their health care providers to provide complete and

quality care.

Just as readmissions are a quality issue that affects all stakeholders, high pain levels and

pressure ulcers affect the surgical units’ nurses and patients. This inference is based on the theory

of nurse-sensitive patient outcomes, which explains that pain and pressure ulcers are patient

outcomes that depend on the quantity and quality of nursing (Stalpers, de Brouwer, Kaljouw, &

Schuurmans, 2015). Based on this inference, it can be assumed that there could be issues in the

performance and quality of nursing in TGH’s surgical units.

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Moreover, there is evidence linking pressure ulcers and postoperative pain to a higher

risk of readmissions (Kirkner, 2017; Lyder et al., 2012). While TGH’s data do not directly link

pressure ulcers and pain to readmission rates, it is possible to theorize that reducing pressure

ulcers and pain in patients will also reduce readmissions. Therefore, the surgical units’ nurses can

help prevent readmissions by preventing ulcers and managing pain in patients more efficiently.

The standard of nursing quality is an important predictor of favorable quality outcomes.

Based on the analysis of the data in the report, TGH’s nurse leaders met with the units’ nurses to

examine the nursing factors that contributed to the unfavorable outcomes. The nurse leaders

identified the problem to be the transactional leadership style practiced by the perioperative

charge nurses. Transactional leadership is defined as an exchange relationship that clearly

distinguishes the follower from the leader and is focused on the contingent reward system with

individuals being rewarded or punished based on their performance (Thomas, 2016).

Transactional leadership may have become the dominant style of leadership in TGH’s surgical

units because of the lack of training and incompetence among nurses. The nurse leaders decided

to change the leadership style of charge nurses with a quality improvement (QI) initiative based

on the data analysis. The proposal for the QI initiative will identify an ideal leadership style and

propose strategies to implement the style. Knowledge gaps or areas of uncertainty that require

further evaluation will also be discussed in the proposal.

Outline for the Quality Improvement Initiative Proposal

Charge nurses occupy a frontline position in influencing the staff engaged in patient care

(Thomas, 2016). They are responsible for functions such as coordinating and evaluating nurse

staffing plans, balancing unit budgets, and making patient assignments. However, the

transactional leadership at TGH was ineffective because the charge nurses were not skilled

Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

Comment [JS2]: This reference is too old to be viable for relevant evidence-based practice. In health care, it is important to use up-to-date references that are not more than 5

years old. I might suggest finding a