Healthcare Quality Improvement Plan: Project Analysis and Development

This project outlines a quality improvement (QI) plan for a healthcare organization, addressing key areas for enhancement. The assignment begins with an overview of the hospital, including its size, services, patient demographics, and current QI culture. The student identifies the strengths of the QI team, potential barriers, and areas needing improvement, specifically focusing on enhancing communication between healthcare staff and patients and preventing medication errors. The plan details the necessary support for the QI team, emphasizing the importance of these improvements for patient satisfaction and safety. The assignment also includes measurable indicators of progress, such as reduced negative feedback and fewer medication-related incidents, along with an action plan outlining specific tasks, responsibilities, and timelines to support the team and foster a QI culture within the agency. The measures to track success and the steps to implement the changes are defined, providing a comprehensive approach to improving the healthcare organization's performance and patient care.

Running head: DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
Name of the Student:
Name of the University:
Author Note:

1DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
Organization Details
Location: 110 Irving Street, NW, Washington, D.C. 20010, United States.
Size: The area occupied by this hospital center is about 19 hectare. The strength of this hospital
is 912 beds and 1344 physicians, 310 advance care providers, 1827 nurses and 5779 associates
(Center, 2020).
Scope or Type of Personnel: The staffs are either from medical or dental background.
Services Provided: Services that involves the treatment of about 72 disease conditions, are
provided. Those services include the treatment of various cancers such as pancreatic cancer,
colorectal cancer, thoracic cancer, breast cancer and 10 more cancerous conditions, advanced
heart failure, neurological treatment, pain management, palliative care, kidney services and
various other disease conditions. The hospital have a nationally recognized vascular and heart
care center and an internationally recognized trauma center (Center, 2020). Additionally the
hospital center also provides a service that involves the use of a diagnostic platform, which has
been newly developed and is robotic in nature in order to diagnose the lung conditions in the
patients.
Patient Demographics: In the year 2018, the number of inpatient admission was 36,233, the
outpatient visits were 396,168. There was 3675 births, 10,271 outpatient surgeries and 11,504
inpatient surgeries (Center, 2020).

2DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
Quality Improvement Plan
I. Current Condition
QI Project and Team QI Culture
o What strengths does your QI team have
that will make them successful?
The team is being operated under the supervision
of an efficient team leader, who is experienced in
the development of a quality improvement plan.
The team members possess proper knowledge on
the evidence based practices and are properly
focused in their work. They are also comfortable
with working in a team with each other.
o What barriers or challenges will the QI
team encounter?
The first possible barrier to be considered while
developing a quality improvement plan can be
the organizational attitude, which might be
negative towards the particular improvement
plan.
The second possible barrier is the possible
limitation of the resources, which can be both
monetary and human resources or any one of
them.
o What is your agency doing well to support
a culture of QI?
The organization is focused on the improvement
of the quality of patient care.
The authority considers the patient feedback
carefully in order to keep a track on the patient
satisfaction level and to identify the fields that in
need of improvement.
The opinions of the staffs in improving the quality
of patient care are considered with importance.
o What two areas would you most like to
improve?
From studying the negative feedback reports in
the patients, two fields of quality improvement
area can be identified for the selected
organization.
The first area of improvement should be the
promotion of better communication between the
healthcare staffs and the patient or patient family.
The second should be the prevention of the
instances of the medication error.

3DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
QI Project and Team QI Culture
o What specific support will the QI team
need to ensure they are successful?
The QI team will require the support of the
organizational authority including the approval of
the management, human resource and the
financial department of the healthcare
organization.
In order to achieve a successful implementation of
the QI plan the support and co-operation of all the
organizational staffs is required.
o Why is it important to improve these areas?
The promotion of better communication between
the healthcare staffs and the patients or patient
family will lower the instances of patient
dissatisfaction. Providing the patient and his or her
family with proper knowledge will lower the
anxiety level in them, which in turn will help in
increasing the satisfaction level in them (Rothberg,
2016).
Lowering the instances of medication error will
lower the instances of additional and unnecessary
health hazards in the patient improving the quality
of care delivered in the patients (Boamah et al.,
2018)
.

4DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
II. Measures: What Will Indicate Progress?
QI Project and Team QI Culture
 List two measures that will show the team is
moving in the right direction toward success.
By March 2020, the team will,
1. Be able to lower the rate of negative
feedbacks from the patients regarding
effective communication. There will be less
reports complaining about the unavailability
of the staffs upon requirement, ignorance of
the staffs in patient care and
misunderstandings regarding the treatment
procedure. The level of patient satisfaction
will increase and the number of
recommendations for the organization will be
higher that will result increased publicity of
the hospital.
2. There will be lower instances of additional
health hazards in the patients after
administration of medication. The patient
satisfaction due to fast recovery will be
evident from the patient feedback. There will
be more patient retention. The awareness in
the healthcare staffs regarding the possible
error practices will be higher.
 List two measures that will show the agency
is moving in the right direction toward
success.
By March 2020, the agency will,
1. Observe a high level of communication
instances between the patient, patient family
and the healthcare staffs, which can be
measured by the documented instances of
communication between the staffs and the
patients or his/ her family. The feedback
survey involving all the staffs, patient and
their respective families will also indicate the
movement towards success.
2. Be able to lower the number of legal disputes
filed regarding the demand of refund due to
ineffective treatment. The measurement can
be done by performing a comparative study
from various documents, recording those
instances of legal complaints, associated with
the organization. The documentations of the
readmission of the patients due to medication
error can also be taken into consideration and
compared for observing the improvement.

5DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
III. Action Plan
List at least 3 things you can you do to support your team and ensure they are successful in
completing a QI project.
Supporting the QI Project and Team
Activities/Tasks Who is
Responsible?
By When? Status/Progress
1. Educating all the
healthcare staffs
about the importance
of communication
with the patients and
their respective
families.
The nurse
leader should
take this
responsibility.
Within 2
weeks.
All the staffs must be
aware of the
importance of
communication and the
patient satisfaction
level will be higher.
2. Educating all the
nursing staff about
the proper medication
administration
procedure and the
“five rights” rule
regarding the
administration.
The nurse
leader should
monitor the
process.
Within 2
weeks.
The staffs will have the
proper knowledge on
the medication
administration process
and the instances of
medication error in the
patients will be
lowered.
3. Implementation of
proper documentation
The healthcare
staffs must be
The
documentation
The weekly summary
of records for every

6DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
in every instances of
communication
between the nurses
and the patient or the
respective family.
responsible for
keeping the
record every
time.
must start
within one
week.
staff should be
monitored on a weekly
basis.
List at least 3 things you can do to help your agency begin to change the culture.
Sustaining a QI Culture
Activities/Tasks Who is
Responsible?
By When? Status/Progress
1. Explanation of
the importance of
development
plan to the
authorities of the
organization.
The QI team
must take this
responsibility.
The time
period must not
be more than
one week.
Obtaining the approval for
the development of QI
plan.
2. A regular survey
in order to keep a
track of the
satisfaction level
in the patients
and their
respective
families must be
A survey team
should be created
specifically for
the
implementation
of this approach.
The team must
be created
within a week
and the survey
must start
within 2
weeks.
The satisfaction level in
the patients will be
measured on a regular
basis.

7DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
put into practice.
3. The
documentation
regarding the
legal dispute
filings and
patient
readmissions
must also be kept
in track on a
regular basis.
The same survey
team should be
given the
responsibility.
The
implementation
must start
within 1 week
of the team
creation.
The fields that invites
patient dissatisfaction will
be under a continuous
monitoring condition.

8DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
IV. Review/Reflect on Results: What Happened?
QI Project and Team QI Culture
 How is the QI team progressing?
The positive feedbacks from the patient is
increasing and the instances of medication errors
along with the number of patient readmissions are
lowered.
 What things am I doing to support the
team’s success?
As a QI team leader I am continuously monitoring
the progress of the plan along with keep my
fellow team members motivated.
 What things am I doing to hinder the
team’s success?
There is no action taken by me to hinder the
success of the team.
 What additional things do I need to do to
help the team be more successful?
I should focus on keeping the whole team
continuously motivated.
 How is the QI Culture progressing?
The authorities have understood the importance of
QI development plans and the documentations and
surveys are being examined regularly which is
showing a higher level of patient satisfaction.
 What things am I doing to support the
progress?
As a team leader I am ensuring the monitoring
team is working properly.
 What things am I doing to hinder progress?
My actions are not hindering the progress.
 What additional things do I need to do to
ensure progress?
I must find the other areas that are in need of
improvement and develop new improvement plans
in regards to those areas.

9DEVELOPMENT OF A QUALITY IMPROVEMENT PLAN
References
Boamah, S. A., Laschinger, H. K. S., Wong, C., & Clarke, S. (2018). Effect of transformational
leadership on job satisfaction and patient safety outcomes. Nursing outlook, 66(2), 180-
189.
Boissy, A., Windover, A. K., Bokar, D., Karafa, M., Neuendorf, K., Frankel, R. M., ... &
Rothberg, M. B. (2016). Communication skills training for physicians improves patient
satisfaction. Journal of general internal medicine, 31(7), 755-761.
Center, M. (2020). Our Hospital. Retrieved 21 January 2020, from
https://www.medstarwashington.org/our-hospital/
Center, M. (2020). Our Services. Retrieved 21 January 2020, from
https://www.medstarwashington.org/our-services/
Center, M. (2020). Facts and Figures. Retrieved 21 January 2020, from
https://www.medstarwashington.org/our-hospital/facts-and-figures/