1 5 Nursing Research Utilization Project Proposal: Monitoring The delivery of individualized care is important in ensuring receipt of optimal benefits of care rendered to patients. Discharged patients should be released to community agencies that provide in-home assistive services. The transition plan must consider the patient's home environment as well as the risks for injury and find ways of mitigating them as soon as possible. Service providers should take advantage of family conferences to advise the patients’ family of how to care for the patient after they have been discharged from the hospital. Hence, there is a need for post-discharge follow-up especially for high-risk patients, to deter readmission rates (Potera, 2009). This paper aims to discuss methods of monitoring solution implementation; evaluate the solution; and lastly, tackle outcome measures and data collection evaluation. Monitoring Monitoring is a scheduled collection and analysis of data so as to track the progress of the implemented solution and ensure that the solution is in compliance with the set health standard regarding patient discharge (Popejoy, L.L., et al., 2015). Monitoring is a critical aspect of any implementation process since it helps in establishing patterns and coming up with strategies for proper management and quality improvement. Monitoring and evaluation in the health care sector are paramount in ensuring quality services. It is critical to monitor the implemented solutions for the issues affecting patient-centered care and discharge planning(Potera, 2009). The Stetler Model assists in the monitoring of the solution using its steps. “The monitoring consists of preparation, validation, decision-making, application and finally evaluation according to the steps of the Stetler Model (Stetler, 2001).” The preparation formonitoring begins with the purpose; sources of the evidence of the research; and then the context of health care. The identification of purpose depends on the solution proposed. Therefore, the contextual factors must be examined to determine the appropriate monitoring strategy. The second phase is the validation of the monitoring process. The solution identified was for the IDT to ensure that patients receive individualized care, which are carried out post hospitalization and prevent patients returning to the hospital. Therefore, the patient-centered care and reduction of readmission would be the ultimate goal of monitoring. The monitoring process starts with the formulation of healthcare providers with unified policy-driven structure ensuring that there are proper communication and coordination and culminates with patient being released in the community. Evaluation All the IDT will be involved in the designing as well as the implementation of the program. Stakeholders are expected to obtain and report their expertise, perspectives and feedback. The next step will be clarifying the scope of the solution plan. In this case, the sc ...

1. 1
5
Nursing Research Utilization Project Proposal: Monitoring
The delivery of individualized care is important in ensuring
receipt of optimal benefits of care rendered to patients.
Discharged patients should be released to community agencies
that provide in-home assistive services. The transition plan must
consider the patient's home environment as well as the risks for
injury and find ways of mitigating them as soon as possible.
Service providers should take advantage of family conferences
to advise the patients’ family of how to care for the patient after
they have been discharged from the hospital. Hence, there is a
need for post-discharge follow-up especially for high-risk
patients, to deter readmission rates (Potera, 2009).
This paper aims to discuss methods of monitoring solution
implementation; evaluate the solution; and lastly, tackle
outcome measures and data collection evaluation.
Monitoring
Monitoring is a scheduled collection and analysis of data
so as to track the progress of the implemented solution and
ensure that the solution is in compliance with the set health
standard regarding patient discharge (Popejoy, L.L., et al.,
2015). Monitoring is a critical aspect of any implementation
process since it helps in establishing patterns and coming up
with strategies for proper management and quality

2. improvement. Monitoring and evaluation in the health care
sector are paramount in ensuring quality services. It is critical
to monitor the implemented solutions for the issues affecting
patient-centered care and discharge planning(Potera, 2009).
The Stetler Model assists in the monitoring of the solution using
its steps. “The monitoring consists of preparation, validation,
decision-making, application and finally evaluation according to
the steps of the Stetler Model (Stetler, 2001).” The preparation
formonitoring begins with the purpose; sources of the evidence
of the research; and then the context of health care. The
identification of purpose depends on the solution proposed.
Therefore, the contextual factors must be examined to determine
the appropriate monitoring strategy.
The second phase is the validation of the monitoring process.
The solution identified was for the IDT to ensure that patients
receive individualized care, which are carried out post
hospitalization and prevent patients returning to the hospital.
Therefore, the patient-centered care and reduction of
readmission would be the ultimate goal of monitoring. The
monitoring process starts with the formulation of healthcare
providers with unified policy-driven structure ensuring that
there are proper communication and coordination and
culminates with patient being released in the community.
Evaluation
All the IDT will be involved in the designing as well as the
implementation of the program. Stakeholders are expected to
obtain and report their expertise, perspectives and feedback.
The next step will be clarifying the scope of the solution plan.
In this case, the scope would entail defining the purpose as well
as evaluating other aspects of the program as the budget and the
target clientele. The second step will entail developing
questions, which will be addressed based on outcome solutions,
after which it would be viable to develop indicators of change
and performance. The third step is developing the questions that
the program is intended to answer. After developing
questionscomes along the selection of relevant indicators.

3. Indicators are useful mechanisms for measuring achievements,
as well as reflect any changes in the program. Following the
selection of the indicators is deciding on the viable methods of
data collection. Data collection method can be qualitative or
quantitative approach. Once data is collected, analysing of data
collected comes into play. Final step would be communicating
the findings, insights, and recommendations to the stakeholders.
Outcome measures. “Patient-reported outcomes measures
(PROMs) are an important component of assessing as well as
evaluating whether clinicians are improving the health of
patients. Unlike process measures, that assist in capturing
provider productivity and adherence to the patient experience
measures, or standards of recommended care which focus on
aspects of care delivery such as communication, the PROMs
seeks to measure whether the services provided improved
patients' health and sense of well-being (Black, 2013).” The
outcomes measures determine whether the process
implementation is successful or not. The outcomes measures
include the following:
· The understanding of the discharge process that starts from the
admission of the patient.
· The effectiveness of unified policy-driven structure that would
ensure that there are coordination and proper communication
amongst different health care providers.
· The number of community agencies that provide in-home
assistive service
· The impact of home environment on the risk of injury.
· The ways to find mitigating strategies to reduce the risk of
injury to the discharged patient.
· The service provider should take advantage of the family
conferences to advise the patients’ family of how to care for the
patient after they have been discharged from the hospital.
· The facilitation of post-discharge follow-up especially for
high-risk patients, to deter readmission rates.
Evaluation Data Collection. The ways to deal with estimation is
useful to make a qualification amongst quantitative and

4. subjective techniques. Reviews utilizing organized surveys are
the most widely recognized type of quantitative measures of
patients' experience (Petitti, D.B., et al., 2000). These are
intended to create numerical information that can be examined
measurably and used to portray and think about results from the
example populace all in all and particular sub-bunches. The
accentuation is on analyzing examples and patterns from a vast
specimen, giving broadness and the capacity to look at, however
regularly inadequate with regards to profundity since inquiries
and reaction alternatives foreordained.
The accompanying quantitative techniques and advancements
for acquiring tolerant criticism (Petitti, D.B., et al., 2000):
· self-consummation postal studies
· Interviewer-managed vis-à-vis studies
· telephone reviews utilizing live questioners
· automated phone reviews (intuitive voice reaction – IVR)
· online reviews utilizing electronic or email polls
· surveys utilizing compact hand-held gadgets (PDAs or tablets)
(on location)
· surveys on touch-screen booths (on location)
· surveys on bedside comforts (nearby)
· Administrative information/routine measurements.
Qualitative techniques are diverse in that the attention is on
acquiring an inside and out comprehension of individual
encounters and the way they clarify or decipher these (Black,
2013). Subjective information is typically reported utilizing
words, not numbers, and it is harder to utilize the confirmation
to make examinations or speculations. Some subjective
techniques that would be utilized incorporates (Black, 2013):
· in-profundity eye to eye meetings (might be sound or
recorded)
· Discovery interviews completed by clinical staff
· Focus group
· web-based free content remarks
· comment cards or proposal boxes (nearby)
· Complaints and compliments

5. · Patient journals
Conclusion
It is important for clinicians to be aware on the goals of
patient-centered care and discharge planning to ensure
understanding that care process starts from patient’s admission.
It is also crucial to set up a unified policy-driven structure that
will ensure coordination and proper communication among
different health care providers in regards to patients’ plan of
care.This paper discussed methods of monitoring solution
implementation; evaluation of solution; and lastly, tackled
outcome measures and data collection evaluation.
References
Black, N. (2013). Patient reported outcome measures could help
transform healthcare. BMJ (Clinical Research Ed.), 346, f167.
Petitti, D. B., Contreras, R., Ziel, F. H., Dudl, J., Domurat, E.
S., & Hyatt, J. A. (2000). Evaluation of the effect of
performance monitoring and feedback on care process,
utilization, and outcome. Diabetes Care, 23(2), 192-
196.doi:10.2337/diacare.23.2.192
Popejoy, L. L., Jaddoo, J., Sherman, J., Howk, C., Nguyen, R.,
& Parker, J. C. (2015). Monitoring resource utilization in a
health care coordination program. Professional Case
Management, 20(6), 310-
320.doi:10.1097/NCM.0000000000000120
Potera, C. (2009). Lowering hospital readmissions and
costs. The American Journal of Nursing
Stetler, C. B. (2001). Updating the stetler model of research
utilization to facilitate evidence-based practice. Nursing
Outlook, 49(6), 272-279. doi:10.1067/mno.2001.120517

6. 1
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Nursing Research Utilization Project Proposal: Implementation
Plan
Objectives
Content
Describe the methods to be used to implement the proposed
solution
The methods that will be utilized in the implementation of the
proposed solution are through coordination, collaboration, and
brainstorming. Coordination is the process wherein stakeholders
work together effectively in achieving goals of care while
collaboration is where stakeholders are willing to assist each
other in order to attain objectives. Brainstorming on the other
hand is the exchange of ideas, expertise, and experiences
necessary to produce a well-planned care for patients. Ensuring
that each patient receives a patient-centered care is the primary
objective of any healthcare organization. The involvement of
stakeholders in creating measures to capture individualized care
aligns perspectives on what’s important and how it is attained
(Epstein & Street, 2011).
Develop a plan for implementing the proposed solution
A plan is a product of a strategic thinking process (Nunn &
McGuire, 2010). The formulation of a judicious plan is a crucial
step in any given project. The initial step is to identify and
engage the stakeholders that will comprise the Interdisciplinary

7. team (IDT) such as physicians, nurses, case managers, social
workers, therapists and dieticians. Second step is to present to
the IDT the objectives of the project which is to facilitate a
patient-centered care discharge plan for patients post
hospitalization.When the goals are known, IDT meets and
discuss the plan of care of the patient through brainstorming
and then presents the details to the patient and support system.
The IDT will involve the patient and family in the finalization
of the care plan. When all has been agreed upon among the IDT,
patient and support system, then implementation of the
objective is initiated.
Incorporate a theory to develop the implementation plan and
explain how it is used to develop the plan.
The theory that will be incorporated with the implementation of
the plan is the theory of reasoned action (TRA). The theory
associates norms, behaviors, attitudes, and intentions to perform
an action (Hill, 1977). It is the intention and goal of healthcare
organizations to provide patient-centered care to their patients.
Therefore, those involved with the care of the patient needs to
have the same belief and intention to make patient safe and be
well. The TRA theorywill pave a way to propel stakeholders in
ensuring that the patients they serve receive individualized plan
of care that they do deserve.
Identify resources needed for the proposed solution’s
implementation and how you plan to gather and incorporate
them.
The resources needed for the implementation of the proposed
solution are as follows: manpower, access to electronic records,
writing materials, and available conference room space to
facilitate the meeting. In order to obtain all resources needed,
the Executive Manager of the organization needs to buy-in with
the proposed solution and the benefits of its implementation. If
a project has the support of upper management, the acquisition
of resources is favorable. Leadership endorsement is essential in
any project success (Ur Rehman Khan, et al., 2014).
Describe outcome measures aligned with planned outcomes

8. The intent of the project is for 85% of patients will have a
patient-centered care discharge plan post hospitalization
following an IDT conference on patient’s care plan. The
conference will focus on a plan suited for patient’s needs, which
will be carried over tothe next level of care. A staff or a third -
party vendor will initiate a post discharge call within 24 hours
of patient’s discharge from the hospital. The aim of this call is
to ensure that the patient is safe and confirm that the care plan,
which was established in the hospital, was carried over by the
patient (and support system) at home or other post hospital
destination.
Discuss the feasibility of the implementation plan.
Patients are readmitted to the hospital sometimes due to poor
and individualized discharge planning. The effects of patient
returning the hospital not only affect the institution financially
but the comfort and safety of the patient is at stake as well. The
proposed solution to this issue is to involve stakeholders in
formulating a plan to promote patient-centered care. With the
knowledge and participation of upper management and staff on
the initiative of personalized care, project objectives can be
attained significantly. Therefore, implementing an IDT
conference

9. References
Epstein, R. M., & Street, R. J. (2011). The values and value of
patient-centered care. Annals Of Family Medicine, 9(2), 100-
103.doi:10.1370/afm.1239
Hill, R. (1977). Contemporary Sociology,6(2), 244-245.
Retrieved from http://www.jstor.org/stable/2065853
Nunn, L., & McGuire, B. (2010). The importance of A good
business plan. Journal of Business & Economics Research, 8(2),
95-105. Retrieved from
http://search.proquest.com/docview/194892288?accountid=3581
2
Ur Rehman Khan, S., Sang Long, C., & Muhammad JavedIqbal,
S. (2014). Top management support, a potential moderator
between project leadership and project success: A theoretical
framework. Research Journal of Applied Sciences, Engineering
and Technology,11(8), 1373-1376. doi:10.19026/rjaset.8.1109