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Guiding Questions
Quality Improvement Initiative Evaluation
This document is designed to give you questions to consider and
additional guidance to help you successfully complete the
Quality Improvement Initiative Evaluation assessment. You may
find it useful to use this document as a prewriting exercise, an
outlining tool, or a final check to ensure you have sufficiently
addressed all the grading criteria for this assessment. This
document is a resource to help you complete the assessment.
Do not turn in this document as your assessment
submission.
Remember, you are analyzing a current QI initiative that is
already in place. You are not creating a new QI initiative
(Assessment 3).
Analyze a current quality improvement initiative in a health
care setting.
· What prompted the implementation of the quality improvement
initiative?
· What problems were not addressed?
· What problems arose from the initiative?
Evaluate the success of a current quality initiative through
recognized benchmarks and outcome measures.
· What benchmarks or outcome measures were used to evaluate
success? Consider requirements for national, state, or
accreditation standards.
· What was most successful?
Incorporate interprofessional perspectives related to initiative
functionality and outcomes.
· How does the interprofessional team contribute to the success

of the QI initiative?
· What are the perspectives of interprofessional team members
involved in the initiative?
· Who did you talk to? From what other professions? How did
their input impact your analysis?
Recommend additional indicators and protocols to improve and
expand outcomes of a current quality initiative.
· What process or protocol changes would you recommend?
· What added technologies would improve quality outcomes?
· What outcome measures are missing, or could be added?
Convey purpose, in an appropriate tone and style, incorporating
supporting evidence and adhering to organizational,
professional, and scholarly writing standards.
· Is your analysis logically structured?
· Is your analysis 5–7 double-spaced pages (not including title
page and reference list)?
· Is your writing clear and free from errors?
· Does your analysis include both a title page and reference list?
· Did you use a minimum of four sources? Were they published
within the last five years?
· Are they cited in current APA format throughout the analysis?
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Introduction
In healthcare settings, plans for process-specific quality
improvement are frequently
reactive and focused on actions to improve a single process.
Harmful incidents or near-misses
will serve as a wake-up call for many healthcare organizations
when patient well-being is a
priority, inspiring activities to enhance care. Quality
improvement projects that concentrate
on particular issues must be carefully planned to elevate the
level of care and expand patient
safety. The primary focus of this paper is the quality program
implemented in the author's

healthcare association to diminish pharmaceutical errors and
improve healthcare safety. To
prevent pharmaceutical errors, interprofessional teams work
together to pinpoint the root
causes of mistakes and implement preventative measures.
An examination of a contemporary QI project
Medication errors were common in the healthcare organization
before initiating the
quality improvement (QI) program. Two mistakes that seriously
hurt patients and were
exposed to the media caused the organization to face a lot of
criticism. A QI program that
focuses on the issue of pharmaceutical errors was developed in
response to these complaints
and the requirement to improve healthcare outcomes. Due to the
high rates, a program was
established. Its primary goal was to address the causes of errors
that were already occurring
to increase patient safety by reducing error rates.
The hospital board established a QI committee to begin a QI
project in response to
medicinal errors. Clinical personnel, office employees, and QI
coordinators made up the

interdisciplinary QI committee. Identifying the underlying
causes of quality issues was the
first stage in testing, putting solutions into practice, and
assessing the results. Although the
committee was established to provide a backing for overall
quality, pharmaceutical errors
were its main area of interest. The Pharmaceutical Error
Prioritization System (MEPS), a
3
system for recording and categorizing drug errors within the
healthcare system, was created
by the committee in response to medication errors. These two
strategies summarize the
committee's efforts to decrease pharmaceutical errors and
improve patient safety.
Even though the effort generally reduced errors, doctors found
it difficult to

implement. Many doctors chose to write traditional paper-based
prescriptions instead of using
the convoluted and poorly developed e-prescription system.
However, changes were made
that made the system easier to use. The QI program did not look
into patient experiences and
how they affect the likelihood of drug errors. Patients did not
immediately benefit from the
MEPS program because it is only available to staff, even though
it improved reporting and
tracking. Due to fewer drug errors, the QI effort may not have
improved patient safety as
successfully as it could have. The healthcare organization must
make changes to increase user
access to the QI and gather patient experiences.
Analyze a current QI initiative's performance.
The QI initiative was successful in part because fewer errors
were made. Frequency
measurement is the primary yardstick for assessing quality
improvement in pharmaceutical
mistakes. A 20% decrease in the reported number of medication
errors was seen when
comparing medication error rates six months before and after

the QI project was
implemented. Despite a trend in the right direction, it's unclear
whether reporting stayed the
same. Control for reporting rates is one of the main obstacles to
evaluating the efficacy of
medication error reduction, according to Donaldson et al.
(2017). Perhaps fewer practitioners
than in the past have reported medication errors. The QI
initiative successfully lowered the
frequency of drug errors in the company, assuming that
reporting remained consistent before
and after the effort.
4
Second, the method lowered the percentage of pharmaceutical
errors that led to both
temporary and severe injuries. The hospital divides errors that
cause no harm, inconsequential

harm, severe harm, or death into three categories. Before the
experiment, 30% of all reported
errors only resulted in temporary damage in 3% of cases and
severe harm in only 1% of
cases. 90% of all issues had been resolved without putting
patients in danger after the project
had been in place for six months. The effort improved patient
safety overall by lowering the
percentage of errors that hurt patients. It is predicted that
reporting rates will remain constant
before and after the program, just like the previous benchmark.
New metrics could be added to the existing metrics to assess the
project's success and
how effectively the technique was performed to increase patient
safety. First, we must
ascertain the reporting rates. Practitioners must operate in a
setting where reporting and
correcting errors is encouraged if the objective is to increase
patient safety by minimizing
prescription errors (Morrison, Cope, & Murray, 2018). It must
be a setting that encourages
higher reporting rates and is victim-free. It is necessary to have
a system in place for

evaluating how well reporting is done within the company.
Second, customer reviews would
benefit the business, particularly regarding how happy
customers are with the healthcare
system. Patient happiness and experience with the healthcare
system are closely related to
patient safety. To accurately assess the effectiveness of the QI
effort, the organization must
incorporate metrics that measure patients' views of safety and
quality.
Perspectives from Various Professions
A multidisciplinary team worked on the QI project and
contributed to this analysis.
Clinical staff, support workers, and QI coordinators were part of
the interprofessional
strategy, which focused on particular and overall health
improvement goals. Members of the
clinical staff, including doctors, nurses, and pharmacists, were
the first category of

5
professionals to be evaluated. The feedback was primarily
concerned with users' opinions of
usability and any issues they had with the QI effort. The rigidity
and lengthy procedure of the
computerized prescription system, according to a nurse
practitioner (NP), made it difficult to
utilize at first. However, she noted that with improvements and
persistence from the
prescribing physician, the system minimized errors compared to
paper-based prescription
methods. She stated that although MEPS accurately monitored
errors, fewer medication
errors were not necessarily the result of its use. She also
thanked the group for considering
clinical staff members' perspectives and experiences when
implementing the quality
initiative.
The e-prescription system has received overwhelmingly positive
feedback from
support staff and QI coordinators for making identifying and
eliminating drug mistakes

easier. The performance of information technology (IT) must
live up to expectations, and
support employees are accountable for this. According to their
perspective, effective
communication was essential for the initiative's speedy
implementation. The IT team utilized
the user interface improvements as an illustration to highlight
the value of clinical staff
feedback in enhancing certain system functions. The QI
coordinator also spoke about the
importance of fast feedback and communication while keeping
track of pharmaceutical
errors. The QI coordinator says that encouraging reporting and
fostering honesty is the most
challenging problem.
The interprofessional team's observations revealed that the key
issues were staff
reaction, motivation, and communication. The communication
perspectives demonstrated that
the system was successful in boosting group efforts to lower
pharmaceutical mistakes.
However, identifying problems with the reporting and e-
prescription systems requires open

and timely communication. The healthcare organization
recognized the pain in the
requirement for a strategy to promote more reporting and gauge
reporting rates.
6
Additional Protocols and Indicators
More indications, protocols, and technological advancements
could help the QI effort.
The first suggested reform is implementing an anonymous
reporting process that covers staff
and patients. It is a fundamental tenet of the healthcare system
that all reports of drug
mistakes be made through a team. However, patients are also
capable of identifying
pharmaceutical errors and the causes behind them. Morrison et
al. (2018) emphasize the
significance of a non-punitive strategy for reporting medication

errors to increase reporting
rates and safety in general. Journalists could avoid punishment
for mistakes they find or make
by anonymous reporting. For instance, if a patient or nurse
observes improper behavior that
could result in errors or safety concerns, they can report the
incident confidently. The QI
committee can then take the appropriate action. The
dependability of reports may degrade as
a result of this reporting method. This illustrates when a
disgruntled employee makes
mistakes by criticizing their manager. The healthcare facility
could utilize an anonymous
reporting method to encourage reporting of pharmaceutical
errors despite the potential risk of
losing credibility.
Additionally, a drug reconciliation strategy based on patient
records must be
implemented throughout the business. The pharmacist is
typically in charge of reconciliation,
making sure the patient's medication list is as current as
practical. An interprofessional QI
team, however, will be involved in reviewing all patient records
as part of an organization-

wide reconciliation effort and working with patients and their
families to update medication
lists. Drug reconciliation has the advantage of using a
collaborative method to find
discrepancies and interactions, boosting the accuracy of the
prescription list and significantly
lowering the possibility of mistakes (Dufay et al., 2017). The
assistance of clinical personnel,
patients, and their families must be enlisted to collect as much
patient data as feasible. Patient
electronic health records (EHR) will be merged during the
reconciliation process with
7
assistance from the records manager and support staff to update
and enhance the correctness
of the repository. Despite the procedure's advantages, executing
widely and maintaining

uniformity is challenging. Taking the process to encourage the
correctness of current data into
account can help the QI effort be improved, regardless of how
much time or money is spent
on reconciliation.
Conclusion
Medication error reduction necessitates coordinated efforts to
overcome practice gaps,
as demonstrated in the healthcare organization. Medication
errors commonly result in
fatalities in the healthcare system, which is detrimental to
patient safety and the standard of
treatment. An increase in significant drug errors influenced the
complex healthcare system,
which led to the creation of a QI project. MEPS and e-
prescriptions helped to achieve the
goal, although more precise reporting and records may have
been used. Throughout the
process, contributions from a range of staff members with
various backgrounds are necessary.
This evaluation shows how improved reporting practices and
reconciliation could benefit the
attempt to improve quality.

8
References
Donaldson, L. J., Kelley, E. T., Dhingra-Kumar, N., Kieny, M.
P., & Sheikh, A. (2017).
Medication without harm: WHO's third global patient safety
challenge. The
Lancet, 389(10080), 1680-1681. https://doi.org/10.1016/S0140-
6736(17)31047-4
Dufay, É., Doerper, S., Michel, B., Marson, C. R., Grain, A.,
Liebbe, A. M., ... & Alquier, I.
(2017). High 5s initiative: implementing medication
reconciliation in France a five
years experimentation. Safety in Health, 3(1), 6.
https://doi.org/10.1186/s40886-017-
0057-6
Morrison, M., Cope, V., & Murray, M. (2018). The

underreporting of medication errors: A
retrospective and comparative root cause analysis in an acute
mental health unit over
three years. International Journal of Mental Health Nursing,
27(6), 1719-1728.
https://doi.org/10.1111/inm.12475
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1
Susie Mayo
Capella University
MSN FP-6016
Dr. Carolyn Morrisey

September 2020
https://www.coursehero.com/file/68879073/Quality-
Improvement-Initiative-Evaluationdocx/
2
Patient safety is a priority in any healthcare setting. Hospitals
utilize quality improvement
(QI) initiatives to improve the quality of patient care, deliver
the highest level of quality care to
our patients safely, focus on patient health outcomes while
attaining cost efficiencies. The
purpose of the Quality Improvement Initiative is to first focus
on patient safety and to foster a
deliberate and thoughtful approach to the provision of services
by providing a common
framework for measurement, assessment, improvement, and
maintenance of performance in
accordance with the corporation's mission, vision, and values
(Ohio Health, 2020). Healthcare

acquired infections (HAIs) are infections patients get in the
hospital while receiving care for
another condition. The U.S. Department of Health and Human
Services (HHS) (2020) states,
"the HHS has identified the reduction of HAIs as an Agency
Priority Goal and is committed to
reducing the national rate of HAIs" (para.4-5).
Analyze Current Quality Improvement Initiative
Infection control and prevention interventions are at the core of
the safe care concept, and
understanding a process before attempting to improve it is
critical in any quality improvement
initiative. Common HAIs that patients get in hospitals include
central-line associated
bloodstream infections (CLABSI), clostridium difficile (c-diff)
infections, pneumonia (PNA),
methicillin-resistant Staphylococcus aureus (MRSA) infections,
surgical site infections, with
catheter-associated urinary tract infections (CAUTI) the most
common of HAIs(The Center for
Diease Control, 2019).
The Ohio Health organization has infection prevention policies
that are OhioHealth

hospital-specific policies. Ohio Health implemented a CAUTI
prevention bundle, within policy
and procedures, that consists of hand hygiene, wearing personal
protective equipment, use of
3
disposable gloves, cleansing of urethral meatus before catheter
insertion using sterile saline,
assessment of catheter need, aseptic urine sampling technique,
and correct draining bag
positioning(Ohio Health, 2017). The Committee on Hospital
Infection Prevention (CHIP)
oversees the planning, organization, development, and
evaluation of the hospital-wide infection
control program for all Ohio Health hospitals based on the
guidelines of The Joint
Commission(Ohio Health, 2017). The goal is to minimize the
hazards of healthcare-associated

infections and infection potentials by instituting and
maintaining measures for the prevention,
investigation, reporting, and control of infections. The
neurocritical care (NCC) and intensive
care unit (ICU) population is at exceptionally high risk for
catheter-associated urinary tract
infections (CAUTIs) due to length of stay, chronic disability,
immobility, agitation, and
confusion(Busl, 2019). These units tend to have higher CAUTI
rates in the United States (U.S.)
than other patient care units(Busl, 2019). Ohio Health NCC and
ICUs have QI guidelines in
place for CAUTI prevention, but omit some of the causes that
can lead to CAUTI(Ohio Health,
2017). The Center for Disease Control (CDC) (2019) reports,
"many of these infections are
preventable, and common reasons that lead to HAIs are an
improper use of catheters, such as
convenience, a break in sterile technique inserting a foley,
improper hygiene and handwashing
by hospital staff spreading germs and bacteria from other
hospitalized patients and understaffing,
which can lead to patients not receiving the attention they need
for foley care leading to infection

and worsening health(pp.34-41 ).
Recognized Benchmarks and Outcome Measures
The National Healthcare Safety Network(NHSN) is the nation's
most widely used
healthcare-associated infection(HAI) tracking system. Since
2009, infection data has been
reported to the NHSN to track the national progress of reducing
HAIs(The U.S. Department of
4
Health and Human Services,2020). Ohio Health follows
guidelines set forth by The Joint
Commission and the CDC for the prevention of HAIs
(G.Howard, personal communication,
September 17, 2020). Ohio Health completes monthly reporting
plans, and collected outcome
data is entered using their Center for Medicare & Medicaid

Services (CMS) Certification
Number (CCN), which is then sent directly to the NHSN HAIs
tracking system(G. Reid,
personal communication, September 17, 2020). The Ohio Health
NCC is compared to other
neurocritical care units(NCC) with > 15 beds in hospitals with >
500 beds, and the data is
calculated taking the number of foleys per 1000 patient days, so
this accounts for our actual size
of 32 beds(G.Howard, personal communication, September 17,
2020). The expected number of
CAUTIs from July 2017 - February 2018 was 17, and Ohio
Health's NCC had 32; this is about
two extra infections per month. The expected number of foley
days from July 2017 – February
2018 was 3980, and the NCC had 4858, which is about 98 extra
foley days a month(G. Howard,
personal communication, September 17, 2020). These numbers
revealed CAUTI was higher
than the national benchmarks( (G. Howard, personal
communication, September 17, 2020).
Education was heightened on the NCC unit to monitor proper
hand hygiene, use of foaming
stations outside of rooms, and adequate patient foley catheter

care( G.Howard, personal
communication, September 17, 2020). The Agency for
Healthcare Research and Quality(AHRQ)
(2015) recommends, "units identify the number of symptomatic
CAUTIs attributable each
month, the CAUTI rate, and days since last CAUTI as metrics
for outcome measures, so the
patient care team and administrators will be able to use NHSN
data for benchmarking purposes"
(para.6-8). The AHRQ(2015), further states, "comparing your
unit's CAUTI rate with other units
of the same patient type and acuity gives the team "apples to
apples" information about how their
patient outcomes compare to other units" (para.8).
5
Interprofessional Perspectives related to Initiative Functionality
and Outcomes

Interprofessional collaboration is critical in promoting quality
and safe patient care and is
fundamental for successfully delivering patient-centered care. A
team approach ensures that
healthcare personnel and others who take care of catheters are
given periodic in-service training
regarding techniques and procedures for urinary catheter
insertion, maintenance, and
removal(Ohio Health, 2017). Provide education about CAUTI,
other complications of urinary
catheterization, and alternatives to indwelling catheters. The
CDC (2017) reports," this builds
consensus on current process strengths and shortcomings, and
also creates team recognition of
areas of improvement targeted to a process and not at
people(para.11). Ohio Health has
incorporated the CAUTI Workgroup, OhioHealth Nursing
Policy, and Procedure Committee that
includes NCC, ICU nurse managers, clinical educators, chief
nursing officer(CNO), and the Ohio
Health medical director(G. Howard, personal communication,
September 17, 2020). The Ohio
Health CAUTI workgroup follows recommendations set forth by
Refer to Perry and Potter's

Clinical Nursing Skills reference text for specific care
instructions, The Joint Commission, and
the CDC(G. Howard, personal communication, September 17,
2020). This writer conducted
personal telephone communication with Gina Howard, MSN,
director of Ohio Health Riverside
Methodist Hospital NCC. Gina Howard provided this writer
with information about their unit
studies on CAUTI due to the patient population and the higher
incidence of CAUTIs in the NCC.
This writer located policy and procedure from the Ohio Health
employee websites.
Additional Indicators and Protocols to Improve/Expand Quality
Outcomes
The AHRQ has initiated a Toolkit To Reduce CAUTI and Other
HAIs in Long-Term Care
Facilities. This toolkit helps long-term care (LTC) facilities
reduce catheter-associated urinary

6
tract infection (CAUTI) and improve practices to prevent
healthcare-associated infections (HAIs)
(Agency for Healthcare and Quality, 2015). The toolkit was
developed during a 3-year project
that involved a national quality improvement collaborative
designed to reduce CAUTIs and
enhance patient safety culture and practices in LTC facilities
and provides resources to enhance
leadership and staff engagement, teamwork, and safety culture,
to facilitate consistent use of
evidence-based practices(Agency for Healthcare and Quality,
2015). Ohio Health utilizes a
CAUTI prevention bundle and still found gaps in care such as
breaks in sterile technique
inserting a foley, improper hygiene, and handwashing by
hospital staff, and lack of proper care
due to understaffed units. The Toolkit To Reduce CAUTI and
Other HAIs in Long-Term Care
Facilities may offer new protocols to improve and expand
quality outcomes of the Ohio Healths
CAUTI quality initiative. Other specific process or protocol
changes that may be beneficial

would be a two registered nurse(RN) insertion checklist. The
purpose of the second RN is to
watch the primary RN's sterile technique. This specific process
would hold staff accountable for
following a specific protocol. Both nurses would document their
names in a CAUTI detailed
document.
Conclusion
The creation of care bundles was one of the innovations to
ensure a set of standard
interventions was performed in 100% of the patients. Even with
the implementation of bundles,
team leaders and staff members must be diligent with the
protocols and processes to reduce the
number of patients at risk for HAIs. Health care professionals
need to be engaged in their patient
care and make care safer by following clinical best practices
and creating a culture of safety.

7
References
Agency for Healthcare Research and Quality. (2015). Toolkit
for reducing catheter-associated
urinary tract infections in hospital units: implementation guide.
https://www.ahrq.gov/hai/cauti-tools/guides/implguide-pt4.html
Busl, K. (2019). Healthcare associated infections in the
neurocritical care unit. Current
Neurology and Neuroscience Reports. Springer Link.
https://doi.org/10.1007/s11910-019-
0987
CDC. Healthcare infection control practices advisory
committee. (2019). Guideline for
prevention of catheter-associated urinary tract infections 2009
[PDF]. Center for Disease
Control..
https://www.cdc.gov/infectionconrol/pdf/guidelines/cauti-
guidelines-H.pdf
Ohio Health. (2017). Committee on Hospital Infection
Prevention. Policy and Procedure.
https://ohesource.ohiohealth.com/departments/clinicalqualitysaf

ety/CAUTI
Ohio Health. (2020). Process Improvement and Patient Safety
Plan. Policy and/or Procedure.
https://ohesource.ohiohealth.com/infocentral/CareConnect/carep
rocess_improvement_an
d_patient_safet_plan
U.S. Department of Health and Human Services. (2020).
Healthcare Associated Infections.
https://health.gov/our-work/health-care-quality/health-care-
associated-infections
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