A successful quality improvement (QI) initiative is essential to help a health care organization boost efficiency and improve its business model. It is critically important that the health care organization measures and monitors whether the anticipated outcomes are achieved. Health information technology (HIT) is often used to support systematic QI efforts by providing timely and valuable feedback on performance.
For your Quality Improvement Initiative final project, you must complete an eight page paper that details your QI initiative.
Summarize your Quality Improvement Initiative: Part 1 and Part 2.
Assess an appropriate advanced HIT that can be used to support your QI initiative.
Be sure to provide the rationales for your selection.
Describe how your QI initiative can be incorporated into the organization’s overall strategic plan.
Determine how to evaluate the effectiveness of your QI initiative.
Must use at least eight scholarly or peer-reviewed sources published in the past 5 years
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Vanderbilt University Medical Center; Complications and Death
Quality Improvement Initiative
Part 1
2
Complications and Death Quality Improvement Initiative
Introduction
Consistent with the high standard of services rendered, Vanderbilt University Medical
Center in Nashville is highly regarded as a leading health service provider serving a variety of
customers locally. Through this paper, we will address the issues of business entity, services and
products it offers and customers it serves. Next step will be to evaluate the rate of complications
and deaths inside the entity, which will be done by the discussion of the issues from the point of
positioning the entity on the reflex plan, patient’s safety and financial stability. Then, we will
elucidate a set of SMART goals targeted at progressive enhancement of such metrics, and after
that, we will include a review of most available policies that were devised to upgrade patient
outcomes.
Nature of Business, Services, and Customers
Vanderbilt University Medical Center is a medical center with high reputations that offers
a wide range of health services, consisting of preventive healthcare, specialized medical and
surgical services, diagnostic services, and research programs. It carries patients of a wide variety,
from patients who apply here to get routine medical care, to the patients who have complicated
medical condition that require specified medical service which are targeted for this group of
patients. VUMC is also towards patients who go in for the acceptation to clinical trials and
research studies (Wilkins et al., 2021). The hospital / medical center does not only serve for the
Nashville local population, but also patients from different counties of Tennessee, across the
state, regions and other countries that demand advanced treatment.
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Evaluation of Complication and Deaths and its Importance
The complication and mortality rates within the hospital are cardinal statistic and slightly
suggests the standard of care, the level of safety and financial health of an institution (Wilkins et
al., 2021). The portion of corresponding to the death and subsequent complications can not only
downgrade the profile status of hospital, but as well upgrade the necessary conditions of care and
safety set by the regulatory bodies like the Joint Commission Committee. In addition to the
patients well-being, such long-term adverse outcomes can result in respective lawsuits, loss of
reputations, and funding availability.
SMART Goals
1. Reduce Hospital-Acquired Infections (HAIs):
Specific: Set a goal of reducing the frequency of HAIs aircrafts, most of all SSIs. Aim to tip it
from 20% to 10%.
Measurable: Make sure to trace and record HAIs monthly and additionally draw a comparison
with the starting baseline data as sourced from a baseline study.
Achievable: Adopt an approach based on evidence based practice and design staff training
programs conquering infectious diseases.
Relevant: Safety and better care for patients are also means of the hospital under its vision and
mission.
Time-bound: Reduce the mortality rate by 15% for a period of 18 months.
Specific: Lower the mortality rates in high-risk operations, like cardiogenic surgeries, by 15%.
Measurable: Complete mortality rate studies for specific procedures every three months and
report them.
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Achievable: Improve retained surgical skills, preoperative assessments, and postoperative care
pathways. Create your own knowledge base and develop your vocabulary. These tools are
specifically designed for independent learners who want to deepen their understanding of
academic or specialized subjects.
Relevant: Saving patients lives and healing, is not just an aim of the healthcare system but also
aimed at long-term positive changes.
Time-bound: Achieve at least 15% reduction in the rate of mortality within the span of 18
months.
Analysis of Policies
Policies in a range from local, state up to and including national, including The Joint
Commission Standards, have paramount significance for inspiring quality enhancement activities
in hospitals (Leape, 2022). Such a set of policies is designed to allow for evenness up by
providing rules as well as guidelines in line with the utmost the most possible evidenced based
practice for enhanced patient and reduced complications to better inventory. An example of this
could be the National Patient Safety Goals of the Joint Commission, which establish particular
directions regarding the reduction of healthcare associated infections and preventing surgical
errors (Basson et al., 2021). This approach also complies with the SMART goals mentioned
earlier. Through adherence to these guidelines and ongoing evaluation of them and the assigned
metrics, hospitals including Vanderbilt University Medical Center can guarantee that the
treatment, safety, and care for people will grow better over time.
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Conclusion
Summing up, VUMC in Nashville caters for a mix spectrum of customers with differing
healthcare products and services. These in-house catastrophes that result in the demise of patients
symbolize poor quality procedures, flawed care plan and economic helter-skelter. The hospital’s
mission is to lower the rate of hospital-acquired infections and to maintain the very low mortality
rate for high-risk operations by setting up SMART goals. In other words, it enables the medical
center to achieve better outcomes for patients and conforms to regulatory standards. Along these
lines, application of evidence-based policies including those of The Joint Commission Standards
is paramount for the purpose of promoting runaway advancement and safe patient outcome.
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References
Basson, T., Montoya, A., Neily, J., Harmon, L., & Watts, B. V. (2021). Improving patient safety
culture: a report of a multifaceted intervention. Journal of patient safety, 17(8), e1097e1104.
Leape, L. L. (2021). Enforcing standards: the joint commission. In Making Healthcare Safe: The
Story of the Patient Safety Movement (pp. 185-202). Cham: Springer International
Publishing.
Wilkins, C. H., Williams, M., Kaur, K., & DeBaun, M. R. (2021). Academic medicines journey
toward racial equity must be grounded in history: Recommendations for becoming an
antiracist academic medical center. Academic Medicine, 96(11), 1507-1512.
https://journals.lww.com/academicmedicine/fulltext/2021/11000/Academic_Medicine_s_
Journey_Toward_Racial_Equity.11.aspx
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Vanderbilt University Medical Center; Complications and Death
Quality Improvement Initiative Part 2
2
Introduction
Quality improvement (QI) is an essential step in healthcare that involves a systematic
approach to solving a problem in a healthcare facility. The healthcare system is comprised of
different healthcare providers and technologies that interact to ensure the best healthcare
outcomes for patients (Mohsen et al., 2021). However, with the interactions between care
providers and medical care technologies, errors may occur that lead to complications or even of
death of patients. In this case, the integration of quality improvement approaches can help
identify these errors thus minimizing adverse events associated with these errors. Quality
improvement is an important process at Vanderbilt University Medical Center because it ensures
that complications and death are prevented at all costs. Against this backdrop, this paper will
evaluate three important QI methodologies, relevant stakeholders, and the resources needed to
implement these QI initiatives.
Quality Improvement or Risk Management Tools
Just like any other healthcare facility, Vanderbilt University Medical Center may
experience challenges in the identification of potential risks that may affect the health outcomes
of patients leading to complications and even death. Quality improvement and risk management
tools are used to identify these risks and make appropriate corrective measures to prevent them
from affecting the healthcare outcomes of the patients (Mohsen et al., 2021). The success of
Vanderbilt University Medical Center is dependent on quality improvement which applies tools
such as Pareto Diagram, Driver Diagram, and Six Sigma tools for quality improvement
initiatives. The tools are important in the identification of gaps and areas of improvement that
would contribute to improved quality in the delivery of healthcare services and prevent incidents
and deaths in the healthcare facility.
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A Pareto Diagram is a bar chart diagram where different factors that may affect quality
are organized in order and accordance with their effects. Such arrangement in terms of their
effect on quality helps the quality improvement team identify the most important factors that
require more attention to improve on quality. The principles applied in the Pareto chart are based
on assumptions that the majority of the factors that influence quality outcomes are contributed by
small factors that must be addressed effectively. By highlighting factors with the greatest impact
on quality, the chart ensures that appropriate decisions are made to rectify the gaps identified and
corrective measures are taken for quality improvement (Mohsen et al., 2021). Vanderbilt
University Medical Center would use this diagram to identify areas that are of high risk such as
delays in the emergency department or areas where infections are likely to occur and address
them by developing mitigation strategies to address them leading to improved care delivery.
Six-Sigma is another important quality improvement and risk assessment tool that would
help improve quality and service delivery at Vanderbilt University Medical Center. It helps
identify defects that contribute to errors during patient care. Research indicates that medical
errors are among the leading causes of death in the United States (Ahmad & Anderson, 2021).
Vanderbilt University Medical Center is committed to ensuring that errors are prevented at all
costs, ensuring that patients receive the best care while eliminating errors that may lead to
complications or deaths. Six Sigma tool can be used by the facility to improve quality by
identifying risks that may contribute to falls and injuries, identifying causes of errors in
medication and prescriptions, and reducing waiting time for lab results and other medical care
services that lead to deaths (Rathi et al., 2021). The tool uses statistical and data analysis to
identify and eradicate defects in care delivery, ensuring that patients receive the best care to help
improve their overall healthcare outcomes.
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After identification of the factors that contribute to incidents and deaths, Vanderbilt
University Medical Center may use the Driver Diagram to develop a framework that would
contribute to quality improvement to reduce incidents. The driver diagram as a visual display
highlights the teams’ theory and shared view of how quality would be achieved. It highlights the
initiatives taken by the quality team to achieve quality objectives. The diagram is important in
developing of hypothesis that would be tested to ensure improved care delivery and eliminate
medical errors that lead to deaths in the healthcare facility (Mohsen et al., 2021). For instance,
the diagram would highlight under staffing as a leading contributor to incidents, identify this
contributes to medical errors and propose a corrective measure through hiring more healthcare
providers.
Stakeholders and Resources required
The quality improvement initiative requires the input of healthcare professionals across
the various departments to ensure quality improvement initiatives are achieved. Nursing
professionals are among the leading care providers in direct contact with patients and should be
involved in the implementation of the QI within the healthcare environment (Mohsen et al.,
2021). The physicians and clinical officers in the emergency department are also important
stakeholders in ensuring that quality improvement initiatives are met by eliminating delays
within the emergency department. These stakeholders have a better understanding of the causes
of poor healthcare quality outcomes within the emergency department and are better position to
help implement quality improvement tools within the healthcare environment. It is also
important to involve patients in the quality improvement initiatives as they are the most affected
by the initiatives (Mohsen et al., 2021). Their contributions are important in highlighting areas of
improvement in the healthcare facility.
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Other resources needed
Time is an important resource that determines the success of the implemented initiatives.
The quality improvement team needs to dedicate enough time to make the changes and ensure
the initiatives are implemented on time. Defining the time needed to implement the changes
ensures that the changes proposed are adopted promptly to ensure adequate prevention of
adverse incidences within the healthcare facility. Financial resources are also needed to support
the changes desired to acquire all the materials needed to improve quality and for training
purposes (Mohsen et al., 2021). Therefore, the healthcare facility must work closely work with
the finance department to dedicate appropriate budget for the quality improvement initiatives and
training of staff members on the changes needed and how they impact the overall healthcare
outcomes.
Conclusion
Quality improvement initiatives are important in the delivery of effective care that
prevents incidents and death in healthcare. The proposed tools for the QI initiatives are Six
Sigma, Driver Diagram, and Pareto Diagram which would help identify causes of incidents in
Vanderbilt University Medical Center. The stakeholders required include staff members, nurses,
physicians and patients to ensure effective implementation of the initiatives. Resources needed
are enough time and finances to ensure training and implementation of the quality improvement
initiatives.
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References
Ahmad, F. B., & Anderson, R. N. (2021). The leading causes of death in the US for 2020. JAMA,
325(18). https://doi.org/10.1001/jama.2021.5469
Mohsen, M. M., Gab Allah, A. R., Amer, N. A., Rashed, A. B., & Shokr, E. A. (2021). Team
Strategies and Tools to Enhance Performance and Patient Safety at primary healthcare
units: Effect on patients outcomes. Nursing Forum, 56(4).
https://doi.org/10.1111/nuf.12627
Rathi, R., Vakharia, A., & Shadab, M. (2021). Lean six sigma in the healthcare sector: A
systematic literature review. Materials Today: Proceedings, 50(5).
https://doi.org/10.1016/j.matpr.2021.05.534
