Data Analysis and Quality Improvement Initiative Proposal Discussion Paper

Data Analysis and Quality Improvement Initiative Proposal Discussion Paper

Data Analysis and Quality Improvement Initiative Proposal Discussion Paper

Data refers to information, particularly facts and numbers, collected to be analyzed and considered and to guide decision-making. Data is utilized to make clinical judgments, solve questions, and track and foster healthcare quality improvement (QI) initiatives (Shah, 2019). QI initiatives purpose to bring a difference in patient care by improving effectiveness, safety, and care experience. They require health providers to apply their understanding of the complex healthcare environment, use a systematic approach, and design, test, and execute changes using real-time measurement for quality improvement. The purpose of this paper is to carry out a data analysis in a healthcare organization and discuss a QI initiative proposal based on a health issue of interest.


Health Care Issue or Area of Concern

Sepsis is the identified healthcare issue at Katherine Shaw Bethea Hospital in Dixon, IL. The hospital is an 80-bed “not-for-profit” facility that provides general and specialized health services. Data on sepsis in the last three years (2019-2021) was analyzed from the hospital’s dashboard metrics. During the period, 10,589 patients above 18 years were admitted to the facility. Sepsis was identified in 230 patients, accounting for a cumulative incidence rate of 7.4% among hospitalized adult patients. In addition, most of the septic cases (56%) were secondary to community-acquired infections. Severe sepsis occurred in 45 patients, which leads to an incidence rate of 45 cases per 100,000 adults annually.

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Furthermore, 17 patients developed septic shock, an incidence rate of 9 cases per 100,000 adults per year. Moreover, most patients met the diagnostic criteria for severe sepsis or septic shock on a day they would have also qualified for the septic status. Besides, some patients had a median time of two days between the sepsis and severe sepsis, while between severe sepsis and septic shock was three days. The facility’s mortality rate due to sepsis was 4.8%; for severe sepsis, it was 5.1%, and for septic shock was 8.7%.

The hospital could measure and use process data to improve its knowledge of the causes of the high sepsis rate in the inpatient units. Process data typically includes information on interventions implemented by healthcare providers to alleviate or prevent incidences of sepsis among hospitalized patients. On the other hand, outcome data includes the outcome of these QI interventions and is used to assess their impact. Vital dashboard metrics that act as process data include The number of patients whose blood cultures drawn before antibiotic administration; The number of patients on antibiotic therapy; The number of patients whose lactate levels were assessed; The number of patients with signs of sepsis administered IV fluids (Shahsavarinia et al., 2020). The process data metrics can enable the facility to identify whether the sepsis rates are contributed by failure to implement crucial measures that prevent sepsis, such as putting patients on antibiotic therapy, reassessing lactate levels, and administering IV fluids.

The hospital can sustain QI processes and outcomes since it has a QI team tasked with ensuring QI initiatives are effectively implemented by the staff in the facility. In addition, the organization’s culture supports innovations in supportive leadership style, effective communication styles, shared values, behaviors, attitudes, and working practices. The hospital’s data on sepsis is reliable since it has been collected and analyzed using scientific methods. Each case of sepsis is reported and recorded in case report forms. In the forms, nurses document the patient’s demographic data, the reason for admission, comorbidities, the origin of primary infection, the date of sepsis diagnosis, and cultures performed with their results.

QI Initiative Proposal

Ineffective screening for sepsis has been attributed to the high sepsis rates at Katherine Shaw Bethea Hospital. Nurses play a major role in recognizing patients with sepsis since they are constantly interacting with patients. However, nurses inadequately screen patients due to inadequate nurse training on screening measures for sepsis and management interventions (Shahsavarinia et al., 2020). Therefore, the proposed QI initiative is nurse training on a nurse-driven sepsis screening tool and management protocol to recognize patients with sepsis and initiate early treatment. Nurses will be trained on the sequential (sepsis-related) organ failure assessment (qSOFA) tool. This is a sepsis screening tool that helps in the early identification of sepsis and is crucial to improving patient care and health outcomes (Guirgis et al., 2018). qSOFA is a bedside score that helps identify patients outside the intensive care unit with suspected infection and who are at higher risk for a poor outcome.

The qSOFA score includes one point for three clinical variables: Respiratory rate ≥ 22 breaths/min, systolic blood pressure (SBP) ≤ 100 mm Hg, or an altered mental status. A patient is considered to have a high chance for sepsis when two of the three clinical criteria are present (Guirgis et al., 2018). The qSOFA is a useful clinical tool, especially for nurses and other providers outside the ICU setting, since the tool relies only on clinical exam findings. It quickly identifies patients with infections with a high likelihood of having poor outcomes (Guirgis et al., 2018). Another advantage is that this simple bedside screening tool is especially applicable in poor-resource settings where diagnostic data is not readily available. Shahsavarinia et al. (2020) found that qSOFA has an acceptable value for the severity of risk stratification, multi-organ failure, and mortality. The study recommended training medical staff and regular screening of patients for warning signs to help increase the qSOFA value in predicting mortality in critically ill septic patients.

The QI initiative proposal will include training nurses on sepsis and using the qSOFA tool to attain the desired patient outcomes. Nurses require to be offered in-service training on the signs and symptoms of sepsis and its impact. Bedside nurses need to exhibit mastery of sepsis before using the qSOFA screening tool on patients (Threatt, 2020). The proposed initiative is to have a two-hour nurse training on sepsis’s pathophysiology, clinical features, and management protocol, which will help them understand the screening parameters. Besides, training is essential to improve nurses’ confidence in using the qSOFA. The training will be conducted when implementing the screening tool, yearly, and when new nurses are hired (Threatt, 2020). This will ensure that all nurses have the required knowledge and skills to identify patients with sepsis and use the qSOFA to promptly identify patients at risk of sepsis in the medical and surgical units.

In addition to the sepsis screening tool, nurses will be trained on the sepsis management protocol to ensure that early treatment interventions are initiated. The prompt treatment interventions aim to prevent sepsis from progressing to severe sepsis, septic shock, and even death (Threatt, 2020). Nurses will be trained on the interventions to take when a patient has a qSOFA score of two or greater using the nurse-driven care bundle-based sepsis protocol. A protocol or care bundle refers to a selected set of patient care interventions designed for implementation when a patient meets the clinical criterion threshold. The care bundle is founded on recommendations from Surviving Sepsis Campaign (Gripp et al., 2021). Nurses will be trained on taking prompt interventions like measuring a patient’s serum lactate, obtaining two blood cultures prior to initiating antibiotics, and initiating antibiotics within three hours.

The QI initiative proposal of a nurse-driven sepsis screening tool and management protocol is expected to lower sepsis rates from 7.4% to below 2.5% within one year. The mortality rate is also expected to reduce to < 2.0 for sepsis, < 3.5% for severe sepsis, and <7% for septic shock within one year. In addition, training nurses is expected to increase their knowledge scores on sepsis, including screening and management interventions. The number of patients who are promptly screened and initiated sepsis treatment interventions is projected to increase from 88% to 98% within a year.

Ensuring nurses have adequate education on sepsis critical for instituting highly functional sepsis screening and management protocols. Therefore, educating all nurses about sepsis management and translating clinical guidelines into practice will improve their capacity to identify sepsis and initiate early treatment measures (Threatt, 2020). However, it is unknown whether training can increase compliance with sepsis performance measures and reduce mortality rates in patients with severe sepsis and septic shock in ICU and medical-surgical settings. Thus, further research is needed to establish the most effective approach to achieve compliance with sepsis screening and treatment protocols by healthcare providers.

Interdisciplinary Team Input to Improve Patient Safety and Quality Outcomes and Work-Life Quality

Interdisciplinary team input will be crucial in implementing the QI initiative on a nurse-driven sepsis screening tool and management protocol. The interdisciplinary team will comprise the chief nursing officer (CNO), hospital administrator, nurse educator, data coordinator, and bedside nurses. The CNO is tasked with developing policies and advising on the best nursing practices that benefit nurses and improve clinical care. Thus, the CNO’s role will include advising the team on the best practices to implement the QI initiative to attain the desired results. Besides, the CNO will ensure the initiative is sustained and conduct performance assessments regarding implementing the protocol. The hospital administrator will ensure adequate resources to facilitate the QI initiative, including the nurse training. Moreover, the administrator will keep the team focused on implementing the initiative to improve patient outcomes.

The nurse educator will facilitate the nurses’ training and evaluate outcomes to ensure that the expected outcomes are attained. In addition, the educator will be involved in developing the education plan and identifying evidence-based recommendations that should be included in the training. Furthermore, the role of the data coordinator will be to collect and interpret data on the implementation of the nurse-driven sepsis screening tool and management protocol in the hospital. The data coordinator will also ensure that patients’ data on sepsis is correctly collected by healthcare providers, which will help monitor the impact of the QI initiative in reducing the incidence of sepsis and related mortalities. Lastly, the bedside nurses will be key members since they will be involved in implementing the screening tool and management protocol in the hospital and must attend the training.

Quality improvement interdisciplinary teams are key strategies to start and execute improvement efforts within healthcare organizations. Much of the QI initiative’s success relies on the team’s ability to identify a problem, develop a solution, lead change, and execute a sustainable QI plan (Erjavec et al., 2022). The proposed QI initiative will depend on the interdisciplinary team’s ability to lead change and implement a plan to sustain the initiative. However, this is based on the assumption that the team will have effective communication, coordination, collaboration, conflict management, and leadership (Erjavec et al., 2022). These are critical factors in ensuring that the interprofessional team is fully engaged in the QI initiative. There is also an assumption that the team members will have a common vision, which is key in steering the team to achieving the overall goal.

Evidence-Based Communication Strategies to Promote Quality Improvement of Interprofessional Care

It is essential for healthcare professionals to engage actively and competently in interprofessional healthcare teams to utilize their specialized knowledge and skills to solve complex healthcare challenges. However, members of the interprofessional team must be aware of the communication requirements for working effectively in QI teams. Erjavec et al. (2022) explain that evidence-based communication strategies should be developed within interprofessional care teams to promote cooperation between members, share pertinent information, and foster coordination in making pertinent QI decisions. Adopting an all-direction communication approach (downward, upward, horizontally, and diagonally) will be an effective communication strategy. It encourages the dissemination of information from lower-level employees to upper management and vice-versa (Renfro et al., 2018). It also encourages peer-to-peer communication, which will allow members to request support and coordinate activities.

Another communication strategy will be electronic messaging through the hospital’s electronic health record (EHR). The EHR provides read-only access and secure messaging features, which will be ideal for the interprofessional team. They can send and receive secure messages among themselves regarding the QI initiative (Renfro et al., 2018). Communication models like the SBAR (situation, background, assessment, and recommendation) will be incorporated to foster communication among the interprofessional team members. Shahid and Thomas (2018) describe SBAR as a reliable and validated communication tool, which reduces adverse events, improved communication among health care providers, and enhances patient safety. SBAR creates a shared mental model around a patient’s condition and is used to transfer patient care in various care settings. Thus, it can be used to communicate care to patients at risk of sepsis and in handing off.

Adverse Event/Near-Miss Data to Be Factored In the Outcomes and Recommendations

The QI initiative’s outcomes and recommendations must account for data on adverse or near-miss events. Inadequate assessment of patients’ mental status, respiratory rate, and systolic blood pressure can result in failure to identify patients with sepsis. Adverse events like antibiotic allergy in the management protocol must also be factored in the QI recommendations. Besides, defective equipment like BP machines can lead to failure to identify a septic patient or unnecessary tests in low-risk patients. Medication errors such as wrong patient or wrong drug will also be factored into the outcomes. The adverse or near-miss events will be determined by documenting the incidences in a case report form.


Dashboard metrics from the Katherine Shaw Bethea Hospital show that sepsis is a major health safety concern with an incidence rate of 7.4% and a mortality rate of 4.8%. The proposed QI initiative is a nurse-driven sepsis screening tool and management protocol to recognize patients with sepsis and initiate early treatment. Nurses will be trained on using the qSOFA screening tool and a sepsis management protocol. The interprofessional team members will employ communication strategies to offer essential input on QI initiatives, address patient safety concerns, and improve health outcomes.


Erjavec, K., Knavs, N., & Bedenčič, K. (2022). Communication in interprofessional health care teams from the perspective of patients and staff. Journal of Health Sciences, 12(1), 29-37.

Gripp, L., Raffoul, M., & Milner, K. A. (2021). Implementation of the Surviving Sepsis Campaign one-hour bundle in a short stay unit: A quality improvement project. Intensive and Critical Care Nursing, 63, 103004.

Guirgis, F., Black, L. P., & DeVos, E. L. (2018). Updates and controversies in the early management of sepsis and septic shock. Emergency medicine practice, 20(10), 1-28.

Renfro, C. P., Ferreri, S., Barber, T. G., & Foley, S. (2018). Development of a Communication Strategy to Increase Interprofessional Collaboration in the Outpatient Setting. Pharmacy (Basel, Switzerland), 6(1), 4.

Shah, A. (2019). Essentials: Using data for improvement. The BMJ, 364.

Shahid, S., & Thomas, S. (2018). Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care–a narrative review. Safety in Health, 4(1), 1-9.

Shahsavarinia, K., Moharramzadeh, P., Arvanagi, R. J., & Mahmoodpoor, A. (2020). qSOFA score for prediction of sepsis outcome in emergency department. Pakistan journal of medical sciences, 36(4), 668–672.

Threatt, D. L. (2020). Improving sepsis bundle implementation times: A nursing process improvement approach. Journal of Nursing Care Quality, 35(2), 135-139.


Prepare an 8-10 page data analysis and quality improvement initiative proposal based on a health issue of interest. Include internal and external benchmark data, evidence-based recommendations to improve health care quality and safety, and communication strategies to gain buy-in from all interprofessional team members responsible for implementing the initiative.

Health care providers are perpetually striving to improve care quality and patient safety. To accomplish enhanced care, outcomes need to be measured. Next, data measures must be validated. Measurement and validation of information support performance improvement. Health care providers must focus attention on evidence-based best practices to improve patient outcomes.

Health informatics, along with new and improved technologies and procedures, are at the core of all quality improvement initiatives. Data analysis begins with provider documentation, researched process improvement models, and recognized quality benchmarks. All of these items work together to improve patient outcomes. Professional nurses must be able to interpret and communicate dashboard information that displays critical care metrics and outcomes along with data collected from the care delivery process.

For this assessment, use your current role or assume a role you hope to have. You will develop a quality improvement (QI) initiative proposal based on a health issue of professional interest. To create this proposal, analyze a health care facility’s dashboard metrics and external benchmark data. Include evidence-based recommendations to improve health care quality and safety relating to your selected issue. Successful QI initiatives depend on the support of nursing staff and other members of the interprofessional team. As a result, a key aspect of your proposal will be the communication strategies you plan to use to get buy-in from these team members.

To develop the QI initiative proposal required for this assessment, you must analyze a health care facility’s dashboard metrics. Choose Option 1 or 2 according to your ability to access dashboard metrics for a QI initiative proposal.

Option 1
If you have access to dashboard metrics related to a QI initiative proposal of interest to you, complete the following:

Analyze data from the health care facility to identify a health care issue or area of concern. You will need access to reports and data related to care quality and patient safety. For example, in a hospital setting, you would contact the quality management department to obtain the needed data. It is your responsibility to determine the appropriate resource to provide the necessary data in your chosen health care setting. If you need help determining how to obtain the needed information, consult your faculty member for guidance.
Include in your proposal basic information about the health care setting, size, and specific type of care delivery related to the identified topic. Please abide by Health Insurance Portability and Accountability Act (HIPAA) compliance standards.
Option 2
If you do not have access to a dashboard or metrics related to a QI initiative proposal:

Use the hospital data set provided in Vila Health: Data Analysis. You will analyze data to identify a health care issue or area of concern.
Include in your proposal basic information about the health care setting, size, and specific type of care delivery related to the identified topic.
Use your current role or assume a role you would like to have. Choose a quality improvement initiative of professional interest to you. Your current organization is probably working on quality improvement initiatives that can be evaluated, so consider starting there.

To develop your proposal you will:

Gather internal and external benchmark data on the subject of your quality improvement initiative proposal.
Analyze data you have collected.
Make evidence-based recommendations about how to improve health care quality and safety relating to your chosen issue.
Remember, your initiative’s success depends on the interprofessional team’s commitment to the QI initiative. Think carefully about these stakeholders and how you plan to include them in the process, as they will help you develop and implement ideas and sustain outcomes. Also, remember how important external stakeholders, such as patients and other health care delivery organizations, are to the process. As you are preparing this assessment, consider carefully the communication strategies you will employ to include the perspectives of all internal and external stakeholders in your proposal.

The following numbered points correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your proposal addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels related to each grading criterion.

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.
Communicate QI initiative proposal in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.
Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.
Example Assessment: Refer to QI Initiative Proposal Exemplar [PDF] for an idea of what an assessment given a proficient or higher rating on the scoring guide would look like.

Additional Requirements
Submission length: 8-10 typed, double-spaced pages of content plus title and reference pages.
Font: Times New Roman, 12 point.
Number of references: Cite a minimum of five current scholarly and/or authoritative sources to support your QI initiative proposal. Current means no older than 5 years unless a seminal work.
APA formatting: Citations and references need to adhere to APA style and formatting guidelines. Consult these resources for an APA refresher:
Evidence and APA.
APA Module.
American Psychological Association. (n.d.). APA style.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 1: Plan quality improvement initiatives in response to adverse events and near-miss analyses.
Determine whether any adverse event or near-miss data must be factored in to outcomes and recommendations.
Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
Develop a QI initiative proposal based on a selected health issue and supporting data analysis.
Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
Analyze data to identify a health care issue or area of concern.
Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work life quality.
Communicate QI initiative proposal, based on interdisciplinary team input, to improve patient safety and quality outcomes and work-life quality.
Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
Integrate relevant sources to support arguments, correctly formatting citations and references using APA style.
Determine evidence-based communication strategies to promote quality improvement of interprofessional care.
Communicate QI initiative proposal in a professional, effective manner, writing clearly and logically, with correct use of grammar, punctuation, and spelling.


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