Quality Improvement: Intrapartum Maternal and Neonatal Mortality Essay
Quality Improvement: Intrapartum Maternal and Neonatal Mortality Essay
Problems in the clinical environment cause significant patient safety and quality challenges. Understanding these issues and addressing them is critical for maintaining a culture of excellence in quality and patient safety. Obstetrics is one of the departments in the health facility that handles a large number of patients. The function of obstetrics is to provide maternal care to women during pregnancy, labor and delivery, and postnatal. A survey of the obstetrics activities reveals there have been recent cases of maternal and stillbirths, or neonatal deaths immediately after delivery that could have been prevented with a more efficient system and highly skilled and supportive obstetrics staff. My trigger to pursue this problem is the concern over high cases of preventable deaths that affect both mothers and infants. I am interested in this as part of global advocacy to eliminate preventable maternal and neonatal deaths, which mostly occur during the labor and delivery window. The purpose of this paper is to present a quality improvement project related to the problem of intrapartum maternal and neonatal deaths.
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The organization is an acute care facility that handles a wide range of healthcare services. The organization serves the surrounding community, which predominantly consists of low socioeconomic populations. The organization is committed to ensuring quality improvement in all its departments. Moreover, the organization encourages staff autonomy, which creates room for creativity and innovation through the spirit of inquiry. The following are the mission and vision of the organization:
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Mission: To provide safe and quality services and be fully responsible for the psychological, physical, social, and spiritual well-being of the community and other populations that we serve.
Vision: To build transformative and innovative healthcare that fosters a culture of quality excellence, safety, and patient-centred care.
The mission and vision all focus on service excellence and commitment to improving the quality and safety of patients. Thus, the QI project aligns with the mission and vision because of the aim to improve the quality of services provided in the obstetric department. This is part of a wider strategic objective to address safety and quality issues at the facility. This QI project will move the organization closer to meeting its mission and vision of transforming healthcare services to ensure quality outcomes and promote the health and well-being of the patients and the entire community served by the hospital.
The quality improvement project seeks to explore the problem of high rates of intrapartum maternal and neonatal mortality. The problem points to possible issues in the obstetrics process that create the risks of complications. The common complications that occur during the intrapartum process include amniotic fluid embolism, haemorrhage, high blood pressure, and intraamniotic infection (Koutra et al., 2018). Most of the complications during intrapartum are preventable through quality care and early detection. Evidence suggests that proper care, which starts from antenatal contact is likely to lessen the risk of complications during pregnancy and the intrapartum period. Effective antenatal care can enable early identification of complications, leading to proper management to eliminate the possibility of complications during labor (Khanam et al., 2018). Likewise, effective emergency obstetric care also contributes to the reduction in complications during labor, subsequently reducing the risks of preventable maternal and neonatal deaths. On the other hand, inadequate antenatal care and response to obstetric procedures cause complications that can lead to the death of a mother, unborn child, or neonate. This has an immense negative impact on the safety and quality of obstetrics services and the hospital at large.
Out of the 13.9 per 1000 births global stillbirth rates, 42·3% are due to intrapartum issues, which are preventable by timely, quality, and responsive obstetrics care (Hug et al., 2021). Further statistics reveal that 300,000 mothers die annually during delivery from preventable causes (Hug et al., 2021). Similarly, a study of deliveries between 2015 and 2020 reported a maternal mortality ratio of 129.34 per 100,000 live births (Sitaula et al., 2021). These mortalities occurred from hemorrhage, sepsis, and hypertensive disorder. Another study showed that out of the 4,476 women investigated, there were 136 stillbirths (Wrammert & Ewald, 2018). Another analysis of obstetric cases between 2012–February 2014 reveals 184 occurrences of near-miss events and 60% of maternal death near-miss events (Rodgers et al., 2018). The near-miss events were caused by hemorrhage at 54.89%, hypertension at 24.45%, and anemia at 13.59% (Rodgers et al., 2018). The common risk factors for stillbirth according to Wrammert and Ewald (2018) are obstetric complications during labor, inadequate antenatal care, hemorrhage, preterm birth, and inadequate monitoring of heart rate. According to Alyahya et al. (2019), proper antenatal care is crucial for the health of the mother and baby throughout the obstetric period including preventing intrapartum complications.
Proper and adequate care extends from antenatal care to care during labor because the effectiveness of the care provided determines the safety of the mother and the child during labor and immediately after delivery. Certain care activities carried out by the obstetrics staff may increase the risk of complications, for example, continuous electro-fetal monitoring, bed rest and restriction of free movement, frequent vaginal checks, limiting oral intake during labor, amniotomy, regional anesthesia, induction, enema, and ineffective pushing (Akyıldız et al., 2021). Another important factor that contributes to the risk of complications is the limited knowledge and expertise of the obstetrics team. Tenaw et al. (2018) note that skilled and knowledgeable obstetrics practitioners who are skilled in the third stage of labor perform proper management of labor and care, reducing the risk of complications.
Intrapartum care is not the only healthcare service affected by complications during labor and delivery, but also postnatal care. According to Wrammert and Ewald (2018) complications encountered during labor increase the risk of having perinatal hypoxia, hemorrhage, and generally, poor postpartum health outcomes for the mother and baby. For example, a study shows that complications during the perinatal period significantly influence postpartum depression in new mothers (Koutra et al., 2018). According to the results, pregnant women who had gestational diabetes and preeclampsia were more likely to have postpartum depression (Koutra et al., 2018). Similarly, hospitalization during pregnancy and unplanned pregnancy were also associated with the odds of postpartum depression. Evidence by Li et al. (2020) reveals similar outcomes that clinical issues during the prenatal and intrapartum period such as complications are more likely to have a psychological impact causing postpartum depression.
Given the evidence on factors that increase the risks of complications during labor and delivery, it is essential that procedures and obstetrics practices are effectively executed to reduce the risk of complications that threaten the life of the mother and baby. According to the World Health Organization (WHO), all healthcare facilities must follow proper guidelines to provide a positive birth experience for mothers. Similarly, the American College of Obstetricians and Gynecologists emphasize the importance of low-intervention approaches during labor period, especially for low-risk women. According to ACOG (2019), using techniques that require minimal interventions during labor has been shown to contribute to high patient satisfaction. As such, gynaecologists and obstetrics teams that support women during labor should avoid practices such as routine amniotomy and continuous electro-fetal monitoring unless there is a concern for a fetal compromise that requires monitoring (ACOG, 2019). Furthermore, instead of high intervention techniques during labor, ACOG (2019) suggests providing a one-to-one emotional, for example, by a doula. Moreover, the staff can provide both non-pharmacological and pharmacological support to cope with labor pain, but avoid restricting movement or position, as well as continuous intravenous fluids infusion. Finally, the obstetrics team should consider family-centric interventions by including the family in the birthing process regardless of the mode of birth (ACOG, 2019).
Medical technologies in maternity interventions have become part of routine care for women during labor in hospitals including in my organization. These have been shown to significantly improve care and reduce maternal and infant mortality due ability to monitor the fetus in high-risk women and perform life-saving procedures. However, routine use without a valid reason to require the user can quickly transform a positive birth experience from a physiological to a medical emergency requiring surgical intervention. Thus, every intervention during labor presents the possibility of an unexpected turn in events that could endanger both the mother and baby.
Observation and survey of the obstetrics practices during labor indicates that the team provides routine interventions including using technologies such as electro-fetal monitoring without validating the decision for such interventions such as when there is a fetal compromise. This approach as evidence suggests, may be putting low-risk women in danger of complications rather than helping them, thereby increasing the risk of maternal or fetal/neonatal deaths (ACOG, 2019). These practices compromise the principles of patient-centred care and patient autonomy, which are meant to support women to have informed choices in their birth process and promote the natural childbirth process as long as there is no risk of complications. Hence, it is necessary to evaluate the process including the policies and procedures that are guiding the decision-making, conduct, and actions of the obstetric team. Since effective obstetric practices start from the initial contact during prenatal care, antenatal procedures and policies also require scrutiny to identify loopholes that might be exposing pregnant women to the risk of complications.
The intrapartum process initiates when a low-risk pregnant woman due for delivery is cleared for admission after taking the vitals and checking the stage of labor for the nonelective CS. After admission is processed, the next step is to identify whether the woman is in for a vaginal birth or elective CS, for elective CS. For elective CS, the pregnant is prepared for the procedure including skin preparation, monitoring vitals, especially high blood pressure, restriction of food intake, blood and urine tests, administering antiacid, and starting an intravenous line (Akyıldız et al., 2021). A woman who is admitted for vaginal birth is put in bed to rest while frequently monitoring the fetus, checking the mother for dilation, and taking vitals. There is no guideline or procedure in place on how often these should be done. The women are advised to lie on the left side and movement is restricted within the ward. Family members are, however, allowed to provide emotional and moral support.
As the monitoring steps continue, if the obstetrician in charge believes that the patient’s labor may be taking too long to progress, they are put on intravenous fluid and an amniotomy performed. Further, if these fail to produce the desired effect, induction with medication would be considered with the authorization of the gynecologists/obstetrician in charge. Once a woman has fully dilated, they are taken to the delivery room and prepared for the delivery process. The outcome can either be a successful delivery or a complication requiring emergency CS surgery. Most new onset complications occur just before delivery or during delivery. If a woman develops complications, they may have a successful vaginal delivery or stillbirth, or go for surgery which will replicate the possible outcomes. Hence, the possible outcomes regardless of the delivery method are live birth, stillbirth, death of the mother, and neonatal death immediately after birth. Variations are found in the lack of policies or guidelines on how obstetric procedures should be performed.
Root Cause Analysis
The root cause analysis uses the 5Whys. The root cause analysis enables analysis of the systemic issues leading to the root cause of the problem. Without the root cause analysis, the presenting or surface problem may just be a symptom of a larger systemic issue. The 5Whys was a tool developed by The Joint Commission (TJC) to help organizations identify the root cause of problems in their clinical environment. The tool involves asking “why” five times to determine where the problem originates rather than the symptom. In the QI project, the event that occurred is that a patient had a stillbirth and later died after developing complications during the intrapartum procedures. The pattern related to this shows that there have been such cases in the past months involving maternal death, stillbirth or both.
The 5Whys starts with identifying the immediate factor responsible for the cause, which was a complication related to amniotic fluid embolism. The second way shows that the fatal event could have been averted with earlier identification of the underlying complication, but this was not the case. The third why solve why the staff did not identify the issue and not that inadequate staff knowledge and training contributed to this outcome. The fourth why reveals that there are no clear guidelines on the procedures required during labor monitoring and delivery and how to handle unexpected events. The fifth why show that there are no strict/updated policies on routine staff training, obstetrics procedures, and other related issues to support carrying out the procedures and ensuring the safety of patients.
The current measurements show that the rate of intrapartum maternal mortality is 30% and neonatal deaths and stillbirths are 27%. The data sets that would be investigated are maternal mortality and infant mortality during and immediately after labor and delivery. The data would be obtained every three from the obstetrics department. The risk officer would be in charge of obtaining the data. Other performances and quality metrics that would be investigated include the rate of intra-amniotic infection, the number of emergency caesarean sections (CS) performed in a month, emergency transfer to labor theatre, obstetrics admission wait time, quality of antenatal care, and patient satisfaction rate. The data would be obtained from incident reports or near-miss reports, electronic health records, a survey of patients and obstetrics team, and admission information.
The gap analysis shows that currently, the obstetrics team conduct frequent electro-fetal monitoring during the labor period. However, best practice indicates that electro-fetal monitoring should be minimal and only conducted when the woman is high-risk or has complications causing fetal compromise (ACOG, 2021). For low-risk women, frequent monitoring is unnecessary and may instead put the mother and baby in danger instead of improving health outcomes. The desired state is an obstetric department that records lower emergency CS, less vacuum extraction, and low rates of infections during the intrapartum period. The second issue practised currently frequent vaginal checks. Like electro-fetal monitoring, these too should be minimized according to best practice evidence as they increase the risk of complications.
Similarly, evaluation of antenatal care procedures reveals inadequate follow-up of the pregnant women throughout the pregnancy period to provide psychosocial support and ensure adherence to clinic appointments. Best practice requires that women start antenatal care as soon as pregnancy is confirmed and be supported to remain consistent with appointments (Yeo et al., 2018). The desired state is for patients to receive high-quality and responsive obstetric care from the initial contact during antennal care through to post-natal. The last issue in gap analysis is inadequate staff training to enhance their expertise and knowledge on handling obstetric procedures properly. According to the WHO, best practice in obstetrics care involves frequent highly trained staff, with high competence in obstetrics care (WHO, 2018). The desired state is for patients to have a positive birth experience and satisfaction with obstetrics care.
The following are the QI project aims:
- Decrease the percentage of intrapartum maternal mortality of obstetrics patients from 30% to below 10% in the next year.
- Decrease the percentage of intrapartum stillbirths of neonates from 27% to less than 7% in the next year.
The key activities that will help in achieving the aims of the project include the use of non-invasive/external methods for fetal monitoring (Liang et al., 2022), availability of adequate equipment and technology for assessing vitals, implementing infection control and prevention guidelines, and conducting effective screening for infections (Blix et al., 2019). Other activities will be the training of staff to become more responsive to patient’s needs, creating a policy and guideline for continuity of care from antenatal, intrapartum to postpartum, and educating pregnant women properly on pregnancy complications and self-care (Ota et al., 2020)
Quality improvement frameworks are roadmaps for a quality improvement project that support effective and efficient implementation. The proposed framework for the QI project is the Plan-Do-Act-Cycle (PDCA). The PDCA cycle provides a constant evaluation and improvement of a project through the identification of challenges and barriers to meeting the project goals. Subsequently, solutions are introduced to address the observed challenges (Chen, 2020). The first stage is planning, which entails planning for changes in the obstetrics department to make the services patient-centred and highly responsive to the needs of the patients who come for labor and delivery. The second phase in PDCA is “Do” denoting activities for implementation or project execution (Pan et al., 2022). The implementation activities for the QI project correspond to the training of obstetric employees, the introduction of guidelines and protocols for obstetrics procedures during intrapartum, education of pregnant mothers during prenatal visits, and equipment update.
The third phase is “Check”, meaning the evaluation of the implemented project to determine how well it is running and whether the objectives are being met. At this stage, the project leader/manager will identify challenges, problems, and risks arising from the implementation of the QI project (Knudsen et al., 2019). The final phase of the cycle is “Act”, which means introducing measures to solve the identified issues in the previous phase. The step ensures that the project continuously runs smoothly by applying solutions to mitigate the risks and challenges that emerge in the course of implementation to keep the project on the course (Qiu & Du, 2021). Furthermore, this last phase of the cycle can act as a standardization step when the goals of the projects are being achieved.
The QI project has been an opportunity to demonstrate key skills and knowledge in QSEN competencies. I have demonstrated improvement and a higher ability not only to understand but also to integrate these competencies in a real practice scenario. For example, my competence in patient-centred care has improved compared to the knowledge and attitude I had in week 1 regarding this QSEN competence. Through this QI exercise, I have gained better knowledge and skills in advocation for patients to promote patient values and choice in services provided. For instance, one sub-objective of the QI is to ensure that patients have a choice of natural birth by ensuring that the obstetrics procedures do not compromise their plans for a natural birthing process. Other competencies that I have improved on include teamwork and collaboration, and evidence-based practice.
I will integrate the competence of evidence-based practice through the skills I have gained in researching and selecting the best evidence. Moreover, as I improve my skills and knowledge in this area, I will appraise sources to determine their quality of evidence and relevance to my QI project. The ability to appraise evidence is critical because not all credible sources are reliable and have the best evidence to support an intervention. Similarly, I will integrate teamwork and collaboration by working with an interdisciplinary team. Interdisciplinary/interprofessional engagement fosters collaboration because of the need to share information and coordinate activities for efficiency and effectiveness. Additionally, teamwork requires setting a goal together that serves the best interests of the patients. Hence, the assessment is an opportunity to work together with the team to set mutual goals and coordinate activities that support excellence in quality and patient safety.
ACOG. (2019). Approaches to Limit Intervention During Labor and Birth. ACOG Committee Opinion, 76. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth.
ACOG. (2021). Approaches to Limit Intervention During Labor and Birth. Committee on Obstetric Practice, 766. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth.
Akyıldız, D., Çoban, A., Gör Uslu, F., & Taşpınar, A. (2021). Effects of Obstetric Interventions During Labor on Birth Process and Newborn Health. Florence Nightingale Journal of Nursing, 29(1):9-21. https://doi.10.5152/FNJN.2021.19093. PMID: 34263219.
Alyahya, M., Khader, Y., & Batieha, A. (2019). The quality of maternal-fetal and newborn care services in Jordan: a qualitative focus group study. BMC Health Service Research, 19, 425. https://doi.org/10.1186/s12913-019-4232-9.
Blix, E., Maude, R., Hals, E., Kisa, S., Karlsen, E., Nohr, EA., de Jonge, A., Lindgren, H., Downe, S., Reinar, LM., Foureur, M., Pay, ASD., Kaasen, A. (2019). Intermittent auscultation fetal monitoring during labour: A systematic scoping review to identify methods, effects, and accuracy. PLoS One,14(7):e0219573. https://doi.10.1371/journal.pone.0219573.
Chen, Y. (2020). Using the Model for Improvement and Plan-Do-Study-Act to effect SMART change and advance quality. Cancer Cytology, 9-14. https://doi.org/10.1002/cncy.22319.
Hug, L., You, D., & Alkema, L. (2021). Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. The Lancet, https://doi.org/10.1016/S0140-6736(21)01112-0.
Khanam, R., Baqui, A., Syed, M., Harrison, M., Begum, N., Quaiyum, A., . . . Ahmed, S. (2018). Projahnmo Study Group in Bangladesh. Can facility delivery reduce the risk of intrapartum complications-related perinatal mortality? Findings from a cohort study. Journal of Global Health, 8(1):010408. https://doi.10.7189/jogh.08.010408.
Knudsen, S.V., Laursen, H.V.B., Johnsen, S.P. (2019). Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Service Research, 19, 683. https://doi.org/10.1186/s12913-019-4482-6
Koutra, K., Vassilaki, M., Georgiou, V., Koutis, A., Bitsios, P., Kogevinas, M., & Chatzi, L. (2018). Pregnancy, perinatal and postpartum complications as determinants of postpartum depression: the Rhea mother-child cohort in Crete, Greece. Epidemiol Psychiatric Science, 27(3), 244-255. https://doi.10.1017/S2045796016001062. .
Li, Q., Yang, S., & Xie, M. (2020). Impact of some social and clinical factors on the development of postpartum depression in Chinese women. BMC Pregnancy Childbirth, 20, 226. https://doi.org/10.1186/s12884-020-02906-y.
Liang, Y., Li, Y., Huang, C., Li, X., Cai, Q., Peng, J., Fan, S. (2022). Safety of Internal Electronic Fetal Heart Rate Monitoring During Labor. Maternal-Fetal Medicine, 4(2), 121-126. https://doi.10.1097/FM9.0000000000000145
Ota, E., da Silva Lopes K, Middleton P, Flenady V, Wariki WM, Rahman MO, Tobe-Gai R, Mori R. (2020). Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews. Cochrane Database Systematic Reviews. 12(12):CD009599. https://doi.10.1002/14651858.CD009599.pub2.
Pan, N, Luo, YY, Duan, QX. (2022). The Influence of PDCA Cycle Management Mode on the Enthusiasm, Efficiency, and Teamwork Ability of Nurses. Biomedical Research International. 2022:9352735. https://doi.10.1155/2022/9352735.
Qiu, H., & Du, W. (2021). Evaluation of the Effect of PDCA in Hospital Health Management. Journal of Health Engineering, 6778045. https://doi: 10.1155/2021/6778045.
Rodgers, R., DeVries, B., Nassar, N., Beik, N., & Brito, I. (2018). Labour and Obstetric Complications (EP8). International Journal of Obstetrics and Gyneacology, 123(S2), 145-169. https://doi.org/10.1111/1471-0528.14106.
Sitaula, S., Basnet, T., & Agrawal, A. (2021). Prevalence and risk factors for maternal mortality at a tertiary care centre in Eastern Nepal- retrospective cross sectional study. BMC Pregnancy Childbirth , 21, 471. https://doi.org/10.1186/s12884-021-039.
Tenaw, Z., Yohannes, Z., & Amano, A. (2018). Obstetric care providers’ knowledge, practice and associated factors towards active management of third stage of labor in Sidama Zone, South Ethiopia. BMC Pregnancy Childbirth , 17, 292. https://doi.org/10.1186/s12.
WHO. (2018). WHO recommendations Intrapartum care for a positive childbirth experience. World Health Organization.
Wrammert, J., & Ewald, U. (2018). Incidence of intrapartum stillbirth and associated risk factors in tertiary care setting of Nepal: a case-control study. Reproductive Health, 13, 103. https://doi.org/10.1186/s12978-016-0226-9.
Yeoh, P. L., Hornetz, K., & Shauki, N. (2018). Evaluating the quality of antenatal care and pregnancy outcomes using content and utilization assessment. International Journal for Quality in Health Care, 30(6),466–471, https://doi.org/10.1093/
Figure 1: Flow Chart
Figure 2: Root cause analysis
Figure 3: Key Drivers
The QI Project Proposal is the mechanism by which you make the case to the organizational stakeholders for your teamâ€™s project. As the leader of your QI project team, you must convey to organizational stakeholders why this project is important and that it is feasible and sustainable.
Complete the following components of your QI Project Proposal using APA (7th edition) student paper format. Review the QI Project Proposal Rubric carefully and consider how to incorporate each required criterion into the proposal. Suggested page lengths for each component are provided below. Write succinctly and with precision; see Chapter 4, pages 113â€“115 of your APA Manual.
Introduction (1 paragraph)
General introduction to the problem. Why did you select this area of interest or what was the trigger to select this practice issue/problem?
Organizational Setting (1/2 â€“ 1 page)
Describe the characteristics of the organization in which the problem occurs. Describe in detail how the QI project fits into the organizational strategic plan, mission, and vision. In other words, how does it align; convince the organizational stakeholders that the QI project is going to move the organization toward their own strategic goals.
Problem Statement (1 paragraph)
Concise statement that clearly articulates the breadth and depth of the problem, why it is a concern, and why it should be evaluated. Justify the need for embarking on this project.
Evidence to Support (2 pages)
Provide a background and significance to give context to the project. Describe the relevance, prevalence, and scope of the problem. Describe the problem including population affected, what is currently happening, and why the stakeholders should care. Include what impacts or influences the problem. Support your findings with a minimum of five recent (published within the past five years) scholarly articles.
Current State (1â€“2 pages)
Summarize the expressed need to evaluate this problem for key stakeholders.
Describe the current process and the sequence of steps/actions/tasks related to the problem. Identify any points of variation.
Provide a copy of your workflow map in the appendix.
Root Cause Analysis (1 page)
Describe the method used and the key findings.
Provide a copy of your completed graphic in the appendix.
Measurement Plan (1/2 page)
Include baseline data that you have and data sets you plan to obtain to further evaluate the problem, including how the data will be obtained, when (what period of time), where (which unit/dept.), and who will be responsible for obtaining.
Gap Analysis (1/2 â€“ 1 page)
Identify the top two priority gaps of the problem (current state). Describe the best practice with supporting evidence and what the desired outcome would be for improvement.
Project Aims(s) in SMART format (1/2 page)
Identify specific project objectives that are explicitly related to the project aim(s). Objectives are measurable actions which support project aims and are written in SMART format: specific, measurable, attainable, relevant, and timely.
Include a copy of your key driver diagram in the appendix.
QI Methodology (1 page)
Identify and describe the model to be used to guide your QI project. Include rationale or justification for the selection of the model. Broadly apply your QI project to the components of the model.
Conclusion (1/2 â€“ 1 page)
Review and reflect upon your QSEN competency assessment from Week 1 and the Graduate QSEN Competencies.
Has your perspective of your skill level changed from Week 1?
Provide examples of how you plan to integrate each competency selected in your assessment to your QI project.
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You may submit your assignment to Turnitin before its due date to assess your work against Turnitinâ€™s database. You may use the Originality Reportâ€™s results to address any originality concerns in your work, and then resubmit your assignment for grading. You may only submit and resubmit until the assignmentâ€™s due date. Any work that has been submitted at the time the assignment is due will be considered your final submission, and this will be the submission used for grading.
For additional information, visit Turnitin and GradeMark: Students.
Submit your assignment [and review full grading criteria] on the Assignment 15.1: QI Project Proposal page.
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