The focus of the Quality Improvement Project.

Sample Answer

Qualitative Review: Survey nurses, patients, and physicians to identify barriers to adherence or positive feedback.

3. Outline of the Action Plan (Phased Approach)

The action plan follows a structured framework to ensure systematic implementation and measurement.

Phase I: Planning and Preparation (The "P" in PDSA)

Form the QI Team: Assemble an interdisciplinary team (nurses, physicians, pharmacy, case management, data analyst).

Define Goal and Scope (AIM Statement): Establish the specific, measurable target (e.g., "Reduce 30-day CHF readmissions from 22% to 15% within 12 months").

Root Cause Analysis: Conduct a deep dive (e.g., Fishbone Diagram) to determine the exact points of failure in the current discharge process (e.g., medication reconciliation gaps, lack of patient comprehension).

Develop Interventions (The Change Idea): Based on the analysis, select high-leverage changes, such as:

Standardizing a Teach-Back Protocol for all discharge instructions.

Mandating a post-discharge PCP/Cardiology appointment before the patient leaves the hospital.

Providing a free digital scale and education on daily weights.

Phase II: Execution and Testing (The "D" in PDSA)

Pilot Small-Scale Tests: Implement the intervention with a small, manageable group (e.g., one floor or one specific physician's patients).

Process Mapping: Map the steps of the new discharge process, noting roles and responsibilities.

Staff Training: Train the pilot unit staff on the new protocol and documentation requirements.

Documentation: Integrate new checklist items or prompts directly into the EHR system to ensure compliance.

Phase III: Measurement and Analysis (The "S" in PDSA)

Data Collection: Collect process data (e.g., daily compliance with the Teach-Back Protocol) and outcome data (30-day readmissions) from the pilot group.

Analysis: Compare the pilot data to the baseline data.

If successful: Proceed to Phase IV.

If unsuccessful: Return to Phase I or II to modify the intervention (e.g., the Teach-Back method was not effective and needs clearer patient materials).

Refine Intervention: Adjust the new process based on lessons learned (e.g., realizing that night shift nurses needed additional training).

Sample Answer

This analysis focuses on a hypothetical but common clinical issue in quality improvement: Reducing 30-Day Hospital Readmissions for Congestive Heart Failure (CHF) Patients.

1. Assessment of the Clinical Issue (CHF Readmissions)

The clinical issue is the persistently high rate of 30-day readmissions for patients diagnosed with Congestive Heart Failure (CHF). This issue represents a significant failure in the transition of care and impacts the healthcare system on multiple levels.

Conclusion: This issue is high-priority due to financial penalties, compromised patient safety, and poor adherence to established evidence-based guidelines for CHF management.

2. Evaluation of the Clinical Project

The project aims to reduce the 30-day CHF readmission rate by improving the discharge process. Evaluation must be conducted using established Quality Improvement metrics to determine success, sustainability, and potential unintended consequences.

Evaluation Metrics Framework

Evaluation Steps

Baseline Data Review: Establish the 12-month average readmission rate before the intervention.

Pilot Data Collection: During the "Do" phase, collect data on process adherence and preliminary readmission rates.

Post-Implementation Data: Collect readmission data for 3-6 months following full implementation.

Statistical Analysis: Use run charts or control charts to determine if the change observed is statistically significant and sustained, or merely random variation.