Proposal Format – Important! You only complete Part A during this course

Part A: PLAN (NURS 711)

A. Clearly explain the quality improvement project – what exactly are you planning to do?

The project plan is going to be centered on outpatient outcomes. The centers for Medicaid Services (CMS) came to our hospital in

December as a result of an outpatient complaint. The CMS surveyors noted that there are no outpatient outcomes being tracked at the

hospital. One of the joint commission’s objectives is to evaluate how leaders of organization oversee the collection in use of data to

evaluate the safety and quality of care being provided to patients. This process helps the organization to understand performance

improvement process and improve patient satisfaction. At this time, it is unknown if the Munson owned outpatient departments are

collecting outcomes and not reporting them, or, not participating in outcome data collection at all.

I was able to meet with my preceptor Anne as well another nurse in the Quality and Safety department, Candy, who serves as the

Compliance Coordinator of Munson Medical Center (MMC) for the joint commission visits. In our meeting we discussed ways to

assess if outcomes are being done and how are they being collected. I proposed the development of a survey to assess each outpatient

clinic. Collecting data from each off site will allow us to determine what outpatient clinics need to be targeted toward implementing

outcome data collection. I presented at the CMS/TJC (Centers for Medicare/The Joint Commission) Safety Ambulatory meeting to

propose my idea to the managers of the outpatient departments at our hospital. The purpose of my presentation was to inform the

group members of the findings from the CMS visit, and to prepare them for the survey that will be planned for my project. My goal

was to demonstrate the need for this project and gain their support and participation. I emphasized that this project will not only help

me out with my educational goals, but will help our organization by being compliant with the CMS guidelines.

The second portion of my project will use the information gained from the survey to create an education resource for staff. The

education that will be created will be an audiovisual tool for managers, coordinators and staff to understand the importance of

collection outcomes related to their specialty clinic. The educational tool will provide resources supported by research for healthcare

professionals on how outcome collection can improve patient satisfaction, patient outcomes, and quality and safety issues. The tool

will be a PowerPoint presentation that includes audio and visual aids to demonstrate the urgency of the situation.

The third portion of my project will be to meet with one of the managers or coordinators of the selected outpatient sites to assist in

establishing a plan of outcome data collection process. The department will be a department that was identified through the results

from the survey of a department not participating in any outcome data collection. The outcomes will be chosen will be based on the

specific population of the given specialty clinic. The outcomes will be dispersed to patients and data collection can begin

immediately.

B. Provide evidence based support that establishes a need for this project. Also include research support for effectiveness

of the proposed improvement project.

There are several research studies that support the need and benefit for outcome data collection. Sullivan, Soefje, Reinhart,

McGeary, and Cabie (2014) discuss how data collection can promote quality care through the LEAN principles. LEAN thinking in

healthcare helps to aid in improved patient satisfaction and improved job satisfaction of employees. The LEAN principles promote

efficiency, improved productivity by decreasing wasted time and resources (Sullivan et al., 2014). The goal of the LEAN principles is

to produce the best outcome with the least amount of steps. In this particular study, workflow was improved as a result of patient

outcome data collection. A workflow chart was created as a result of the outcome information so that the patient would spend less

time waiting for pharmacological treatment (Sullivan et al., 2014).

A second study by Rodts et al., (2014) explains how outcomes can help healthcare professionals to understand how to improve

current practices. Outcomes collection can be valuable, but evaluation of the outcomes is a key element to improve processes within

the workplace. Medicare and Medicaid reimbursement is starting to consider patient feedback of quality and safe patient experience.

The National Institutes of Health are advocates of outcome data collection (Rodts et al., 2014). This organization has developed an

online tool called Patient-Reported Outcomes Measurement Information Systems (PROMIS) which provides tools to measure the

physical, emotional, and social aspects of the patient (Rodts et al., 2014). Choosing outcome measurement tools that are specific to

patient population type is an important component of outcome data collection. Clinical outcome questionnaires are an effective way

for healthcare professionals to achieve understanding of a specific population. The Affordable Care Act is also in support of

improving quality care. Outcome data collection meets the Affordable Care Act’s goals by improving the patient experience,

improving the health of patients, and decreasing the cost of healthcare expenses (Rodts et al., 2014). Healthcare providers must use

the patients’ responses that are derived from solid clinical data and perceived care that the patient received (Rodts et al., 2014).

C. Where will this project take place? Describe the environment/facility/unit etc.

This project will take place at outpatient services Munson Medical Center in Traverse City, Michigan. There are 44 outpatient

clinics that will be involved in the initial survey. One of the outpatient specialty clinics will be chosen to implement an outcomes data

collection program that is specific to the patient population type.

Attached is the CMS/TJC Safety Ambulatory Leaders Meeting agenda from the meeting I presented my project idea at on

2/19/15. This document shows the team members and what outpatient services they represent. This attachment will be found in

appendix a.

D. Who else will be involved in this project? What will their roles be? (Include the agency and preceptor in this section, and

provide an overview of the agency and the preceptor’s qualifications, title, and contact information. A signed agreement from

the agency representative and preceptor should be included in this section.

This project will involve the managers or coordinators that represent any of the outpatient services clinics that are owned by

Munson Medical Center. MMC is a 391 bed, nonprofit hospital that is the largest of eight regional hospitals located in Northern

Michigan (Munson Medical Center, 2014). There is a focus on rural health nursing as Munson Healthcare system serves a five county

radius, but is equipped to care for patients in 24 counties in Northern Michigan as well as the Eastern Upper Peninsula of Michigan.

MMC is a certified Rural Referral Center by the Centers for Medicare and Medicaid Services (Munson Medical Center, 2014).

The role of the manager of each outpatient clinic will be to provide information regarding their involvement in outcome data

collection. It will be important to learn if outcomes are being completed and how they are being used to improve quality and safety

within the department. It will also be important to identify departments were not participating an outcome data collection. The

research that I will provide will display a need for an organized system for outcome data collection.

My preceptor is Anne Bacon RN, MSN, who serves as the manager of clinical quality at the hospital. Her contact information

is 231-392-0187 and can be reached by email at abacon@mhc.net. The signed preceptor agreement can be found in appendix b.

E. Complete an assessment of the QSEN graduate level competencies. Consider a minimum of 3 KSAs within the 6

competencies that you will focus on as a part of the overall quality improvement project. (Note: These should align with your

project goals.)

My graduate QSEN competencies are from the Quality Improvement Domain.

a) Describe strategies for improving outcomes of care in the setting in which one is engaged in clinical practice. Analyze the impact

of context (such as, access, cost, team functioning) on improvement efforts (knowledge)

b) Use a variety of sources of information to review outcomes of care and identify potential areas for improvement. Assert leadership

in shaping the dialogue about and providing leadership for the introduction of best practices (skills)

c) Appreciate the importance of data that allows one to estimate the quality of local care (attitude)

F. Complete an assessment of the ANA Scope & Standards of Practice for your specialty role. Identify a minimum of three

professional standards that will be met by completion of

a) Standard 10. Quality of Practice

●Provides leadership in the design and implementation of quality improvements.

● Designs innovations to effect change in practice and improve health outcomes.

●Use the results of quality improvement to initiate changes in nursing practice in the healthcare delivery system.

b) Standard 13. Collaboration

● Partners with other disciplines to enhance Health Care consumer outcomes through Interprofessional activities, such as education,

consultation, management, and technological development, or research opportunities.

● Invites the contribution of the healthcare consumer, family, and team members in order to achieve optimal outcomes.

● Leads in establishing, improving, and sustaining collaborative relationships to achieve safe, quality healthcare consumer care.

c) Standard 15. Resource Utilization

● Utilizes organizational and community resources to formulate interprofessional plans of care.

● Formulates innovative solutions for healthcare consumer care problems that utilize resources effectively and maintain quality.

● Designs evaluation strategies that demonstrate cost effectiveness, cost benefit, and efficiency factors associated with nursing

practice

G. Complete an RCA or FMEA with key stakeholders and/or peers with an understanding of the issue you will be addressing.

Include a conceptual map as part of your plan. (Note: Examples you may use are included in this project guide.)

Outpatient outcomes are not being collected in a

centralized location

Outcomes are being completed but are not being reported to a

centralized location for CMS to have easy access

Outcomes are being administered, but are not being used to their potential to

improve quality and safety

Outpatient outcomes are not being collected at all

CMS guidelines have changed. Awareness increased after December 2014 CMS visit

Managers and or coordinators have no

experience in outcome data collection Managers and coordinators don’t

where to start

Outcomes haven’t been checked in the past, “Why

start now?”

No one takes initiative because “It’s not my job”

“We have never collected outcomes, why start now?”

“I don’t see the benefit in outcomes data collection”

No systematic process established of using outcomes the department

Too much work load to organize outcomes

Outcomes are being used at the department level but

never being reported outside the department

44 outpatient departments involved-difficult to organize

No leadership to initiate process change

H. Identify a change and leadership theory that you will employ during project implementation. Support.

Above is the IDEAL model change theory that I will be using to complete my project (Carnegie Mellon University, 2015).

Using this strategy will help me stay on track with my plan as each step is sequential to the next step. The IDEAL model is comprised

of 5 phases; Initiating, Diagnosis, Establishing, Acting, Learning (IDEAL) (Carnegie Mellon University, 2015). This change theory

serves as a guide to quality improvement by breaking down each phase into specific activities to achieve a successful result. The

initiating phase asks why this project is needed. The need for a centralized data collection system was identified by the CMS survey

as described above in part A. One important quality of the initiating stage is gaining the support of key stakeholders. (Carnegie

Mellon University, 2015). I was able to do this by establishing a preceptor and gaining the support of the quality and safety

department at the hospital. The diagnosing phase helps to build a solid plan. It is important to understand the current state of outcome

data collection methods in the outpatient departments to initiate the change process. The establishing phase helps to plan actions such

as the development of a timeline for resources needed to begin the action phase of the process. The action and learning phases will

take place in class NURS 791. In the action phase, predictions are made of what will happen as a result of the first three phases

(Carnegie Mellon University, 2015). Predictions of this project are discussed in section J of this proposal. Lastly, the learning phase

allows participants to look at the strengths and weaknesses of the plan (Carnegie Mellon University, 2015). Was the ultimate goal

accomplished? When change can be made to further improve outcome data collection? What recommendations could be offered to

accomplish change?

A leadership theory will also be helpful in the success of this project. Jacelon, Furman, Rea, Macdonald and Donoghue (2011)

provide information regarding Lewin’s change theory and long term care facilities.  In this study, the authors promote the engagement

of staff and providing education in the unfreezing stage of Lewin’s change theory.   In this proposal, the need for change is clearly

communicated in section A of this proposal.  Presenting evidenced based data to the stakeholders such as the RCA or research that

supports this program will improve the necessary buy in from staff and administration.  The moving stage, according to Lewin,

involves executing the proposal into action (Jacelon, Furman, Rea, Macdonald & Donoghue, 2011).  The timeline found in section K

of this proposal demonstrates a well thought out plan to implement the steps of the process that is created to establish outcome data

collection process in outpatient departments.  Lastly, the refreezing stage directs focus to maintaining the changes that is provided in

this proposal (Jacelon, Furman, Rea, Macdonald & Donoghue, 2011).  From this proposal, it is clear that a plan to evaluate the

program will be done with the results of the survey.  A strategy is established to select and assist the implementation of initiation of

outcome data collection in the third phase of this proposal. Providing support to the outpatient department will help to increase the

success of establishing outcome data collection process.

I. How will you assess or measure whether your improvement project worked? How/will informatics technology be used?

I plan to create an electronic survey using a program such as survey monkey. This will be sent to the representatives of the

CMS/TJC Safety Ambulatory Group. I will send out the e-survey in early May and allow two weeks for completion. I plan to send a

reminder e-mail to the group after one week to encourage participation. After I receive the results, I will compile them in graph form

and a short written summery. I will disperse the results to the participants so that the group members can identify current strengths

and weaknesses. Then, appropriate changes can be made to the outcomes data collection process specific to each outpatient service.

The second portion of my project will highlight my ability to use technology to deliver education. I plan to create a

PowerPoint that will provide detailed information of why outcome measurement assessment is an important component to providing

safe and quality care to the patient.

Improving outcome data attainment will be the goal of the third portion of my project. I plan to meet with one of the managers

or coordinators of one of the specialty outpatient clinics. The purpose will be to guide in the initiation of outcome data collection. I

will be satisfied with the effectiveness of my project if I can see that it made an impact on an outpatient specialty clinic. This will be

evidenced by the establishment of an outcome data disbursement/collection method by a specialty clinic that was not previously

participating in outcome data collection.

J. Predict what you think will happen as a result of your improvement project.

I hope that my project will increase the awareness of the importance of outcome data collection and how it impacts patient

quality and safety. By sharing the information among the outpatient services, collaboration between departments can be initiated.

Appropriate changes can be made to how outcomes are collected and used. With the information that I receive from the survey, I can

help to create a centralized data collection system for the outpatient services. This system will be compliant with the

recommendations that CMS provides

I predict that only 20% of the 44 outpatient clinics are participating in an organized outcome data collection. I also predict that

only 10% are using outcomes that are specific to patient population type. As stated above, clinical outcome questionnaires are an

effective way for healthcare professionals to achieve understanding of a specific population. The Affordable Care Act is also in

support of improving quality care. Outcome data collection meets the Affordable Care Act’s goals by improving the patient

experience, improving the health of patients, and decreasing the cost of healthcare expenses (Rodts et al., 2014).

K. Create goals, objectives, and timelines for the project. Consider the earlier identified QSEN competencies and “DSA”

components of the “PDSA” model in completing the grid.

QUALITY IMPROVEMENT PROJECT PROPOSAL PLANNING GUIDETitle of Quality Improvement Project:

Centralized outpatient outcomes data collection projectGoals with QSEN/ANA Support Sub-Objectives to meet Goal Activities to meet Each Sub-objective Timeline for each

Goal 1: State GoalDevelop an e-survey to assess each outpatient clinics current involvement in outcomes data collection

Meets QSEN Competency(ies)/KSA(s):Describe strategies for improving outcomes of care in the setting in which one is engaged in clinical practice. Analyze the impact of context (such as, access, cost, team functioning) on improvement efforts (knowledge)

Meets ANA Scope & Standards for specialty role:Standard 10. Quality of Practice

Standard 15. Resource Utilization

1.1 explore e-survey options. Make sure site meets the needs of the project.

1.2 develop questions to include in the survey

1.3 utilize technology to create the survey

1.1.Choose an e-survey site and become familiar with the features/options.

1.2 meet with Anne and Candy to discuss questions needed to gain insight regarding the current process about comes data collection in each department. Use current CMS guidelines to guide the questions of the e-survey

1.3 send out a survey to members of CMS/TJC Ambulatory Safety Group via email utilize technology to create the survey. Participants will have 2 weeks to complete. A reminder email to encourage participation will be sent out one week after survey was initially dispersed.

1.1 Complete by 5/26

1.2 Complete by 5/31

1.3 Complete by 6/7. Send out e-survey on 6/8/15. Send out reminder email to encourage participation on 6/15/15

Goals with QSEN/ANA Support Sub-Objectives to meet Goal Activities to meet Each Sub-objective Timeline for eachGoal 2: State GoalOrganize and share results of e-survey to members of the CMS/TJC Ambulatory Safety Group

Meets QSEN Competency(ies)/KSA(s):

2.1 create a short narrative of results

2.2 send the results via graph and short narrative to members of the CMS/TJC Ambulatory Safety Group

2.1 Utilize technology to create a graph of the results from the survey

2.2 Write a short summary of the results from the survey. Utilize the CMS/TJC Ambulatory Safety Group email to send out graph and narrative explaining the results of the survey

2.1 Complete by 6/28

2.2 Complete by 7/5

●Use a variety of sources of

information to review outcomes of

care and identify potential areas for

improvement. Assert leadership in

shaping the dialogue about and

providing leadership for the

introduction of best practices (skills)

●Appreciate the importance of data

that allows one to estimate the quality

of local care (attitude)

Meets ANA Scope & Standards for specialty role:Standard 10. Quality of Practice

Standard 13. Collaboration

Standard 15. Resource Utilization

2.3 Choose an outpatient department that was identified to not be participating in any outcome data collection

2.3a Meet with the coordinator/manager of the identified outpatient clinic and assist in an outcome data collection method

2.3b Meet with the coordinator/manager the identified outpatient clinic and assess/evaluate programs progress

2.3 Complete by 7/12

2.3b Complete by 8/7

References

Atkott Consulting. (2015) IDEA model. Retrieved from http://www.atkott.com/Consult/CONSULT.HTML

American Nurses Association. (2010). Scope and standards of practice. (2nd ed.). Silver Springs, Maryland: nursesbooks.org.

Carnegie Mellon University. (2015). IDEAL model. Retrieved from http://www.sei.cmu.edu/acquisition/start/work/

Jacelon, C. S., Furman, E., Rea, A., Macdonald, B., & Donoghue, L. C. (2011). Creating a professional practice model for post-acute

care: Adapting the chronic care model for long-term care. Journal of Gerontological Nursing, 37(3), 53-60.

doi:10.3928/00989134-20100831-0

Munson Healthcare. (2015). Community health implementation strategy. Retrieved

from https://www.munsonhealthcare.org/upload/docs/CHNA/2013-2015%20MMC%20Health%20Implementation

%20Strategy%20(FINAL).pdf

Rodts, M. F., Glanzman, R., Gray, A., Johnson, R., Viellieu, D., & Hachem, F. (2014). Measuring outcomes in orthopaedics:

Implementation of an outcomes program in an outpatient orthopaedic practice. Orthopaedic Nursing, 33(6), 331-341.

doi:10.1097/NOR.0000000000000103

Sherwood, G., & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach to improving outcomes. Hoboken, NJ:

John Wiley & Sons.

Sullivan, P., Soefje, S., Reinhart, D., McGeary, C., & Cabie, E. D. (2014). Using lean methodology to improve productivity in a

hospital oncology pharmacy. American Journal of Health-System Pharmacy, 71(17), 1491-1498. doi:10.2146/ajhp130436

Quality and Safety Education for Nurses. (2015). Graduate competencies. Retrieved from http://qsen.org/competencies/graduate-

ksas/

Appendix a CMS/TJC meeting minutes

Appendix b Preceptor Agreement