All of your previous assessments have been built up to complete this one. Now, it is time to create a quality improvement project plan, using data to create a sense of urgency. You should include depictions of pre- and post-implementation workflows and the risk management mitigation plan you developed. Use the Quality Improvement Project Plan Template [DOCX] to complete this assessment. Remember to use evidence-based practice to support your plan.
Overall, your assessment will be assessed on the following criteria:
Explain the problem, its significance, and its impact on the chosen health care environment.Make sure you use appropriate data from sources like Leapfrog and Medicare Compare to support your explanation.Outline proposed technology/informatics solutions and the plan to implement them within the chosen health care environment.Make sure you address why your plan is relevant to your problem. Explain potential implementation challenges related to the proposed plan.Think about the logistical, personnel, and resources that might be part of the challenges or that could help overcome the challenges.Explain the role of leaders in change management related to the proposed plan.Think about who the relevant leaders would be for implementing your plan and what type of communication plan they should be using to help with implementation.
Risk Mitigation Plan
Risk Management Plan
Risk identified by
SAFER Guides
Possibility of
Occurrence
(Frequent,
Sometimes,
Never)
Potential for
Harm (Severe,
Mild, None)
Inadequate training
among healthcare
providers
Sometimes
Severe
Mitigation to Address Risks
Possibility of
Occurrence
(Frequent,
Sometimes,
Never)
Potential for
Harm (Severe,
Mild, None)
1. Develop specialized
training programs on
EHR and CPOE for
healthcare providers.
Sometimes
Mild
Frequent
Severe
2. Develop specialized
training programs on
EHR and CPOE for
healthcare providers.
Limited
interoperability
Frequent
Severe
1. Invest in developing
system-to-system
interfaces to enhance
interoperability.
2. Improve information
distribution and
utilization across
different departments.
1
Unavailability of
EHR functionalities
Sometimes
Severe
1. Implement contingency
planning to manage
instances of unplanned
unavailability.
Sometimes
Mild
Sometimes
Mild
2. Redesign workflows
using the appropriate
SAFER Guide to
address downtime
issues.
Medication errors
Sometimes
Severe
1. Utilize technology to
flag medication errors
2. Develop a contingency
plan to identify and
address potential
causes of errors.
3. Implement multifaceted
solutions to reduce
medication errors
Ethical or Legal Issues Related to Identified Risks
The identified risks in the table above present potential ethical and legal issues that must be addressed. For instance,
inadequate training among healthcare providers raises concerns about patient safety and the moral responsibility of healthcare
professionals to provide competent care. Furthermore, suppose healthcare providers must be adequately trained in using electronic
health records (EHR) and computerized physician order entry (CPOE). In that case, it can lead to errors in medication administration
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and compromised patient outcomes (Varkey, 2021). Therefore, healthcare organizations must ensure that their staff members are
properly trained and competent in using EHR systems to meet regulatory requirements and protect patients’ rights.
Similarly, limited interoperability poses ethical and legal challenges regarding patient information access and care
coordination. Interoperability issues also hinder the seamless exchange of patient data among different healthcare departments and
systems, impacting timely decision-making, continuity of care, and patient safety (Varkey, 2021). Additionally, patients have a right
to expect their healthcare information to be accessible to authorized healthcare providers when needed from an ethical perspective.
The Health Insurance Portability and Accountability Act (HIPAA) also mandates the protection and secure exchange of patient health
information. Therefore, addressing the limited interoperability is essential to ensure ethical obligations and legal compliance in
safeguarding patient privacy and promoting coordinated care.
Lastly, the unavailability of EHR functionalities also raises ethical and legal concerns. This is because patients rely on the
availability of EHR systems to receive timely and appropriate care. If the EHR system becomes unavailable due to technical issues or
lack of contingency planning, it can result in delayed or canceled procedures, medication errors, and compromised patient safety
(Varkey, 2021). Hence, healthcare organizations must provide continuous and reliable access to patient information and services from
an ethical perspective. Additionally, any disruptions in care provision due to EHR unavailability may raise liability issues and
potential legal claims from patients. Therefore, implementing robust contingency planning and redesigning workflows can help
mitigate these risks and uphold ethical obligations while complying with legal requirements.
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Justification of Actions to Address Identified Risks
Furthermore, the actions proposed to address the identified risks are justified based on their potential to mitigate them and
improve patient safety and organizational efficiency. First, inadequate training among healthcare providers can lead to medication
errors and compromised patient outcomes. Hence, healthcare providers can enhance their knowledge and skills in utilizing these
systems effectively by implementing specialized training programs on EHR and CPOE (Fennelly et al., 2020). Continuous evaluation
of staff competencies and providing further training opportunities also ensure ongoing improvement and competence. Therefore, these
actions justify the investment in training since it aligns with the ethical responsibility of healthcare organizations to provide competent
care and comply with legal requirements.
Likewise, limited interoperability poses risks to patient information access and care coordination. However, developing
system-to-system interfaces and improving information distribution addresses this challenge. These actions enable the seamless
exchange of patient data, support interactive clinical decision-making, and promote coordinated care (Fennelly et al., 2020).
Therefore, justifying the investment in enhancing interoperability aligns with ethical obligations to protect patient privacy and
confidentiality. It also supports legal compliance with HIPAA requirements, ensuring secure and appropriate access to patient
information by authorized healthcare providers.
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Lastly, the unavailability of EHR functionalities can have severe consequences, such as delayed procedures, medication errors,
and compromised patient safety. However, implementing contingency planning and redesigning workflows addresses these risks.
Contingency planning ensures that proactive measures are in place to manage instances of unplanned unavailability, minimizing
disruptions in patient care. Moreover, redesigned workflows enable healthcare professionals to continue providing care even during
EHR downtimes (Fennelly et al., 2020). Therefore, these actions align with ethical responsibilities to ensure continuous and reliable
patient information and services access. Additionally, these actions help mitigate the potential liability associated with EHR
unavailability and demonstrate compliance with legal requirements from a legal perspective.
Change Management Strategies
Additionally, implementing the proposed actions to address the identified risks requires effective change management
strategies to support their successful implementation in healthcare practice. Therefore, one change management strategy is effective
communication and stakeholder engagement. It is essential to communicate the reasons for the proposed actions, their benefits, and
their potential impact on workflows and patient outcomes (Perregrini, 2019). Likewise, engaging stakeholders, including healthcare
providers, administrators, and IT personnel, foster their buy-in and involvement in the change process. This can be achieved through
regular meetings, workshops, and training sessions to address concerns, provide clarifications, and ensure that all stakeholders are
informed and actively participate in implementing the proposed actions.
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Another change management strategy is providing comprehensive training and support. When implementing specialized
training programs, it is crucial to provide healthcare professionals with the necessary knowledge and skills to utilize EHR systems and
workflows effectively. Additionally, training should be interactive, practical, and tailored to the specific needs of different healthcare
roles (Perregrini, 2019). Ongoing support, such as dedicated help desks, user manuals, and access to experts, can further reinforce the
training and address any challenges or questions that arise during the transition (Perregrini, 2019). Therefore, healthcare organizations
can empower their staff to confidently embrace the proposed actions and successfully integrate them into their practice by providing
comprehensive training and support.
In summary, effective change management strategies are vital for successfully implementing the proposed actions to address
the identified risks. Furthermore, communication and stakeholder engagement ensure that all relevant parties understand the reasons
behind the changes and actively participate in the process. Comprehensive training and support empower healthcare professionals to
adopt and incorporate the proposed actions into their daily workflows. Therefore, healthcare organizations can foster a culture of
continuous improvement, facilitate the adoption of new practices, and ultimately enhance patient safety and organizational outcomes
by employing these change management strategies.
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References
Fennelly, O., Cunningham, C., Grogan, L., Cronin, H., O’Shea, C., Roche, M., Lawlor, F., & O’Hare, N. (2020). Successfully
implementing a national electronic health record: a rapid umbrella review. International journal of medical informatics, p. 144,
104281. https://doi.org/10.1016/j.ijmedinf.2020.104281
Pellegrini, M. (2019). Mitigating Resistance to Change in the Workplace. Creative Nursing, 25(2), 154–156.
https://doi.org/10.1891/1078-4535.25.2.154
Varkey, B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice: international
journal of the Kuwait University, Health Science Centre, 30(1), 17–28. https://doi.org/10.1159/000509119
7
Using Data to Make Evidence-Based
Technology Recommendations
Baptist Health South Florida
Leapfrog Score and Medicare score
To measure its performance and provide transparency to
patients and stakeholders
Allow patients to assess hospital performance, make
informed decisions, and prioritize their health and safety
LEAPFROG SCORE
• The Leapfrog hospital grade for Baptist Health South
Florida is C.
• The selected patient safety areas that will be evaluated
include:
• Infections – performance score of 1.240.
• Safety problems – performance score of 1.62.
• Practices to avoid errors – performance score of 100 (Leapfrog
Group, 2023).
MEDICARE SCORE
• Baptist Health South Florida
The patient safety
3 out of 5.
Comparison with:
West Kendall Baptist Hospital and HCA Florida Kendall Hospital.
The patient safety score for these two hospitals is as follows:
• West Kendall Baptist Hospital – 3/5.
• HCA Florida Kendall Hospital – 1/6.
IMPLEMENTATION OF
INFORMATICS/TECHNOLOGY
Telehealth
.
Improve Leapfrog and
Medicare Compare
scores
THE INFLUENCE OF TELEHEALTH ON
LEAPFROG AND MEDICARE SCORES
The implementation of telehealth in Baptist Health South
Florida can be applied to improve Leapfrog and Medicare
Compare scores by:
• Making healthcare easier to obtain for individuals living
in remote communities.
• Keeping individuals safe if they have an infectious
illness.
• Making services available for persons with mobility,
time, or transportation issues.
THE INFLUENCE OF TELEHEALTH ON LEAPFROG
AND MEDICARE SCORES
The implementation of telehealth in Baptist Health South Florida
can also be applied to improve Leapfrog and Medicare Compare
scores by:
• Improving Baptist Health’s access to other medical
specialists.
• Advancing coordination of care and communication among
the facility’s healthcare teams and a patient obtaining care.
• Improving the hospital’s capacity to educate and train both
its patients and healthcare providers.
THE INFLUENCE OF TELEHEALTH ON LEAPFROG
AND MEDICARE SCORES CONT’D
The implementation of telehealth in Baptist Health South
Florida can also be applied to improve Leapfrog and Medicare
Compare scores by:
• Introducing an online patient portal.
Using the patient portal, patients can safely contact Baptist
Health South Florida to do the following:
• Request prescription refills.
• Review earlier visits summaries and test outcomes.
• Schedule visits and preventive care reminders.
RATIONALE OF THE PRESENTATION
STRUCTURE AND SUPPORTING EVIDENCE
The presentation structure:
✓ It is appealing and catches the attention of the audience.
✓ It highlights each critical idea in different ways allowing
them to absorb meaning.
The supporting evidence:
✓ It builds the credibility of my presentation and supports
the main idea.
REFERENCES
• Gajarawala, S. N., & Pelkowski, J. N. (2021). Telehealth benefits and
barriers. The Journal for Nurse Practitioners, 17(2), 218-221.
https://doi.org/10.1016%2Fj.nurpra.2020.09.013
• Leapfrog Group. (2023). Baptist Health Baptist Hospital of Miami. Leapfrog
Hospital Safety Grade. https://www.hospitalsafetygrade.org/h/baptist-healthbaptist-hospital-ofmiami?findBy=hospital&hospital=Baptist%2BHealth%2BBaptist%2BHospital
%2Bof%2BMiami&rPos=154&rSort=grade
• Monaghesh, E., & Hajizadeh, A. (2020). The role of telehealth during COVID19 outbreak: a systematic review based on current evidence. BMC public
health, 20, 1-9. https://doi.org/10.1186/s12889-020-09301-4
THANK YOU
Quality Improvement Project Plan Using
Informatics/Technology
This project is based upon your interest, as well as an identified need within your current,
proposed, or future organization or healthcare setting using what you discovered in the Week 2,
4, 6, and 8 assignments.
You will identify one or more potential informatics/technology-based solutions to the problem
identified and an associated proposed practice change.
The plan should be submitted as an APA-formatted paper.
This is a suggested format for the paper.
Introduction
Problem
•
Define and/ or describe the problem.
•
Detail the significance and impact of the problem.
o
Who are the stakeholders? (Examples: executive leadership, clinical
departments, IT department, medical staff, and legal counsel.)
o
Why is the problem important to the stakeholders?
Data to Support the Problem and Trigger a Need for a Practice
Change
•
What does the Leapfrog data tell you?
•
What does the Medicare Compare information reveal?
Proposed Solution
•
Outline the proposed solutions.
o
Clearly outline what you are trying to accomplish, compelling vision.
o
Define the technologies/informatics.
o
Articulate how the technologies/informatics will facilitate workflow and/or
transform practice to improve patient outcomes.
1
o
•
Explain implementation issues and challenges for the identified informatics priorities.
(Example: ethical, human and financial resources, coordination with other entities, and
composition of the workflow redesign team.)
o
•
Specify at least three data points to be measured and the monitoring tool that will
be used to show opportunities for improvement, modifications, and/ or
sustainability.
You can reference your risk mitigation plan here.
State the role of the leaders in introducing a change strategy.
o
Consider organizational readiness, strengths, and barriers
o
Include suggested model for leading organizational change, including rationale
for selection. (Examples: Kotter’s eight-step process, Lewin’s change
management model.)
o
Include proposed communication plan.
▪
What information would you provide to the executive leadership and/or
board to garner support for the proposes change?
Workflow Analysis
•
Visual depiction of the existing process or practice (a process map).
•
Analyze and describe where inefficiencies, breakdown of process, and/ or
communication occurs.
o
•
Differentiate value-added versus non-value-added steps.
Visual depiction of the post practice change process or practice (a process map).
Summary: Final Recommendations and Conclusions
2