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MSN FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal KP


MSN FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal KP

There has been a constant need to improve the quality of care in many hospitals worldwide. Improved quality of health care means that the patients have a favorable prognosis. The working condition will be conducive for the health care workers and an overall improvement in the performance of the health facility. This improvement can only be achieved if there is good and effective teamwork among the medical staff, continuous professional development, and utilization of practical quality improvement innovations (Goodman et al., 2018). The main objective of the quality improvement initiative is to improve the quality of health care provided to patients and minimize errors that may be present in the health care system. Nurses play an essential role in quality improvement since they are constantly interacting with patients, which partly determines the patient’s outcome. This proposal will analyze and interpret dashboard information displaying the critical care metrics and product and data collected from the care delivery process (Horntverdt et al., 2018).

Problem areas

A hospital-acquired pressure injury is a preventable adverse effect in many health organizations; its prevalence is usually reported through the national database of nursing quality indicators (NDNQI). Many hospitals are involved in this NDNQI program to report the cases of adverse effects and thus provide a basis for nursing quality improvement; pressure ulcer is still considered a global problem even though guidelines, education, and equipment are readily available (Waung and Beringer, 2020). The Heart Hospital reported very high-pressure injury rates in 2015, with a prevalence of 5.53%, which exceeded the NDNQI magnet benchmark of 1.74% for 2015 (Boyle et al., 2017). The total number of hospital-acquired pressure injuries reported was 120, with the majority in intensive care units; for instance, out of the total of 120 pressure injuries occurring in the Heart Hospital, more than 50% took place in the intensive care unit setting (Boyle et al., 2017).

Orlando Heart Hospital is a cardiac facility in Orlando, and its Cardiothoracic Intensive care Unit started an attempt to reduce Pressure Injuries to serve Post cardiac surgery patients. In April then, the program was undertaken by other patient care units.

Available Knowledge.

A pressure injury is any localized damage to the skin and underlying soft tissue that occurs mainly above a bony prominence due to pressure or in combination with shear (Ayello and sabbald, 2017). A pressure injury is a very traumatizing experience for patients and at the same time costly as a lot of resources such as time, both nursing and surgical, and medication are used in the management (Ayello and Sabbald, 2017). Pressure injury occurs due to pressure exerted on the skin and underlying tissues resulting in disruption of the local blood flow leading to ischemia and necrosis. Some of its etiological causes include shearing, which can be defined as pressure occurring when layers of skin are forced down due to gravity or friction. Second, friction is the pressure caused by clothing or bedding rubbing the skin’s surface, commonly seen on the elbows and heels. Thirdly moisture wet skin may cause rashes that make it susceptible to breaking (Black, 2019). A pressure injury is staged according to severity as follows (Wassel et al.,2020):

Stage 1Skin is usually intact with non-blanchable redness on the localized area, darkly pigmented compared to surrounding areas.
Stage 2There is a partial loss in dermis thickness resulting in shallow open ulceration with red or pink wound bed, which presents as either intact or available serum-filled blister.
Stage 3There is a complete loss of the dermis thickness or tissue with visible subcutaneous fat, but tendons and muscles are not visible.
Stage 4Complete loss of dermis thickness with visible muscles and tendon, slough may be present in some parts.
Suspected Deep Tissue InjuryIntact skin, but there is a purple or maroon discoloration or a serum-filled blister due to damage of underlying tissues. 
UnstageableTissue thickness is lost, and the ulcer’s base is covered by a yellow or brown wound bed.

Prevention measures include relief of the causative pressure, such as air mattresses or water mattresses, heel protectors, regular turning of the patient, skin inspection for any soreness, and dietitian if the cause was nutrition (Wassel et al., 2020).


From the data obtained concerning the prevalence of pressure injury in the hospital after a keen analysis by the improvement task force, it was observed that 50 % of cases of pressure injury occurred in intensive care units where patients are acutely ill and have comorbid conditions. These cases arose because the patient was immobile and susceptible to medical-related pressure injuries, such as endotracheal tubes and continuous positive pressure masks (Tomlinsol and Limbert,2020).


To reduce the incidence of pressure injury in heart hospitals in the inpatient unit by 70% by 31 December 2022.


  1. To follow evidence-based practice by a multidisciplinary team approach
  2. To decrease the cases of hospital-acquired pressure injury in the inpatient units
  3. To promote the use of preventive measures of pressure injury instead of the treatment measures in the management of pressure injury.



To improve the quality, the administration of Heart hospital initiated a program of data analysis and quality improvement in critical areas, for example, the intensive care units, general wards, and the perioperative regions; therefore, in this report, we focus on the overall effort.

MSN FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal KP


By using the Institute of Health Improvement model, which seeks to use a multidisciplinary approach to improve quality: nurses, doctors, nutritionists, and physiotherapists, among many other health care professionals, are actively involved in patient care. This model focuses on setting an improvement project by setting an aim statement then establishing the measures needed to know the effectiveness of change and choosing the best changes for that particular setting, thus plan do study act (PDSA) is used to test changes. We did a Pareto analysis to identify the problem areas, for example, non-adherence to the preventive measures, use of inappropriate assessment criteria other than the recommended Braden scale, and poor management procedure in care of the Pressure injury incident. In this experiment, the nurses are educated on the risk assessment tool and proper use of the Braden scale to manage pressure injury.

Quality Initiative 

Communication of quality initiative.

Patient-centered care.

All health care providers need to be educated on the importance of patient-centered care to ensure what it entails. They will be educated on the significance of compensating care, non-maleficence, and providing patients autonomy throughout the project period. We will inform the patients and their families about hospital-acquired pressure injury, causes, and how it is being managed to be aware of the patient’s condition. Throughout the treatment, the family will also be educated on the importance of providing emotional and mental support, which is expected to improve the patient’s outcome (Holbrook et al.,2021).


To improve safety, we implemented system effectiveness and medication safety. In system safety, we looked for the causes of medication errors which commonly relied on one profession, the doctors to prescribe the drugs for the HAPI patients; therefore, we incorporated the role of pharmacists in dosage calculation, dose determination, and determination of the possible drug-drug interactions and possible ways to mitigate them. We introduced the respiratory therapist to reduce respiratory infection due to nasogastric tubes and intubation tubes (Mussa et al.,2018). Nutritionists were trained to determine the patient’s diet. If the patient is in critical condition, we will consult a physician in deciding the meals for the patient; The interdisciplinary team ensured good communication by consulting before making any changes to the patient and by providing a high degree of respect among the team members.


Implementation of all these changes is expected to improve the efficiency of the therapy. The database will be analyzed by an expert internet technologist who will be educated first on the key parameters being studied in this project to prevent medical errors (Kiymaz and Koy,2018). They will solve any identified problem by applying the required changes. The health professionals will go through continuous medical education classes to improve their knowledge of managing the patient; they will also be taught the importance of the culture of quality, root cause analysis, and land use stream mapping according to the Six Sigma model (Limbert and Santy, 2020).

MSN FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal KP

Management of adverse drug effects

Effectiveness of therapy.

To ensure the effectiveness of the therapy, hospital-acquired pressure injury patients were treated and monitored frequently. The doctors were present to ensure that the cases of patients did not deteriorate, and in case they declined, they changed the regimen to suit the patients’ needs. The pharmacist was also present to ensure that any adverse drug reaction and therapeutic drug monitoring were implemented. For instance, patients using phenytoin were regularly monitored to prevent adverse effects. The nurses confirmed that they embrace an appropriate hand washing procedure and hygiene to avoid the spread of infection between the patient and the nurses. All this was aimed to promote the effectiveness of the therapy.

Timely administration of therapy.

To improve quality, patient management needs to be timely, for example, the use of turning clocks by nurses to prevent them from forgetting to turn the patient as per the surface, skin inspection, keeping movement, incontinence, and nutrition (SSKIN bundle ). The interdisciplinary team was educated on the components of the SSKIN bundle, and they assisted each other in ensuring that the patient was managed on time (Limbert and Santy, 2020). The nutritionist had meal timetables in place, and the nurses and the physician did a skin inspection every 2 hours to look for any injury and prevent further damage.

Equitable treatment.

To ensure equitable therapy of patients, all water mattresses were exchanged for air mattresses. The nurses constantly checked all patients, and the physician altered their regimens as needed. All patients could be visited by their families, and none was discriminated against. The nutritionist adjusted the patient’s meal to suit each patient. For instance, for those with deficiencies, their meal will be supplemented by the required nutrient, which has been shown to improve their outcome (Limbert and Santy, 2020).

Effective Quality Improvement Communication Strategies

Communication among all the healthcare stakeholders is critical for the improvement of quality and patient safety. Medical facilities utilize various tools to communicate with their stakeholders. The hospital is supposed to be a partner in the care. This may involve informing the patient and the stakeholders of the available opportunities as they interact with the health care. Also, the hospital can establish relationships with patients and parents to enable a clear understanding of the possible medical outcomes; thus, the patient and family can be able to gauge whether the quality and patient safety parameters are attained. Furthermore, communication can prepare health care professionals to deal with patients and address when errors occur during practice. 

The rationale behind communicating to improve care quality and patient safety is that it creates an engaging environment where patients, their families, health care professionals, and hospital staff work in unison to improve quality. Therefore, communication is the foundation of partnership between the stakeholders. Besides, communication strategies are vital in linking patient outcomes. Various research has showcased how effective communication strategies allow easy interaction between clinicians and patients, thereby minimizing the occurrence of medical errors. It positively impacts the attainment of patient outcomes like pain control and emotional health.

Furthermore, an effective communication strategy can enhance overall patient safety. Studies indicate that medical errors result from communication breakdowns, especially during changeovers, transfers, and interprofessional relationships between doctors and nurses. Also, other research showcase patient safety can be improved when communication is used to inform the patients of medical procedures like drug administration, reporting of complications, and self-management initiatives. 

Nevertheless, communication strategies can improve the perception of care quality. Quality is usually a perception of patients and families due to their interactions with health care professionals and medical facilities. Clinicians who are perceived to be empathetic and attuned to the needs of the patients are usually judged to provide more quality services.

According to the Agency for Healthcare Research and Quality, communication models such as Situation Background Assessment Recommendation (SBAR) and CUS tools are helpful in the communication of quality improvement initiatives. SBAR communication tool is used to highlight communication challenges in health care by looking at the situation leading to breaches of ineffective communication. The background information then follows this. An assessment of the problem follows. Finally, recommendations are provided for the problem identified and assessed (Shahid & Thomas, 2018). For instance, SBAR dictates that a clinician does a complete assessment of the situation before providing a diagnosis. 

On the other hand, the CUS communication tool is usually used to improve communication in a tensed medical environment like a surgical room. It denotes I am concerned, I am uncomfortable, and this is a safety issue (Shahid & Thomas, 2018). This tool requires the clinician to identify themselves and showcase the reason for the concern, and highlight that they have no trust in the current medical diagnosis. Thus, this tool significantly eliminates medical errors.


After collaborative effort, it was observed that there was an 80% decrease in the total number of Hospital Acquired Pressure Injuries. The annual count decreased from 120 in 2015 to 24 cases (Boyle et al., 2017).

There was a remarkable reduction in the prevalence of stage 2 and above pressure injuries 70% reduction from 6.1% per 100 patients to 1.5% per100 patients (Boyle et al., 2017).

There was a remarkable reduction in quarterly prevalence of pressure injuries 75% reduction from 9.5%per 100 patients to 2 % per100 patients (Boyle et al., 2017).

MSN FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal KP


The project was able to achieve more remarkable than the expected 70%. The quarterly survey dropped from 9.5% per 100 patients to 2% per 100 patients, thus a 75% decrease. Stage 2 and above reduced 6.1% to 1.5% in 100 patients, thereby a 70% drop observed (Boyle et al., 2017).


The improvement was cumulative over time, as shown above; based on the research tool, change in the parameters measured resulted in a decrease in hospital-acquired pressure injuries. As shown in both graphs, some of the causes of the high prevalence of pressure injury can be a lack of regular akin inspection, improper use of the Braden tool, and lack of evidence-based approaches in treating pressure injury (Horntvedt et al., 2018). This project has indicated the role of evidence-based practices, has provided knowledge to the nurses on the prevention of pressure injury, and has demonstrated the role and benefits of using a multidisciplinary team to prevent pressure injury. Some of the challenges encountered in this project are; a lack of understanding of the Braden risk assessment tool, lubricant unavailability, and no appreciation of the importance of medical device-induced pressure injury.

Near-Miss Events in QI

Assessment of quality improvement outcomes may encompass factoring in adverse or near-miss data. According to the World Health Organization (WHO), a near miss is an error that can cause an adverse event like patient harm but fails to do so because of chance or because it is intercepted. In this regard, there is a minimum chance of the patient getting hurt in near-miss events. Thus, the near-miss events present a limited opportunity to improve patient safety and advocate patient expectations regarding disclosure of medical errors, both factors associated with medical malpractice claims. 

The introduction of a near-miss events reporting system during a quality improvement initiative has been established to improve interprofessional care by more than 70 percent. However, in a typical health care setting, many barriers hamper reporting of near-miss events. For example, healthcare professionals are often faced with immense workloads; thus, incorporating a near-miss event into this immense workload may not be received well by healthcare professionals. Also, recording near-miss events may lead to punitive actions. 

Besides, understanding the causes of near-miss events plays a vital hand in improving health care delivery. Work-related interruptions, distractions, and patient communication have been termed to be the leading attributing factors of near misses in health care. Thus, according to Speroni et al. (2013), hospital management should consider personal and institutional factors when assessing quality improvement initiatives, especially when dealing with near-miss events. 


Hospital-acquired Pressure Injury is preventable and can be avoided by utilizing a proper quality improvement tool such as the one used in this project. Approaches such as evidence-based medicine and the utilization of a well-equipped multidisciplinary team have proven to reduce pressure injury, which has helped improve outcomes for patients and reduce the cost associated with the treatment of this injury.


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Black, J. M. (2019). Root cause analysis for hospital-acquired pressure injury. Journal of Wound Ostomy & Continence Nursing46(4), 298-304

Boyle, D. K., Jayawardhana, A., Burman, M. E., Dunton, N. E., Staggs, V. S., Bergquist-Beringer, S., & Gajewski, B. J. (2017). A pressure ulcer and fall rate quality composite index for acute care units: A measure development study. International Journal of Nursing Studies, 63, 73-81.

MSN FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal KP

Goodman, L., Khemani, E., Cacao, F., Yoon, J., Burkoski, V., Jarrett, S., Collins, B., & Hall, T. (2018). A comparison of hospital-acquired pressure injuries in intensive care and non-intensive care units: a multifaceted quality improvement initiative. BMJ open quality7(4), e000425. https://doi.org/10.1136/bmjoq-2018-000425.

Henry, M. (2019). Nursing education program for hospital-acquired pressure injury prevention in an adult acute care setting: a quality improvement project. Journal of Wound Ostomy & Continence Nursing, 46(2), 161-164.

Holbrook, S., O’Brien-Malone, C., Barton, A., & Harper, K. (2021). A quality improvement initiative to reduce hospital-acquired pressure injuries (HAPI) in an acute inpatient setting by improving patient education and seating. Wound Practice & Research, 29(4).

Horntvedt, M. E. T., Nordsteien, A., Fermann, T., & Severinsson, E. (2018). Strategies for teaching evidence-based practice in nursing education: a thematic literature review. BMC Medical Education, 18(1), 1-11.

Kiymaz, D., & Koç, Z. (2018). Identification of factors that affect the tendency towards and attitudes of emergency unit nurses to make medical errors. Journal of Clinical Nursing, 27(5-6), 1160-1169.

Mussa, C. C., Meksraityte, E., Li, J., Gulczynski, B., Liu, J., & Kuruc, A. (2018). Factors associated with an endotracheal tube-related pressure injury. SM J Nurs, 4(1), 1018.

Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist73(4), 433.

MSN FPX 6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal KP

Santy-Tomlinson, J., & Limbert, E. (2020). Using the SSKIN care bundle to prevent pressure ulcers in the intensive care unit. Nursing Standard (Royal College of Nursing (Great Britain): 1987).

Shahid, S., & Thomas, S. (2018). The Situation, Background, Assessment, recommendation (SBAR) communication tool for handoff in health care – A narrative review. Safety in Health, 4(7). doi:10.1186/s40886-018-0073-1

Speroni, K., Fisher, J., Dennis, J., & Daniel, J. (2013). What causes near-misses and how they are mitigated: Nursing, 43(2), 19-24. doi: 10.1097/01.NURSE.0000427995.92553.ef

Wassel, C. L., Delhougne, G., Gayle, J. A., Dreyfus, J., & Larson, B. (2020). Risk of readmissions, mortality, and hospital‐acquired conditions across hospital‐acquired pressure injury (HAPI) stages in a US National Hospital Discharge database. International Wound Journal, 17(6), 1924-1934.

Waugh, S. M., & Bergquist-Beringer, S. (2020). Methods and processes used to collect pressure injury risk and prevention measures in the National Database of Nursing Quality Indicators®(NDNQI®). Journal of Nursing Care Quality, 35(2), 182-188.

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