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NHS FPX 8010 Assessment 4 Quality Improvement Proposal

Department Strategic Priorities

A successful nurse leader can establish a successful strategic plan to be used now and in the future. It is a quick fresh start for the nursing executives to redo the organization or recharge. To achieve the best patient care outcomes and goals, nurse executives need to prepare an excellent strategic plan with the team (Lal, 2020). For the company to offer cost-effective care and high-quality patient care, the executive team can organize a team to be involved in the strategic planning and creation of the balanced scorecard (see Figure A1). Inbox management continues to be an issue with providers and patients regarding communication. We have started to see how common email communication and text are becoming communication sources. ECW is the platform used at Life Care Centers is used to communicate with patients but the system has a delay in the transmission time that they are currently working on. Patients use the portal to communicate with their providers. The system has caused some issues with delay in care because of inboxes not being checked by providers or their assistants and causing issues and in the last quarter, there was a 15% increase in those incidents. Unfortunately, this could impact the reputation of the organization. 

The issue with the inbox is a current issue because the more messages are not attended to, the longer it will take providers to catch up and causing patient issues and reputation. The better way to address the issue is that the staff is overworked with tasks, and does not have enough time and in the end, the patients are the ones who feel it the most. Life Care Center has a key performance indicator which is patient satisfaction scores which is on their scorecard. The nursing executive team needs to start implementing measures for change and make sure it is patient-centered as it relates to Life Care Center. The reason behind this quality improvement project is decreasing the provider’s messages in their inbox so that we can increase patient experience and have a positive impact in the survey scores. We will need to come up with a plan to educate the team and hold daily meetings so that we continue to increase patient satisfaction rates by greater than 90%. There is a proposal attached at the end of this paper in Figure A2.

NHS FPX 8010 Assessment 4 Quality Improvement Proposal

Key Stakeholder and Policy Recommendations

The best way to target this issue and fix it is by analyzing to see the issues. This will require the providers to agree to the plan. There are many stakeholders in an organization, but the patients are the most important and the are the reason everyone there has a job (Eicher, Boechl-Daum, Broich et al.,2018). For this to be successful, we need the help from our leaders. A.B who oversees the informatics and data will assist with the collection of data and analysis for this project. He will be able to see where we can add alerts regarding priority to assist with the inbox issues. The next person will be F.R who oversees the Quality and Improvement plans and will be able to collect the data, organize it while keeping the patients experience as a priority. The Medical director for the facility will be involved in making sure the providers are complying and address any concerns they have. The executive sponsors for this project are the CFO and CEO at Life Care Center. 

The CEO will be the one to relay information to the medical director to ensure safe outcomes within the system. The providers will need to buy in as stakeholders and support will come from the CEO who has the political and power to help and support this project. When reviewing and assessing the policy regarding inbox management, they do exist. We need to implement a rule where when a message comes in, who is responsible for it and how can we route it to someone to handle like the providers assistants. They can help manage and filter those messages in the providers message board. We also need to update the policy on turn around of messages for patients. This is crucial to prevent any issues or delays in care. 

NHS FPX 8010 Assessment 4 Quality Improvement Proposal

There could be a policy where non urgent messages are responded within 72 hours and urgent within 2 hours. The patients need to understand that the messages inbox are not for emergency or matters that require immediate assistance. This helps the executive team hold people accountable and review data on a monthly basis for opportunities of improvements. Communication among the team will prevent patient errors and increase patient outcomes. A patients issues becomes center stage of a problem in healthcare (Lang, 2020). The projects success will be measured by patient survey results showing the response times and communication with their providers. This will assist with the reputation in the community for Life Care Center making it easier to get referrals.

Swot Analysis and Contemporary Change Theory

When discussing the overall political plan and landscape t Life Care Center, the CEO is still the highest rank like original organizational charts. Every change needs to be passed by him. This title is an example of informal power line power. Life Care Center has earned it respect from leader who have built relationships in the community and have gained the trust and respect. When considering a change theory, there are many different factors like recommendations for policy change and quality improvement. The Lewins change theory has been adopted by many organizations when dealing with changes. The theory has three stage which are unfreezing, change and freeze (Petiprin, 2020). Executives needs to understand this theory how it has worked for decades. The first stage is what Lewin describes as people learning new techniques and old habits are no longer effective which in Life care center, its lacking policies centered on provider and patient communication. In this project, the expectation is that all leaders will be held accountable and their team on supporting change and implementing new policies. We do not want to go back to old habits and have it affect our patients. 

Life Care Center has 4 different sections on their strategic priorities. They are the finances, patients, people, and wellness. The nursing department proposal for this quality improvement proposal goes directly with its patient satisfaction objectives.  While doing the SWOT analysis, there were four sections reviewed which were strength, weakness, opportunities and threats as outlined below.


Life care Center has experienced a decrease in referrals and admission related to the effects of communication between providers and patients via EMR system. The delay in care and communication has affected relationships with local hospitals and referral sources. In order to resolve this issue, everyone needs to be able to understand the plan and buy in to it including the executive and leadership team members. Applying the Lewin change theory, Life care Center will be able to increase patient satisfaction rates and overall improve the relationship in the community while seeing higher patient satisfaction scores. The SWOT analysis concluded that with all the treats, teamwork helps to balance the strengths. Patient centric models helps the nursing department elevate the patient experience. The issue with messages to providers will be corrected with everyone’s collaboration and will measure that success by surveys yielding 90%. The policy for patient and provider will be done through weekly educational meetings and updates.


Eichler HG, Bloechl-Daum B, Broich K, et al. Data rich, information poor: can we use electronic health records to create a learning healthcare system for pharmaceuticals? Clin Pharmacol Ther 2018;September 4. doi: 10.1002/cpt.1226. [Epub ahead of print]

Lal, M. Maureen DNP, MSN, RN. Why You Need a Nursing Strategic Plan. JONA: The Journal of Nursing Administration: April 2020 – Volume 50 – Issue 4 – p 183-184 doi: 10.1097/NNA.0000000000000863

Lang EV. A Better Patient Experience Through Better Communication. J Radiol Nurs. 2012 Dec 1;31(4):114-119. doi: 10.1016/j.jradnu.2012.08.001. PMID: 23471099; PMCID: PMC3587056

Petiprin, A. (2020, July 19). Lewin’s change theory. Nursing Theory. Retrieved October 12, 2022, from https://nursing-theory.org/theories-and-models/lewin-change-theory.php

Executive Summary

Delay in patient communication through the portal to providers has caused a delay in care, proper diagnosis, near missed events and communication. This issue has caused Life care Centers reputation and has decreased referrals due to the communication gap between patients and their providers. The overall goal is patient satisfaction and reputation of the company. We will draft a plan to improve communication and patient experiences. Patient satisfaction will be done through survey yielding 90% as the expected rating. This will be accomplished by reviewing daily at team meetings and at the weekly executive meeting so that we enhance communication between everyone. Our goal is patient safety.


January 30, 2023- Review the plan and team members.

February 6, 2023- Education of the clinical team and guidelines for project

February 13, 2023- Implement project and have a source of communication through team lead

March 20, 2023- project ends and data is collected and analyzed and reevaluated

There is no current policy in place regarding communication via messages with providers and patients. Current proposal will have the development and implementation  of the new policy change and the course for rolling it out. The goal is for messages t be responded back within 72 hours and urgent matter are not being left in the patient portal. Reassessment will be ongoing.

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