NURS FPX 8012 Assessment 5 Quality Improvement Project Plan

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NURS FPX 8012 Assessment 5

Quality Improvement Project Plan

It is vital to understanding that QI contributes to the Patient attainment of better results and the organisation’s operations being optimised. According to the (QSEN) project, the DNP-prepared nurse plays a central role in administering QI projects, especially those in the use of information systems and technology. This project plan focuses on the problem of high HAI rates in a tertiary care hospital, and the rates obtained from Leapfrog hospital safety scores and Medicare compare prove that this is a matter of life and death (Leapfrog Group, 2020; Centers for Medicare & Medicaid Services, 2021).

It is a factual evidence that HAIs impact morbidity and mortality rates, length of stay, number and cost of treatments, all of which influence patients’ opinions and hospitals’ image.

layouts = stakeholders = management decisions = academic heads/chiefs, the clinical departments, IT department, medical staff, and legal advisors. These findings indicate that decreasing HAIs is beneficial to increase congruency with organizational objectives, beneficial to patient care, and has implications to increase intrinsic motivation among healthcare personnel.

Significance and its Impact

HAIs are a significant issue due to the high morbidity and mortality rates associated with them, leading to prolonged hospitalization and additional treatments, which in turn contribute to the rise in healthcare-related costs. These infections pose a threat to the safety and quality of the services that patients receive, tarnishing the hospital’s image, and also lead to poor performance indicators which attract penalties from the healthcare insurers.

For the executive leadership, infection control addresses HAIs because it is in the organization’s best interest to offer a quality and safe hospital, improving the hospital’s positions on quality rankings which in turn, might lead to gain more funding. Patient care clinical departments such as surgery, medicine, and pediatrics practices benefit from the increase in patient satisfaction ratings and satisfaction of their employees, while the IT department demonstrates IT’s impact on contributing to hospital technological progress through successful implementation of infection control systems.

To hospital administration, securing medical staff enhances personal protection and lowers medical staff’s burden while effectively preventing infections, while legal help also means that a hospital avoids legal troubles due to violation of health regulations. The financial benefits of reducing HAIs are significant, as it can lead to a decrease in treatment costs, penalties, and reputational costs, thereby enhancing the hospital’s ability to invest in important areas.

The high rate of HAIs also impacts the operational efficiency in that there is increased complexity in the care that needs to be delivered which puts pressure on the staff and causes burn out and lessen job satisfaction. Operationally, costs such as treatment costs of HAI patients, costs of additional day’s care, which are usually provided free by the hospital, staff costs, penalties, and reputational costs impact the hospital’s ability to invest in important areas.

Comparing the hospital’s performance with other facilities across the country, data obtained from Leapfrog Group reveal that in the HAI segment, the hospital earns low scores in the scale and thus shows the degree of necessary improvement (Leapfrog Group, 2020). Medicare Compare data reports that the hospital has a higher frequency of CLABSI & CAUTI, which are some of the common types of HAIs.

Therefore, it is severe. Reducing the incidence of HAIs is important in enhancing the safety of individuals who receive care, the effectiveness and productivity of organizations that provide care, and the economic stability of care delivery institutions. An eMHHS can be implemented to focus on important measures of infection control to decrease incidence rates and save patients, thus regaining the reputation of the hospital. This quality improvement plan is another intervention to promote culture and system enhancement in infection control at the hospital through data and technology enhancements, highlighting the crucial role of the IT department in this process.

Technology Solutions and the Plan to Implement Them

The solution put forward to tackle the situation connived to as hospital-acquired infections (HAIs) is an e-hand hygiene monitoring system. This system will improve standard precautions about infection control since it will make a point of ensuring that people in the health care section maintain cleanliness of their hands as recommended.

NURS FPX 8012 Assessment 5 Quality Improvement Project Plan

Statistics obtained from Leapfrog and Medicare Compare show the extent of a problem that demands attention since our HAI rate ranking is higher than the comparable national rates (Leapfrog Group, 2020; Centers for Medicare & Medicaid Services, 2021).

Related utility of the proposed solution

The EHHMS is important as it focuses on the key areas of hand hygiene that are most likely to have poor compliance, thus contributing to HAIs. Offering timely analysis and evaluation, the system increases readiness and responsibility among staff and ensures patients’ safety and the observance of the corresponding objectives and requirements.

Implementation Plan

  • Needs Assessment and Stakeholder Engagement:

Identify the current best practices and consult with key stakeholders (including Executive leadership, Clinical departments, IT, Medical staff, and legal counsel) to determine an appropriate approach to the implementation of the EHHMS.

  • Selection and Customization of EHHMS:

Select a format for the vendor, modify the system to match the hospital processes, and connect its EHR with other EHRs.

  • Pilot Testing and Evaluation:

The EHHMS should be adopted gradually across the units in the hospital, thus gaining feedback data and using the pilot results to make modifications to the system.

Potential Implementation Challenges

The adoption of an electronic hand hygiene monitoring system (EHHMS) in order to tackle hospital-acquired infections (HAIs) entails various issues that have to be considered and managed to enhance the integration of the system within the healthcare facility. Among these, some key ones include staff resistance and the need to train the staff in order to make them understand the need for change and embrace innovation.

Employees in horizontal relationships may fail to adopt the new technology because of the low level of technological understanding or because they expect the new technology to disturb the present sequence of operations. To counter this, effective learning needs to be supported by the consistent integration of instructional strategies, which need to be targeted to the individual learner, their position and preferences. Practical demonstrative sessions accompanied by reinforcement and regular abounding training will reduce anxiety and provide assurance to the staff while practising EHHMS (Stone et al. , 2019).

The next major issue that needs to be adopted and implemented is the connectivity with other systems that are already in place. The documentation of patient care and other processes, along with data exchange with other information technology systems of the hospital, requires compatibility and integration of EHHMS with the hospital’s Electronic Health Record (EHR) and other information technology systems.

Securing IT specialists’ involvement during the planning phase, performing extensive compatibility checks, and developing gradual integration strategies are some of the measures that help minimise potential technical issues when integrating the components of a complex system.

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Role of Leaders in Change Management

This paper focuses on a case study of an intention to adopt an EHHMS apt for change management with leadership since improved infection control is a supreme goal in a healthcare setting due to high rates of HAIs. The levels of leadership activities within this context include the following: Leadership responsibilities essential in responding to the anticipated organisational transformation and the implementation of new technologies.

Leaders have to give a clear vision for people to see why the EHHMS is needed which is normally referred to as purpose. They should ensure this vision fits within the organization’s strategic plan by expanding on the organizational commitment to combating patient harm and elevating the quality of health care with an increase in hand hygiene compliance (Stone et al. , 2019). If the organisational leaders are clear with the vision, goals and objectives of the EHHMS implementation and the intended outcomes, then the stakeholders within the respective organisational levels shall be convinced fully to embrace such integration.

Communication Plan for Change Management

The importance of communication can also not be overemphasised in the change management process as it helps the leaders improve on the change management plan and to ensure that everyone in the organisation is on the same page. Leaders can implement various strategies to effectively communicate the EHHMS initiative and facilitate smooth adoption:

Managers and other leaders should communicate as they proclaim the existence of EHHMS as a crucial plan for achieving better outcomes. It provides the change blueprint, which outlines the change process and intentions, and it creates trust from the onset of the change process.

It is important to provide updates and status reports to keep the stakeholders informed of the implementation plan and process and any changes that have been made. Having more than one approach to reaching out to staff, entails early morning meetings, newsletters, and Intranet portal notices, which guarantees the dissemination of pertinent information to all stakeholders.

Workflow Related to the Technology

A study of the workflow of a health-care setting before and after installing the electronic hand hygiene monitoring system (EHHMS) entails assessing the strengths and weaknesses of the operational process before the new upgrade is put in place. This analysis is helpful in providing perspective on how the technology will improve infection control measures and decrease HAIs.

Pre-Implementation Workflow Analysis

Prior to the EHHMS being instituted, the monitoring of hand hygiene was a largely observational and documentation-based endeavour. Other forms of compliance checks include a lack of structure and organisation, such as peer observation, paper checklists, which produce less than ideal data and checklists done occasionally without proper documentation. Lack of communication was observed mainly because the workers in the establishment did not use systematic ways of alert or notification in case of breach of the guidelines.

Post-Implementation Workflow Analysis

They ensure a smooth delivery of services whenever the EHHMS is in place because several areas of the workings are subjected to improvement meant to increase efficiency, minimise errors and ensure compliance with the required hand hygiene. The EHHMS mechanises monitoring through equipment or items worn as bracelets that record hand-washing episodes in real-time. This automation also entails that data collection can proceed without breaking coasting to manual entries; this reduces human interference and thus enhances data quality, as noted by Stone et al. (2019).


Altogether, the improvement proposal to place an EHHMS means that our healthcare context’s infection control standards are about to be boosted by a concrete project: The Quality Improvement Project Plan. This project aims to make a positive impact in addressing specific issues concerning HAIs by incorporating technology-based systems to enhance the level of hand hygiene among personnel. In this project plan we have discussed a need for improvement of hand hygiene compliance and its negative effects to the patients as well as the health care facility.

Accumulated from current research works (Stone et al. , 2019), we have highlight the importance of this issue which needs the implementation of an EHHMS, to monitor it and reduce the HAIs occurrence as it will be automated to perform this task.

The evaluation of an existing and proposed technology solution has been discussed here to ensure the selection of the EHHMS which could provide real-time data analyzing of the existing work-flow of ICME organizations and an ability to provide feedback to the related work-flow automatically. Apart from improving the regularity of hand hygiene check, this approach also aids in the promotion of structural changes and improvement measures on hand hygiene and practices, and contributes to staff commitment on hand hygiene compliance.

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NURS FPX 8012 Assessment 1


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