Quality Improvement Initiative Evaluation

Imagine you have been asked to prepare and deliver an analysis of an existing QI initiative at your workplace. The QI initiative you choose to analyze should be related to a specific disease, condition, or public health issue of personal or professional interest to you, or you may use the hospice information provided in the Vila Health: Data Analysis activity in this assessment. The purpose of the report is to assess whether the specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Your target audience is nurses and other health professionals with specializations or interest in your chosen condition, disease, or public health issue.

In your report, you will:

Analyze a current QI initiative in a health care setting.
Identify what prompted implementation of the QI initiative.
Evaluate problems that arose during the initiative or problems that were not addressed.
Evaluate the success of a current QI initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements.
Identify the core performance measurements related to successful treatment or management of the condition.
Evaluate the impact of the quality indicators on the health care facility.
Incorporate interprofessional perspectives related to the success of actions used in the QI initiative as they relate to functionality and outcomes.
Recommend additional indicators and protocols to improve and expand outcomes of a current quality initiative.
Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.
Be sure to address all of the bullet points. You may also want to read the Quality Improvement Initiative Evaluation Scoring Guide to better understand the performance levels that relate to each grading criterion. Additionally, be sure to review the Guiding Questions: Quality Improvement Initiative Evaluation [DOCX] document for additional clarification about things to consider when creating your assessment.

Additional Requirements
Your assessment should also meet the following requirements:

Length of submission: A minimum of five but no more than seven double-spaced, typed pages, not including the title page and References section.
Number of references: Cite a minimum of four sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work. Review the Nursing Master\'s Program (MSN) Library Guide for guidance.
APA formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 2: Plan quality improvement initiatives in response to routine data surveillance.
Recommend additional indicators and protocols to improve and expand outcomes of a quality initiative.
Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.
Analyze a current quality improvement initiative in a health care setting.
Evaluate the success of a current quality improvement initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements.
Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work life quality.
Incorporate interprofessional perspectives related to the success of actions utilized in a quality improvement initiative as they relate to functionality and outcomes.
Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.
Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.


Quality Improvement Initiative Evaluation

Quality of care is a profound, multifactorial concept that defines practices, policies, and initiatives of global healthcare systems. Although ensuring care quality is an overarching goal for healthcare organizations and professionals, it is a daunting endeavor to provide care services that address all dimensions of quality care. According to Keßler & Heidecke (2017), factors that define the quality of care are process safety, effectiveness, patient-centeredness, timelines, equity, and efficiency. Amidst the determination to achieve all these dimensions of quality care, healthcare professionals encounter various challenges that compromise service delivery and expose patients to multiple safety threats. Hospital-acquired infections (HAIs) are among the major threats to patient safety and care quality. Asfaw (2021) argues that hospital-acquired infections pose a significant health and safety threat to hospitalized patients by perpetuating multiple adverse consequences, including increased mortality rates, prolonged hospitalization, and increased care costs. Examples of HAIs are catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), and ventilator-associated pneumonia (VAP) (Centers for Disease Control and Prevention, 2019). This paper provides an analysis of an organizational-level quality improvement initiative for preventing hospital-acquired infections.

Analyzing a Current Quality Improvement Initiative in a Healthcare Setting

Our organization has a functional policy and quality improvement program for preventing and controlling hospital-acquired infections. This policy focuses on a bundled model that has various strategies and procedures, including hand washing protocol, cleansing of urethral meatus before catheter insertion, wearing personal protective equipment (PPEs), the use of CHG sponge (chlorhexidine gluconate impregnated dressings), and patient bath using antiseptics. According to Puro et al. (2022), healthcare facilities can prevent hospital-acquired infections by implementing effective infection prevention and control (IPC) measures that focus on collaboration among healthcare professionals, widespread diffusion across hospital units, and shared knowledge. As a result, healthcare professionals in our organization have emphasized the use of a bundled model in preventing hospital-acquired infections, especially after the COVID-19 pandemic.

Identifying Factors that Prompted the Implementation of the Quality Improvement Initiative

The major factor that informed the need to implement a contingency plan for preventing hospital-acquired infections is the overarching objective of safeguarding patient safety by addressing threats to clients’ health and wellness. Our organization shares the mission of improving individual and community health by emphasizing collaborative and evidence-based practices. Equally, the emergence of the COVID-19 pandemic as a highly transmissible viral infection prompted the implementation of urgent, yet evidence-based approaches for preventing the disease transmission and progression. Baker et al. (2021) contend that COVID-19 contributed massively to improving organizational interventions for infection prevention and control. In this sense, healthcare facilities embarked on hand washing protocols, training employees on donning and doffing of personal protective equipment, compliance with contact precautions, and improving hygiene standards through environmental disinfection. Our hospital was not an exception to the impacts of the COVID-19 pandemic on institutional measures for preventing and controlling infections.

Problems that Arose During the Initiative

Although our institution has a functional quality improvement initiative for preventing and controlling infections, various challenges emerge during the enactment of an organizational-wide bundled plan. These problems are nursing staff shortages, healthcare professionals’ unfamiliarity with new approaches for containing the COVID-19 pandemic, and resource issues. Lowe et al. (2021) contend that inadequate hospital infrastructure, a lack of in-service training, supply chain distributions, high infection rates, and many patients needing timely care interventions are challenges that compromise interventions for preventing and controlling hospital-acquired infections. During the COVID-19 pandemic, our hospital grappled with overcrowding, overwhelmed departments, nursing staff shortages, and time pressures that affected the implementation of the quality improvement initiative.

Recognized Benchmarks and Outcome Measures as Required to Meet National, State, or Accreditation Requirements

Healthcare facilities can track benchmarks and outcome measures for hospital-acquired infections by using data from the National Healthcare Safety Network (NHSN). According to Healthy People 2030 (n.d.), the NHSN collects data from over 37000 healthcare facilities in all states. Our organization is among health facilities that use data from the National Healthcare Safety Network to track and report hospital-acquired infections. The data obtained from over 37000 health facilities enables the NHSN to establish a national, state, and local benchmarks for hospital-acquired infections. According to the National Healthcare Safety Network [NHSN] (2022), healthcare institutions can calculate the rate of HAIs, including catheter-associated urinary tract infections [CAUTI) by dividing the number of CAUTIs by the number of catheter days and multiplying the result by 1000. Further, the NHSN argues that CAUTI rates range from 0.0 per 1000 catheter days to 35.3 per 1000 catheter days depending on various considerations, including location types, bed size, and type of medical school affiliated with the facility.

Our hospital’s performance has been consistently unconvincing when using the NHSN recommendations for CAUTI rates as the guiding benchmark. Over the last two years, the facility has maintained an average CAUTI rate of 33 per 1000 catheter days, creating a sense of urgency for the implementation of evidence-based quality improvement initiatives. Equally, a high rate of HAIs has resulted in financial consequences for the hospital. For instance, Vokes et al. (2018) argue that the Center for Medicare and Medicaid Services (CMS) implements the Value-based purchasing (VBP) program and the Hospital-acquired condition reduction program that reduce reimbursement by 1% for healthcare facilities whose performances fall in the worst 25% of hospitals for HAC metrics. Our hospital is at risk of enduring these financial regulations and deductions.

Core Performance Measurements Related to Successful Treatment or Management of the Condition

The hospital can use various core performance measurements to assess the effectiveness of a quality improvement initiative for preventing and controlling hospital-acquired infections (HAIs). Examples of these measures include compliance with the use of personal protective equipment (PPEs), adherence to hand hygiene protocols, effective environmental risk assessments, development of comprehensive patient safety guidelines, in-service training programs for healthcare professionals, safer working systems, and approaches for reporting, managing, and analyzing incidents of hospital-acquired infections. These core performance measurements are consistent with the Donabedian model for care quality that focuses on synergistic relationships between organizational structure, process, and outcome measures.

The Impact of the Quality Indicators on the Healthcare Facility

Quality indicators of a contingency plan for preventing and controlling hospital-acquired infections include improved adherence to hand hygiene, the development of comprehensive clinical guidelines for ensuring patient safety, in-service training and education programs, and the implementation of safer working systems. These indicators emphasize the synergistic relationships between organizational structure, process, and outcome measures (Binder et al. 2020). Consequently, they influence team perspectives of care quality, encourage the healthcare facility to invest massively in interventions to prevent adverse events like hospital-acquired infections, and establish the rationale for improving employees’ knowledge and awareness of quality improvement initiatives through education and in-service training.

Interprofessional Perspectives Related to the Success of Actions Used in the Quality Improvement Initiative

Teamwork and interprofessional collaboration are profound aspects of enhancing the effectiveness of a quality improvement initiative for preventing and controlling hospital-acquired infections. The Joint Commission (2022) documents a compendium of updated strategies for preventing healthcare-associated infections. These advanced approaches include synthesizing the best evidence to prevent infections and emphasizing individual and group accountability in implementing infection prevention practices. In this sense, a team-based approach to effective prevention and control of HAIs consolidates inputs and knowledge from physicians, nurses, nurse assistants, and other healthcare stakeholders to facilitate the enactment of evidence-based practices, including periodic in-service training, development of clinical guidelines for urinary catheter insertion, maintenance, and removal, environmental hygiene, and timely reporting and communication of adverse incidents.

Additional Indicators and Protocols to Improve and Expand Outcomes of the Current Quality Initiative

The hospital can strengthen the current quality improvement initiative for HAIs prevention and control by implementing various additional indicators and protocols. Vokes et al. (2018) recommend horizontal and vertical interventions, including active detection of infections, development of safety checklists that emphasize risk reduction, change implementation, and environmental modification strategies like fitting clinical rooms with copper alloy surfaces to prevent infections. Equally, educating healthcare professionals, implementing a laboratory-based alert system, using single occupancy rooms, and improving infection surveillance reporting systems are profound approaches for enhancing and expanding outcomes of the current healthcare Initiative.


Healthcare-associated infections (HAIs) pose a significant health concern by increasing the mortality rate, inflicting a massive economic burden on healthcare systems, and compromising patient safety. Although our hospital has a functional policy and quality improvement initiative for HAIs, it is essential to address problems that manifest when actualizing contingency plans. The proven options for improving and expanding outcomes of the current quality initiative for HAIs prevention and control are emphasizing in-service training and education, enhancing infection surveillance using advanced technologies, including laboratory-based alert systems, implementing single occupancy rooms policy to prevent overcrowding, and analyzing the best evidence to inform decisions and practices.


Asfaw, N. (2021). Knowledge and practice of nurses towards prevention of hospital-acquired infections and its associated factors. International Journal of Africa Nursing Sciences, 15, 100333. https://doi.org/10.1016/j.ijans.2021.100333

Binder, C., Torres, R. E., & Elwell, D. (2020). Use of the Donabedian model as a framework for COVID-19 response at a hospital in suburban Westchester County, New York: A facility-level case report. Journal of Emergency Nursing, 47(2). https://doi.org/10.1016/j.jen.2020.10.008

Centers for Disease Control and Prevention. (2019). Types of healthcare-associated infections. https://www.cdc.gov/hai/infectiontypes.html

Healthy People 2030. (n.d.). National Healthcare Safety Network (NHSN). Retrieved November 26, 2022, from https://health.gov/healthypeople/objectives-and-data/data-sources-and-methods/data-sources/national-healthcare-safety-network-nhsn

Keßler, W., & Heidecke, C.-D. (2017). Dimensions of quality and their increasing relevance for Visceral Medicine in Germany. Visceral Medicine, 33(2), 119–124. https://doi.org/10.1159/000462997

Lowe, H., Woodd, S., Lange, I. L., Janjanin, S., Barnett, J., & Graham, W. (2021). Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: A qualitative study. Conflict and Health, 15(1). https://doi.org/10.1186/s13031-021-00428-8

National Healthcare Safety Network. (2022). Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) events (pp. 1–18). https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf

Puro, V., Coppola, N., Frasca, A., Gentile, I., Luzzaro, F., Peghetti, A., & Sganga, G. (2022). Pillars for prevention and control of healthcare-associated infections: An Italian expert opinion statement. Antimicrobial Resistance & Infection Control, 11(1). https://doi.org/10.1186/s13756-022-01125-8

The Joint Commission. (2022). Compendium of strategies to prevent healthcare-associated infections. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/compendium-of-strategies-to-prevent-healthcare-associated-infections/

Vokes, R. A., Bearman, G., & Bazzoli, G. J. (2018). Hospital-acquired infections under pay-for-performance systems: An administrative perspective on management and change. Current Infectious Disease Reports, 20(9). https://doi.org/10.1007/s11908-018-0638-5

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