Defining quality

NURS 4220

Capstone Paper Guide

The Capstone Paper is the culminating assignment of your undergraduate-nursing program at Walden University. In this assignment you will identify a quality improvement practice problem, review and synthesize evidence-based practice evidence, and propose an evidence-based quality improvement plan that you will use to address your practice problem.

Capstone Paper Overview

The Capstone Paper is written in sections each week and submitted for grading in two parts.

Capstone Paper: Part I (3-4 pages) includes the Practice Problem; Analysis of Evidence; and Quality Improvement Process sections that are written during the first three weeks of the course. The Capstone Paper, Part I will be submitted for grading at the conclusion of Week 3.

Capstone Paper: Part II (3-4 pages) includes the Evidence-Based Practice Quality Improvement Plan Explanation and Project Resources sections written in weeks 4 and 5. Part II of the capstone paper is submitted for grading at the conclusion of Week 5.

The two parts of the Capstone paper are designed to be combined into one document and used in conjunction with your storyboard to present a quality improvement plan. You may use these documents demonstrate to your employer an understanding of quality improvement processes that improve patient care and/or patient
safety.

Assignment Template

You will use the Walden University APA Course Template to complete this Assignment.

· Walden University Writing Center. (n.d.).
Walden templates: General templates.
http://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-2774360

· Download the APA course paper template with advice.

· Review the webinar on using a template.

· Delete the abstract page in the template. This is not required for this course.

· The template includes the correct font and formatting: 12 pt. Times New Roman font, double spacing, and 1-inch margins on all sides.

Writing Standards

· Note the new expectations for

Use of evidence

and
Credit to Source

· Review the following websites and webinars on writing:

· Walden University Writing Center. (n.d.).
Scholarly voice: Overview.
http://academicguides.waldenu.edu/writingcenter/scholarlyvoice

· Walden University Writing Center. (n.d.).
Webinars: Scholarly writing.
http://academicguides.waldenu.edu/writingcenter/webinars/scholarlywriting#s-lg-box-2773859

· Walden University Writing Center. (n.d.).
Using evidence: Synthesis.
http://academicguides.waldenu.edu/writingcenter/evidence/synthesis

Rubrics (found on the Course Information page)

· Week 3 Assignment Rubric

· Week 5 Assignment Rubric

Capstone Paper, Part I

·
Introduction (Completed in Week 1)

· State the practice problem in measurable terms and that reflect quality indicators.

This is the same problem described in the Week 1 Practice Experience discussion.

Provide the rationale for selecting the practice problem

· Include a purpose statement.

·
Analysis of Evidence (Completed in Week 2)

· Synthesize a minimum of 5 evidence-based practice resources that support your practice problem. Include a minimum of two to three research studies obtained from the Walden Library.

·
Quality Improvement Process (Completed in Week 3)

· Describe the quality improvement process and a brief overview the quality model that will be used to improve your practice problem. Include a description of a quality tool that will be used in the quality improvement plan.

· This process will be used to support the detailed proposed quality improvement plan in Week 4

· Explain why the specific quality model was selected and document your explanation with references.

·
Summary

· Summarize the key points discussed in the paper.

Capstone Paper, Part II

·
Quality Improvement Plan (Completed in Week 4)

· Using the Quality Improvement Model as a framework provide a detailed explanation of the quality improvement plan that you will use to address the practice problem.

· Use the scholarly references identified in the analysis of evidence to support the quality improvement plan.

·
Resources (Completed in Week 5)

· Describe the resources needed to support the change in practice such as personnel time, supplies for staff education, cost of new equipment, or cost of software.

· Explain why each resource is necessary.

·
Summary

· Summarize the key points discussed in the paper.

Capstone Paper Schedule and Due Dates

Capstone Paper, Part 1	Week Assigned	Date Due
Introduction  · State the practice problem in measurable terms and that reflect quality indicators. · This is the same problem described in the Week 1 Practice Experience discussion. · Keep in mind that this section may need to be revised after you complete all of the other sections. · Provide the rationale for selecting the practice problem.	Week 1	Day 7 of Week 3
Analysis of Evidence · Synthesize a minimum of at least five evidence-based practice resources that support your practice problem.	Week 2	Day 7 of Week 3
Quality Improvement Process  · Describe the quality improvement process. Include a description of a quality tool that will be used in the quality improvement plan · This process will be used to support the proposed quality improvement plan. · Explain why the specific process was selected and document your explanation with references. · Summary  · Summarize the key points discussed in the paper. · Submit to Week 3 Assignment submission link	Week 3	Day 7 of Week 3
Capstone Paper, Part II	Week Assigned	Date Due
Quality Improvement Plan  · Using the Quality Improvement Process described in Week 3, provide a detailed explanation of the quality improvement plan that you will use to address the practice problem. · Use scholarly references identified during the analysis of evidence to support the plan.	Week 4	Day 7 of Week 5
Resources (2–3 paragraphs) · Describe the resources needed to support the change in practice such as personnel time, supplies for staff education, cost of new equipment, or cost of software. · Explain why each resource is necessary. Summary  · Summarize the key points discussed in the paper.	Week 5	Day 7 of Week 5
· Submit to the Week 5 Assignment submission link	Week 5	Day 7 of Week 5

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NURS 4220: Leadership Competencies in Nursing and Healthcare

Full Guide: Practice Experience Quality and Safety Project

Learning Outcomes

· Apply definition of quality to work setting

· Identify a quality improvement practice problem

· Identify measurement standards for a problem identified in healthcare

· Summarize the purpose, methods, and findings from the evidence-based literature that relate to a practice problem

· Apply a quality improvement model to a practice problem

· Apply a quality improvement process to an improvement plan

· Recommend strategies to reduce the cost of care

· Develop a quality improvement storyboard to address a practice problem

Suggestions for Discussions

The more you discuss your project with your group the better it will turn out. Consider posting earlier than Thursday to have a better discussion.  Provide honest, respectful feedback to each other. (
Picture yourself as someone practicing in the other student’s work setting, working with and listening to your colleagues’ ideas weekly (as your read each other’s posts). You are responsible for helping your colleagues make the best decision in class in the same you would be if you were working side-by-side.

Each week’s activities are geared to help you move along with your proposal. Use this time well and utilize some aspect of your capstone paper to support your proposal as well.
R
ead about the whole project before you start.

Practice Experience Quality and Safety Project

The practice Experience is an active learning experience that provides you with the opportunity to apply nursing knowledge and skills that you are acquiring in NURS 4220 to experiences in a healthcare setting. The practice experience is comprised of selected onsite experiences and weekly practice experience discussions. Throughout your practice experience you will collaborate with leaders and other colleagues, with fellow students in practice experience discussion groups, and with your faculty who serve as preceptors. Each week of the course outlines specific activities or reflections you will engage in during your practice experience as you complete your proposed Practice Experience Quality and Safety Project
. (
Note: The practice problem must be related to patient outcomes, and staffing cannot be your main practice problem for the completion of the capstone project.) A complete description is presented on the Practice Experience discussion page of each week and is included below. A brief outline of the activities is also presented below. The practice experience for NURS 4220 is approximately 72 hours (a time log is not required).

The purpose of the Practice Experience Quality and Safety Project is for you to design and offer an evidence-based change in practice to improve a quality and safety problem specific to your work setting to possibly be
implemented once the course is over and once approved by management at your setting. The team discussion provides an avenue for you to share ideas, to critique each other’s work, and to offer support to each other as a team. Your instructor acts as the preceptor to facilitate your team discussions to offer guidance as needed.

Each week, your instructor will assign a discussion to the class. Within an instructor-assigned discussion team, you will participate in a total of five discussions for this project. Satisfactory completion of these five discussions, Storyboard Presentation of your Practice Experience Quality and Safety Project, and satisfactory mentor feedback will satisfy the requirement for the practice experience.

Throughout your practice experience you are expected to collaborate with leaders and other colleagues in your practice setting. Your approved mentor will electronically verify your participation in the Practice Experience. This verification must occur by the last day of the course. All students who do not have mentor feedback in Meditrek or the designated electronic system by the last day of the term, will receive a grade of F regardless of points earned on other course assignments. If a student receives a grade of F due to lack of mentor feedback it is the student’s responsibility to work with the faculty, mentor, and or Field Office to correct the situation within 60 days of the last day of the course and notify the faculty mentor feedback has been submitted to Meditrek. After 60 days if mentor feedback has not been received the grade of F will be final.

Week 1

Practice Experience Discussion: Identifying a Practice Problem in Need of Improvement

In this week’s main discussion, you shared your experiences with healthcare practice problems as a consumer and/or as a practitioner. Now, consider your current practice setting and think about something specific and relevant to your practice setting that you would like to see improved or changed. Interview a key leader in your practice setting who can confirm that your practice problem is needed for enhancing delivery or performance in the field. It is important to remember from the beginning that your practice problem must be
measurable.

The practice problem identified will be the topic of both your practice experience project, capstone paper, and your storyboard. The capstone paper will be the detailed written explanation of the steps needed to address the practice problem using a quality improvement model. These steps will be explained during the practice experience discussion during Weeks 1 – 5 and presented on the quality improvement storyboard in Week 6.

By Day 4

Identify a measurable patient-centered practice problem related to quality or safety and relevant to your practice setting that you will also focus on in your Capstone Paper and post a brief description of the problem and an explanation of why you selected it. Explain how the conversation you had with the key leader in your practice setting impacted your decision to address this particular practice problem. Be sure to support your practice problem with the literature that indicates the relevance of this problem for nursing practice. Provide evidence from your practice area and describe the data that is available.

You will not be collecting any data during the practice experience project; you will use data already available to you in your workplace or other practice setting. Think about the different kinds of data that is shared with you in your work area. For example, data may include patient satisfaction scores, medication error rates, fall, CLABSI or CAUTI rates. Analyzing the data available to you is how you will identify that a quality problem exists. Data identifies potential areas for improvement and monitors the effectiveness of any changes. 
It is important to obtain baseline data before beginning a quality improvement project and to analyze results during and at the end of a project.

Note: The practice problem must be related to patient outcomes. (
Staffing cannot be your main practice problem for the completion of the Practice Experience Project and Capstone Paper.)

Note: If you use the same practice problem that was presented in the Week 1 Discussion on quality theories, keep in mind that you must be much more specific in this post and explain how it is relevant to your setting and nursing practice.

By Day 7

Read two or more of your colleagues’ postings from the Discussion question. 

Respond to at least two of your classmates. As a member of a community of practice, help each other refine and clarify the patient-centered Practice Experience Project. Provide support and suggestions on the importance of the practice problem in improving patient outcomes.

Post a Discussion entry on 
three different days of the week.

Week 2

Practice Experience Discussion: Applying Measurement Tools to a Practice Problem

Conduct a collaboration interview with two or three key leaders in your practice setting to determine the measures for your practice problem and associated challenges impacting measurement for your practice problem (include confidentiality, anonymity, access issues, etc.). Perform a literature review on your practice problem that elicits how this problem is measured across the country.

By Day 4

Post a description of the measures identified from the interviews, the challenges to obtaining the data that were discussed, and a summary of how this quality indicator is measured in the literature. Discuss any gaps in the data that were identified and additional sources that might be needed to obtain this data. Be sure to support your practice problem with the literature that indicates the relevance of this problem for nursing practice. Provide evidence from practice and data that is available.

By Day 7

Read and respond to two or more of your colleagues’ postings from the Discussion question. Provide feedback on the quality of data that was obtained and recommendations on where additional sources of data might be found. As a member of a community of practice, help each other refine and clarify the patient-centered Practice Experience Project.

Post a Discussion entry on 
three different days of the week

Week 3

Practice Experience Discussion: Applying Process Improvement Models to your practice problem.

Choose a Quality Improvement Model from Chapter 5 in the Spath (2018) textbook and apply this model to your practice problem. Please do not choose Lean or Six Sigma as your quality model unless you have an expert in these quality models in your organization to guide you through the process.

PDSA (p.124).
RCI (p.127).
FOCUS PDCA (p.128).
FADE (p.129).

By Day 4

Post a Discussion entry describing the model that you selected and how each step of the model will be used to develop the plan for the Practice Experience Project. Continue to collaborate with the selected individuals in your practice environment as needed in the development of the Practice Experience Project and share this information with your group.

By Day 7

Read and respond to two or more of your colleagues’ postings from the Discussion question. Provide feedback on the selected model, and offer other models if appropriate for their project. As a member of a community of practice, help each other refine and clarify the patient-centered Practice Experience Project.

Post a Discussion entry on 
three different days of the week.

Week 4

Practice Experience Discussion: Developing the Quality Improvement Plan

The next step in the process is to begin identifying the challenges and impediments to implementing a quality improvement plan. In the analysis consider the individuals affected by the change as well as the cost of implementing the quality improvement plan.

By Day 4

Post a description of some of the proposed action steps for implementing improved practice and explain where potential challenges might compromise your proposed improvement project. Describe what resources are needed for your solution and explain whether those resources are cost-effective or not. Continue to collaborate with the selected individuals in your practice environment as needed in the development of the Practice Experience Project and share this information with your group.

By Day 7

Read and respond to two or more of your colleagues’ postings from the Discussion question. Provide feedback on potential challenges you see might compromise the improvement project and what other resources might be more cost effective. As a member of a community of practice, help each other refine and clarify the patient-centered Practice Experience Project. 

Post a Discussion entry on 
three different days of the week.

Looking Ahead: Discuss this potential project with a leader or manager in your facility and incorporate their feedback into the quality improvement storyboard you will submit in Week 6.

Week 5

Practice Experience Discussion: Applying Key Interventions to a Practice Problem

The final step is to develop the plan discussing the steps clearly and succinctly. The plan must be evidence-based.

By Day 4

Post an explanation of how you could apply key interventions supported by the scholarly research evidence to potentially help resolve the issue in measurable ways. Continue to collaborate with the selected individuals in your practice environment as needed in the development of the Practice Experience Project and share this information with your group.

By Day 7

Read and respond to two or more of your colleagues’ postings from the Discussion question. Provide feedback about the selected measures or provide suggestions for improving how the patient quality and safety outcomes could be addressed by care coordination techniques and effective leadership style. As a member of a community of practice, help each other refine and clarify the patient-centered Practice Experience Project.

Post a Discussion entry on 
three different days of the week.

Looking Ahead: Discuss this potential project with a leader or manager in your facility and incorporate their feedback into the quality improvement storyboard you will submit in Week 6.

Week 6

Practice Experience Discussion: Presenting a Quality Improvement Plan

Storyboard Instructions

The Practice Experience Project Storyboard is a brief, visual summary of a completed quality improvement initiative. The storyboard highlights key aspects of a quality improvement effort by documenting the Practice Experience Project from beginning to end.

The course template uses a PowerPoint format to complete this assignment. You only need to provide 
two slides, 
no more. The first slide is the summary of your project; the second slide is the reference page. You will need to choose the most pertinent information from your practice experience and Capstone Paper to complete the Storyboard. No voiceover is required. 

The completed storyboard is submitted for grading. 
Optional: You may submit your storyboard to the group discussion area and share your presentation with your classmates and instructor.

By Day 4

Submit your quality improvement storyboard using the provided template.

Revised 07/2021

DEFINING QUALITY

As health care consumers, we all expect quality care and positive outcomes. It is important as professionals that we meet these demands of health care consumers. Consider the work of the major theorists you examined in this week’s Resources and think about how these theories apply to your own experience as a health care customer and/or practitioner.

Resources:

· Spath, P. (2018). 
Introduction to healthcare quality management (3rd ed.). Health Administration Press.

· Chapter 1, “Focus on Quality” (pp. 1–12)

· Chapter 2, “Quality Management Building Blocks” (pp. 13–34)

· Preview Chapter 3, “Measuring Performance” (pp. 43–46)

 

· Yoder-Wise, P. S. (2019). 
Leading and managing in nursing (7th ed.). Mosby.

· Chapter 1, “Leading, Managing, and Following” (pp. 1-18)

· Chapter 2, “Clinical Safety: The Core of Leading, Managing and Following” (pp. 19-31)

· QP staff. (2010). 

Guru guide: Six thought leaders who changed the quality world foreverLinks to an external site.
. 
Quality Progress, 43(11), 14–21.

 

·
Document: 

Practice Experience Full Guide (PDF)

Download Practice Experience Full Guide (PDF)

 

·
Document: 

Quality Improvement Storyboard Template (PPT)

Download Quality Improvement Storyboard Template (PPT)

 

·
Document: 

Capstone Paper Assignment Guides (Word Document)

Post your definition of quality, and apply it to the work of one major quality theorist (e.g., Donabedian, Juran, Deming, Triple Aim (IHI) – Berwick). Identify a practice problem that you have had some experience with as a customer or as a practitioner and explain how eliminating wasteful practices could have improved the experience. Include how your definition of quality applies to that experience.

Support your response with references from the professional nursing literature. Your posts need to be written at the capstone level.

Notes Initial Post: This should be a 3-paragraph (at least 350 words) response.

Read two or more of your colleagues’ postings from the Discussion question.

Respond with a comment that asks for clarification, provides support for, or contributes additional information to 
two or more of your colleagues’ postings.

Frances Pittman

Quality in healthcare 

Quality in healthcare is a paramount concern and can be defined as the degree to which a product, service, or process meets or exceeds customer or stakeholder expectations and requirements. It encompasses various dimensions such as safety, effectiveness, efficiency, timeliness, patient-centeredness, equity, and accessibility. Achieving and maintaining high-quality outcomes is a fundamental goal in healthcare, as it ensures safe, effective, and patient-centered care delivery. 

Applying Quality Theory to the Work of Donabedian: A major quality theorist in healthcare is Avedis Donabedian. Donabedian developed the framework of quality assessment and improvement, known as the Donabedian model or the structure-process-outcome model. According to Donabedian, the quality of healthcare can be assessed based on three interrelated components: structure, process, and outcomes. The structure refers to the characteristics of the healthcare system, such as resources, facilities, and personnel. The process involves the activities and interactions that take place in healthcare delivery. The outcomes are the effects of healthcare on patients’ health status and satisfaction. 

Wasteful practices 

One practice problem that can be improved by eliminating wasteful practices is excessive documentation in nursing. Excessive documentation can lead to inefficiencies, decreased time spent with patients, and increased nurse workload. To address this issue, evidence-based strategies have been suggested. For example, the use of standardized documentation templates has shown promise in reducing redundancy and unnecessary paperwork (Blackwood et al., 2017). Additionally, effectively utilizing electronic health records (EHRs) and streamlining documentation processes can help optimize workflow and enhance direct patient care (Keenan et al., 2018). 

Streamlining documentation practices not only increase efficiency but also positively affects patient outcomes and satisfaction. Research suggests that excessive documentation can divert nurses’ attention from direct patient care, potentially leading to communication breakdowns and errors. By reducing documentation burdens, nurses can devote more time to patient interaction, assessment, and intervention, resulting in improved patient experiences and outcomes (Scholl et al., 2018). 

In conclusion, addressing wasteful practices in nursing, such as excessive documentation, is crucial for enhancing the quality of patient care. Through the application of strategies like standardized templates and optimized EHR utilization, nurses can streamline documentation processes and allocate more time to direct patient care. Ultimately, this can lead to improved patient outcomes, increased satisfaction, and better utilization of nursing resources. By incorporating evidence-based approaches and focusing on the structure, process, and outcome aspects of healthcare quality, healthcare organizations can continue to strive for excellence in nursing practice and patient care. 

References 

Blackwood, J., Cummings, G., Espin, S., & Scott, S. D. (2017). The impact of electronic health records on nurses’ productivity: An interrupted time series analysis. Journal of the American Medical Informatics Association, 24(3), 596-601. doi:10.1093/jamia/ocw152 

Keenan, G. M., Yakel, E., Tschannen, D., & Mandeville, M. (2018). Nursing workflow and environmental disruptions: A qualitative study using EHR event reconstruction. AMIA Annual Symposium Proceedings, 2018, 684-692. 

Scholl, I., Zill, J. M., Härter, M., Dirmaier, J., & Ansmann, L. (2018). Documentation of patient involvement in decision-making in medical encounters: A systematic review. Health Expectations, 21(3), 539-553. doi:10.1111/hex.12644 

Csilla Orban Bonacci

 

I believe quality is a measure of how well we do something in such a way that it adheres to standards of care while having positive outcomes. I think I agree with Donabedian’s approach to measuring healthcare: we need to look at structure, process, and outcomes. It starts with structure and which can affect somewhat process and then the process affects outcomes. I do believe though that even though structure might be affected, process does not mean it has to in every aspect. For example, just because we have 4 nurses instead of 5 working the floor it does not mean that those 4 cannot or should not wash hands before patient care just because there is one less nurse on the floor. I think even if the structure is a bit weak, there are areas where nurses can still do well by adhering to standards of care. I do believe that some structural issues can affect processes, too, but I just believe not all processes should be affected because of structural issues. Process however can greatly affect outcomes. Not using sterile instruments on a patient can lead to infection or sepsis ( Berwick, 2016).

In terms of wasteful practices I have found that a lot of the big hospitals waste a lot of products by not using certain products of using them by mistake by untrained staff. For example, many new nurses do not know the difference between the tubing used for regular IV and those for blood administration. So, he or she picks one up from the clean supplies room and opens the bag in the patient room only to realize it was the wrong tubing. Same thing happens with dressings, gauze, etc. I believe patients should have everything available even if it costs the hospital money. Quality care is given by using enough resources and quality resources; however, waste happens that costs the hospital money when we do not appropriately train staff to recognize products. This is just one example of an area where waste occurs. Then we are out of products we need and we have to make do with other products until the hospital orders more. This can delay appropriate care using the right products, right tools, and right materials. Not using the appropriate medicines, gauze, dressing, etc. can affect patient care; it can affect the quality of care. Donabedian believed that quality is measured by “the end results of healthcare”(Berwick, 2016).

References

Berwick D, Fox DM. “Evaluating the Quality of Medical Care”: Donabedian’s Classic Article 50 Years Later. Milbank Q. 2016 Jun;94(2):237-41. doi: 10.1111/1468-0009.12189. PMID: 27265554; PMCID: PMC4911723.