Project: Healthcare Quality Improvement Initiative And Evaluation Report Competencies you will demonstrate your mastery of the following competencies: A

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you will demonstrate your mastery of the following competencies:

  • Analyze healthcare quality metrics
  • Determine an opportunity for a healthcare improvement initiative
  • Recommend a healthcare quality improvement initiative and evaluation process


Throughout this course, you have learned how to analyze healthcare quality metrics, determine an opportunity for a healthcare improvement initiative, and recommend a healthcare quality improvement implementation plan and evaluation process. In this project, you will demonstrate the knowledge and skills needed to improve healthcare delivery for an organization. Choose a clinically or non-clinically based healthcare organization that releases public-facing data. You may decide to select a local organization or one where you work or have been a patient. For this project, you will be creating a healthcare quality improvement initiative and evaluation report in which you will describe the issue at the outset, the setting, the problem to be solved, the parties affected, and the reason why the issue is important to address. You will recommend a concise implementation plan and describe in detail how you plan to evaluate if your implementation was successful.


For the purposes of this project, imagine that you work on a team that monitors quality and risk management within the organization you selected. Whether you are coming from a nursing lens or a healthcare administration lens, your task is to analyze the healthcare quality metrics for the organization you selected. Based upon your analysis of the data, you will determine an opportunity for a healthcare improvement initiative for the organization. Then, you will provide a recommendation so that the organization can improve the quality and/or safety of its healthcare delivery. Finally, describe how you will evaluate the effectiveness of your plan.


Your report should contain the following sections:

  1. Metric analysis: Analyze the healthcare quality metrics of your chosen healthcare organization based on their public data.
    1. Interpret the data and metrics related to the effectiveness of a healthcare organization.
    2. Assess the validity and quality of the healthcare quality improvement data that support the need for the improvement opportunity you will include in your report.
    3. Derive insights and opportunities from the data.
  2. Opportunity for improvement: Determine an opportunity for a healthcare quality improvement initiative for the healthcare organization you selected.
    1. Explain how the metrics drive an opportunity for improvement.
    2. Determine an evidence-based quality improvement tool for addressing an improvement opportunity.
    3. Apply a problem-solving framework or tool to identify what could have been done differently based on the metrics and show and/or describe your application of the tool or framework.
  3. Recommendation: Provide a recommendation for the organization you selected so that the organization can improve the quality and/or safety of its healthcare delivery and determine how to evaluate if your recommendations were successful.
    1. Develop a healthcare quality improvement initiative using a framework, such as plan-do-study-act (PDSA), root cause analysis (RCA), and failure mode effect analysis (FMEA).
    2. Determine an evaluation method for a healthcare quality improvement initiative for 1, 3, 6, and 12 months and describe that method in detail.
    3. Determine data-collection tool(s).

Your project should provide evidence from at least five scholarly sources.

What to Submit

To complete this project, you must submit the following:

Healthcare Quality Improvement Initiative and Evaluation Report
Submit your healthcare quality improvement initiative and evaluation report as a Word document. Your submission should be approximately 4 to 6 pages 

Supporting Materials

Website: Find and Compare Nursing Homes, Hospitals, and Other Providers Near You
This website will help you find and compare homes, hospitals, and other providers near you.

Website: AHRQ
The Agency for Healthcare Research and Quality website will help you find metrics from healthcare providers. The data visualizations under the Data tab are also worth exploring. AHRQ also has toolkits and best/leading practices that you may want to refer to.


Healthcare Improvement Initiative

Veronica Horne

Southern New Hampshire University

February 6, 2022

IHP 604

Selection of Area of Improvement

St. Jude Children’s Research hospital’s area of improvement is the cancer services required for children with cancer. There needs to be efficacy in applying the services through information technology to reduce human errors. The public-facing data that will be utilized will include the Public Access Data Tables, which will show the information collected and analyzed from participants in the Childhood Cancer Survivor Study (CCSS).

Selection of Method of Improvement

The method adopted for improving cancer care is implementing and improving electronic order entry with a system to activate order sets (Dobrozsi et al., 2019). The plan would help notify the health providers in St. Jude of fever or related complications before the patient arrives on the hospital premises.

Selection of Framework to Use in Improvement Initiative

Program-wide interventions through process maps will be the utilized method of improvement for cancer care in children. There will be an initiation of a PDSA process in each affiliate program (Coury et al., 2017). Specifically, it will improve timely antibiotic administration for children with febrile neutropenia. Besides, it will also help cancer patients with sepsis.

Discuss your Selections

I selected the area of improvement because diagnosing cancer in a child or young adult is an emotionally overwhelming experience (Morgan et al., 2019). Therefore, the kind of care offered at St. Jude hospital must improve the child’s condition without risking health. The selected method of improvement will help the health practitioners determine the patients with additional complications such as Sepsis and those who require prompt administration of antibiotics. The chosen framework will enable the hospital to use rapid small-step change cycles to implement the intervention.

Report Sections

The report sections to be included in my course project to describe my healthcare quality improvement initiative will consist of the background information where I will identify background on the services offered at St. Jude, the state of cancer patient care, the implemented technologies, and other relevant information. The scope of the study section will describe the purpose and objective of the report. The literature review will provide research information on the issue. The methodology section will describe the application of the intervention. The conclusions and recommendations section will be the last segment of the report.


Coury, J., Schneider, J., Rivelli, J., Petrik, A., Seibel, E., & D’Agostini, B. et al. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a sizeable pragmatic study involving safety net clinics. BMC Health Services Research17(1).

Dobrozsi, S., Tomlinson, K., Chan, S., Belongia, M., Herda, C., & Maloney, K. et al. (2019). Education Milestones for Newly Diagnosed Pediatric, Adolescent, and Young Adult Cancer Patients: A Quality Improvement Initiative. Journal Of Pediatric Oncology Nursing36(2), 103-118.

Morgan, J., Deyo, J., Cox, J., Fasipe, F., Mohamed, A., & Russo, C. (2019). Quality Improvement Interventions across a Network of Pediatric Hematology-Oncology Clinics. Pediatric Quality & Safety4(2), e149.

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