HCM 672 Unit 5 Individual Project 5

Unit 5 Individual Project 5

Colorado Technical University

Quality Improvement in Healthcare (HCM672-1904A-01)


A change management plan is a plan put into place to help an organization improve in the areas where they fall short. The change management process by which changes are made for improvement, like the scope, deliverables, timescales and resources. The changes needed are formally laid out, evaluated and approved prior to implementing. “A change management process is used to ensure that every change identified is formally: communicated, documented, reviewed, approved and implemented.” (Technology, W.V.A.O., (n.d.). In an organization that is not meeting the regulations and standards set forth by the governing agencies, change management is a way to observe where an organization is presently, and what are they going to do to get to where the want to be. Everyone must be on board for the change to happen and be successful. According to Williams, 2014, 70% of large- scale change programs don’t succeed in meeting their goals.” (Technology, W.V.A.O., (n.d.)

Introduction to Issues and QI Goals and Objectives

A Quality Improvement Plan (QI) is a detailed work plan for an organization’s clinical and service quality improvement activities. The QI plan is generally developed by the executive and clinical leadership of a healthcare organization, it must be approved by the Board of Directors. The plan is a blueprint for all activities involving quality for the clinical and operations departments. This plan is a summarization of the specific clinical focus areas that need additional evaluation of its services. A good QI plan will include and define the mission, goals and objectives that will detail how training and communication will take place within the organization. Measurements will depict the chosen areas of focus, data will be collected for assessment and accomplishment of the goals. Barriers that may hinder the QI plan will need to be overcame, in order to thrive in the healthcare industry. If a hospital loses its accreditation it can have dire consequences. From the perspective of the stakeholders, the Joint Commission stamp of approval is a gold star status. Quality and safety are the main issues the hospitals are focusing on because of all the reforms taking place today. Being able to demonstrate safety, efficient and effective medical care must be continually measured to gain knowledge on whether to leave the plans that are working in place, or if changes are needed for improvement. (Health Resources and Service Administration (HRSA)., (n.d.)

Eastside Medical Center is an acute care hospital located in Snellville, Georgia it has recently been failing in the areas of HEDIS, ORYX, low patient- satisfaction and are no longer meeting the accreditation standards. The purpose of this paper is to develop a change management plan for East Medical Center before it reaches impending financial ruin.

The Board of Directors approved the change management plan that leadership will be implementing. The QI leadership team for the change management plan will consist of the CEO who will oversee all aspects of the change plan, the CMO will oversee the medical aspects of the change plan, the CNO who will oversee all clinical aspects of the change plan. The emergency department medical director, the emergency department nurse manager, director of the laboratory, staff member from the X-ray department, director of the pharmacy, director of information technology, director of medical records, staff member from respiratory therapy, staff nurses from all three shifts, and nursing department secretary, who is responsible for keeping and circulating minutes of every QI leadership meeting, outside agencies will also be assisting by conducting patient satisfaction surveys of Eastside. The CNO will oversee the emergency room, he/she will be tasked with reducing the ER wait times by 30 percent. Turnaround time for the ER is the total amount of time from the admission to the ER to the discharge. At current our ER time is below the local average, target for our turnaround time should be 90 minutes or less. (Prybutok, G. L. 2018).

In addition to improving our turnaround time, hospitality of the staff is another issue to look at. Staff should always be hospitable answering questions in a professional manner, offering refreshments if patient can have them, being kind, courteous, and polite always while interacting with patients in the ER. (Prybutok, G. L. 2018).

Improving the clinical processes is another area that needs attention, Under the supervision of the CNO staff will work on the following initiatives; being cheerful and empathetic when interacting with patients, Staff should actively supplicate patient needs, be concerned about the patient’s privacy, briefing the patient often with updates about their condition, any delays in getting testing done or receiving test results, explaining all treatments and medication and allowing patient time to ask questions, involving family and caregivers in treatment plan if the patient is requesting, communicating with family members in the waiting area as often as possible, a collaborative effort by all parties involved in the care and treatment of the patient. (Prybutok, G. L. 2018).

The next issue to look at is healthcare acquired infections (HAI), according to Carnes, T. A., 2018, 1 and 25 patients in an acute care hospital get a HAI, meaning no traces of infections were found during admission. There are an estimated 1.7 million HAI’s acquired by patients entering the hospital each year, these can range from central line associated bloodstream infections, surgical site infections, hospital-onset c-difficile, catheter associated urinary tract infections and MRSA. The average for additional care for these infections is $34,400. This represents $58.5 billion dollars spent per year on these preventable infections. (Carnes, T. A., 2018). There is still a large amount of money and time spent on treating these infections despite quality improvement efforts. When hospitals readmit patients within 30 days of discharge, what Medicare pays them is less then what the hospital spent on the patient’s treatment. “While most hospitals have hand sanitizer dispensers placed in each room for doctors and nurses to use, one study found that a common cause of infection was the inability for patients themselves to be able to wash their hands (Haverstick et al., 2017). Because patients are often unable to get up without assistance due to weakness or catheters/IVs, they often go days without washing their hands. This increases the patient’s risk of cross-contamination. Haverstick et al. (2017) also found that when patients could wash their hands on a regular basis there was a significant reduction in the rates of infection during hospital stays.” (Carnes, T. A., 2018)

The last area we will be looking to change is the heart failure rate, the current scorecard has Eastside as being just average, this is not acceptable, and change is a must. Heart failure hits 900,000 people each year, a forth of the patients die and many of those patients end up with other complications related to their condition. Research and scientific studies have shown potential in treating heart conditions, but the full understanding has not been reached yet because of the gap between knowledge and its application to clinical care. “The American Heart Association (AHA)/American College of Cardiology (ACC) Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke brought together national leaders and committed practitioners to share knowledge and insights on measuring and improving the quality of cardiac care.” (Pertus, J.A., et al., 2003). Below is a copy of the scorecard for Eastside so, that the short comings can be seen and addressed. (Pertus, J.A., et al., 2003)

Heart Failure Scorecard

A hospital’s heart failure score is based on multiple data categories, including patient survival, volume and more. Hospitals received one of three ratings high performing, average or below average unless they treated an insufficient number of patients to be rated. Hospitals that earned a high performing rating were significantly better than the national average. (News, U. S. (n.d.).




Quality Indicators


Relative survival 30 days after hospitalization for heart failure, compared to other hospitals treating similar patients.


Discharging patients to home

How often patients can go directly home from the hospital rather than being discharged to another facility. Recovery at home is preferred by most patients and families.


Number of patients

Relative volume of Medicare inpatients age 65 and over who had this procedure or condition in 2013-17. Higher volume is associated with better outcomes

Very High

Range: 1083 to 12742

Influenza immunization of patients

Percentage of patients who received a timely vaccination during flu season.

Nearly All


Noninvasive breathing aid for heart failure

Whether the hospital uses a mask, instead of inserting a breathing tube or performing surgery, to provide respiratory support for at least 20 percent of patients with heart failure who need assistance with breathing. Masks are less invasive and represent the standard of care.

Advanced heart program

Whether the hospital implants left ventricular assist devices (LVAD) or performs heart transplants. These procedures are among the most complex for heart patients

Does Not Perform

Nurse staffing

More nursing care per patient is associated with better outcomes and better patient experience.



Whether the hospital has at least one adult intensive-care unit staffed by a doctor specifically certified or trained to care for ICU patients.

Cardiac ICU

Whether the hospital has a specialized intensive-care unit for heart patients.

Data Not Available (News, U. S. (n.d.).

Mission and Vision of Eastside Medical Center

Eastside Medical Center is committed to the care and improvement of human life. In acknowledging the commitment Eastside has to the mission and vision statement, Eastside strives to give high-quality, cost-effective healthcare to the communities that are served. Staying true to the mission Eastside, believes the values statements are essential and timeless: Eastside recognizes that everyone person is different and unique and should be treated as such, treating those served with compassion and kindness, be honest, show integrity and fairness in the way business is done, and how our lives are lived, trusting our colleagues as valued members of the team and pledge to treat one another with dignity, respect and loyalty. (Eastside Medical Center., (n.d.)

Goals and Objectives to be met

Goal 1. Improve patient turnaround times in the ER. Patient turnaround currently at Eastside is 4 hour rolling average that is updated every 30 minutes. (Eastside Medical Center., (n.d.)

Objective- to lessen the ER wait times, the goal is to reduce the wait times in the ER to 90 minutes or less, by assigning a nurse to every shift to keep the patient flow moving and speak with patients in ER at least once every 30 minutes. Treatment rooms were made illness specific, bedside registration on rolling computer, change payment talk to the last thing done before discharge this with help with patient satisfaction as well.

Measurements- Collecting data on the ER in and out times of patients. Weekly chart reviews of all non-evasive visits, to see where things are being held up at. Patients will receive a follow-up phone call asking about how they are doing, and about the ER visit. They will also receive a survey to complete asking about their ER visit along with a self-addressed stamped return envelope. Data will be looked quarterly so that timely adjustments can be made.

Goal 2. Making staff more hospitable, empathetic, attentive and to communicate with family and patients timelier.

Objective-be cheerful and empathetic when interacting with patients, Staff should actively supplicate patient needs, have concern about the patient’s privacy, brief the patient often with updates about their condition, explain any delays in getting testing done or receiving test results, explaining all treatments and medication and allowing patient time to ask questions, involving family and caregivers in treatment plan if the patient is requesting, communicating with family members in the waiting area as often as possible, a collaborative effort by all parties involved in the care and treatment of the patient. (Prybutok, G. L. 2018).

Measurements- Results will be seen in the patient satisfaction surveys that will be emailed and mailed to patients post ER visits. A log will be kept of any patient complaints received while in the ER, round table discussion meetings will be held monthly with the ER department heads to discuss the complaints and find solutions to decrease complaints. Patients will be given a short 4 question survey about staff helpfulness, with a drop box to put the survey in when leaving. The data will be looked at monthly and discussed at round table meetings.

Goal 3. Decreasing the amount of HAI’s, the hospital has, reduction in readmissions.

Objectives- Staff will wash hands regularly between patients visits or use hand sanitizer, staff will assist patients who aren’t able to get out of bed with bathing more often, change gloves between patient visits, wear PPE’s to reduce risk of spreading infections to patients, stay home if staff is sick to reduce spreading germs to those susceptible patients, educate patient on infection risk so that they can play an active role in reducing their risk.

Measurements- Observation audits of hand washing techniques, develop a plan of action for education training quarterly, real-time data collection, monthly reviews of HAI’s to see if there is a pattern, develop an infection control team to conduct audits, make PPE’s readily available for use, real-time data will be collected quarterly and reviewed so, that training and reeducation can be done.

Goal 4. Increase the scorecard of our heart failure rate, from average to above average. If Eastside is average in heart failure, that means we give average care in heart failure.

Objectives- Increasing Eastside’s overall rating from average to above average or to excellent. The better our ratings are, the better our perceived quality of care will be.

Measurements- Obtaining HCAHPS scores well tell us how we are doing overall, and patients perceives the care they receive at Eastside. Careful analyzation of the hospital will be done by the leadership time in place of the QI plan, they will make recommendations for improving the scores and initiatives for the staff to keep them motivated and focused on the QI change plan. The focus will be on the lowest scores of the surveys, and implementation of changes will be related to those questions.

Overview of HEDIS and ORYX

Healthcare Effectiveness Data and Information Set (HEDIS), is a tool that is used to measure performance on different levels of care. The measures are made to be specific so, a comparison between health plans exists. The results show where an organization should focus their improvement efforts on. The National Committee for Quality Assurance (NCQA), sets the measures used yearly. The goal is to move quality improvement to its highest levels. Making HEDIS successful, required an independent audit that is done by NCQA- certified auditors to keep the consistency and integrity of the process. (National Committee for Quality Assurance. (n.d.)

HEDIS has 5 domains for measurement, effectiveness of care, access and availability of care, experience of the care received, utilization and risk adjusted utilization and resource use. Identifying what data set the hospital is failing at is the key to having a plan in place for improving. (National Committee for Quality Assurance. (n.d.)

ORYX is the Joint Commission’s performance measurement initiative. The measurements of ORYX support’s the Joint Commission accredited organizations with their quality improvement efforts. The Joint Commission tries to align its measures as closely as it can to the CMS’s regulations. ORYX is reported publicly so, that consumers can do a comparison of different hospitals performance. “In 2020, accredited hospitals will submit both electronic clinical quality measure (eCQM) and chart-abstracted measure data via The Joint Commission’s Direct Data Submission Platform (DDSP). In 2019, all hospitals transitioned to DDSP for submission of eCQM data annually, and in 2020 chart-abstracted aggregate data will be submitted via the DDSP on a quarterly basis.” (The Joint Commission. (2014, October 10)

ORYX helps to educate hospitals and offer resources to help the hospitals. JACHO launched ORYX in 1997, this program integrates performance measures into the accreditation process. The purpose of ORYX is to link accreditation and patient outcomes, this would work toward the goal of making the process of accrediting more valuable. Putting the focus on quality and patient outcomes. The organization getting ready for accreditation chose 2 measures that are current to their facility, from a list of available performance measurements. (Viswanathan, et al., 2000)

Patient Satisfaction Surveys

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a survey of the patient’s perspective of hospital care by collecting data. The survey has 3 broad goals; 1. To produce data that allows objectives and meaningful comparisons, and their importance to the patient. 2. Public reporting of all the results, this will generate a new set of incentives for improving the quality of hospital care. 3. Creates accountability by increasing the transparency of the quality of care given in a hospital. The survey is given to random adults within 48 hours or up to 6 weeks after discharge. (Centers for Medicare & Medicaid Services. (n.d.)

Medicare reimbursements are partly based on patient satisfaction now, hospitals have become concerned with increasing their patient satisfaction. “As of 2012, up to 1.75% of hospital reimbursement could be withheld based on performance on key metrics, one of them being patient satisfaction scores measured by the HCAHPS.” (Mazurenko, O, et al., 2017). The HCAHPS has 10 questions that capture patient satisfaction across many domains, which includes; quality of communication with nurses and physicians, responsiveness of hospital staff, aspects of the hospital environment, adequacy of pain management, and communication about medications and discharge information. (Mazurenko, O, et al., 2017)

“Improving interprofessional relationships within a hospital or other health care organization to promote a positive working culture for staff and patients is a sensible place to start in this effort.” (Thomas, J., 2018). Decentralizing operations is a way to improve patient satisfaction, hosting multidiscipline meetings, constant communication, investigate technological solutions, seeking feedback. These strategies can help East to improve the patient satisfaction and increase revenue. (Thomas, J., 2018)

Patient Experience at Eastside Medical Center

     2 stars out of 5

Scores are based on surveys taken from this hospital’s inpatients after they were discharged inquiring about different aspects of their stay. The scores are not used in the Best Hospitals rankings. (News, U. S. (n.d.)

Satisfaction with the hospital overall

How the patient felt about their hospital stay and discharge overall.


2 stars out of 5

Willingness to recommend

Willingness of patients to recommend this hospital to others.


2 stars out of 5

Satisfaction with doctors’ communications

How patients rated physicians in listening and explaining in a way that patients could understand.


2 stars out of 5

Satisfaction with nurses’ communications

How patients rated nurses in listening and explaining in a way that patients could understand.


2 stars out of 5

Satisfaction with efforts to prevent medication harm

How well medications, how they were to be taken, and side effects were explained before they were administered.


2 stars out of 5

Satisfaction with quality of discharge information

How well staff reviewed adequacy of help at home and provided enough information in writing about symptoms and problems to watch for.


2 stars out of 5

Satisfaction with involvement in recovery

How well patients’ wishes were considered in discharge planning and how well patients understood when they left how to care for themselves, what medications they will take and why.


2 stars out of 5

Satisfaction with staff responsiveness

How promptly help was provided when needed or requested.


2 stars out of 5

Satisfaction with hospital room cleanliness

How patients rated the cleanliness of their hospital room and bathroom.


2 stars out of 5

Satisfaction with noise volume

How well patients rated the quietness of their hospital experience.


3 stars out of 5 (News, U. S. (n.d.)

Communication Approaches

Efficient, accurate and timely communication is needed for quality healthcare and it is linked to staff job satisfaction. Developing way to have better communication is an essential key to increase the quality of care, and interdisciplinary care teams allows for improved communication among health care professionals. “Structured interdisciplinary bedside rounds (SIBR) provide the validated structure that operationalizes interdisciplinary communication while bringing together many care providers involved in the patients care at the bedside, including an emphasis on including the patient and family.” (Gausvik, C, et al., 2015). Having bedside rounds increases the sense of teamwork, increases staff understanding of the plan of care, enhances communication abilities between team members, gives an increase in addressing patient fears and worries, improves the staff’s efficiency, improves patient safety, improves job satisfaction. Because communication is so important in keeping a hospital’s environment safe, these changes increase job satisfaction and decrease job turn-overs, r, but they are also a key step toward breaking down the hospital hierarchies that often diminish effective and safe communication. (Gausvik, C, et al., 2015)

Accreditation Standards

Eastside Medical Center is currently accredited by the Joint Commission, but it could always use improvement. Research on accreditation has mostly focused on assessing its impact using large scale quantitative studies, yet little is known on how quality is improved in practice through an accreditation process. “In the late 1990s, this focus on quality management, and more specifically on patient safety, gained a new impetus with the publication of reports such as To Err is Human (Kohn et al., 2000) which alongside highlighting the magnitude of adverse events, argued about the possibility of preventing a significant number of them.” (Melo, S., 2016). Accreditation is the preferred method to promote healthcare quality and the organizational and service levels. Accreditation is an expensive process, but hospitals find it worth the expense. Hospitals that are accredited have higher performance levels, than those who are not accredited. Eastside aligns with the principles of the accreditations standards and adheres to them. In keeping up with the standards that the Joint Commission and other accrediting agencies have set forth, it is good to have monthly audits using the accreditation standards. Doing this will allow Eastside to see in problems arising so, they can be addressed. Have a outside agency come in a do a mock Joint Commission audit, after the audit share the results with the whole organization. Change doesn’t happen all at once, focus on one or two standards at a time, once those are improved upon, move on to another set of standards, when standards are met give praise to your staff for a job well done! (Melo, S., 2016)


Implementing a QI plan is not an easy thing to do. It requires a lot of planning and everyone must be committed to the plan. The culture of Eastside Medical Center is to always strive for improvements when goals are met add new goals never stop improving. Although, Eastside is not perfect we are continually learning and making our hospital better for our patients and staff. Starting with a few goals so, the staff does not become overwhelmed is the plan. Everything will not be corrected at once in any hospital, but along as the hospital is always learning and improving. Someday Eastside will reach the High Reliability status like the airlines and nuclear power plants. With the implementation put in place Eastside should be stepping in the right direction.


Carnes, T. A. (2018). Better health (Order No. 10751103). Available from ProQuest Central; ProQuest Dissertations & Theses Global. (2038370457). Retrieved from https://proxy.cecybrary.com/login?url=https://search-proquest-com.proxy.cecybrary.com/docview/2038370457?accountid=26967

Centers for Medicare & Medicaid Services. (n.d.). HCAHPS: Patients’ perspectives of care survey. Retrieved from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html

Gausvik, C., Lautar, A., Miller, L., Pallerla, H., & Schlaudecker, J. (2015). Structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan and teamwork as well as job satisfaction. Journal of Multidisciplinary Healthcare, 8, 33-37. doi: http://dx.doi.org.proxy.cecybrary.com/10.2147/JMDH.S72623

Health Resources and Service Administration (HRSA). (n.d.). Developing & implementing a QI plan. Retrieved from the U.S. Department of Health and Human Services Web site: http://www.hrsa.gov/quality/toolbox/methodology/developingandimplementingaqiplan/index.html

Mazurenko, Olena, PhD., M.D., Collum, T., PhD., Ferdinand, Alva, DrP.H., J.D., & Menachemi, N., PhD. (2017). Predictors of hospital patient satisfaction as measured by HCAHPS: A systematic review. Journal of Healthcare Management, 62(4), 272-283. doi: http://dx.doi.org.proxy.cecybrary.com/10.1097/JHM-D-15-00050

Melo, S. (2016). The impact of accreditation on healthcare quality improvement: A qualitative case study. Journal of Health Organization and Management, 30(8), 1242-1258. doi: http://dx.doi.org.proxy.cecybrary.com/10.1108/JHOM-01-2016-0021

National Committee for Quality Assurance. (n.d.). HEDIS & performance measurement. Retrieved from http://www.ncqa.org/HEDISQualityMeasurement.aspx

News, U. S. (n.d.). Health Failure Scorecard. Retrieved November 6, 2019, from https://health.usnews.com/best-hospitals/area/ga/emory-eastside-medical-center-6381075/heart-failure.

Pertus, J. A., Radford, M. J., Every, N. R., Ellerbeck, E. F., Peterson, E. D., & Krumholz, H. M. (2003). Challenges and opportunities in quantifying the quality of care for acute myocardial infarction: Summary from the acute myocardial infarction working group of the American heart association/American college of cardiology first scientific forum on quality of care and outcomes research in cardiovascular disease and stroke. Journal of the American College of Cardiology, 41(9), 1653-1663. doi:http://dx.doi.org.proxy.cecybrary.com/10.1016/S0735-1097(03)00415-7

Prybutok, G. L. (2018). Ninety to nothing: A PDSA quality improvement project. International Journal of Health Care Quality Assurance, 31(4), 361-372. doi:http://dx.doi.org.proxy.cecybrary.com/10.1108/IJHCQA-06-2017-0093

Technology, W. V. A. O. (n.d.). Change Management Process. Retrieved November 6, 2019, from http://technology.wv.gov/SiteCollectionDocuments/Project Management Templates/Change Management Process 03 22 2012.pdf.

Thomas, J., PharmD. (2018). KEY TACTICS TO BUILD STRONGER TEAMWORK. Physician Leadership Journal, 5(4), 26-29. Retrieved from https://proxy.cecybrary.com/login?url=https://search-proquest-com.proxy.cecybrary.com/docview/2069490828?accountid=144789

The Joint Commission. (2014, October 10). Facts about ORYX® for hospitals (national hospital quality measures). Retrieved from http://www.jointcommission.org/facts_about_oryx_for_hospitals/

Viswanathan, Hema & Salmon, Jack. (2000). Accrediting organizations and quality improvement. The American journal of managed care. 6. 1117-30.

Place an Order

Plagiarism Free!

Scroll to Top