NURS FPX6016 Assessment 3 Data Analysis and Quality Improvement Initiative Proposal

Assessment 3: Data Analysis and Quality Improvement Initiative Proposal

Student Name
Capella University
Prof Name
Month Date, Year

Data Analysis and Quality Improvement Initiative Proposal

Healthcare professionals are constantly looking for ways to improve the level of care and security they offer to their patients. For a stable platform of quality treatment and patient experience, a working environment that supports leadership, evidence-based work, open communication, and inter-disciplinary practice is crucial. Nursing professionals play a crucial role in creating this atmosphere and significantly influence the level of quality achieved across an institution. Professionals increasingly rely on e-health and data analysis approaches to enhance documentation, prevent some harmful medical errors, and avoid possible human error (Mutshatshi et al., 2018). By working closely with patients and other parties via screens and technological solutions, trained and certified nurses are enhancing their job (Respicio et al 2018; Winter et al., 2018).

Data Analysis of Health Concerns

Medical Case Study

According to Vila health center’s hospice unit, in the monthly reports for the years 2020 and 2021, there have been 121 and 130 patients altogether respectively. The summary of the data report is as follows:


Hospice patients whose hospice care team 

always treated them with dignity and respect, 

and really cared about them

Hospice patients whose hospice care team 

always communicated well with their family 

caregivers about taking care them

Hospice patients who always received enough 

helps for pain, sadness, breathing, or 

constipation from hospice care team

Hospice patients and family caregivers who 

always got help as soon as they need from 

hospice care team



Year 2020

121 total patients





Year 2021

130 total patients





From this data we can observe that not all of the patients have been given relief from their symptoms and had the care providers available to provide care. If this continues then the standard of the hospice will diminish and the patients especially those that are at the hospice for their end-of-life care won’t be comfortable utilizing the services of the hospice as they might get the idea that the care providers aren’t competent enough and won’t make their stay peaceful and painless.

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The organization regarding the data should include the number of patients that were admitted to the hospice in the specific month. This will make the data analysis much simpler and easier. Along with this, it will have a significant effect on knowing what kind of disease the patients had and what was the reason behind not giving efficient care to the rest of the patients.

Outcomes and Recommendations for Adverse/Near-miss Events

By not treating all of the patients equally for their ailments, the nurses should be aware that it might cause an adverse event in the future. By neglecting patients in treating their diseases the nurses might cause the patient’s symptoms to aggravate and in the worst-case scenario might cause the patient to die an untimely death. 

From the data given, we can see that some of the patients didn’t receive efficient Health Care from the care providers. This statement is supported by the data from the quality initiative given by the hospice. In the year 2020, In July zero patients were treated with dignity and respect by the hospice care team. In the same month, 0 patients from the hospice received help as soon as they needed from the care team. The reason behind the negligence in providing care to the patients is unclear in the data given however we assume that the care providers were either incompetent in treating the patient or had no idea how to treat the symptom of the disease that the patients were experiencing. The other reason can be personal problems like burnout, stress, or fatigue. 

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However, improvement in the quality of care and patient satisfaction can be seen in the year 2021 as more patients wait for the symptoms and are relieved of their pains and constipation. These patients were cared for by the care team as the communication between the care providers and the patients was observed to have improved. But still, the numbers aren’t that high.  If the staff continues to show incompetency and negligence then it would be possible to say that a near miss or an adverse event will probably happen if the problems that the staff is facing aren’t solved.

QI Initiative Proposal

There are various palliative care policies in the US, varying by state, claim Donlon et al. (2018). Some jurisdictions base care decisions on a patient’s disease stage and whether it is terminal or not. Others provide treatment based on the patients’ ages. The measurements used by these states to evaluate their healthcare each year, meanwhile, are a factor that unites them all. To determine if the care their hospices are offering is effective or not, the majority of them use pain screening as a key indicator of palliative care as part of a quality improvement project. This demonstrates that our QI for patient care is ineffective based on this parameter.

By putting into practice, the following suggestions, such as training the staff in palliative care and symptom control, we may improve the quality of healthcare, according to the National Academy for State Health Policy. Only with prior knowledge can the personnel function effectively in the hospice. The second option is to increase workforce capacity, which entails hiring more personnel to provide patient care. This will not only benefit the patients, but it will also relieve stress and burnout among the already-busy staff members by lowering their burden.

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Another strategy can be to utilize technologies to help treat patients. These technologies can include video conferencing. This tech solution can not only help patients communicate with their loved ones and also their doctors in cases where their physicians are in another care center and commuting there isn’t possible. For healthcare providers, video conferencing can be useful in communicating with other professionals and experts in cases where they are in doubt about the therapy and treatment, they are providing their patients and need a second opinion.

QI Initiative Proposal Based on Interdisciplinary Team Input

The palliative care team is made up of the nurses who are providing the patients with care, the patient’s physicians, the management, directors, the patient’s families, and the patients themselves. It is important to note that the term “doctors’ staff” refers to more than just the individuals who are now employed by VHC; it may also refer to other professionals who are based in other states or other countries and who can assist the VHC staff in reducing near-miss incidents. These experts can provide crucial information about the patient’s illness and how to treat them. This realization will improve the hospice’s standard of care.

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 It will be simple for them to develop a stable working atmosphere where everyone is assisting one another to resolve an issue when such a team performs well together and discusses the data, information, and difficulties with one another. With such a team, it will be simpler for each person to grasp the other’s line of work, and when one is unavailable, the other person may simply carry out their obligations (Feder et al., 2020).

When it is assessed as important for the patient’s health, the hospice has an interprofessional team treating them (Seaman et al., 2020). When it was enforced at our hospice, the interprofessional coordination helped our nurses and doctors to prevent medication errors by lowering burnout. Furthermore, it encouraged better outcomes, which reduced costs and improved the perspectives of the patients in the hospice center. The business was also able to conserve important financial resources by reducing inconsistencies in the workflow.

Communication Strategies

Nursing relationships and effective communication depend on mutual respect since it shows that everyone may learn new skills from anybody. Every communication strategy used in a healthcare institution to help nurses strengthen their bonds with coworkers and patients is based on these principles. All through the PDSA and QI stages, these strategies will support the QI activities.

 The first advantage of the latest collaboration and teamwork strategies is that every weekend, a document of the care strategies put in place by the interdisciplinary team will be sent to the employees, who can read it and ask any questions they may have. This copy will also include EBP, which has been proven to increase staff performance by improving their knowledge. This will guarantee that the personnel are knowledgeable about the most recent information. Additionally, all correspondence will be shared via email to the appropriate nurses, welcoming them to the workshop so they may learn everything there is to understand about the QI initiatives and goals before they start working with terminally ill patients. This suggests that the bulk of staff decisions will be based on the discussions from meetings, and nurses will be given meeting records and a summary of deliverable outcomes to help them understand where they can make improvements.

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Additionally, as the QI process develops and is implemented in the Vila Health Hospital system, the personnel may examine and incorporate cutting-edge techniques to enhance communication and use the PDSA framework to effect improvements. As it aims to strengthen our hospice’s current activities to perform even better the following time, the PDSA quality improvement strategy was selected unanimously. As we intend to implement these strategies across all divisions, we picked the PDSA quality improvement technique. This proves that our team is committed to facilitating extensive transformation activities and practices in order to bring about significant change inside the organization.

The Situation, Background, Assessment, and Recommendations (SARS) tool was one of the remaining two tools we used. With the help of this tool, we were able to create a problem description, condensed data about the situation, conduct an evaluation, and eventually create a successful strategy to increase collaboration. We also used the CUS approach, which serves as an indication, to assist our nurses in understanding the difficulties in communicating. The CUS addressed the nurses’ worries, explained why they were exhausted, and explained the real safety risks and the precautions they are required to take to prevent them.


Donlon, R., Purington, K., & Williams, N. (2018). Advancing palliative care for adults with serious illness: A national review of state palliative care policies and programs. Washington, DC: NASHP.

Feder, S. L., Akgün, K. M., & Schulman-Green, D. (2020). Palliative care strategies offer guidance to clinicians and comfort for COVID-19 patients and families. Heart & Lung: The Journal of Critical Care, 49(3), 227–228.

Mutshatshi, T. E., Mothiba, T. M., Mamogobo, P. M., & Mbombi, M. O. (2018). Record-keeping: Challenges experienced by nurses in selected public hospitals. Curationis, 41(1), 1-6. DOI: 10.4102/curationis. v41i1.1931

Respicio, A., Moz, M., Pato, M. V., Somensi, R., & Dias Flores, C. (2018). A computational application for multi-skill nurse staffing in hospital units. BMC Medical Informatics and Decision Making, 18(1), 1-9.

Seaman, J. B., Lakin, J. R., Anderson, E., Bernacki, R., Candria, C., Cotter, V. T., Desanto-Madeya, S., Epstein, A. S., Kestenbaum, A., Izumi, S., Sumser, B., Tjia, J., & Hurd, C. J. (2020). Interdisciplinary or interprofessional: why terminology in teamwork matters to hospice and palliative care. Journal Of Palliative Medicine, 23(9), 1157–1158.

Winter, A., Stäubert, S., Ammon, D., Aiche, S., Beyan, O., Bischoff, V., & Löffler, M. (2018). Smart medical information technology for healthcare (SMITH). Methods of Information in Medicine, 57(S 01), e92-e105. DOI: