NURS FPX 6016 Assessment 3: Data Analysis and Quality Improvement Initiative Proposal
Medical professionals can provide medical services because of the knowledge and abilities they have gained during their training (Khorana et al., 2021). Healthcare workers desire to enhance the well-being of patients who are in a critical state of health, and one of their objectives is to employ evidence-based practices (Feehan et al., 2020). In order for healthcare professionals to diagnose, treat, distribute healthcare information, data information analysis, and recommend preventative measures to stop the spread of diseases, they need be trained with the necessary skills. Healthcare professionals can also be seen as advocates for healthy living since they encourage better lifestyle choices and communicate the need for policies that promote population health and well-being (Agarwal et al., 2021). Depending on their understanding of patient data and other obstacles that might be preventing the attainment of better healthcare, the nurses can also recommend any action that might improve the type of healthcare services they provide. NURS FPX 6016 Assessment 3 is concerned with using data analysis to suggest an improvement program in a neonatal intensive care unit. The concept is driven by the fact that nurses and other medical practitioners have the information and skills to implement the data quality improvement plan in the workplace to embrace procedures that have the potential of enhancing patient outcomes.
The NICU unit is one of the medical institutions’ where prematurely born kids with underlying diseases are kept and babies who could require surgery are monitored. NICUs frequently have high-tech equipment and knowledgeable nurses and staff to help
with the infants’ care (Shlomai et al., 2021). Low-weight infants, infants with blood infections, heart problems, respiratory illnesses, and children born before 37 weeks of gestation are among the common characteristics of infants admitted to the NICU (Merewood et al., 2021). These babies need special attention because of their frailty. As a result, neonatal nurse practitioners and other interdisciplinary professionals routinely review NICU units to assess the quality, safety, and data quality objectives.
Problem and Needs
Previous studies claim that breast milk is healthy to babies. Among the nutritional elements that are absorbed and make breast milk vital in the health of infants, the WHO and the American Academy of Pediatrics have acknowledged the importance of breast milk to infants (Pelizzo et al., 2020). Breast milk has several benefits, including improving early cognitive development, preventing sepsis and respiratory tract infections, and increasing feeding sensitivity in premature infants. Additionally, according to the experts, breast milk can reduce the number of premature newborns who get necrotizing enterocolitis (Wang et al., 2019). Over the past ten years, most hospitals have modified the human milk feeding rate in light of the information above about the benefits of breast milk for infants. However, several human errors in newborn feeding have resulted from the preference for breast milk as the infants’ main food source. NICU has stated that, because to data analysis tools, the errors have increased in recent years.
According to the NICU’s quality management team, which has already conducted an annual assessment of the organization’s quality outcomes in 2020 and 2021, there were almost adverse misses in the administration of breast milk. The measures on the
dashboard were reviewed following some tests of variables, including the determination of infants less than 34 weeks old, Cytomegalovirus (CMV) inactivity and screening at the organizations units, and the occurrence of errors in delivering mother milk in the units of NICUs. The quality management team discovered that two of the organization’s quality indicators fell short of the hospital’s standards based on the dashboard metrics study. CMV served as the quality indicator for the NICU units’ screening level, inactivation rate, and mistake rate when it came to mother’s milk administration. NURS FPX 6016 Assessment 3 offers a data quality improvement plan template based on efficient breast milk scanning to reduce human error that has been reported because of mothers supplying milk to their infants, based on the data analysis at the NICU.
Proposed Solution
The most important part of NURS FPX 6016 Assessment 3 is the segment that will analyze the connection between the two quality indicators that have failed the hospital and what it implies on the delivery of high-quality healthcare within the facility. The report will then recommend quality improvement strategies which can reduce error rates and also increase hospital CWV inactivation and screening rates. To facilitate the development of the hypotheses that influence the nursing attributes and health service quality, the report will analyze patterns of interactions between information and signals in the process of proposal-making. The evaluation will also provide the underlying causes of the quality issues in order to formulate a plan and a framework to enhance the satisfactory outcomes of the NICU units.
Determining quality complication using the analysis of dashboard metrics
The table below provides the dashboard display of safety and quality parameters of NICU unit of the target hospital.
| Year | Babies born less than 34 weeks | Error rate in the
administration of mother’s milk |
CMV level of
screening and inactivation |
| NICU 2020 | 20 | 30-percent | 80-percent |
| NICU 2021 | 25 | 40-percent | 76-percent |
Based on the data, infants admitted to the NICU in 2021 were more than in 2020. Also, the rate of the mistake in 2021 was increased by 10 percent in the process of providing breast milk. The other disclosure is the decline in the level of CMV screening and inactivation in 2021 compared to 2020 levels. The hospital administration is concerned about the decline in patient care quality in 2021, as indicated by the data in the above table. According to the data, there are anecdotes that give the hospital a bad reputation for providing high-quality prenatal and postnatal care for babies. In the alternative, the hospital’s nurses and other medical staff have been careless about giving infants the right amount of milk. Another possibility is that the margin of error in the table may lead to the feeding of other mothers’ nursing milk to neonates, increasing the risk of HIV transmission in the NICU. Additionally, a low level of milk scanning before the milk is given to the babies could contribute to the administration of tainted milk, which could have negative effects on the patient. The healthcare facility is dealing with a quality issue in the care of infants, according to the NICU department analysis above.
Among the consequences of the above examination of the dashboard metrics is the possibility that the organization will face legal problems should parents initiate lawsuits against the hospital (Lumbreras-Marquez et al., 2021). The second impact is that the health professionals transferred to the unit or identified to have handled the infants without care can be subject to disciplinary measure and loss of nursing practice license. It can also impact the infants, particularly when they contract infections due to poor milk screening and mistakes associated with the delivery of mothers milk to the appropriate babies (Klotz et al., 2018). In case babies contract infections, they will be able to stay longer in the NICU, and this will raise the medical expenses of the parents.
Besides the table mentioned above, the quality assessment report prepared by the NICU department of the hospital revealed additional leadership issues. To demonstrate this, the findings of the dialogue between the nurses on the unit and the managers of the nurses revealed that the transactional leadership style applied in the unit could be a contributing factor to the errors observed in the data analysis report. Subordinates should follow their superiors’ directions to avoid punishment or rewards since transactional leadership uses these strategies as a motivating factor (Shlomai et al., 2021). Since most of the lower-level employees are inexperienced and dependent on their superiors for guidance, the NICU branch exemplifies the transactional leadership style. Therefore, the lack of guidance on how to handle the issues that arise in the NICU department will inevitably result in mistakes made by lower-level staff, which will build up to the subpar performance shown in the above table.
Quality Improvement Proposal
The idea that is emphasized in NURS FPX 6016 Assessment 3 is rooted in the main problem that led to the decline in the quality standards in the NICU department. Due to the transactional style of leadership, the facility could not offer the infants higher quality healthcare. It is on this basis that transformation leadership of the department of NICU should be advanced in place of the transactional leadership. Transformational leadership model is more active than the transactional leadership model, and its leaders are adaptative and receptive to novel ideas capable of transforming the culture of an organization (Wang et al., 2019). In order to have the healthcare institution realize the difference in the quality of care offered to their infants, the culture of the NICU department should be modified.
The ability to motivate subordinates and empower staff to accomplish organizational goals and objectives by addressing higher ideals and moral values is the second facility-likely helpful feature of the transformational type of leadership style (Merewood et al., 2021). The healthcare facility’s fortunes will improve with the use of transformational leadership, and the nurses will be committed to giving the infants higher-quality treatment, which will lead to increased patient satisfaction.
The plan-do-study-act paradigm indicates that the transformational style of leadership is to be employed according to NURS FPX 6016 Assessment 3. The institutions and organizations are applying this strategy to speed up the transition, a necessary requirement in the NICU section. The institution will require the following strategies in the process of implementing the PDSA.
Plan: To confirm the conclusion on the next topic, say the leadership style employed in the NICU department, an interdisciplinary team of different stakeholders
- will be assembled and will use questionnaire survey. Survey will be administered to nurses and other medical staff who work in the department. Once the team has analyzed the results, the team will advise that, to enhance the two quality indicators in the above table, it is the leadership behavior change that should be altered to transformational leadership.
- Do: The creation of a strategic plan that may contribute in the achievement of the targeted NICU quality targets was emphasized within the framework of this element. Training the department’s nurses and equipping them with the information and abilities they need to carry out their responsibilities would be one such framework.
- Study: The goal of this section is to track data from the Do section and see how it differs and leads to the NICU department achieving its goals.
- Act: This component’s goal is to reevaluate the goals outlined in the first step in order to determine how well transformational leadership meets the institution’s quality standards. After that, the management of data analysis in the quality indicators to see if there has been an increase or decrease. Depending on the facts at hand, the department may decide to implement new goals and strategies, and PDSA may be used to carry them out.
One of the problems with using the PDSA model is that, as this example shows, using only a few quality indicators would result in a skewed perception of the department’s issue (Lumbreras-Marquez et al., 2021).
To better understand the elements that may be influencing quality achievements in the department, NURS FPX 6016 Assessment 3 suggests introducing additional
- quality indicators, such as patient happiness, nurse satisfaction, and mortality rate. According to theories like the foundation theory, inefficiencies in one department may indicate the existence of an organizational issue that has a detrimental effect on other departments (Shlomai et al., 2021). As a result, management should look into whether other departments in the facility are experiencing the same quality issues as the NICU department.
Guideline Support of Improvement of Quality with Interprofessional Perspective
The notion that the inefficiencies of one set of healthcare professionals affect the quality outcomes of other healthcare professionals is one of the presumptions made regarding quality improvement in a healthcare facility. According to Wang et al. (2019), if the nurses working in the NICU section exhibit a lack of professionalism in their service delivery, the doctors working alongside them will be unable to produce their work efficiently since they are receiving information from the incompetent nurses. At such point, other professionals in the same field should help the quality aspects management of one set of specialists. Furthermore, the medical institution’s administration must enhance resource delivery to enable all professional teams operating there to provide the desired outcomes (Merewood et al., 2021). Although other strategies must be offered to improve interdisciplinary relationships within the department to achieve cohesiveness and harmony in the provision of healthcare services at the department, in this case, the nurses must be given the freedom to implement the changes they need to start improving the quality levels within the NICU department.
Leadership is the latent element, in accordance with the assumptions outlined above and highlighted in NURS FPX 6016 Assessment 3. The suggested
- transformational leadership style will help the NICU department shift, particularly among the nurses, even though it might affect the nurses’ interactions with other department professionals. In light of this, the department’s interdisciplinary approach to change implementation can increase the possibility that the suggested fixes would achieve their goals (Jawdeh et al., 2020). Additionally, since the newborns will spend less days in the facility, the improved communication and contact between the many experts in the NICU department can benefit the babies.
Communication strategies that will bring about quality improvement
To ensure the delivery of high-quality results, the leaders in question must ensure that their subordinates are aware of the tactics that they employ. The success of the change process could also be affected by the absence of an effective communication strategy, meaning that subordinates are not aware of what the leadership wants (Agarwal et al., 2021). As the above discussion has shown, one of the factors that led to the failure in quality within the NICU department was the inability of the nursing leadership to allow their staff to perform their duties without having to be constantly ordered around by the seniors. The subordinates were not aware of how to screen the milk appropriately, label the mother milk and hand the milk to the babies. This led to the increase in the error rate of the department. The communication strategy failures of the NICU department nursing leadership should no longer exist provided the recommended tactics of enhancing the performance of the department are implemented.
Putting in place correspondence mechanisms that allow for clear communication between the department’s nurses, the nurse leadership, and other medical experts that work nearby is the best course of action for the hospital. The combined efforts of
- transformational leadership style will help the NICU department shift, particularly among the nurses, even though it might affect the nurses’ interactions with other department professionals. In light of this, the department’s interdisciplinary approach to change implementation can increase the possibility that the suggested fixes would achieve their goals (Jawdeh et al., 2020). Additionally, since the newborns will spend less days in the facility, the improved communication and contact between the many experts in the NICU department can benefit the babies.
Communication strategies that will bring about quality improvement
To ensure the delivery of high-quality results, the leaders in question must ensure that their subordinates are aware of the tactics that they employ. The success of the change process could also be affected by the absence of an effective communication strategy, meaning that subordinates are not aware of what the leadership wants (Agarwal et al., 2021). As the above discussion has shown, one of the factors that led to the failure in quality within the NICU department was the inability of the nursing leadership to allow their staff to perform their duties without having to be constantly ordered around by the seniors. The subordinates were not aware of how to screen the milk appropriately, label the mother milk and hand the milk to the babies. This led to the increase in the error rate of the department. The communication strategy failures of the NICU department nursing leadership should no longer exist provided the recommended tactics of enhancing the performance of the department are implemented.
Putting in place correspondence mechanisms that allow for clear communication between the department’s nurses, the nurse leadership, and other medical experts that work nearby is the best course of action for the hospital. The combined efforts of
between the nurses and other medical personnel, improved communication techniques would also be required. By eliminating some of the inefficiencies and mistakes that contributed to the decline in quality, the proposal will assist the healthcare facility improve its NICU department quality measurements.
References
Agarwal, S., Patodia, J., Mittal, J., Singh, Y., Agnihotri, V., & Sharma, V. (2021). Antibiotic stewardship in a tertiary care NICU of northern India: A quality improvement initiative. BMJ open quality, 10(Suppl 1), e001470.
Feehan, K., Kehinde, F., Sachs, K., Mossabeb, R., Berhane, Z., Pachter, L. M., … & Turchi, R. M. (2020). Development of a multidisciplinary medical home program for NICU graduates. Maternal and Child Health Journal, 24(1), 11-21.
Jawdeh, E. G. A., Huang, C., Mazdeyasna, S., Chen, L., Chen, L., Bada, H. S., & Yu, G. (2020). Noncontact optical imaging of brain hemodynamics in preterm infants: A preliminary study. Physics in Medicine & Biology, 65(24), 245009.
Khorana, M., Wongsin, P., Torbunsupachai, R., & Kanjanapattanakul, W. (2021). Effect of domperidone on breast milk production in mothers of sick neonates: A randomized, double-blinded, placebo-controlled trial. Breastfeeding Medicine, 16(3), 245-250.
Klotz, D., Jansen, S., Gebauer, C., & Fuchs, H. (2018). Handling of breast milk by neonatal units: Large differences in current practices and beliefs. Frontiers in pediatrics, 235.
Lumbreras-Marquez, M. I., Campos-Zamora, M., Ramirez-De Avila, A. L., Soto-Galindo, J. C., Olivas-Chavez, J. C., Tecayehuatl-Delgado, G., … & Farber, M. K. (2021). Training for the surgical management of postpartum hemorrhage: A multicenter survey of resident physicians. The Journal of Maternal-Fetal & Neonatal Medicine, 34(21), 3503-3509.
Merewood, A., Davanzo, R., Haas-Kogan, M., Vertecchi, G., Gizzi, C., Mosca, F., … & Moretti, C. (2021). Breastfeeding supportive practices in European hospitals during the COVID- 19 pandemic. The Journal of Maternal-Fetal & Neonatal Medicine, 1-7.
Shlomai, N. O., Kasirer, Y., Strauss, T., Smolkin, T., Marom, R., Shinwell, E. S., … & Eventov- Friedman, S. (2021). Neonatal SARS-CoV-2 infections in breastfeeding mothers. Pediatrics, 147(5).
Wang, Y., Briere, C. E., Xu, W., & Cong, X. (2019). Factors affecting breastfeeding outcomes at six months in preterm infants. Journal of human lactation, 35(1), 80-89.
