Section 1: Identify
Describe your assigned topic and why it is a concern in healthcare.
Summarize a current policy or procedure at your facility related to this issue. How is this issue currently addressed?
What inconsistencies exist between your facility’s current policies, actual nursing practice, and best evidence related to your assigned topic? What evidence (data, observation, incident reports) suggests a need for improvement?
Section 2: Analyze
Review national safety resources related to your topic. Name at least two national organizations or initiatives (e.g., CMS, AHRQ, CDC, IHI, NPSG) and summarize the guidance they provide related to your topic.
Present and interpret data from your organization to justify your need for change. Use real or hypothetical data (e.g., rates, trends, benchmarks).
Section 3: Plan
State a clear, measurable QI goal related to your topic (e.g., “Reduce CAUTIs by 25% within 6 months”).
Describe a proposed change to the current policy or procedure to support QI related to your topic.
Which evidence-based strategies support your proposed changes? Include at least one scholarly source to support your plan.
Section 4: Act
Which stakeholders need to be involved in implementing this change?
What leadership and communication strategies would you use to gain buy-in and support implementation?
How would you educate staff about the new or revised procedure?
Section 5: Sustain
How will you monitor the impact of the change? What data will you collect and how often?
What criteria will you use to evaluate success? Include short-term and long-term outcomes.
How will you ensure the improvement is sustained over time?
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