D030 HIP Paper Template

D030 HIP Paper Template

Student Name

Western Governors University

D030 Leadership & Management in Complex Healthcare Systems

Prof. Name:

Date

Task 1: Healthcare Improvement Project – Introduction and Project Initiation

Stakeholder Identification

How were the stakeholders identified for this healthcare improvement project?
The identification of stakeholders for this project began by compiling a comprehensive list of leadership figures, decision-makers, and personnel specializing in infection control within the organization. The primary focus was on individuals passionate about infection control and the early recognition and treatment of sepsis in oncology patients. After careful consideration, three key stakeholders were selected based on their roles and expertise:

1. Sepsis Coordinator: Serving as Co-Chair of the Sepsis Committee, she has over five years of experience in infection prevention. Her leadership role and deep knowledge make her pivotal for this project.

2. Assistant Manager of Urgent Care: This individual has been actively involved in recent initiatives aimed at enhancing early sepsis detection in the Urgent Care Department. Since many patients first present here, implementing sepsis screening at this point is crucial. She is responsible for data collection, organizing statistics on the sepsis tool’s effectiveness, identifying reasons for delays in treatment interventions, and acting as the educator for any new processes related to sepsis screening.

3. Urgent Care Charge Nurse: With experience as an ER nurse and involvement in various hospital committees, including Nursing Standards and Policy and Skin Integrity, this clinical nurse leader is a key resource for updating staff and tracking project milestones, timelines, and feedback throughout the project.

Needs Assessment

What process was used to assess the needs for the healthcare improvement project?
To assess the needs, the project lead met with each stakeholder individually, either in-person or virtually, requesting suggestions for potential improvements at the Moffitt Cancer Center. Each stakeholder provided one to two project ideas, which were collated and shared with the group for review. A 30-minute Zoom meeting was then held, where stakeholders anonymously ranked the ideas using the Nominal Group Technique via an online questionnaire.

After discussion and voting, the top three ideas were identified: early sepsis identification, transfers of care, and prevention of nurse burnout/employee retention. The group reached consensus on focusing the project on early sepsis identification due to the high risk and vulnerability of oncology patients to sepsis-related complications.

Problem Identification

What is the primary problem addressed by the project?
Moffitt Cancer Center serves adult oncology patients, many of whom have compromised immune systems due to cancer treatments. Despite advances, cancer patients with sepsis have a mortality rate twice as high as non-cancer patients (Chae, Kim, & Lee, 2020). Sepsis in these patients often leads to delays in chemotherapy, prolonged hospital stays, and increased healthcare costs (Mert et al., 2021).

The project aims to identify the best sepsis screening tool tailored to oncology patients within the Urgent Care Department. This tool must account for atypical signs of infection that differ from non-cancer populations, such as variations in vital signs and laboratory markers, to enable prompt recognition and intervention.

Problem Description

Why is an early sepsis identification screening tool necessary at Moffitt Cancer Center?
The Infection Prevention and Sepsis Committee discovered multiple areas for improvement in managing sepsis in the Urgent Care Department. Frequent data and chart reviews revealed delays in initiating sepsis protocols for eligible patients. These findings underscore the need for a dedicated screening tool to facilitate faster diagnosis and treatment, reducing mortality rates and improving overall patient outcomes.

Impact Analysis

What are the potential benefits and risks associated with the project?
The project’s impact was evaluated by considering two categories: Patient Satisfaction and Decreased Length of Stay. Each category included benefits and risks, rated on a scale from 1 (low) to 3 (high) impact.

The total benefits score was 11, while the risks scored 9. Calculating the impact ratio (benefits ÷ risks = 1.2) suggests the project’s benefits outweigh its risks, supporting its implementation.

SWOT Analysis

How was the organizational readiness assessed?
A SWOT analysis was conducted collaboratively with stakeholders. Each member completed a preliminary SWOT draft, focusing on internal factors (Leadership and Morale) and external factors (Stakeholder Involvement and Knowledge Uptake). After a 45-minute group discussion and voting, the following were established:

The analysis supported the project’s feasibility and highlighted areas for proactive management.

Ethical Considerations

What ethical standards support this healthcare improvement project?
Moffitt Cancer Center’s Code of Ethics prioritizes delivering high-quality, safe, and patient-centered care (Moffitt Cancer Center, 2018). The commitment to effective, equitable, and culturally competent care aligns with the goals of early sepsis identification, emphasizing the urgency in protecting immunocompromised oncology patients.

Task 2: Healthcare Improvement Project – Project Purpose and Review of Scholarly Sources

Purpose Statement

The primary purpose of this project is to implement an early sepsis identification tool in the Urgent Care Department to improve the timeliness of response and treatment for oncology patients exhibiting signs of sepsis. The goal is to enhance clinical outcomes by integrating this screening tool into triage processes.

Review of Relevant Scholarly Sources

Research underscores the heightened risk and mortality for cancer patients with sepsis, necessitating tailored screening protocols (Chae et al., 2020; Mert et al., 2021). Studies demonstrate that nurse-driven sepsis protocols and community screening tools improve early recognition and outcomes (Baker, 2022; Moore et al., 2019). These insights validate the project’s focus and guide its implementation strategy.

Appendix D: SMART+C Goal Worksheet

SMART+C Goal:
To implement an early sepsis identification tool in the Urgent Care Department to enhance sepsis protocol response and treatment times for oncology patients by December 2022.

Expected Outcome:
Data collected will facilitate the development of an oncology-specific sepsis tool, decreasing mortality, reducing hospital stays and healthcare costs, and improving patient outcomes and satisfaction.

References

Baker, E. (2022). Improving sepsis recognition through use of the Sepsis Trust’s community screening tool. British Journal of Community Nursing, 27(2), 69–75. https://doi.org/10.12968/bjcn.2022.27.2.69

Chae, B.-R., Kim, Y.-J., & Lee, Y.-S. (2020). Prognostic accuracy of the sequential organ failure assessment (SOFA) and quick SOFA for mortality in cancer patients with sepsis defined by systemic inflammatory response syndrome (SIRS). Supportive Care in Cancer, 28(2), 653–659. https://doi.org/10.1007/s00520-019-04869-z

Mert, D., Merdin, A., Kandemir, N., Çakar, M. K., Dirim, E., Çeken, S., Altuntaş, F., & Ertek, M. (2021). Evaluation of risk factors and causative pathogens in bloodstream infections in cancer patients. Gulhane Medical Journal, 63(1), 42–51. https://doi.org/10.4274/gulhane.galenos.2020.1320

Moffitt Cancer Center. (2018). Code of Ethics and Professional Conduct. https://moffitt.org/about-moffitt/corporate-compliance/code-of-ethics-and-professional-conduct/

Moore, W. R., Vermuelen, A., Taylor, R., Kihara, D., & Wahome, E. (2019). Improving 3-Hour Sepsis Bundled Care Outcomes: Implementation of a Nurse-Driven Sepsis Protocol in the Emergency Department. Journal of Emergency Nursing, 45(6), 690–698. https://doi.org/10.1016/j.jen.2019.05.005