D158 Healthcare Improvement Project Paper

D158 Healthcare Improvement Project Paper

Student Name

Western Governors University

D158 Strategically Planning the Execution of a Healthcare Improvement Project

Prof. Name:

Date

D158 Healthcare Improvement Project Paper

Implementation Approach

A dedicated project team, consisting of several members from the organization, was formed to advance the healthcare improvement project (HIP) focused on reducing surgical cancellations. The project journey began with an initial meeting between myself and my preceptor during the initiation phase. This meeting helped define the scope of the HIP, which was subsequently presented to the project team to gain consensus.

The team then moved into the planning phase, holding biweekly meetings to assess the resources required for effective implementation. During this phase, we also developed a budget based on a detailed personnel pay and hours spreadsheet.

Currently, the project is in the implementation phase, the most critical stage where success hinges on proper execution. After researching various consensus methods, I selected the Nominal Group Technique (NGT) for decision-making, suitable for our small group and in-person environment. NGT involves four distinct stages:

1. Silent Generation: Team members individually write down their ideas.

2. Round Robin: Each member presents one idea to the group.

3. Clarification: Group members ask questions and elaborate on ideas.

4. Ranking: Members rank ideas by importance.

This method was effective and harmonious, leading the team to a unanimous agreement on the HIP.

To maintain momentum during implementation, I propose biweekly meetings. Scheduling too frequently might not allow enough time to observe the effectiveness of changes, while infrequent meetings could cause loss of focus. The project manager organizes these meetings, creating agendas aligned with the action plan worksheet and the updated Gantt chart to track progress. Weekly email updates supplement these meetings, ensuring continuous communication.

An ongoing agenda item during planning and implementation phases involved evaluating if existing policies required updates. The team reviewed the hospital’s exclusion criteria policy and found no need for changes. However, adjustments were made to the preadmission testing guidelines, shifting from a single phone call to weekly touchpoint calls with patients to improve engagement. Given the small, overlapping nature of the project team and stakeholders, changes were discussed and voted on during meetings, with unanimous approval.

Action Plan

The action plan was created collaboratively and outlines five key steps, each specifying responsibility, phase, and target completion dates. It aligns closely with the Gantt chart, which details subtasks under each action item.

The project timeline, spanning from January to the end of July 2024, gave clear deadlines that helped in structuring the middle phases toward success.

Gantt Chart Utilization

The Gantt chart serves as a dynamic spreadsheet tool to help the project manager and team visualize tasks and deadlines, promoting accountability. Updates to the chart were made collaboratively to reflect current progress and future plans.

The chart is divided into phases with associated subtasks. For example:

Social Determinants of Health (SDOH) and Target Population

This HIP aims to reduce surgical cancellations by 5% by June 30, 2024, at Ortho Colorado Hospital (OCH) in Lakewood, Colorado—a 48-bed facility with 17 pre-op/PACU bays and 8 operating rooms, employing 187 staff (175 clinical). The target population’s key sociodemographic features include age, ethnicity, income, veteran status, education, and insurance status.

Lakewood’s population (156,149 in 2022) has a median age of 38.1 years and a median household income of $82,786. The ethnic breakdown is predominantly White Non-Hispanic (68.2%), followed by Hispanic (7.42%), Asian Non-Hispanic (3.89%), and African American (1.6%). Veteran presence is significant at 5.25%. Education levels commonly include bachelor’s degrees (20.8%), some college (12.5%), and high school diplomas (14.8%). The uninsured rate slightly increased from 7.38% to 7.54% from 2021 to 2022 (Data USA, n.d.).

Addressing the following SDOH is critical for successful implementation:

• Education Access and Quality: Educational materials will be written at a sixth-grade reading level in both English and Spanish to match the population’s literacy and language needs.

• Economic Stability: While the median income is relatively moderate, some residents face poverty (8.8%), which may affect pre- and postoperative care adherence due to competing financial priorities.

• Neighborhood Environment: While Lakewood offers ample parks and transit options, safety concerns related to public transportation (light rail) may hinder residents’ mobility and recovery activities.

• Social and Community Support: The community has strong social networks, supported by community centers, food banks, and pharmacies offering discounted medications, all contributing positively to patient well-being.

• Healthcare Access and Quality: Although Ortho Colorado is a for-profit entity, it partners with Common Spirit Health, a non-profit organization offering discounted and free clinics, increasing healthcare accessibility for the underserved.

This project will empower patients with clear expectations and educational tools to reduce anxiety and increase confidence during their surgical journey. Weekly follow-up calls by preadmission nurses will further reinforce patient engagement and trust.

Force Field Analysis

The project team identified key driving and restraining forces impacting the HIP implementation:

To leverage these forces, strategies include monthly executive updates with cancellation data, leadership walk-throughs to foster empathy, and justification for hiring additional staff to improve patient communication and reduce cancellations. Resistance will be addressed by involving staff in developing patient educational materials to enhance ownership and reduce perceived workload increases.

Scope Statement

The improved process includes increased patient engagement through additional phone touchpoints and the development of informational handouts and educational booklets or classes. These resources will clarify surgical requirements and journey milestones to enhance patient understanding and compliance.

SMART Goal

The project’s objective is to reduce surgical cancellations at Ortho Colorado Hospital by 5% by June 30, 2024. This will be achieved through improved patient communication via increased touchpoints, informational materials, and education.

Key Performance Indicators (KPIs)

Communication and Training Plans

Communication

Training

The surgeon’s clinic, preadmission, pre-op, and operating staff will receive training focusing on the new informational materials, compliance checklist, and additional preadmission touchpoints. Training includes:

• Four education sessions per week for two weeks (starting May 20, 2024, through June 7, 2024), each lasting two hours.

• Morning and evening huddles and virtual sessions at the surgeon’s clinic.

• Competency sign-off involving a walkthrough and explanation of HIP goals.

References

Arakawa, N., & Bader, L. R. (2022). Consensus development methods: Considerations for national and global frameworks and policy development. Research in Social and Administrative Pharmacy, 18(1), 2222–2229. https://doi.org/10.1016/j.sapharm.2021.06.024

Data USA: Lakewood, Colorado. (n.d.). Data USA. https://datausa.io/profile/geo/lakewood-co/#demographics