NURS FPX 6612 Assessment 2 Quality Improvement Proposal

NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Quality Improvement Proposal

In this assessment, I assume the case manager role at Sacred Heart Hospital. I will develop a proposal to track quality metrics throughout this assessment to qualify the hospital for accountable care organization status. Also, I will recommend ways for the SHH health information technology to include quality metrics. Meantime, I will shed light on information gathering and how it contributes to organizational practices. Additionally, we will discuss the problems that arise during data gathering and provide suggestions to avoid such practices.

NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Recommendation to Expand Hospital’s HIT

As the case manager at Sacred Heart Hospital, my primary responsibility is to develop a strategy for tracking quality metrics to facilitate the hospital’s qualification for accountable care organization status. The following methods can be used to incorporate quality measurements into the hospital’s HIT:

  1. Upgrade the Electronic Health Records System: The hospital’s EHR system is outdated and needs to be updated to improve tracking quality metrics. Upgrading the system will help the hospital to capture more data, generate reports, and identify gaps in care. This information will help the hospital measure progress and make changes to enhance the quality of care.
  2. Implement a Patient Portal: A portal will allow patients to access their health information, including test results, appointments, and medication lists. The portal will improve patient engagement and enable patients to participate actively in their healthcare (El-Toukhy et al., 2020). The portal can also help the hospital capture patient data, which can improve care quality.
  3. Use Clinical Decision Support (CDS) Tools: Clinical decision support (CDS) systems help medical professionals in determining the most appropriate treatment options for their patients. CDS tools can be integrated with the EHR system to provide clinicians with alerts and reminders about necessary tests and procedures (Vinks et al., 2019). The tools can also provide recommendations on evidence-based practices and clinical guidelines, which can improve care quality.

Patients who do not undergo diagnostic procedures done on them, such as mammograms or colonoscopies, can still benefit from the information gathered through the following methods, which address the issue of care coordination:

  1. Conduct Patient Outreach: The hospital can conduct outreach programs to educate patients about the importance of diagnostic tests and preventive care (Świątoniowska et al., 2019). This program can include phone calls, mailings, and reminders through the patient portal.
  2. Implement Care Coordination: The hospital can implement care coordination programs to ensure patients receive the necessary tests and procedures. Care coordinators can help patients schedule appointments, follow up with physicians, and provide support throughout the care process (Kianfar et al., 2019).

Keeping tabs on local or targeted population health data can help us make the right adjustments:

  1. Use Population Health Management Tools: Population health management tools can help the hospital to track health trends and identify areas for improvement. The tools can also provide insights into the community’s health and help the hospital develop targeted interventions to improve health outcomes.
  2. Partner with Community Organizations: The hospital can partner with community organizations to collect data and share information. The hospital can work with community health clinics, public health departments, and other organizations to develop comprehensive data-sharing agreements.

The following methods/strategies can be used to illustrate how important informatics is to the efficient coordination of nursing care:

  1. Use EHRs: EHRs can help to coordinate care among clinicians, patients, and other care team members. The EHR can provide a comprehensive view of patient data, including test results, medications, and care plans (Cohen et al., 2020). The EHR can also provide alerts and reminders to clinicians about necessary tests and procedures.
  2. Use Telehealth: Telehealth can improve care access and help coordinate care among care team members (Sinsky et al., 2021). Telehealth can provide remote consultations, monitor patients remotely, and educate and support patients and caregivers.

The evidence supports using HIT to track quality metrics and improve care coordination. Studies have shown that HIT can improve care quality and patient outcomes and reduce costs. For example, a study published in the Journal of the American Medical Informatics Association found that using EHRs can improve care quality and reduce hospital readmissions. Another study published in the Journal of Medical Internet Research found that telehealth can improve patient outcomes and reduce costs.

NURS FPX 6612 Assessment 2 Quality Improvement Proposal

Information Gathering in Healthcare

The focus of information gathering in healthcare is to collect and analyze data related to patients, treatments, and outcomes to improve the quality of care and guide the development of organizational practice (Hjollund et al., 2019). This process involves collecting, storing, and analyzing various types of data, including patient records, medical history, and clinical outcomes.

Using Electronic Health Records (EHRs) is one way in which information collection aids in directing the growth of the organizational practice. EHRs provide a centralized and secure database of patient information that can be accessed by healthcare providers across different settings, facilitating coordinated and efficient care delivery. Another example is clinical decision support systems (CDSS), which utilize patient data to provide recommendations and alerts to healthcare providers, improving the accuracy and safety of clinical decision-making.

Healthcare organizations need to gather relevant information to guide the development of their organizational practices. This information gathering focuses on quality metrics, and it contributes to improving the healthcare services provided to patients. For Sacred Heart Hospital (SHH), a small rural hospital acquired by Vila Health, this information gathering is essential to develop a strategy for making quality improvements to become an ACO. The first step towards achieving ACO status is to track quality metrics better, and this is where the role of the case manager comes in.

The quality improvements required to become an ACO focus on four key areas: preventive health, patient experience, at-risk population health, and care coordination/patient safety. The hospital needs to show improvements in these areas to become an ACO. The hospital’s Health Information Technology (HIT) system requires updating if it is going to be able to keep track of this information. Karen Wellington, the Admissions and Discharge Director, has informed the case manager that the hospital needs recommendations for improving HIT so that they can track the information needed to understand how to make the necessary improvements.

The first step in improving HIT is to meet with patients such as Caroline McGlade, who have not received enough preventative care. Caroline’s Electronic Health Record (EHR) is not thorough, and the case manager needs to ask themselves how the hospital could track data better to help them make the necessary improvements to become an ACO. Additionally, as a case manager, I need to interview various stakeholders who can provide relevant information about the changes that need to be made in their HIT.

As a case manager, I would interview healthcare providers who work closely with patients. These providers can provide valuable insights into the barriers to care and community issues that affect the quality of healthcare provided. They can help identify the kind of data that needs to be tracked to measure problems and improvements. For example, providers can help identify the preventive care services that are not provided to patients, such as mammograms and colonoscopies. Gathering data on these services can help the hospital track improvements in preventive health, one of the key areas required for ACO status. With the right HIT solutions and data tracking, Sacred Heart Hospital can make the necessary quality improvements to achieve ACO status.

Potential Problems with Data Gathering Systems

Data-gathering systems are essential to healthcare organizations as they provide the necessary information to make informed decisions and provide quality patient care. However, potential problems can arise with these systems that can negatively impact patient care and organizational practice. In this response, I will identify some of these problems and suggest avoiding them.

One potential problem with data-gathering systems is the collection of inaccurate or incomplete data. This can occur if staff members are not properly trained in using the system or if it is flawed (HHS, 2023). For example, if a system is set up to capture specific data points, but the staff member is unaware of these requirements, the data captured may be incomplete or inaccurate. This can lead to poor decision-making and potentially harmful patient outcomes. To avoid this problem, organizations should invest in staff training to ensure that they are proficient in using the system. Additionally, systems should be thoroughly tested to identify any flaws or gaps in data collection.

Another potential problem is the overreliance on data output without proper analysis. Healthcare organizations can gather large amounts of data, but it can be meaningless or even misleading if they do not analyze it properly (Razzak et al., 2019). For example, if an organization is measuring patient satisfaction scores but they do not account for patient demographics, such as age or socioeconomic status, the results may be skewed. To avoid this problem, organizations should have a robust data analysis process in place. This can include hiring a data analyst or investing in data analysis software. Additionally, organizations should ensure that they are measuring the right metrics relevant to their goals and objectives.

A third potential problem is data security breaches. With the increasing use of electronic health records, the risk of data breaches has also increased. Breaches can occur due to hacking, phishing scams, or even staff negligence, such as leaving a computer unlocked. Data breaches can compromise patient privacy and lead to legal and financial consequences for the organization. Organizations should invest in security systems to avoid this problem and ensure staff members are properly trained on data security protocols. This can include regular training sessions, password requirements, and two-factor authentication.

Although data-gathering systems are crucial to healthcare organizations, they can also pose potential problems if not properly managed. By investing in staff training, data analysis processes, and secure systems, organizations can avoid these problems and ensure quality patient care.

NURS FPX 6612 Assessment 2 Quality Improvement Proposal


Expanding the hospital’s Health Information Technology is a critical component of improving patient outcomes and the quality of care. HIT can help to track quality metrics, coordinate care, collect information from the community, and show the role of informatics in nursing care coordination. HIT can be used by upgrading EHR systems, implementing patient portals, using CDS tools, conducting patient outreach, implementing care coordination, and partnering with community organizations. However, potential problems with data-gathering systems, such as collecting inaccurate or incomplete data and overreliance on data output without proper analysis, must be avoided. Information gathering in healthcare is critical in providing data-driven insights that can inform organizational practice and improve patient outcomes.


Cohen, D. J., Wyte-Lake, T., Dorr, D. A., Gold, R., Holden, R. J., Koopman, R. J., Colasurdo, J., & Warren, N. (2020). Unmet information needs of clinical teams delivering care to complex patients and design strategies to address those needs. Journal of the American Medical Informatics Association, 27(5), 690–699. 

El-Toukhy, S., Méndez, A., Collins, S., & Pérez-Stable, E. J. (2020). Barriers to patient portal access and use: Evidence from the Health Information National Trends Survey. The Journal of the American Board of Family Medicine, 33(6), 953–968. 

HHS. (2023). Data Collection. 

Hjollund, N. H. I., Valderas, J. M., Kyte, D., & Calvert, M. J. (2019). Health data processes: A framework for analyzing and discussing efficient use and reuse of health data with a focus on patient-reported outcome measures. Journal of Medical Internet Research, 21(5), e12412.

Kianfar, S., Carayon, P., Hundt, A. S., & Hoonakker, P. (2019). Care coordination for chronically ill patients: Identifying coordination activities and interdependencies. Applied Ergonomics, 80, 9–16. 

Razzak, M. I., Imran, M., & Xu, G. (2019). Big data analytics for preventive medicine. Neural Computing and Applications, 32(9), 4417–4451. 

Sinsky, C. A., Jerzak, J. T., & Hopkins, K. D. (2021). Telemedicine and team-based care. Mayo Clinic Proceedings, 96(2), 429–437. 

Świątoniowska, N., Sarzyńska, K., Szymańska-Chabowska, A., & Jankowska-Polańska, B. (2019). The role of education in type 2 diabetes treatment. Diabetes Research and Clinical Practice, 151, 237–246. 

Vinks, A. A., Peck, R. W., Neely, M., & Mould, D. R. (2019). Development and implementation of Electronic Health Records–integrated model‐informed clinical decision support tools for the precision dosing of drugs. Clinical Pharmacology & Therapeutics, 107(1), 129–135. 

Struggling With Your Paper?
Get in Touch