NURS FPX 8020 Assessment 3 Quality Improvement Proposal

Student name

Capella University

NURS-FPX8020

Professor Name

Submission Date

Quality Improvement Proposal

Slide 1

Hello everyone! My name is currently________ And my QI project will involve a superior patient experience in the Department of Medicine at the University of Alabama at Birmingham, in support of the overall strategic goals and organizational excellence goals of the organization.

Slide 2

The quality improvement programs are highly crucial processes that enable the delivery of health care, patient safety level, and organizational efficacy in the dynamic medical environments. The programs address the key gaps in care delivery and help to implement the evidence-based practice and regulatory compliance requirements. Quality improvement strategies involve the enhancement of patient outcomes, clinical errors, and resource efficiency in care institutions (Bhati et al., 2023). The strategic quality programs assist in aligning the departmental goals with the overall visions of the institution as well as provide it with financial sustainability. The models of healthcare delivery eventually transform with the positive quality improvement initiatives.

The Rationale for Establishing a Strategic Priority

Slide 3

The forced development of evidence-based strategic priorities by healthcare organizations will improve and solve key performance gaps and achievement of institutional mission. Among the key quality improvement initiatives that would facilitate the shifts in the current healthcare communication and care coordination gaps that are reported are the customer priority of the Department of Medicine at the University of Alabama at Birmingham to improve patient experience by increasing the scores on healthcare consumer assessment of healthcare providers and systems (HCAHPS) and clinician and group consumer assessment of healthcare providers and systems (CGCAHPS) satisfaction. 

It is established that the scores of patient satisfaction are directly linked to clinical outcomes, readmission rates, and financial performance of organizations, and priority is one of the keys to the overall quality improvement (Ferreira et al., 2023). As has been shown, formal communication practices and care coordination initiatives can boost the level of patient satisfaction, and, at the same time, enhance the level of staff engagement and decrease turnover (Weller et al., 2024).

The pillar of patient care of UAB aligns with the customer focus since it is committed to delivering the best patient-centered integrative care and resulting in the organizational objective of ensuring that the satisfaction scores remain above 90 percent across all the health-related organizations (The University of Alabama at Birmingham, 2024). The strategic priorities should give the clear evidence based reasoning and tangible results that may be effectively measured and put into practice to promote the excellence of the departmental and institutional strategic objectives.

SWOT Analysis

Slide 4

The strategic initiatives involve carrying out the overall formulation of the strengths, weaknesses, opportunities, and threats (SWOT) analysis that will determine the internal capabilities and external factors that can determine the success of the implementation and organizational performance. The strengths of the Department of Medicine customer priority to increase patient experience by increasing HCAHPS and CGCAHPS scores are the presence of the quality improvement infrastructure, the presence of the electronic health record systems, and the fact that it is connected to the strategic pillar of the patient care of the UAB that intends to achieve 90 percent satisfaction (The University of Alabama at Birmingham, 2024).

Nevertheless, the potential constraints of the resources due to the conflicting priorities in eight strategic areas and the necessity to invest tremendous amounts of resources into the workforce training to initiate the communication protocol enhancements are also regarded as the weaknesses (Canale et al., 2023). The political environment provides the opportunities like the institutional mission to patient-centered care, financial stability with Aa2/AA+ credit rating, and rising trend of value-based healthcare delivery models to compensate patient satisfaction outcomes (The University of Alabama at Birmingham, 2024).

Conversely, high competition with other academic medical centers, potential regulatory changes connected to the reimbursement rate depending on the satisfaction score, and the lack of personnel that might limit the large-scale staff development initiatives (Sommer et al., 2024). The customer priority ought to be in a position to manage the competing institutional requirements and leverage on available strengths to overcome obstacles to implementation. An effective SWOT analysis would enable the strategic leaders to devise certain interventions that would harness the organizational strength to the maximum and mitigate the risks of the threats to the strategic priority realization.

Key Performance Indicators

Slide 5

The elaborate measurement system like plan-do-study-act (PDSA) that tracks the progress of different areas of the organization and the results of the stakeholders should be actively supported by quality improvement programs. The key performance indicators necessary to make the Department of Medicine customer priority to enhance the patient experience by raising the scores of HCAHPS and CGCAHPS are required to be strong to align with the UAB strategic goals and UAB Medicine 2025 goals (UAB Medicine, 2025). Earning before interest, tax, depreciation, and amortization (EBITDA) performance and revenue per patient encounter are some financial measures to ensure that it is sustainable with the economic impact goals of UAB being 15 billion (The University of Alabama at Birmingham, 2024).

The customer indicators are based on the HCAHPS and CGCAHPS satisfaction scores in which the target is to reach above 90 percent in accordance with the patient care pillar of UAB (The University of Alabama at Birmingham, 2024). Internal process measures consist of the UHC quality scorecard performance and accuracy of chart documentation which utilizes the available electronic health record systems to support AMC21 quality pillars. The indicators of learning and growth keep track of the staff engagement ratings, and the communication competency ratings, which contribute to the workforce development across the various divisions of the clinic (The University of Alabama at Birmingham, 2024).

The measures also enable monitoring the systematic progress and, at the same time, ensure that it corresponds to the pillar of patient care and the requirements of institutional quality excellence of UAB. The formal KPI systems provide some sort of responsibility that may transform strategic priorities into quantifiable outcomes and long-term organizational benefits.

Table 1

Department of Medicine Key Performance Indicators

Note. Information is one of the key performance indicators of the Department of Medicine customer priority enhancement initiative, which is in accordance with the domains of the balanced scorecard. Target goals indicate the institutional benchmarks of UAB such as patient satisfaction goals set at above 90, financial sustainability goals with Aa2/AA+ credit ratings, and 15 billion economic impact goals. The references used to retrieve data were The University of Alabama at Birmingham (2024) and UAB Medicine (2025).

Stakeholders Identification

Slide 6

The stakeholders must be formally involved in the quality improvement campaigns in healthcare so that sustainable implementation and transformational organizational performance can be achieved in different areas of operation. The crucial individuals that will be significant to the patient experience improvement initiative in the Department of Medicine are the UAB President Ray Watts and the strategic planning council, which provides institutional leadership through the entire planning framework that engaged 55 representatives throughout the network of universities and the health system (The University of Alabama at Birmingham, 2024). Clinical leadership: Department chairs, division directors, and physicians of the faculty all offer specialized knowledge that facilitates the growth of HCAHPS and CGCAHPS performance objectives that align with the AMC21 strategic pillars (UAB Medicine, 2025).

The relevant information on care processes and satisfaction improvements are offered by various stakeholder groups in patients served by UAB health entities, nursing staff, medical students, and fellowship members to support strategic priorities of patient care in the institution. This is to be carried out by the research teams and administrative support staff to facilitate the coordination of initiatives with the organizational mission of UAB and ensure adherence to go beyond the levels of patient satisfaction amidst varied patient demographics.

Process for Collaborating with Stakeholders

Quality improvement to be achieved must be systematic in the collection of the opinions of the stakeholders and interactive ways of involvement that integrates various views and experience. The feedback mechanism will be based on the structured feedback, i.e., employee-satisfaction survey, patient experience survey, and multi-disciplinary team feedback using the UAB time-tested town hall and public comment process (Marcinow et al., 2022). The stakeholder meetings between the Department of Medicine faculty, healthcare workers, and management units will preserve the continuous contact to aid in the application of HCAHPS improvement techniques (Petkovic et al., 2020).

The knowledge of the stakeholders and the research-based approaches of the UAB will be combined, using the joint planning meetings that will enhance the general strategic structure of the institution and the excellence standards of the AMC21. The deliberate collaboration with stakeholders increases the impact of the initiatives and produces organizational commitment that guarantees the long-term positive change in patient experiences in compliance with the strategic goals of the university.

Leveraging Stakeholder Feedback

To enhance efforts and achieve long-term quality improvements and excellence in patient care, healthcare organizations will have to systematize the incorporation of stakeholder input. The customer-focused initiative of the Department of Medicine will assume the systematic feedback strategies with clinical faculty and staff to address communication barriers and enhance the organization of care in the already-established systems of operation (Boehnke and Rutherford, 2021).

Insights and patient satisfaction data will be shared as teams to identify HCAHPS improvement plans basing on UAB institutional excellence criteria and 15 billion economic impact objectives (The University of Alabama at Birmingham, 2024). The departmental heads will present similar assessment activities to the clinical staff to identify the satisfaction outcomes and modify the communication strategies to fulfill organizational goals (Restivo et al., 2022). The integration of ongoing feedback allows the implementation of the ongoing improvement of the initiative, and, simultaneously, compliance with the demands of the UAB patient care strategic pillar and the AMC21 operational framework.

Top of Form

Role of Change Theory

Slide 7

In any healthcare setting, modern change theories provide systematic ways of how quality improvement programs could be introduced and change in the organization could be managed. The three-stage change theory created by Lewin can be applied systematically to enhance customer priority in the Department of Medicine as the initial step of the change theory is unfreezing, in which the leadership can identify the current gaps in HCAHPS performance and create a sense of urgency to change the communication protocols among clinical staff (Sheehan et al., 2021).

The changing phase is identified with the implementation of new care coordination processes, training the staff about new and better ways of communicating with patients, and standardization of procedures of improving satisfaction in relation to the AMC21 quality pillars (Albertson et al., 2021). The refreezing stage is a process that solidifies the changes, inculcating new communication patterns into the normal work processes, establishing monitoring systems on a periodic basis, and reinforcing the episodes that establish patient satisfaction that is long-term and over 90 percent (Hibbert et al., 2023). Structured change theories ensure that changes and even involvement of stakeholders in implementation processes in organizations can be systematically transformed and ensured.

Interpretation

One can experiment with organizational change by using the three stage change theory by Lewin because human resistance to change is handled systematically where the theory takes into consideration the reality that the implementation process is realized in stages. The unfreezing level acknowledges the fact that people and companies are resistant to change and that motivation and readiness must be developed through communication and education (Barrow and Annamararaju, 2022). The changing stage accommodates the fact that change must be actively brought about with a sense of direction, support systems, and continuous reinforcement to the stakeholders as they pass through the new behavior and troubleshooting (Ahmed et al., 2022).

The maintenance of the refreezing stage is ensured by the fact that the new practices are integrated into the organizational culture and policies and in the daily operations there is no propensity to revert to the previous behaviours. The theory highlights that the successful change should be well planned, carried out in a methodical fashion and supported in a specific way with the perspective of realizing the success of the long term organizational change.

Policy Recommendation

Slide 8

A supportive policy framework should be enacted by healthcare organizations to enable the quality improvement implementation to close the gap towards organization transformation at all levels of operation that it participates in. The Department of Medicine will have to have a strategy plan in the area of patient communication and care coordination, whereby the standard HCAHPS improvement policies would involve having the clinical staff members receive patient communications training, and regular competence testing will be conducted to assess the improvement plan to be used in order to meet the quality improvement objectives (Mrayyan et al., 2023).

Moreover, revising the current quality metrics reporting policies to include the real time update of the satisfaction dashboard will enable provision of timely feedback on the performance and implementation of corrective actions to meet the objective of patient satisfaction in the institution. This company needs to get rid of old documentation policies that create an administrative overhead without a value benefit, streamlining work processes in favor of patient-oriented communication processes and care coordination processes (Harbi et al., 2024).

Finally, the policies of patient experience incentives basing the staff performance rating on the rise in the patient satisfaction scores will help to support the behavioral change and ensure the long-term dedication to excellence in all clinical divisions (Marcinow et al., 2022). The strategic policy development is based on the foundation of long-term pillars of organizational excellence and continuous quality enhancement programs in healthcare establishments.

Policy Implications and Justification

Slide 9

The implementation of policies has great organizational implications that ought to be considered like allocation of resources, the effect on the stakeholders, and the alteration in the functioning of the healthcare environment. The given policy of patient communication and care coordination will also necessitate a significant amount of investments in the staff training and personnel resources allocation, as well as the technological infrastructure upgrades that are bound to facilitate the introduction of the real-time HCAHPS monitoring systems into the reality. It has also been found in one of the studies that the greater the satisfaction of patients, the fewer the readmission rates, and the better clinical outcomes (Ferreira et al., 2023).

It is demonstrated that properly designed communication training interventions positively affect patient satisfaction scores and also enhance staff involvement (Chen et al., 2025). According to a study, the performance-based incentive policies transform the long-lasting behavioral changes that promote the quality improvement endeavors (Gadsden et al., 2021). The new policy of quality metrics reporting will enable proactive intervention steps, and the patient experience incentive policy will enable staff behavior to be adapted to the institutional objectives and that is important to establish the accountability structures to promote the long-term performance enhancement in clinical divisions. The achievement of sustainable organizational change and the best healthcare delivery systems are dependent on strategic policy frameworks.

Conclusion

Slide 10

The strategic planning key of healthcare organizations suggests the overall incorporation of evidence-based priorities, stakeholder engagement and effective change management processes. The customer priority in the department of medicine shows the effectiveness of integrating the patient satisfaction improvement strategies and institutional strategic programs under the balanced scorecard framework with strong key performance indicators. The supporting policy, efficient cooperation between the stakeholders and systematic application of the change theory that tackles the issues of organizational change are the keys to success. The strategic plan is good by providing sustainable competitive advantage that can be measured with positive effect and constant improvement in all functional areas of operation.