The Government Hospital: Quality Improvement Program


The objective of this proposal is to present an evaluation study that will examine a quality improvement (QI) program of a 500-bed government hospital. This goal has been motivated by the need to evaluate the achievements of the QI program since its implementation since its inception in 2010. The rationale for the performance evaluation is to identify inherent gaps and the opportunities for growth. The proposed research will achieve this aim by reviewing the QI infrastructure and activities. In the first instance, structural and system changes are essential to enhancing the performance of the QI program. Thus, it is imperative to determine how the hospital leadership and other management bodies have built the capacity for progress. On the other hand, the analysis of the QI activities will be of the essence to ascertain the extent of effectiveness. The ensuing discussion will also discuss the standards and methodologies that will facilitate the completion of this task successfully.

Background Information

The healthcare industry has increasingly become under immense pressure to enhance the quality and safety of care (Gale & Schaffer, 2009). Two critical factors have influenced the incessant demands for quality improvement (QI). First, the rising incidences of medication errors, hospital-acquired infections, and other adverse events have necessitated the transformation of the current processes (Oman, Duran, & Fink, 2008). Second, the unprecedented advances in technology coupled with the shift towards evidence-based practice have brought the issues of quality and safety to the forefront (Gale & Schaffer, 2009). As such, it is imperative to implement QI programs that will improve clinical outcomes and optimize the use of resources.

This paper will propose the procedures and methodologies of evaluating a quality improvement (QI) program in a health institution. The 500-bed government hospital implemented the QI project to enhance clinical processes and outcomes. Nonetheless, the progress has been unsatisfactory five years after the implementation of the intervention. The proposed evaluation research will play a fundamental role in appraising the program’s infrastructure and components, as well as the implementation processes that are affecting the performance improvement. The following discussions will also define the standards and methodologies, which will be useful in assessing the ongoing operations of the QI project.

Infrastructure Aspects of the QI Program

The principal challenges facing the healthcare industry today include the improvement of person-centeredness, efficiency, and quality (Gale & Schaffer, 2009). The mitigation of these obstacles necessitates the development of strategic plans that will enhance the current capacities (Oman et al., 2008). The quality infrastructure includes the elements of management and organization that affect the degree of QI implementation in a hospital (Ransom, Joshi, Nash, & Ransom, 2008). According to Ransom et al., the high-performing health organizations and systems have implemented QI projects successfully by constructing sustainable and feasible systems. The proceeding discussions will describe the most important QI infrastructure.

The Management Commitment

The successful implementation of a QI program depends on the commitment of the top management. The primary function of the hospital administrators is to coordinate the activities of the junior staff to achieve organizational goals (De Souza, 2009). The management commitment entails three critical aspects. First, the active involvement of the employees in the decision-making processes is essential to the planning and execution phases (Gale & Schaffer, 2009). Second, the top management should mobilize and provide adequate resources to actualize the QI program (Newhouse, 2007). Third, the hospital administrators should support the change initiatives by endorsing and participating in the QI activities (De Souza, 2009).

The Management Aspects to Consider during the Evaluation

First, the assessment study will analyze the effects of the various leadership styles on the quality performance. A strong commitment from the executive will facilitate the incorporation of quality standards into the hospital’s work processes and protocols (Gale & Schaffer, 2009). The leadership styles are essential to establishing and preserving a culture of safety and quality. According to De Souza (2009), organizational culture is a contextual component that determines if the organization has institutionalized QI programs or not. Thus, the performance assessment will establish if the leaders have created a vision and have been sustaining it throughout the implementation process. Gale and Schaffer have underscored the significance of transformational and visionary leadership styles in the management of change.

Second, it will be imperative to evaluate if the hospital managers and administrators have adopted robust management practices. Newhouse (2007) has noted that these attributes support the integration of QI approaches in the organization. Firstly, the evaluation study will determine if the leaders have developed strong structures to encourage the implementation of the QI program. Secondly, it is essential to find out if the hospital administrators are providing adequate resources to support the seamless execution of the procedures. For instance, it will be crucial to examine if the hospital has provided enough funds to recruit skilled employees and purchase equipment. This example highlights the importance of building the hospital’s capacity.

Third, the evaluation process will examine if the hospital management has developed adequate training programs. One of the elemental factors that undermine the prevention of adverse events is limited knowledge and skills. The organizational culture that does not value professional growth and development exacerbates the previous limitations further (Oman et al., 2008). It is necessary to evaluate if the leaders are providing mentorship and training programs to enhance the competencies of the care providers. Transformational leaders do not employ punitive measures but rather lead by example (De Souza, 2009). Further, such leaders do not introduce change before ensuring that their followers have requisite skills and knowledge.

Finally, the evaluation study will examine the extent to which the managers are facilitating effective communication. Efficient communication is essential throughout the implementation process because it provides timely feedback (Machado & Leitner, 2010). It will be critical to identify the structures that the hospital administrators have developed to facilitate coordination and the dissemination of information. The management should have developed explicit channels of interacting with the employees. For instance, regular workshops, seminars, podium presentations, and newsletters are vital to sharing knowledge and experiences among the various stakeholders. The management uses these forums to sensitize the participants about the progress of the QI program (Gale & Schaffer, 2009).

The Quality Council

A quality council or committee plays a fundamental role in spearheading the quality improvement process. Ransom et al. (2008) have described a quality council as a committee created by the top management to oversee the functions of the professionals drawn from various “disciplines, departments, and units” (p. 23). The primary function of these individuals is to formulate policies and guidelines on health care quality (HRSA, 2014). The hospital’s CEO carries the mandate of constituting the quality council in consultation with the quality coordinator. The membership of this organization consists of high-ranking professionals and front line managers from different specialties and departments (Brown, Bessant, & Lamming, 2013).

Aspects to Consider when Evaluating the Quality Council

The proposed study will examine the extent to which the roles and responsibilities of the quality council have been delineated adequately. The first task that follows the establishment of this committee is the development of a charter document. The objective of this policy document is to specify the functions of the members (HRSA, 2014). Kroch, Duan, Silow-Carroll, and Meyer (2007) have found out that the absence of explicit roles and responsibilities often causes confusion and an overlap of the mandates. It is also essential to determine if the selected individuals are qualified and capable of fulfilling their obligations. Further, the quality council should include people from all the departments and units of the hospital (Newhouse, 2007).

Secondly, the study will evaluate whether the quality council has developed plans, policies, and procedures to track the performance of the QI program. One of the functions of the quality committee is to meet periodically with the aim of directing the activities of the QI programs (Kroch et al., 2007). Thus, it will be necessary to assess if the quality council is communicating efficiently, as well as coordinating the implementation of the QI activities throughout the health facility. The quality council should disseminate progress reports to the governing board and multidisciplinary improvement teams. The continuous flow of information helps the quality council to measure the current performance and make strategic revisions where feasible and necessary (Gale & Schaffer, 2009).

Thirdly, it is essential to strengthen the role of the quality council in addressing the present concerns (HRSA, 2014). The evaluation study will describe the mechanisms that the hospital has employed to enhance the capacity of the council. The concept of quality is multidimensional and complex in health care settings considering the multiplicity of the required principles, techniques, skills, and tools (Oman et al., 2008). It is of the essence to ensure that the members of the quality council have adequate knowledge of the quality improvement activities (Kroch et al., 2007). The evaluation study will determine if the members of the quality council have participated in seminars and intellectual discussions to gain an in-depth understand of the QI program. It will be necessary to ascertain if the quality coordinator and other members attend these meetings regularly besides providing timely feedback.

The Quality Unit

The quality unit monitors the quality indicators in all the departments of an organization to ensure the sustainability of the QI program and activities (Varkey, Peller, & Resar, 2007). The support and input of each of the departments support the operations of the quality unit (Ransom et al., 2008). The principal mandate of this QI infrastructure is to monitor the performance of individual units within the heath facility. Another function entails the institutionalization of the QI activities (Kroch et al., 2007). The health organization’s CEO and board provide political support and financial resources to facilitate the operations of the quality unit. The leadership also authorizes this entity to monitor and survey the quality performance of any department within the health institution (HRSA, 2014).

Aspects to Consider when Evaluating the Quality Unit

The study will assess if the hospital’s quality unit has set organizational standards for measuring quality improvements. This process will entail assessing if essential procedures and policies exist within the hospital. It will be crucial to determine if the quality unit has developed guidelines to ensure proper documentation of activities and processes in the organization (Varkey et al., 2007). In the same vein, the assessment will establish if the quality unit has formulated efficient systems to communicate the quality standards to the employees and other stakeholders (Oman et al., 2008). The review will also analyze the mechanisms that the quality unit has developed to ensure the effective compliance with the established rules and protocols (Gale & Schaffer, 2009).

The purpose of the QI program is to improve the quality and safety of the health care processes and procedures (Kroch et al., 2007). Thus, it is necessary to assess if the quality unit is fulfilling the mandate of identifying the opportunities for continuous improvements. The quality unit should also develop feasible strategies to initiate and coordinate the implementation and management of change. This crucial goal mandates the quality unit to oversee the formulation of performance improvements and measurements (Gale & Schaffer, 2009). The evaluation study will determine if the quality unit is utilizing technological tools to support the achievement of these objectives. The use of technology is particularly critical to reducing the incidences of the adverse incidents inherent in the clinical setting (Oman et al., 2008).

The hospital environments have increasingly become risky for both the care providers and patients. The quality team carries the responsibility of controlling, preventing, and managing these risks (Gale & Schaffer, 2009). The evaluation study will determine if the quality unit has developed efficient reporting systems to manage medication errors and other undesirable outcomes. The quality unit also has the mandate of coordinating all the activities and functions related to the minimization of both the internal and external risks (Ransom et al., 2008). For instance, it will be crucial to find out how the quality unit is addressing the intrinsic and extrinsic factors that are affecting the nursing turnover and adequate staffing. This objective requires the quality unit to work closely with all the departments (HRSA, 2014).

Quality units involve various organizational structures that vary across health facilities (Gale & Schaffer, 2009). The study will document the organizational fabric of the unit in terms of reporting lines and functions. Ransom et al. (2008) have asserted that the quality unit falls under the clinical staff department. Conversely, the hospital CEO oversees its operations in other organizational models (HRSA, 2014). On the other hand, most hospitals require clinical and administrative departments to report to the quality control unit. According to Ransom et al., the other components of the quality unit include “control, utilization, case management, risk management, and credentialing” (p. 27). The study will analyze the effectiveness of the organizational structure adopted by the quality unit.

The Quality Coordinator

The quality coordinator is the change agent that oversees the implementation of the QI program. This role is critical because it ensures the successful institutionalizing of the QI program (Varkey et al., 2007). A highly experienced doctor or nurse leader often occupies this position. Oman et al. (2008) have underscored the significance of assigning this position to an individual with a clinical background. The essence of this assertion is that this role entails the interaction with multidisciplinary teams to develop and execute QI protocols and processes (Ransom et al., 2008). A quality coordinator should be conversant with the quality techniques used in hospitals. The position also requires the selection of leaders that display credibility and authority (Kroch et al., 2007).

The evaluation of this role will focus on several aspects. First, it will be necessary to identify the systems and policies that the quality coordinator has developed to champion for healthcare quality (Kroch et al., 2007). Second, it is crucial to establish the relationship between the quality coordinator and the hospital CEO. This relationship is essential because the quality coordinator is responsible for building the QI infrastructure, as well as mobilizing the required resources (Oman et al., 2008). The study will also assess if the quality coordinator has established the channels of liaising with external agencies and other hospitals. Finally, this study will examine the systems developed by the quality coordinator to procure non-human resources, which include medical equipment and advanced technologies.

The Standards and Criteria for Evaluating the QI Infrastructure

The QI infrastructure requires effective leadership to ensure the successful implementation of the QI program (De Souza, 2009). As such, the evaluation study will assess the performance of the ongoing project using the Joint Commission’s Leadership Standards. First, the hospital should have a clear leadership structure to coordinate the provision of care and other hospital operations (Parry, Carson-Stevens, Luff, McPherson, & Goldmann, 2013). Each component of the QI infrastructure should have skilled and professional leaders to support the efficient implementation of the QI program (Greone, 2011). For instance, the commitment of the top management will play a significant role in facilitating the implementation of the quality improvement plans.

Second, all the leaders should have delineated roles and responsibilities to avoid confusion and the overlap of their duties. The leaders may share or delegate some of their roles to increase the scope of participation (Gale & Schaffer, 2009). For example, the hospital CEO should work closely with the quality council to enhance effectiveness. The manner in which the administrators collaborate will certainly influence the performance of the QI program. The hospital CEO is responsible for constituting another quality council if the current one is not fulfilling its mandate accountable to the team (Parry et al., 2013). This standard is crucial because the top management handles the safety and quality of health care. Nonetheless, collaboration is essential in decision-making processes (Toussaint & Berry, 2013).

Finally, the hospital’s governing body has both a legal responsibility and operational authority to ensure the quality and safety of care (Greone, 2011). This organization should provide adequate resources and facilitate the development of internal structures to support the QI program (Parry et al., 2013). For example, the governing council should work with the hospital CEO, the top management, and other administrators to evaluate the performance of the QI intervention. The complexity of the healthcare system often increases the risk of conflict. Such contentions have adverse effects on teamwork and the implementation process (Kroch et al., 2007). The governing body should formulate the mechanisms of resolving conflicts using sound management policies and standards (Schmaltz, Williams, Chassin, Loeb, & Wachter, 2011).

Data Collection Methods and Tools

The first data collection method will entail interviewing the quality coordinator, the hospital CEO, senior managers and board members, as well as the members of the quality council and unit. This fact-finding technique will provide crucial information, which will assess how these individuals are fulfilling their respective mandates. For instance, it will be necessary to find out if the hospital CEO is supporting the QI program by availing adequate resources to the various departments. The interviews will also provide the platform for examining the challenges that these individuals are encountering while accomplishing their roles and responsibilities. The engagement with such persons will identify their perceptions and views regarding the progress of the QI program.

The second data collection technique will be conducting an expert review of the QI procedures, policies, and standards. This panel of professionals will include internal and external reviewers who will appraise the performance of the QI program. In the same vein, the review board will conduct a task evaluation and root-cause analysis. The former procedure will diagnose the current needs and detect the opportunities for quality improvements. This approach will precede the assessment of performance indicators established at the baseline. The latter process will analyze the vulnerabilities of the current systems and activities to identify the vulnerabilities in the current systems. Nonetheless, it is imperative to note that these methodologies consume a lot of time and resources.

The final method will entail the review of the existing documentation to validate the information gathered using the previous techniques. As such, the panel of professionals will review policy documents and hospital records to retrieve crucial information. This process will also involve the random selection of incident reports, notes from the suggestion boxes, financial reports, and other documents. These records will be in both the hard and electronic (soft) copies. The appraisal of the policy papers and guidelines will be essential to identify the sections that require reforms. On the other hand, it will be necessary to review external reports and other documents to provide the basis for the evaluation.

The data collection tools will include interview schedules, performance evaluation protocols, and data mining tools. In the first case, the interview schedules will be essential in gathering information from the key informants. The interview schedules will contain open-ended questions to collect qualitative data and personal opinions. Second, the performance evaluation protocols will provide standardized indicators to assess the scope of performance. It will be necessary to adopt the procedures that have been successful in other hospitals and health institutions. Finally, the data mining tools (including data analysis tools) will be used to identify and retrieve information from documents systematically. The complexity of these processes mandates adequate planning.

Data Sources, Sample Size, and Data Collectors

The data sources will be both primary and secondary. The primary sources will include the quality coordinator, the hospital CEO, four senior managers, and three board members. Other individuals will include six members of the quality council and four from the quality unit. The secondary sources will include policy documents, incident reports, notes from the suggestion boxes, financial reports, and other records (both internal and external). The primary data collectors will be the panel of experts, which will constitute three professionals from the hospital and four from external institutions. The board of reviewers will appraise the existing processes and documentation to assess the effectiveness of the QI program. These individuals will also conduct the face-to-face interviews with the key informants.

The Specific Components of the QI Program

The principal goal of continuous quality improvement is to upgrade the current processes and systems. The implementation of a quality improvement program can enhance performance and clinical outcomes significantly (Varkey et al., 2007). Nonetheless, the introduction of such a program requires the development of the essential components. In practice, the success of the QI initiatives depends on the feasibility of the QI activities (Newhouse, 2007). Kroch et al. (2007) have noted that these components create a supportive culture that encourages safety and quality. The quality improvement activities constitute the initiatives implemented to enhance performance in high-risk areas (Ransom et al., 2008). The following discussions will outline and describe the components of the QI program, including the implementation processes.

Improving Patient Safety and Outcomes

The impetus behind the quality improvement program is to enhance the quality and safety of health care (Parry et al., 2013). The management of patient safety and care quality is central to the success of a quality improvement program. The study will evaluate the organizational culture at the hospital. The QI program can only be successful if the hospital combines quality standards with a culture of safety (Gale & Schaffer, 2009). A clinical environment that supports the culture of safety makes it easy to institutionalize quality in every department within the health organization (Machado & Leitner, 2010). Thus, the evaluation study will determine if the employees are aware of the quality improvement concept and its execution in clinical practice.

The nurse leaders are advocates of patient safety because they oversee the activities of the nursing staff. These administrators create the urgency for change and support the nurses to incorporate the change into the care processes (Newhouse, 2007). The nurse managers should empower their subordinates to achieve the organizational goals (De Souza, 2009). First, the study will evaluate if the nurse leaders involve the nursing staff in decision-making processes. This objective will be essential to discern the nurse administrators’ leadership styles. For instance, authoritative leaders make autonomous decisions while the democratic ones involve their followers from the inception to execution stages. Second, the evaluation will establish if the managers are commitment to quality by assessing their involvement in the planning and implementation processes.

Prioritization of Improvement Opportunities

The identification and prioritization of the opportunities for improvement is one of the critical activities of a QI program. Quality improvement is not static but rather a continuous process (Gale & Schaffer, 2009). It is imperative to identify the opportunities for progress to enhance performance. This process plays an integral role in optimizing the available resources by identifying wastages and redundant activities (Brown et al., 2013). Newhouse (2007) has cautioned against the expansion of QI programs to other areas before establishing a stable and sustainable foundation. Thus, prioritization enables the change agents to focus the implementation process on the achievement of the predetermined goals. The execution of the QI program should be cautious, gradual, and rooted in systematic improvements to achieve tangible and positive outcomes (Oman et al., 2008).

The evaluation study will determine if the hospital has developed tools and systems of collecting quantitative and qualitative data. These procedures are essential to measure the level of effectiveness (Gale & Schaffer, 2009). It is also critical to establish if the hospital has formulated pre and post status indicators to assess the scope of progress from the baseline. According to Kroch et al. (2007), the identification of measurable parameters supports the sustainability and credibility of the QI program. The review will also ascertain if the quality council, unit, and coordinator have formulated clear channels of disseminating information regarding the achievements of the project. This exercise assists the change agents to identify the opportunities for improvement in collaboration with all the stakeholders (Oman et al., 2008).

The formulation of adequate policies is of the essence to support the institutionalization of quality and safety in clinical settings. According to Oman et al. (2008), effectual guidelines and standards create an organizational culture that fosters quality and safety. Policies and directives are particularly essential in measuring the progress of the QI program (Ransom et al., 2008). For instance, the use of electronic health records is crucial to organizing the patients’ information systematically and efficiently. Nonetheless, the inadequacy of proper standards hinders the efficient utilization of the medical technologies (Gale & Schaffer, 2009). The evaluation study will appraise the policies that the hospital has put in place to strengthen the QI program.

Continuous Training and Education

The staff training geared towards improving skills and efficiency is another essential program activity that the study will describe. The majority of QI programs fail to reach their full potential because of clinicians’ insufficient knowledge and skills (Varnell, Haas, Duke, & Hudson, 2008). For instance, Gale and Schaffer (2009) have found out that most care providers lack the capacity and self-efficacy to use technological tools and applications. The continuous training and education programs will update the competencies and knowledge of the care providers (Varnell et al., 2008). Information literacy requires the health professionals to identify the information needs and retrieve it efficiently and adequately (Oman et al., 2008). The study will examine whether the in-house training programs are comprehensive to meet the current demands.

The health facility should foster a clinical environment of learning rather than that of reprimand and judgment. The clinicians cannot make sound decisions if they lack the knowledge and capacity (De Souza, 2009). For instance, the management of medication errors mandates the nursing administrators to develop training programs. These initiatives ensure that the nurses use scientific evidence to make sound decisions during the medication administration (Newhouse, 2007). The research will seek to identify if the hospital has cultivated a culture of blame or continuous improvement. Varnell et al. (2008) have found out that nurses are receptive to QI programs if the top management supports them to adapt to the changes effectively.

Effectual Communication and Coordination

The incorporation of the QI activities into the existing communication channels is crucial to the success of the QI program. Gale and Schaffer (2009) have highlighted the significance of using both the written and verbal communication strategies to discuss the issue of quality wherever clinicians are gathered. The QI program usually brings together professionals from diverse disciplines. Effectual communication facilitates the seamless coordination of activities among the different groups (Kroch et al., 2007). The continuous flow of information reduces the risk of failure since all the stakeholders collaborate to identify gaps and opportunities for improvement (Newhouse, 2007). Conversely, the complexity of the health care system makes inter and intra-departmental communication challenging. Despite this limitation, it is imperative to develop explicit systems to support efficient communication (Gale & Schaffer, 2009).

The proposed study will assess if the dissemination of information is efficient in all the departments. For instance, it will be essential to ascertain if the nurses participate in the decision-making processes or whether they seek permission before making clinical decisions. The research will also seek to find out if the hospital has any formal channels of written communication, such as an official newsletter. The hospitals that produce newsletters often provide suggestion boxes in every department to collect the views that will be assimilated in this publication (Gale & Schaffer, 2009). The assessment will determine if the hospital has made such provisions. It will be essential to evaluate if the current communication methods are convenient and provide timely feedback (Varkey et al., 2007).

The number of health organizations that are now implementing QI programs has increased significantly (Parry et al., 2013). It is essential to form linkages across the institutional boundaries to share experiences and critical lessons (Machado & Leitner, 2010). The evaluation study will identify if the hospital has developed protocols for interagency collaboration, communication, and teamwork. The review will determine if the implementation team has developed a dedicated unit of coordinating the exchange of information between the agencies. For example, it will be essential for the hospital to consult the quality coordinators of the hospitals that have already institutionalized a similar QI program. The hospital’s quality director will use this experience as a benchmark for instituting the best practices (Gale & Schaffer, 2009).

The Standards and Criteria for Evaluating the QI Components

The rationale underpinning the QI components and activities is the enhancement of health care quality (Greone, 2011). Thus, the proposed study will evaluate the performance of the QI program based on the patient safety and quality standards formulated by the Joint Commission International (JCI). First, it is imperative to ascertain if the hospital has developed safety and quality goals based on the JCI standards (Menachemi, Chukmaitor, Brown, Saunders, & Brooks, 2008). For instance, improving patient safety and outcomes is one of the fundamental aspects of the QI programs. As such, it is indispensable to assess if the QI program has assimilated the patient safety and quality standards of the current practice (Schmaltz et al., 2011).

Secondly, the patient-centered communication standards play an elemental role in enhancing effective interprofessional communication, patient-centered care, and cultural competence (Parry et al., 2013). The essence of the QI program was to improve the quality and safety of care. Conversely, challenging communication within the clinical setting undermines the safety of care. Thus, it will be essential to evaluate if the communication strategies and channels within the hospital adhere to the JCI standards (Greone, 2011). The communication standard is especially critical during the medication processes considering the effects of adverse drug events on the patient outcomes. The hospital should have developed medication administration and management guidelines to avoid the medication errors (Gale & Schaffer, 2009).

Thirdly, the JCI has also developed a raft of standards to address the rising incidences of the hospital-acquired infections (HAIs). The evaluation study will assess if the hospital has incorporated infection prevention guidelines into the QI program. For instance, it is necessary to determine if the nurses have received adequate training to support the adoption of the most effective hand washing techniques. It will be crucial to find out if the critical care nurses use evidence-based guidelines to provide postoperative care. Another area of concern will be the use of proven standards to manage the catheter-associated urinary tract infections in gerontology units. The combination of these standards will identify the safety issues that the current program is not addressing adequately (Varnell et al., 2008).

Data Collection Methods and Tools

First, the nurse administrator and line managers will be engaged through face-to-face interviews. These meetings will be crucial to gathering critical information regarding the nurse administrator and line managers’ leadership styles. The findings from this data collection technique will evaluate if the administrators are creating a culture of quality and safety. This process will identify the measures that the line managers have developed to facilitate education, effectual communication, and the prioritization of improvement opportunities. The interviews will also provide the rationale for assessing the link between leadership and the implementation of the QI program.

Second, the evaluation study will employ a survey to gather information from the clinicians and patients. The purpose of this investigation will be to collect information about the clinicians’ perceptions and attitudes towards quality improvement. It will be necessary to evaluate if the clinicians have the requisite skills and knowledge to support the implementation of the QI activities. For instance, the survey will establish if the nurses underwent training before the introduction of the quality improvement tools in the clinical practice. The clinicians will also provide views about the effectiveness of the current leadership, including the scope of interdisciplinary communication and teamwork. On the other hand, patients will also provide crucial information regarding their experiences since the inception of the QI program.

Third, the focus group discussions will triangulate the preceding methodologies. The focus group will provide an opportunity for the nurses to share their experiences and identify the challenges inherent in the QI program. The participants will use the reactions and assertions of their colleagues to develop a synergy of discussions. Fourth, performance observations will be crucial to document the performance and effectiveness of the current procedures and processes. This technique will provide first-hand information about the clinicians’ acuity and self-confidence in using the new protocols. For instance, it will necessary to observe how the nurses are using technological tools to record and report medication errors and other adverse events.

The data collection tools will include interview schedules and protocols, open-ended questionnaires, and observation worksheets. First, the interview schedules and protocols will be useful in collecting data from the line managers and nurse administrators. Second, the questionnaires will gather both qualitative and quantitative data from the clinicians and patients. These data collection tools will contain semi-structured questions to guide the interview process. Third, the Excel worksheet will be modified and used during the performance observation. This document will be essential to highlight the gaps in the current procedures, as well as the opportunities for continuous improvement.

Data Sources, Sample Size, and Data Collectors

The primary sources of data will include the line managers, nurse administrator, clinicians, and patients. The sample size will include six line managers (departmental heads), one nurse executive, 50 clinicians, and 150 patients. The clinicians and patients will be selected randomly from the population frame to generate a representative sample. It is essential to note that the latter participants will be sampled from different departments within the hospital. On the other hand, the evaluation team will include four trained and qualified professionals to administer the questionnaires and interview. By contrast, a group of four individuals from different health facilities and two persons from the hospital will conduct the performance observations.


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Appendix 1: Time Plan for Data Collection

Month (2015) Data Collection Activity Tool (s)
May/June Interviews
  1. Administrative staff
  2. Nurses
  3. Physicians
  4. Pharmacists
  5. QI unit/council members
– Interview protocol
June/July Surveys
  1. Patient
  2. Clinical staff
– Patient satisfaction questionnaire
– Staff satisfaction questionnaire
July Participant observation
a. QI council meetings
b. Clinical processes/procedures
– Observation checklist
August/September Reviewing of documents
– Clinical reports
– Minutes of meetings
– Published articles
– Content analysis framework
September Focus groups
October Analysis and interpretation of data – Qualitative and quantitative analysis tools

Appendix 2: Sample Dummy Tables for Presenting the Findings

Quality Indicators before and after the Implementation of the QI Program

Indicator Frequency (2010) Frequency (2015)
  1. Hospital Infections
  1. Medical errors
  1. Readmission Rates
  1. Falls and Injuries

Quality Improvement Process before and after the Implementation Process

Organizational/Structural Changes Practice Changes Implications for Practice and Recommendations

Appendix 3: A Sample of Data Collections Tools

Interview Protocol Sample for the Hospital CEO

  1. One of your critical roles in the implementation of the QI program is the constitution of the quality council. what strategies did you employ to ensure that this crucial body is credible and functioning efficiently?
  2. You have identified critical performance indicators in the policy document. How have you ensured the seamless incorporation of change into the clinical practices?
  3. Change is a complicated process with the likelihood that some of the employees may not be willing to abandon the status quo. What measures have you established to address the resistance to change to ensure that the hospital improves its quality performance?
  4. According to your assertions, the introduction of the QI program aimed at enhancing the quality and safety care. How have you engaged with the other managers and employees to realize this goal?
  5. IT investments often require substantial resources from planning to post-implementation evaluation. How has the hospital financed the QI activities? Have you received support from the hospital’s governing body?

Questionnaire Sample for the Nurses

The hospital administration has contracted our firm to investigate the quality improvement (QI) program that was introduced five years ago. The aim of this evaluation study is to identify gaps and opportunities for improvement. As such, your input and suggestions regarding this procedure will be very valuable to facilitate the implementation of the necessary changes. We would appreciate it if you complete the following questionnaire and return it to [designated name] by [designated date]. If you have any questions, kindly call [designated name] at 123456 or send an email to [email protected].

Has the introduction of the QI program contributed to any significant changes in the delivery of care?

  • Yes [ ]
  • No [ ]

Kindly provide more details to substantiate your answer ————————————————————————————————————————————————————————————————————————————————————————-

Did you receive any training prior to the introduction of the QI program?

  • Yes [ ]
  • No [ ]

Could you please outline the courses that you have undertaken since the inception of the QI program? ———————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————————

What has been the effect of these training programs on your clinical practice?


What are your views regarding the leadership styles adopted by the nursing administrator and line managers?

————————————————————————————————————————————————————————————————————————————————————————————————————————————b) How do you think that these leadership styles are affecting the implementation of the QI program?


At what levels do you participate in decision-making processes?


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