NURS FPX 8020 Assessment 4 - Topmycousre 1.pdf

NURS FPX 8020 Assessment 4 is assessment of capella DNP , class 8020

1. NURS FPX 8020 Assessment 4: Initiating a
Quality Improvement Project
Student Name
Capella University
NURS FPX 8020: Advanced Nursing Leadership and Management
Professor’s Name
Date











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2. Introduction
Quality improvement (QI) is a cornerstone of advanced nursing leadership, focusing on
measurable, sustainable changes that enhance patient outcomes, organizational performance, and
professional practice. Unlike short-term interventions, QI initiatives require systematic planning,
stakeholder engagement, and alignment with organizational priorities. This paper presents a
proposal for initiating a quality improvement project at Suncrest Home Health and Hospice,
targeting improved communication, patient-centered care planning, and family engagement.
Building upon evidence-based strategies, the initiative will utilize a structured framework to
ensure measurable progress, regulatory compliance, and sustainable organizational growth.
Identification ofthe Practice Issue
Patient and family satisfaction remains a critical determinant of organizational success in home
health and hospice care. While Suncrest has demonstrated compliance with Medicare and
industry standards, patient experience data highlight ongoing challenges with communication
breakdowns, limited care customization, and inconsistent feedback integration. These
deficiencies can negatively influence referral rates, reimbursement, and long-term organizational
reputation.
National benchmarks reveal that patient satisfaction strongly correlates with treatment
adherence, safety outcomes, and healthcare credibility (Ferreira et al., 2023). Additionally, the
Centers for Medicare and Medicaid Services (CMS, 2025) link value-based reimbursement to
patient-reported outcomes, making improvement in this domain not only a clinical but also a
financial imperative. Addressing these gaps requires a systematic QI project that ensures
consistent communication, responsive care plans, and real-time integration of family feedback.
Evidence-Based Rationale for QI Initiative
Studies confirm that enhanced patient-provider communication improves trust, reduces
complaints, and strengthens adherence to treatment regimens (Kwame & Petrucka, 2021).
Furthermore, customized care planning—sensitive to cultural, social, and personal preferences—
has been associated with improved health outcomes and higher satisfaction scores (Bolton et al.,
2020).
A recent analysis by Tsai et al. (2020) demonstrated that integrating electronic health records
(EHRs) with real-time feedback loops reduces miscommunication and enhances care
coordination. Additionally, simulation-based caregiver communication training improves
empathy, listening, and patient interaction (Jun & Eckardt, 2023). Evidence supports that
systematic surveys and structured communication training directly influence organizational
reputation, patient loyalty, and financial performance.
By integrating these evidence-based strategies, the QI project will enhance Suncrest’s ability to
deliver holistic, patient-centered, and financially sustainable care.

3. Quality Improvement Framework
The QI initiative will be guided by Plan-Do-Study-Act (PDSA), an iterative framework that
facilitates rapid-cycle testing and continuous refinement.
1. Plan: Identify specific communication barriers, design family-centered feedback tools,
and establish training modules for staff.
2. Do: Pilot the intervention with a small patient group over six weeks, implementing real-
time surveys and enhanced care planning.
3. Study: Analyze results, comparing patient satisfaction scores, referral rates, and
complaint frequencies with baseline data.
4. Act: Scale successful interventions across all Suncrest units, institutionalizing them into
policy and workflow.
The PDSA framework allows flexibility, immediate corrective action, and evidence-informed
decision-making, ensuring that the QI initiative is both practical and scalable.
Stakeholder Engagement Strategy
The success of the QI initiative depends on comprehensive stakeholder collaboration. Key
participants include:
• Patients and Families: Providing feedback on care experience, ensuring interventions
reflect lived realities.
• Nurses and Caregivers: Offering insights into workflow challenges and communication
barriers.
• Leadership and Administrators: Aligning initiatives with strategic goals, resource
allocation, and performance benchmarks.
• Regulatory Agencies: Ensuring compliance with CMS quality measures and
accreditation standards.
Engagement will be facilitated through surveys, focus groups, and interdisciplinary meetings.
Transparent communication and shared accountability will enhance buy-in and create a culture
of continuous improvement.
Implementation Plan
The QI project will be implemented in three phases:
1. Phase One (Month 1–2): Develop surveys, training modules, and workflow
modifications. Train staff on effective communication and feedback integration.
2. Phase Two (Month 3–4): Launch a pilot program with 25 patients and families. Collect
quantitative (satisfaction scores, referral rates) and qualitative (testimonials, narrative
feedback) data.

4. 3. Phase Three (Month 5–6): Evaluate pilot results, refine strategies, and expand across
Suncrest facilities.
Progress will be monitored using Key Performance Indicators (KPIs) such as:
• ≥90% patient/family satisfaction scores
• 15% increase in referrals within six months
• ≥90% staff completion of communication training
• Reduction in complaints by 20%
Policy and Ethical Considerations
Policy reinforcement is essential to sustain improvements. The QI initiative recommends a
revised patient communication and feedback policy requiring quarterly surveys, mandatory
care plan personalization, and structured staff communication training. Ethical considerations
include maintaining patient autonomy, cultural sensitivity, and data confidentiality while
promoting transparency in reporting satisfaction outcomes.
Anticipated Outcomes
The initiative is expected to generate:
• Improved patient and family satisfaction (≥90%).
• Increased referral rates, enhancing organizational growth.
• Strengthened employee engagement through training and skill-building.
• Enhanced compliance with Medicare quality metrics, ensuring financial sustainability.
• Long-term cultural transformation toward patient-centered excellence.
Conclusion
The proposed QI project at Suncrest Home Health and Hospice demonstrates how evidence-
based practice, stakeholder collaboration, and structured frameworks can address critical gaps in
patient and family satisfaction. By leveraging communication training, feedback integration, and
care customization, the initiative will not only improve health outcomes but also reinforce
Suncrest’s reputation as a trusted, patient-centered organization. Sustained commitment,
transparent policies, and ongoing evaluation will ensure that the QI initiative delivers measurable
improvements and long-term success.
References
• Bolton, L. B., et al. (2020). Patient-centered care and cultural responsiveness in quality
improvement initiatives. Journal of Nursing Care Quality, 35(2), 123–131.
https://doi.org/10.1097/NCQ.0000000000000410

5. • Ferreira, D., et al. (2023). Patient satisfaction as a driver of health outcomes and
organizational performance. BMC Health Services Research, 23(1), 421.
https://doi.org/10.1186/s12913-023-09450-1
• Jun, J., & Eckardt, P. (2023). Simulation-based communication training for healthcare
professionals: A systematic review. Nurse Education Today, 125, 105761.
https://doi.org/10.1016/j.nedt.2023.105761
• Kwame, A., & Petrucka, P. (2021). A literature review of patient-centered
communication in nursing practice. Journal of Clinical Nursing, 30(9-10), 1213–1224.
https://doi.org/10.1111/jocn.15674
• Tsai, C. H., et al. (2020). Electronic health records and patient-centered care: Impacts
on communication and satisfaction. Health Informatics Journal, 26(2), 1124–1136.
https://doi.org/10.1177/1460458219896805
• U.S. Centers for Medicare and Medicaid Services (CMS). (2025). Quality initiatives:
Patient experience and value-based reimbursement. https://www.cms.gov











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