NURS FPX 8022 Assessment 4 - Capella DNP

NURS FPX 8022 Assessment 4 Develop a comprehensive training and support plan for successful adoption of a health information system.

1. NURS FPX 8022 Assessment 4: Quality Improvement Project Plan

Student Name
Capella University
NURS-FPX 8022: Nursing Technology & Advanced Healthcare Information
Systems
Professor’s Name
Date









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2. Introduction
Despite advances in cardiovascular care, hospital readmission rates for heart failure patients
remain alarmingly high, with nearly one in five patients rehospitalized within 30 days of
discharge. These frequent readmissions not only adversely affect patient well-being but also
contribute substantially to healthcare expenditures and system strain. This Quality Improvement
(QI) project proposes the implementation of a nurse-driven transitional care model aimed at
reducing 30-day heart failure readmissions. The initiative seeks to improve patient outcomes and
streamline interprofessional collaboration within Capella University’s associated healthcare
facility.
Problem Statement and Significance
Heart failure is the predominant cause of hospitalization among older adults, and early
readmissions often signal deficiencies in discharge processes, patient education, and post-
discharge continuity. High readmission rates attract financial penalties under Medicare's value-
based purchasing program, exacerbating institutional strain. Moreover, these readmissions
contribute to declining patient quality of life and increased morbidity. Addressing these
challenges with structured interventions aligns with priorities for improving healthcare quality
and reducing avoidable hospital utilization.
Project Aim and Objectives
The primary objective is to achieve a measurable reduction in 30-day readmission rates among
heart failure patients by introducing a comprehensive, nurse-led transitional care approach that
includes:
1. Enhanced education for patients and caregivers focusing on disease management and
early symptom recognition
2. Accurate and thorough medication reconciliation with adherence supports
3. Timely nurse-conducted home visits and telehealth follow-ups within 72 hours of
discharge
4. Integration of EHR-generated reminders and risk alerts to assist clinicians in managing
post-discharge care
This intervention is designed for scalability and adaptability across diverse clinical settings.
Theoretical Framework and Methodology
Guided by a systems-thinking approach, this QI plan employs root cause analysis to understand
factors contributing to readmissions. A pilot will be conducted with a defined patient sample,
applying Plan-Do-Study-Act (PDSA) cycles to iteratively refine processes. Data collected will

3. include readmission rates, patient satisfaction scores, medication compliance metrics, and staff
feedback to guide continual improvement.
Intervention Details
1. Nurse-Led Transitional Care Model
• Deliver comprehensive, tailored education pre-discharge about heart failure
management, lifestyle modifications, and symptom monitoring
• Conduct detailed medication reconciliation, ensuring clear communication with
outpatient providers
2. Post-Discharge Clinical Support
• Arrange nurse-led home visits or telehealth consultations within the critical 72-
hour post-discharge window
• Reinforce education, assess medication adherence, and identify early signs
requiring escalation
3. Health Informatics Integration
• Utilize automated EHR alerts to prompt timely follow-up and flag high-risk
patients for readmission prevention
• Leverage telehealth technology to facilitate remote monitoring and increase
patient access
4. Pilot Implementation and Expansion Strategy
• Initiate the project on a small scale to monitor feasibility and effectiveness
• Use outcome and process data to adapt the approach before broader institutional
adoption
Evaluation Metrics and Outcome Measures
Success will be evaluated through:
• Reduction in 30-day readmission rates compared to baseline data
• Increased patient satisfaction as measured by validated post-discharge surveys
• Improved medication adherence rates documented during follow-ups
• Enhanced workflow efficiency and staff engagement in transitional care activities
Leadership Role and Sustainability

4. Nurse leaders will spearhead the initiative by facilitating interdisciplinary collaboration among
physicians, pharmacists, and IT specialists. They will oversee continuous data monitoring,
support iterative refinements, and advocate for sustained integration. Embedding the model into
staff orientation, clinical protocols, and performance reviews will ensure lasting adoption and
organizational resilience.
Ethical and Organizational Implications
• Patient Safety and Autonomy: Empowering patients through education minimizes
preventable readmissions and promotes self-management
• Cost Containment: Reduced penalties and resource optimization alleviate financial
burdens on the healthcare system
• Health Equity: Telehealth modalities enhance access for vulnerable populations facing
transportation or mobility challenges
Conclusion
This Quality Improvement project applies systems thinking, robust nursing interventions, and
health informatics tools to address the persistent issue of heart failure readmissions. Through a
structured transitional care model, measurable improvements in patient outcomes, workflow
integration, and cost reduction are achievable. Nurse leadership will remain central to driving
this initiative’s success, fostering a sustainable culture of evidence-based practice and continuous
quality enhancement within diverse healthcare settings.
References
• Tutors Academy. (2025). A nurse-led transitional care model to reduce heart failure
readmissions. NURS FPX 8022 Assessment 4: Quality Improvement Project Plan.

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8022-assessment-4-quality-improvement/