D030 HIP Paper Template

D030 HIP Paper Template

Name

 Western Governors University

D030 Leadership & Management in Complex Healthcare Systems

Prof. Name

Date

Task 1: Healthcare Improvement Project – Introduction and Project Initiation

Stakeholder Identification

How were the stakeholders identified for this healthcare improvement project?

The process of identifying stakeholders began with compiling a comprehensive list of key leadership members, decision-makers, and staff who possess expertise in infection control within the organization. The primary focus was on professionals engaged in infection prevention and the early detection of sepsis, particularly in oncology patients. After a thorough review of potential candidates, three critical stakeholders were selected based on their roles and experience:

Stakeholder	Experience & Responsibilities	Contribution to Project
Sepsis Coordinator	Over 5 years in infection prevention; Co-Chair of Sepsis Committee	Provides leadership and expert guidance
Assistant Manager of Urgent Care	Participated in sepsis improvement initiatives; data collection; staff education	Organizes data, trains staff, and implements process changes
Urgent Care Charge Nurse	Experienced ER nurse; active in hospital committees (Nursing Standards, Policy, Skin Integrity)	Tracks project milestones, communicates with staff, manages timelines

The Sepsis Coordinator offers strategic leadership and deep knowledge of infection control. The Assistant Manager oversees data collection and analysis regarding the sepsis screening tool’s effectiveness and is responsible for educating staff about new protocols. The Urgent Care Charge Nurse uses clinical experience and committee involvement to ensure smooth communication and monitor the project’s progression.

Needs Assessment

What process was used to assess the needs for the healthcare improvement project?

The project lead conducted individual meetings—both in-person and virtual—with each stakeholder to gather improvement ideas for the Moffitt Cancer Center. Each stakeholder contributed one or two project ideas, which were then compiled for collective evaluation. A 30-minute Zoom session was held where stakeholders anonymously ranked these ideas using the Nominal Group Technique through an online questionnaire.

The top three prioritized project ideas emerging from this process were early sepsis identification, improving transfers of care, and preventing nurse burnout/employee retention. Ultimately, consensus was reached to focus on early sepsis identification due to the significant risk it posed for oncology patients.

Problem Identification

What is the primary problem addressed by the project?

Moffitt Cancer Center primarily serves adult oncology patients, many of whom have compromised immune systems due to cancer treatments. Despite advances in healthcare, sepsis-related mortality among cancer patients remains twice as high as in non-cancer populations (Chae, Kim, & Lee, 2020). Sepsis causes treatment delays, extended hospital stays, and increased healthcare costs (Mert et al., 2021).

The project’s goal is to identify and implement the most effective sepsis screening tool customized for oncology patients in the Urgent Care Department. This tool needs to detect atypical signs of infection, including adjusted vital sign thresholds and lab markers specific to cancer patients, to facilitate timely intervention.

Problem Description

Why is an early sepsis identification screening tool necessary at Moffitt Cancer Center?

The Infection Prevention and Sepsis Committee pinpointed significant gaps in sepsis management within Urgent Care. Chart audits revealed frequent delays in activating sepsis protocols for eligible patients. These insights emphasized the urgent need for a dedicated, oncology-specific screening tool to support rapid diagnosis and treatment, aiming to reduce mortality and enhance patient outcomes.

Impact Analysis

What are the potential benefits and risks associated with the project?

The project’s impact was assessed in two key areas: Patient Satisfaction and Decreased Length of Stay. Each area included examples of potential benefits and risks, rated on a scale from 1 (low) to 3 (high) impact:

Category	Benefits (Examples)	Impact Score	Risks (Examples)	Impact Score
Patient Satisfaction	Enhanced communication; timely care	3	Resistance to change; staff training demands	2
Length of Stay	Shorter hospital stays; faster recovery	3	Implementation delays; data accuracy issues	3

The total benefits score reached 11, while risks totaled 9, resulting in a benefit-to-risk ratio of 1.2. This suggests that the expected benefits outweigh potential risks, supporting the project’s implementation.

SWOT Analysis

How was the organizational readiness assessed?

A SWOT analysis was collaboratively developed by stakeholders. Each member drafted a preliminary SWOT focusing on internal (leadership, morale) and external (stakeholder involvement, knowledge uptake) factors. During a 45-minute group discussion, findings were refined and voted upon:

SWOT Component	Internal Criteria	External Criteria	Key Findings
Strengths	Strong leadership	Active stakeholder involvement	Committed leadership and engaged stakeholders
Weaknesses	Variable staff morale	Limited uptake of best practices	Concerns about staff burnout and dissemination of knowledge
Opportunities	Training programs	External partnerships	Opportunities for education and collaboration
Threats	Staff turnover	Regulatory changes	Risk of turnover and evolving compliance demands

This analysis confirmed the project’s feasibility while identifying areas requiring proactive management.

Ethical Considerations

What ethical standards support this healthcare improvement project?

The Moffitt Cancer Center Code of Ethics prioritizes delivering high-quality, safe, and patient-centered care (Moffitt Cancer Center, 2018). The project aligns with these principles by aiming for timely, equitable, and culturally sensitive care, especially for immunocompromised oncology patients. Early sepsis detection reflects the center’s commitment to safeguarding vulnerable populations.

Task 2: Healthcare Improvement Project – Project Purpose and Review of Scholarly Sources

Purpose Statement

The project’s central objective is to integrate an early sepsis identification tool within the Urgent Care Department. This tool aims to accelerate clinical response and treatment for oncology patients presenting with sepsis symptoms. By embedding this tool into triage procedures, the project seeks to improve clinical outcomes through faster intervention.

Review of Relevant Scholarly Sources

Extensive research underscores the heightened risk and mortality of sepsis in cancer patients, highlighting the need for specialized screening tools (Chae et al., 2020; Mert et al., 2021). Nurse-led sepsis protocols and community-based screening tools have demonstrated effectiveness in promoting early detection and improving patient outcomes (Baker, 2022; Moore et al., 2019). These findings provide a robust evidence base that informs and validates the project’s approach.

Appendix D: SMART+C Goal Worksheet

SMART+C Criteria	Question	Answer
Specific	What is the specific project?	Implementing an early sepsis screening tool in Urgent Care to expedite intervention.
Measurable	What indicators will be measured?	Increase in timely initiation of sepsis protocols by December 2022, based on collected data.
Achievable	How feasible is the project?	Highly feasible due to supportive impact and SWOT analyses and patient risk profile.
Relevant	How worthwhile is the project?	Expected to reduce mortality, shorten hospital stays, and enhance patient satisfaction.
Time-Bound	What are the project timelines?	Project to start in June 2022 and complete by December 2022.
Challenge	What is the stretch goal?	Develop a cancer-specific sepsis screening tool using identified clinical indicators.

SMART+C Goal:
To implement an early sepsis identification tool in the Urgent Care Department aimed at improving sepsis protocol response and treatment times for oncology patients by December 2022.

Expected Outcome:
It is anticipated that the project will produce data facilitating the development of an oncology-specific sepsis screening tool. This is expected to decrease mortality rates, shorten hospital stays, reduce healthcare costs, and improve overall patient satisfaction and outcomes.

References

Baker, E. (2022). Improving sepsis recognition through use of the Sepsis Trust’s community screening tool. British Journal of Community Nursing, 27(2), 69–75. https://doi.org/10.12968/bjcn.2022.27.2.69

Chae, B.-R., Kim, Y.-J., & Lee, Y.-S. (2020). Prognostic accuracy of the sequential organ failure assessment (SOFA) and quick SOFA for mortality in cancer patients with sepsis defined by systemic inflammatory response syndrome (SIRS). Supportive Care in Cancer, 28(2), 653–659. https://doi.org/10.1007/s00520-019-04869-z

Mert, D., Merdin, A., Kandemir, N., Çakar, M. K., Dirim, E., Çeken, S., Altuntaş, F., & Ertek, M. (2021). Evaluation of risk factors and causative pathogens in bloodstream infections in cancer patients. Gulhane Medical Journal, 63(1), 42–51. https://doi.org/10.4274/gulhane.galenos.2020.1320

D030 HIP Paper Template

Moffitt Cancer Center. (2018). Code of Ethics and Professional Conduct. https://moffitt.org/about-moffitt/corporate-compliance/code-of-ethics-and-professional-conduct/

Moore, W. R., Vermuelen, A., Taylor, R., Kihara, D., & Wahome, E. (2019). Improving 3-Hour Sepsis Bundled Care Outcomes: Implementation of a Nurse-Driven Sepsis Protocol in the Emergency Department. Journal of Emergency Nursing, 45(6), 690–698. https://doi.org/10.1016/j.jen.2019.05.00

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