D158 Healthcare Improvement Project Paper

D158 Healthcare Improvement Project Paper

Name

 Western Governors University

D158 Strategically Planning the Execution of a Healthcare Improvement Project

Prof. Name

Date

D158 Healthcare Improvement Project Paper

Implementation Approach

What was the first step taken to advance the Healthcare Improvement Project (HIP)?

The initial step involved assembling a dedicated project team made up of several members from the organization, all focused on reducing surgical cancellations. The project was officially launched with a foundational meeting between myself and my preceptor. This session was crucial as it established the scope and objectives of the HIP, which were subsequently shared with the full project team to gain their agreement and commitment to the project’s goals.

How did the team organize the project planning?

During the planning phase, the team convened every two weeks to review and discuss the resources necessary for the project’s successful execution. A significant outcome of this phase was the creation of a detailed budget. This budget was carefully calculated using a spreadsheet that tracked personnel pay and hours, which ensured clarity in financial planning and proper allocation of resources.

What decision-making process was adopted and why?

For making decisions during implementation, the Nominal Group Technique (NGT) was chosen due to its suitability for small, in-person group settings. NGT is a structured, four-step process that encourages equal participation and consensus:

Stage	Description
Silent Generation	Team members individually write down ideas without discussion.
Round Robin	Each member shares one idea in turn with the group.
Clarification	Group discusses ideas and asks questions for clarity.
Ranking	Participants rank the ideas by importance or relevance.

This method fostered a collaborative environment and helped the team reach unanimous agreement on the HIP plan, supporting a harmonious working atmosphere.

How is momentum maintained throughout the project implementation?

To maintain steady progress, biweekly meetings were established as a balanced approach. Meetings held too frequently could limit time for assessing implemented changes, while less frequent meetings risked loss of focus. The project manager is responsible for organizing these meetings, preparing agendas aligned with the action plan and Gantt chart, and updating the chart regularly to monitor progress. Weekly email updates supplement these meetings by ensuring ongoing communication and engagement among team members.

Were any policies reviewed or updated during the project?

Policy review was an ongoing agenda item throughout the project. While the hospital’s exclusion criteria policy remained unchanged, the preadmission testing policy underwent revision. Previously, patients received a single preadmission phone call; the revised protocol introduced weekly follow-up calls to enhance patient engagement and compliance. Due to overlapping membership between the project team and stakeholders, these policy changes were discussed openly and voted upon in meetings, receiving unanimous approval.

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Action Plan

The action plan was created through a collaborative process and outlined five essential steps, each with clearly assigned responsibilities, phases, and deadlines. This plan is closely linked to a detailed Gantt chart, which breaks down each major action into smaller, manageable subtasks.

Phase	Action Item Description	Responsible Parties	Target Completion Date
Initiation	Define HIP goal to reduce surgical cancellations by 5%	Project Manager, Preceptor	01/29/2024
Planning	Determine financial resources and complete budget	Project Manager, Preceptor, Team	04/25/2024
Implementation	Train surgical, pre-op, operating, and preadmission staff	Project Manager, Preceptor, Team	06/10/2024
Control	Monitor and manage budget variances	Project Manager	07/31/2024
Evaluation/Closure	Assess HIP outcomes and report to leadership	Project Manager, Preceptor	07/31/2024

The project timeline extends from late January to the end of July 2024, establishing structured deadlines to ensure team alignment and timely task completion.

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Gantt Chart Utilization

What is the function of the Gantt chart in this project?

The Gantt chart serves as a vital visual tool for planning and tracking the progress of the HIP. It allows both the project manager and team members to monitor tasks, deadlines, and status updates. The chart is updated collaboratively to reflect ongoing progress and schedule future activities, thereby reinforcing team accountability.

Phase	Key Tasks/Subtasks	Target Date
Initiation	Identify HIP, select stakeholders, conduct needs assessment	01/30/2024
Planning	Complete financial analysis and personnel budgeting	04/19/2024
Implementation	Conduct training sessions and process walkthroughs	06/07/2024
Control	Review monthly financial reports and weekly budget updates	07/31/2024
Evaluation	Analyze cancellation data and prepare leadership presentation	07/29/2024

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Social Determinants of Health (SDOH) and Target Population

Who is the target population, and what are their key social determinants?

The HIP aims to reduce surgical cancellations by 5% at Ortho Colorado Hospital (OCH) by June 30, 2024. OCH is a 48-bed facility located in Lakewood, Colorado, with 17 pre-op/PACU bays and 8 operating rooms, supported by 187 employees (175 of whom are clinical staff). The surrounding community of Lakewood exhibits diverse sociodemographic characteristics, summarized below:

Factor	Description
Population	156,149 (2022)
Median Age	38.1 years
Median Household Income	$82,786
Ethnicity	White Non-Hispanic (68.2%), Hispanic (7.42%), Asian Non-Hispanic (3.89%), African American (1.6%)
Veteran Status	5.25%
Education Level	Bachelor’s degree (20.8%), Some college (12.5%), High school diploma (14.8%)
Insurance Coverage	Uninsured rate slightly increased from 7.38% to 7.54% (2021–2022)
Poverty Rate	8.8% below poverty level

How are social determinants integrated into the project’s strategy?

The project addresses social determinants through various strategies:

• Education Access and Quality: All educational materials are crafted at a sixth-grade reading level and translated into Spanish to meet the literacy and language needs of the community.
• Economic Stability: While the median income is moderate, some patients may face financial challenges affecting their ability to follow pre- and postoperative care instructions. This is mitigated by frequent patient outreach.
• Neighborhood Environment: Lakewood provides parks and transit options; however, safety concerns around public transportation could impact patient mobility and recovery.
• Social and Community Support: Community resources such as food banks and pharmacies offering discounted medications support patient wellbeing.
• Healthcare Access and Quality: OCH collaborates with Common Spirit Health to provide discounted and free clinic services, improving access for underserved populations.

The project empowers patients by setting clear expectations, providing educational resources to reduce anxiety, and conducting weekly preadmission nurse calls to strengthen engagement and trust.

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Force Field Analysis

What driving and restraining forces affect HIP implementation?

Driving Forces	Restraining Forces
Increasing surgical cancellations	Resistance from surgeon’s office leadership due to workload
Strong support from executive leadership	Challenges in maintaining staff accountability
Budget approval for additional preadmission staff	Staffing shortages limiting communication

What strategies are used to manage these forces?

• Providing monthly executive updates with surgical cancellation data to maintain leadership support.
• Organizing leadership walkthroughs to foster empathy and understanding of frontline challenges.
• Justifying the addition of staff to reduce workload and improve communication.
• Engaging staff in creating educational materials to boost ownership and reduce resistance.

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Scope Statement

The project focuses on improving patient engagement by implementing multiple phone touchpoints and developing educational materials such as handouts, booklets, and classes. These resources aim to clarify surgical requirements and milestones, enhancing patient comprehension and compliance throughout the surgical process.

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SMART Goal

The project’s SMART goal is to reduce surgical cancellations at Ortho Colorado Hospital by 5% by June 30, 2024. This will be achieved by increasing patient communication frequency, delivering comprehensive educational materials, and providing focused staff training.

Project Timeline	Start Date	End Date
HIP Duration	01/29/2024	07/31/2024

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Key Performance Indicators (KPIs)

KPI Description	Target/Deliverable
Development and implementation of educational materials with staff competency sign-off	Complete by June 10, 2024
Achieve 100% compliance with preadmission checklist in surgeon’s clinic and preadmission staff	Checklist deployed by June 7, 2024

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Communication and Training Plans

Communication

Communication Type	Audience	Purpose	Expected Outcome	Medium
Biweekly Meeting Reminder	Project Team	Maintain focus and engagement	Ensure attendance and participation	Email, Text
Biweekly Progress Update	Stakeholders, clinic/hospital staff, leadership	Inform on project progress and upcoming tasks	Increase stakeholder awareness and support	Email

Training

Surgical, preadmission, pre-op, and operating room staff will undergo targeted training focused on:

• New informational materials
• Compliance checklist
• Additional preadmission communication touchpoints

Training Details:

• Four sessions per week over two weeks (May 20 – June 7, 2024), each lasting two hours
• Sessions include morning and evening huddles, plus virtual sessions at the surgeon’s clinic
• Competency sign-off includes walkthroughs and explanations of project objectives

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References

Arakawa, N., & Bader, L. R. (2022). Consensus development methods: Considerations for national and global frameworks and policy development. Research in Social and Administrative Pharmacy, 18(1), 2222–2229. https://doi.org/10.1016/j.sapharm.2021.06.024

Data USA: Lakewood, Colorado. (n.d.). Data USA. https://datausa.io/profile/geo/lakewood-co/#demographics

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