BBQ Instructions
Health Improvement Project is:
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Improving PRN Medication Effectiveness Documentation in a Veterans Affairs Nursing Home.
- Identify three data elements that your team determined would be necessary for evaluating the success of your proposed HIP.
Please use the following elements:
- Number of patients who receive PRN meds- 40 patients
- Number of patients with accurate documentation of PRN meds- 38 patients out of 40 patients.
- Number of patients with purposeful rounding implemented. 40 patients.
These data elements will say whether there has been an improvement in the documentation or not.
The training goals would have been met in your KPIS and an expectation of the project implementation, but not something that will say if the documentation is accurate or not.
KPI #1 – By 7/15/24, 90% of all staff will have attended the training on how to
effectively conduct purposeful rounds and learning how to effectively apply these
evidencedbased principles which have proven to improve prn medication effectiveness.
KPI #2: By 8/15/24,The project team will develop a skill check off list that will be used to track and ensure compliance of purposeful rounding in 100% of the staff.
1. Describe why each of the three data elements from part A are essential for evaluating the success of the HIP.
This section is asking you to list the three data elements to evaluate the success of your healthcare improvement project.
Here’s the thing-your data elements should reflect your SMART C goal and any KPI that you would use to help you achieve that goal. Three different elements can measure your SMART-C outcome. They may just measure different aspects of it- and that is perfectly okay! Please don’t go crazy here with really complex elements. Keep it simple. You will name the three data elements and in section A1 you will describe “why” those data elements are essential for evaluating the success of your project.
Data Management Plan
B. Describe the source(s) of each of the three data elements from part A that will be used to measure the success of the HIP.
If you think about it, your three data elements might be found in numerous areas or from different data sources. As an example, if one of your KPI’s would be to develop and implement staff education as a component of bed side report, or improved discharge teaching, you may find that in your organization’s staff education software program- so that’s a data source. You wouldn’t find patient data in employee education software, so you might have to go to the EMR to see if the patient received the discharge instructions, or if the staff completed daily bedside shift report. Those are two different data sources, and that’s perfectly okay.
This section requires that you identify three data sources, even if all the data elements are gathered from the same data source, don’t assume that the reader will understand that. Your best approach is to repeat Data element #1 of____________ will be gathered from the following data source__________. Then repeat for Data element #s 2 and 3.
C. Identify two process KPIs.
Note: You may present your process KPIs from D158.
KPI #1 – By 7/15/24, 90% of all staff will have attended the training on how to
effectively conduct purposeful rounds and learning how to effectively apply these
evidencedbased principles which have proven to improve prn medication effectiveness.
KPI #2: By 8/15/24,The project team will develop a skill check off list that will be used to track and ensure compliance of purposeful rounding in 100% of the staff.
Here are some resources and ideas about KPIS that might be helpful:
KPI’s are “milestones” that will let you know that your project is on course to help you achieve your goal. KPIs. KPI’s can be measurements of processes, or measurements of organizational structural changes (i.e. policies). You will also have outcome KPI’s. Your SMART goal is an outcome KPI.
· There is a very good way to think about KPI’s. These are the things that have to happen in order to achieve your goal.
Example: The goal of the project is to reduce CAUTI’s be 20%.
One of the ways that we can help to achieve that goal is to educate staff. Our process KPI would be: 95% of the staff will be educated of the new processes/documentation for CAUTI care.
Our second KPI would be that 95% of all patients will be assessed for CAUTI risk and risk and interventions will be documented.
If we can achieve both of those, we will be able to meet our SMART C goal.
KPI 1 + KPI 2 = Achieving SMART C goal.
Your deliverables work the same way. Deliverables are something that you are going to need to implement your project.
We are going to need an education packet for the staff-so that’s a deliverable. It also relates to the KPI
As a second deliverable, we might need a checklist to ensure all of the components of our CAUTI risk assessment is complete-because we need this information documented. So our second deliverable is a CAUTI checklist.
As you can see, these components all work together-it’s like making a cake. If you have the right ingredients (deliverables), and you mix it right (KPI 1) and you bake it at the right temperature (KPI 2), you are going to get a great cake (SMART-C)
D. Describe one internal or external benchmark established by your organization to measure the SMART goal against.
You have to find a benchmark to measure your SMART goal against- Your SMART-C goal is the goal you are going to try to attain.
This section is for your understanding of how to use benchmarks in goal settings only.
A benchmark is a measurement that you will compare to your results. As an example, let’s talk RN turnover rates. The year 2021 benchmark for registered nurses in hospital settings was 27.1%. That is a national benchmark and as such would require a citation. My hospital’s turnover rate is 22.3%, and by benchmarking against, we can see that we started out better than the benchmark-but that does not make any difference it is still the benchmark. We will still use this to benchmark, but again, this has NOTHING to do with what our ultimate goal of the SMART-C is. Please don’t fall into that hole-it’s a deep one to get out of .
You can pick an internal or external benchmark such as one from CMS, The Joint Commission, AHRQ, etc.
If you select an external benchmark you will need to cite the information with an in-text citation and supporting reference.
If you use an internal benchmark, you will need to state: “The internal benchmark of ___________was pre-determined by the healthcare improvement project team at the initiation of the project”. You may also benchmark or compare to another unit within the hospital or sister or like organization. If you are citing information that is only “internally” accessible you can use personal communication as the reference. Please see 7th edition APA formatting for the appropriate use of personal communication.
E. Evaluate the process you would use to collect your quantitative data by doing the following:
1. Explain how the project team will collect the data (e.g., downloading data from a system, gathering data from a chart audit or survey).
2. Explain how the project team will protect the data.
3. Identify the parameters you will use to collect data (e.g., dates, data elements, calculated fields).
E1: Since you have already identified which data elements you will collect, and you know the source that you will be getting them from, it’s time to discuss the method that you will use to collect them.
As an example, imagine that you are using the EMR to determine if discharge information was provided for patients. You would go to the source (EMR) and then program that data to be downloaded into a type of format. You will also ask yourself 1) If they can be downloaded electronically, or if they have to be manually downloaded. Most statistical analytics (at least the simpler ones) can be run on Excel. So, if you plan to use Excel, then that is the first component of your method. The second component would be how you plan to protect any data. Will you de-identify any of the data elements so they cannot be tied to a person (which is maintaining HIPAA laws). Will you be the only person who can access the raw data and will you password protect it to ensure that it is not ‘out there’? You’ll want to explain the process that you plan to use (de identification/password protected etc.) as part of your method. Finally, will you be delimiting the data (meaning make it numeric values (versus words) for data analysis (that would be yes, you plan to delimit the data (i.e. yes=1 no=2).
E2: Protection of the data: This section will be similar to what you placed in the CPE requirements for protecting the data. Is the information coming from password protected sources? Is the information just percentages or numbers that do not have any patient identification factors? If you are using a logbook or hand audits, then is the information locked in a lockable file cabinet in a locked office, if there are patient identifiers on it?
E3: The next part of this will be the parameters. You will need to present the dates of your evaluation data capture. In the Gantt chart, you stated that you will be collecting data starting on a certain date and ending that data on a certain date. Those are the collection dates. Parameters can be daily, weekly, monthly, from a certain date to an ending date, for 6 weeks, etc.
The next thing that you are going to do is determine the intervals in which you download that data. You have three data points (the data elements from above), are you going to download them at the same time interval or different intervals. As an example, if you are educating staff and there is a testing time limit, will you gather the data during (perhaps weekly), or when the testing is over to capture it all? You need to discuss this for all three data points.
If you are going to gather at certain points to determine effectiveness, what would those be? As an example, if you are looking for discharge information from the ED (to see if it was completed and documented) you might want to download that data daily (because it will be hard to download and capture the information all at once). Will you be excluding any data (i.e. individuals under 18)? Or perhaps including different information to look at during the interpretation of the data (i.e. when it occurred morning, evening or night?). You can download the data at the intervals you believe will be most effective for your project, you get to pick it 
F. Evaluate the process you would use to analyze and interpret your data by doing the following:
1. Describe a method you will use to analyze the three essential data elements from part A (e.g., descriptive statistics, such as counts, averages, or percentages).
The high priority data are the data elements that you will be using to determine effectiveness of your intervention to achieve the goal. (i.e. education for staff to ensure that discharge information is provided), or even the number of readmissions for a particular disease (i.e. CHF). They are asking you what methods that you can use to analyze and interpret the data.
There are a few simple statistical methods that you might want to use. The first one is central tendency (CT) or univariate analysis. The second one is Bivariate/Multivariate analysis.
1. CT/UA measure one element at certain points in time. CT will give you the mean (average), median (middle value), and the mode (number that occurs most often in the data being measured). This will help you trend your data on a monthly basis.
1. The second type of statistical analysis could be bivariate or multivariate analysis. This tests the relationship between two (or more-multivariate) variables. Using bivariate analysis will let you know if there is a significant relationship between those elements (data points) that you used. As an example, does fall education decrease fall risk? Bivariate analysis would tell you if it was, and if the numbers that you have are significant enough to determine causality. This information is determined mathematically and presented on a scatter plot.
I could go into the plotting it on the X or Y axis, Pearson’s coefficient, but you don’t need to know that. You only need to know that the scatter plot will demonstrate the results of bivariate analysis. CT is used to determine the mean, median and mode, and can trend the data over time.
2. Describe the process for how you will interpret initial results.
This is a process question. Processes or methods are systematic.
1. You have collected the data and downloaded it into your excel or statistical software.
2. You are going to make sure that the data that you wanted is the data that you got.
3. You would initially look at your CT results to determine if there was trending, and from the mean, you could determine the standard deviation to see what the trending shows (left shift/right shift). You could initially interpret the data this way.
4. From there, you could use bivariate analysis and look at the relationship between those variables, to determine if it is significant (you can trust the results). It may not be (because you don’t have the numbers), but you can interpret and estimate the data at this point… Is your project improving the situation or not?
5. From those numbers you can also see if you chose the wrong data points, or if there is an intervention that you can do based upon the data. This would be plan B.
6. You would review and discuss the findings with the team. This is where timing of the collection becomes important because you can see what the data is doing to determine if it is real, or just a fluke. This is why we trend data.
AppendixA: SMART Goal
| SMARTQuestions | SMARTAnswers |
| Specific:Whatisyourproject?(Bespecific)Howwillyouaccomplishthis?(interventions) | The project is to improve Prn medication effectiveness documentation. The interventions will be to provide nursing education and training and to do purposely rounding to remind nurses of documentation. |
| Measurable:Whatwillyoumeasuretodetermineyourproject’ssuccess?(Indicatorsormetrics)Howwillyouknowthatchangehasoccurred?Whatpercentageoftheoutcomewillyouaccomplishbydate?(Numbersandquantitiesprovidemeansofmeasurementandcomparison). | Success will be measured by improving PRN medication effectiveness, as measured by a 20% improvement in documentation. Data following the intervention will be compared with data from before the intervention. Staff morale will also be measured via qualitative survey assessment. 20% completion by March 15, 2024.40% completion by April 21, 2024.60% completion by June 4, 2024.80% completion by July 21, 2024.100% completion by August 15, 2024. |
| Achievable:BasedonyourimpactanalysisandSWOTanalysis,whatsupport,resources,andjustificationexistforyourproject? | The impact analysis reveals that overly cumbersome PRN medication documentation protocols increase errors due to nurses having insufficient time and training to administer PRNs accurately. This results in errors, including wrong medications, delayed medications, double doses, and missed doses.These risks compromise patient safety, justifying the need for the HIP. |
| Relevant:Isyourprojectworthwhile?Whydoesyourprojectmattertothetargetpopulation,theorganization,andnursingpractice? | The project is worthwhile because it improves patient safety. The project matters because errors create unnecessary and avoidable health risks to the target population. Successful implementation will also reduce stress among staff. |
| Time-Bound:Includethesedates:HealthPlacementApprovaldate.D156coursestartdate.Projectstartdate. Projectenddate.Graduationdate.YourprojectstartdatemustbeafterthehealthplacementapprovaldateandD156startdates.Foranimplementationproject, yourprojectenddatemustbebeforeyourexpectedgraduationdate.Foranapprovedmodifiedclinicalactivityproject, your end date must be after your graduation. | Health Placement Approval date: 12/27/23.D156 Course Start Date: 1/17/24.Project Start Date: 2/1/24.Project End Date: 8/15/ 2024.Graduation Date: 11/30/24. |
| SMARTProjectGoal:Toimprovethe PRN effectivenessdocumentationby20%by August 15,2024, implementing neweducationandpurposefulroundingprogram. | |