Quality improvement (QI) can be defined as the effort to better patient outcomes, system performance, and professional development (Batalden & Davidoff, 2007). The Institute of Medicine (IOM) has challenged professionals to improve healthcare quality, with quality described using the following six domains: safety, timeliness, effectiveness, efficiency, equity and patient-centeredness. These quality aims provide a framework for focusing improvement efforts. The unrelenting engagement of all providers is required to transform healthcare. APNs are well positioned to lead quality initiatives by virtue of their advanced knowledge and preparation. To effectively lead quality improvement requires understanding that organizations are complex adaptive systems; dynamic, unpredictable, and are composed of moving parts. Knowledge of theoretical underpinnings of change (theory explicating the phenomenon of human behavioral change) is foundational to successful improvement. A wide variety of QI models, tools, and methods are available to guide the APN in facilitating improvement.
For this assignment, select a practice improvement issue within your organizational system and within the realm of your practice area. Using the grading rubric as a guide, develop a quality improvement plan to address the identified issue. The purpose of this paper is to demonstrate knowledge of the essential elements of quality improvement, with change theory as an underpinning for the process. Students are not expected to implement the plan; however, the process for implementation and evaluation is addressed as part of the planning process.
The paper should be carefully written in a formal style, based on primary sources, provide an integration of ideas, and be 4-6 pages in length, excluding title page & reference list. Organized flow, logical progression of ideas, and clarity in thought are essential. Please use headings to separate content.
Papers over the page limit will be penalized by a disregard of content over the page limit.
Scholarship Expectations:
A lack of Scholarship deduction of up to 20% of the total point value of the assignment will be applied to address such deficiencies as APA errors, Title or Reference page errors, a lack of clarity and conciseness in writing, grammatical and spelling errors, exceeding the prescribed page limit, and poor overall writing skills. For example, an assignment worth 15 points could have a maximum lack of scholarship deduction of 3points (20% x 15). The amount of the deduction will be at the discretion of the faculty member.
You are clinical nurse scholars in the making. You are the nurses with advanced education/DNPs and members of the highly literate profession of advanced practice nursing who will chart the future of health care. Good writing ability is as much a required skill for nurses in advanced practice as performing clinical functions. Therefore, precision and scholarship is expected in all assignments.

Possible Points

Introduction paragraph (one paragraph). Introduce a practice issue appropriate for a quality improvement project facilitated by a MSN or DNP prepared nurse. There must be a thesis statement at the end of the paragraph that tells the reader the purpose of paper and what will be discussed.
Briefly provide the background/context of the practice issue. Integrate at least two of the six dimensions of quality defined by the IOM.


Discuss a theoretical underpinning of change (Lewin, Rogers, Kotter, Havelock, Proschaska & Diclemente, Bandura) for the proposed quality initiative. Using the selected change theory, describe the profound importance of staff engagement, empowerment, commitment, and ownership of practice improvement initiatives/projects.
Describe how at least one improvement tool (flow chart, root cause analysis, cause and effect diagram, FMEA, etc.) can be used to better understand the practice issue.

Select a model (e.g., PDSA, FADE, Six Sigma, TCAB, TeamSTEPPs) for the quality improvement project. Describe the model and summarize the practice improvement initiative/intervention(s) using the steps of the model.
Discuss the resources (human, structural, financial) required for this organizational systems change

Propose evaluation method(s) of quality measures. (What qualitative and quantitative methods are identified to determine effectiveness of quality initiative?) Identify both process and outcomes performance measures for determining effectiveness of your intervention(s). Identify at least two visual displays for data reporting of outcome data (e.g. histogram, run chart, pie chart, bar graph, etc.). How would qualitative findings contribute to the evaluation of this quality initiative?
Conclusions: Summarize the essential points of paper (one paragraph).



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Managed Care
Paper, Order, or Assignment Requirements

Part 1
1. I am interested in your ideas on how managed care organizations can more effectively prevent diseases or more specifically preventing the spread of disease among its contracted population. In other words, what can HMOs do to promote health and reduce illness rather than treating it after the fact. Address cost implications, patient receptivity, provider cooperation and other factors impacting this issue.
2. One of the cornerstones of Accountable Care Organizations is the use of Evidence-Based Medicine. What is this, what are the negatives of EBM, and how can HMOs encourage the positive benefits of EBM.
3. The Health Care Industry has espoused “quality management” for decades. Please identify and briefly discuss three quality management processes, at whatever level you wish (insurance companies, hospitals, medical groups, nursing homes, etc.).
Part 2
1. Years ago it was quite common for HMOs to offer a wide range of behavioral health services, including in-patient hospitalization. More recently, HMOs have limited in-patient programs and encouraged out-patient services. Discuss some of the reasons for this shift.
2. One of the benefits to patients joining an HMO is the relatively strict peer-review and physician credentialing process required for accreditation. Discuss why the credentialing process is important and how it relates to quality management.
3. Discuss how managed care organizations design, market and sell their products to consumers, including individuals and companies.
4. Years ago when I worked for an HMO is Arizona, we contracted with a private company to provide our HMO with hospital discharge and cost data by physician specialty. We used this data to contract with the more cost effective physicians in the State. In effect, we were “provider profiling”. What are some of the potential negatives with using this type of data in the provider contracting process?
Part 3
1. In an attempt to improve quality in managed care, a report called HEDIS was established and expanded upon over the years. What is HEDIS and what is its proported value to health care?
2. One of the most important documents established between a contracted medical group and an HMO is a DOFR (Division of Financial Responsibility). Discuss the DOFR and identify three reasons why this document is important.
3. The American Recovery and Reinvestment Act of 2009 included a provision to establish the HITECH Act (Health Information Technology for Economic and Clinical Health Act). Identify and discuss three provisions of this Act.
4. Identify and discuss three basic ways to ensure the accuracy of claims processing within managed care.
Part 4
1. ACA requires HMOs to achieve a certain “medical loss ratio”. What is a “medical loss ratio” and why is this an important issue?
2. After the passage of Medicare, the federal government has played a major role in setting health policy. Identify and briefly discuss three federal laws regulating health care which have had a material impact on HMOs and the health care industry in general.
3. Over a dozen years ago, California established the Department of Managed Health Care, one of the first in the nation to recognize that HMOs were different from other forms of health care insurance. Please identify and discuss three major functions of this Department.
4. Incurred But Not Reported (IBNR) in claims processing can (and has) led to insolvency on the part of some medical group. Discuss IBNR and identify several ways capitated medical groups try to address this issue.
5. There are two basic methods HMOs (and other insurance companies) use to rate the risk of providing insurance to employers: experience rating and community rating. Briefly discuss each method and explain the merits and problems associated with each method.

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