Health care organizations face constant changes in the internal and external environments. Continuous quality improvement has no end and depends on effective teamwork to implement successful quality improvement (QI) initiatives to meet accreditation requirements and exceed patients’ expectations. For this last component of the QI initiatives project, your designated team leader must compile your team’s work for the hospital quarterly meeting. The team leader must collect individual QI initiative slide from each team member on Day 1. You must include the team composition on one slide, and the mission and vision statement on another slide, followed by each team member’s presentation. The team leader will share the final PowerPoint presentation with team members before the due date and each team member must individually submit the Collaborative Project: Quality Improvement Initiatives assignment.In your group presentation,Summarize the team composition. Be sure to list the names and job titles in the QI Department.Identify the mission and vision statement of QI department.Organize the QI Initiative for each team member. Be sure to include the member’s name, QI Initiative, and SMART goals in each slide.
Enhancing Stroke Care Delivery at Vanderbilt Hospital: A Quality
Improvement Initiative
The University of Arizona Global Campus
Proprietary & Confidential – For Internal Use Only
1
Introduction To Vanderbilt
Hospital
Vanderbilt Hospital, renowned for its specialized stroke care services, caters to a diverse patient population. Understanding its nature of business is crucial for our quality improvement journey.
Vanderbilt Hospital excels in stroke care with advanced treatments, expert staff, and innovative technologies. Demonstrating excellence in critical healthcare, setting the bar high for quality improvement.

Selected Measure: Enhancing Stroke Care Delivery
• Strategic alignment
Ensure QII aligns with hospital’s overall plan for effectiveness
• 30-day survivability enhancement
Focus on post-ED admission outcomes for stroke patients
• Advanced HIT integration
Incorporate cutting-edge Health Information Technology for better care.
• Stakeholder engagement
Involve key actors for collaborative care improvement
30-Day Stroke Survivability
•
Assess patient outcomes with 30-day
survivability post-stroke. Track effectiveness
of interventions. Align with quality
improvement objectives for enhanced care.
•
Key Metric for Quality 30-day survivability
reflects hospital quality in stroke care
•
Timeliness and Efficiency Measure indicates
hospital’s prompt and effective stroke care
provision
•
Alignment with Quality Goals Improving
survivability supports hospital quality
improvement objectives

Understanding the SMART Framework
SMART framework: Specific, Measurable, Achievable, Relevant, Time-bound. In stroke care, SMART goals enhance patient outcomes by setting clear and achievable objectives. Key Metric for Quality 30-day survivability reflects hospital quality in stroke care
•
Timely Intervention
Swift response to stroke symptoms for optimal outcomes
•
Rehabilitation Milestones
Measurable progress markers for effective recovery
•
Patient Education
Empowering patients for better post-stroke management
• SMART Framework Alignment
Efficient goal-setting for enhanced stroke care delivery

Regulatory Standards
The Joint Commission Standards
• Comprehensive Stroke Center Certification: Sets benchmarks
for treatment times, care coordination, and patient outcomes.
• Guidelines for Healthcare Quality: Provides standards for
quality improvement and patient safety, focusing on key areas
like stroke care.
• Compliance: Ensures hospitals meet quality expectations for
accreditation.
• American Stroke Association Guidelines
• Focus on Acute Stroke Care: Guidelines offer evidence-based
practices for thrombolytic therapy, endovascular procedures,
and patient monitoring.

Quality Improvement / Risk Management Tools
Root Cause Analysis (RCA)
Six Sigma
Flowcharts
Description: RCA is a problem-solving methodology used to identify the root causes of issues in healthcare processes. It helps understand why errors or adverse events occur and provides a systematic approach to prevent recurrences.
Description: Six Sigma is a data-driven approach to quality improvement that aims to reduce variability and defects in processes. It uses statistical methods to identify and eliminate sources of variation.
Description: Flowcharts are visual representations of
processes, showing the sequence of steps and
decision points. They are useful for mapping out care
pathways and identifying inefficiencies or
bottlenecks.
Application: In stroke care, RCA can be
used to analyze incidents such as delays in
treatment or communication breakdowns.
It helps healthcare teams uncover
underlying causes and implement
corrective actions to improve patient
outcomes.
Application: In the context of stroke care, Six
Sigma can be applied to streamline processes,
improve treatment times, and ensure consistent
outcomes. By analyzing key metrics, such as the
time from ED admission to initial stroke
treatment, Six Sigma helps identify areas for
improvement and guides continuous quality
improvement.
Application: Flowcharts can be used to visualize the
entire stroke care pathway, from ED admission to
discharge. By analyzing these visual representations,
healthcare teams can identify areas where delays or
redundancies occur and make changes to improve
efficiency and patient care.
The University of Arizona Global Campus
Proprietary & Confidential – For Internal Use Only
7
Key Stakeholders for Quality Improvement Initiative
7. Patients
Families
6. Patients
5. Care Coordinators
The University of Arizona Global Campus
Proprietary & Confidential – For Internal Use Only
1. Physicians
and
Neurologists
2. Nurses
Stakeholders
3. Hospital
Administrators
4. Quality Improvement
Coordinators
8
Resources Required
Time Resources: Implementation Phase,
Training and Development, Continuous
Improvement
Financial Resources: Funding for HIT
Tools, Staff Training, Operational Costs
Material Resources: Medical Equipment,
Quality Improvement Tools, Supplies for
Patient Care
The University of Arizona Global Campus
Proprietary & Confidential – For Internal Use Only
9
Advanced HIT
• Electronic Health Records (EHR): EHRs are digital
versions of patients’ medical records, providing
real-time access to patient information.
• Telemedicine and Remote Monitoring:
Telemedicine allows healthcare providers to
connect with patients remotely, while remote
monitoring systems track patient vitals and other
health indicators from a distance..
• Advanced Imaging Systems: Advanced imaging
systems, such as CT and MRI, are essential for
diagnosing and treating stroke. These systems are
often integrated with HIT to enable quick sharing of
images and data.
The University of Arizona Global Campus
Proprietary & Confidential – For Internal Use Only
10
Incorporating Quality Improvement Initiative into the Strategic Plan
1. Stakeholder
Engagement
2. Compliance and
Regulations
7. Strategic Vision
6. Collaborative Approach
5. Regulatory Alignment
The University of Arizona Global Campus
Proprietary & Confidential – For Internal Use Only
Align with
Organizational Goals
3. Continuous Improvement
Evaluation
4. Evidence Based Practices
11
Evaluation of Effectiveness
• Key Performance Metrics
• 30-Day Survivability: Track the percentage of stroke patients who survive 30 days post-emergency department (ED) admission. This
metric is a critical indicator of the QII’s success in improving stroke care.
• Data Analysis: Implement a system for continuous data collection and analysis. This allows for real-time tracking of performance
metrics and early detection of any deviations from the QII’s goals.
• Trends and Patterns: Analyze data to identify trends and patterns in stroke care delivery. This can reveal areas for improvement and
guide future quality improvement efforts.
• Stakeholder Feedback: Conduct sessions with stakeholders, including physicians, nurses, Quality Improvement Coordinators, and
hospital administrators. This feedback provides insights into the QII’s effectiveness from multiple perspectives.
• Patient and Family Feedback: Gather input from patients and their families to understand their experiences and identify
opportunities for improvement.
The University of Arizona Global Campus
Proprietary & Confidential – For Internal Use Only
12
References
• You must include a reference list with sources formatted according to the Publication Manual of the American Psychosocial
Association, 7th edition.
• The type font can be small, but must be legible. You will not present this slide,; rather it will be part of your archived presentation.
• Journal article: Author, A. A., & Author, B. B. (Date). Name of the article: Only the first word, proper nouns, acronyms, and words
following a colon or dash are capitalized. Name of the Journal, volume number(series number), XX – XX.
• Book: Author, A. A., & Author B. B. (Date). Name of the book: Only the first word, proper nouns, acronyms and words following a
colon or dash are capitalized. Name of Publisher.
• Chapter in a Book: Chapter Author, C. (date). Name of the chapter. In A. A. Editor & B. B. Editor (Eds.), Name of the book: Only the
first word, proper nouns, acronyms and words following a colon or dash are capitalized (pp. XX-XX). State: Name of Publisher.
• Internet source/report: Author or Institutional Author. (date or n.d.). Title of the internet document or resource you accessed.
https://doi.org/XXXXXXX
• This should be your last slide!
The University of Arizona Global Campus
Proprietary & Confidential – For Internal Use Only
13
Reducing Maternal Mortality Rates
Vanderbilt University Medical Center, Nashville
Quality Improvement Initiative to Reduce Maternal Mortality
•
Reduce Maternal Mortality Rates
• Maternal care and delivery and maternal addiction and recovery program currently within the
network
• 17 facilities with specially trained team members
•
SMART GOALS
• S – Goal is to reduce maternal mortality rate through Vanderbilt University Medical Center’s
current maternal care and maternal addiction programs.
• M – Measured by utilizing quality improvement tools and methodologies within a small group of
individuals
• A – Plan, Do, Study, and Act and involving key stakeholders
• R – Ensure the data utilized is relevant to the group that is being targeted to reduce these rates
• T – Complete the analysis within a reasonable time to ensure the initiative will fit into Vanderbilt’s
current strategic plan
Vanderbilt University Medical Center, Nashville
Quality Improvement Initiative to Reduce Maternal Mortality
•
Clinical Microsystem
• Focus on small group rather than larger group to obtain data
• Haddon’s methodology on how to reduce losses based on social determinants
• Factors to analyze
• Patient and their family
• Health care professional team
• Healthcare system
• Environment
•
Plan, Do, Study, and Act
• Attaining sustainable development goals to implement the initiative
•
SBAR Tool Implementation
• Allow for advance communication, teamwork and perception of patient safety culture while reducing maternal
mortality rates
•
Involving the right people
• Involving key stakeholders to help improve the quality of care and reduce the maternal factors
References
•
Bonds, R.L. (2018). SBAR Tool Implementation to Advance Communication, Teamwork, and the Perception of Patient Safety Culture. Creative Nursing, 24(2), 116-124.
https://doi.org/10.1891/1078-4535.24.2.116
•
Geremia, S., Valente, E.P., Mariani, I., Dalena, P., & Lazzerini, M. (2023). Women’s suggestions on how to improve the quality of maternal and newborn care during the
COVID-19 pandemic in Italy: A co-occurrence network analysis. Journal of Global Health, 13, 1-8. https://doi.org/10.7189/jogh.13.06013
•
Johnson, J.K., & Sollecito, W.A. (2020). McLaughlin and Kaluzny’s continuous quality improvement in health care (5th ed.). Jones & Bartlett Learning.
•
Karp, C., Edwards, E. M., & Tappis, H. (2024). Quality improvement in maternal and reproductive health services. BMC Pregnancy & Childbirth, 24(1), 1-3.
https://doi.org/10.1186/s12884-023-06207-y
•
Spencer, J., Gilmore, B., Lodenstein, E., & Portela, A. (2021). A mapping and synthesis of tools for stakeholder and community engagement in quality improvement initiatives
for reproductive, maternal, newborn, child and adolescent health. Health Expectations, 24(3), 744-756. https://doi.org/10.1111/hex.13237
•
Tarigan, D.B., & Dhamanti, I. (2023). Quality Improvement for Maternal and Child Health in Primary Health Care: A Scoping Review. Journal of Public Health Research &
Community Health Development, 6(2), 144-152. https://doi.org/10.20473/jphrecode.v6i2.34624
•
Vanderbilt University Medical Center. (2024, March 22). https://www.vumc.org/
•
Vanderbilt University Medical Center. (n.d.). Maternal Addiction and Recovery Program | Vanderbilt Health Nashville, TN
•
Vanderbilt University Medical Center. (n.d.). Pregnancy Care and Delivery | Vanderbilt Health Nashville, TN
Healthcare Quality Improvement Initiatives at
Vanderbilt University Medical Center:
Innovative Strategies for Patient-Centered Care
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Introduction
Vanderbilt University Medical Center (VUMC) is dedicated to continuous quality improvement to
prevent hospital incidents and deaths.
?
?
The focus is on offering the best services while preventing mistakes and ensuring patient safety.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Nature of Business and Customer Base
? VUMC is a leading healthcare
provider in Nashville, offering a wide
range of healthcare services to a
diverse customer base.
? The hospital welcomes patients with
various medical conditions, ensuring
equal and high-quality care for all.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Challenges Faced: Complications and Deaths
? Complications and deaths are significant
challenges impacting the hospital’s revenue,
reputation, and patient outcomes.
? Quality improvement is crucial to prevent
adverse events, loss of funding, and legal
issues.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
SMART Goals for Quality Improvement
? – SMART Goal 1: Reduce hospital-
acquired infections from 20% to 10%
within 18 months.
? – SMART Goal 2: Lower mortality
rates in high-risk operations by 15%
within 18 months.
? – These goals align with VUMC’s
mission of improving healthcare
delivery and patient satisfaction.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Policies and Guidelines
? Adherence to local and national
standards, such as The Joint Commission
Standards, is essential for quality
improvement.
? Following guidelines ensure the
hospital meets regulatory requirements
and enhances patient safety.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Quality Improvement Tools and Methodologies
? Pareto Diagram: Organizes factors affecting
quality to identify key areas for improvement.
? Driver Diagram: Provides an overview of
processes and causes of errors to initiate
improvement strategies.
? Six Sigma: Helps identify and eliminate
errors, improving the quality of service and
patient outcomes.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Stakeholders and Resources
? Key stakeholders include
nurses, physicians, clinical staff,
patients, and administrators.
? Resources like time, finances,
materials, and technology are
allocated to support quality
improvement initiatives.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Advanced Health Information Technology (HIT)
? Electronic Health Records
(EHRs) are essential for data
management, communication,
and coordination among
healthcare providers.
? EHRs facilitate analysis of
patient data, support evidencebased practices, and improve
overall healthcare quality.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Incorporating QI into Strategic Plan
? Aligning QI initiatives with
VUMC’s strategic goals ensures a
focused approach towards quality
improvement.
? Establishing a dedicated
committee and allocating resources
are crucial for successful
implementation.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Evaluating Effectiveness
? Evaluation includes qualitative and
quantitative metrics to assess the success
of QI initiatives.
? Stakeholder feedback, patient surveys,
and data analysis help determine the
effectiveness of implemented strategies.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
Conclusion
? Quality improvement is integral to
VUMC’s commitment to delivering
high-quality, safe, and patientcentered care.
? Advanced HIT, stakeholder
engagement, strategic planning, and
continuous evaluation are key
elements in achieving QI goals.
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center
References
?
Ahmad, F. B., &; Anderson, R. N. (2021). The leading causes of death in the US for 2020. JAMA, 325(18). https://doi.org/10.1001/jama.2021.5469
?
Basson, T., Montoya, A., Neily, J., Harmon, L., & Watts, B. V. (2021). Improving patient safety culture: a report of a multifaceted intervention. Journal of patient safety, 17(8), e1097-e1104.
?
Butler, J. M., Gibson, B., Lewis, L., Reiber, G., Kramer, H., Rupper, R., … & Nebeker, J. (2020). Patient-centred care and the electronic health record: exploring functionality and gaps.
Jamia Open, 3(3), 360-368. https://doi.org/10.1016/j.matpr.2021.05.534
?
Johnson, J. K., & Sollecito, W. A. (2020). McLaughlin and Kaluzny’s continuous quality improvement in health care (5th ed.). Jones & Bartlett Learning.
?
Leape, L. L. (2021). Enforcing standards: the joint commission. In Making Healthcare Safe: The Story of the Patient Safety Movement (pp. 185-202). Cham: Springer International
Publishing.
?
Manias, E., Kusljic, S., & Wu, A. (2020). Interventions to reduce medication errors in adult medical and surgical settings: a systematic review. Therapeutic advances in drug safety, 11,
2042098620968309.
?
Rathi, R., Vakharia, A., & Shadab, M. (2021). Lean six sigma in the healthcare sector: A
?
Renjith, V., Yesodharan, R., Noronha, J. A., Ladd, E., & George, A. (2021). Qualitative Methods in Health Care Research. International journal of preventive medicine, 12, 20.
https://doi.org/10.4103/ijpvm.IJPVM_321_19 systematic literature review. Materials Today: Proceedings, 50(5)
Healthcare Quality Improvement Initiatives at Vanderbilt University Medical Center