D156 Updated HIP Paper Template for Nursing Weekly Assessment

Student Name

Western Governors University 

D156 Business Case Analysis for Healthcare Improvement

Prof. Name

Date

Healthcare Improvement Project: Introduction and Project Initiation

Organizational Problem

What organizational challenge does this healthcare improvement project address?
This healthcare improvement initiative focuses on the development and implementation of a standardized weekly nursing assessment tool tailored for patients admitted to acute psychiatric units. The primary intent of this initiative is to consolidate fragmented clinical documentation into a single, structured format that accurately reflects patient progress, treatment response, and discharge readiness. By doing so, the tool will enhance interdisciplinary communication and support timely, informed clinical decision-making.

At present, nursing documentation within the psychiatric setting is inconsistent and dispersed across multiple disciplines and staff roles. Licensed nurses document patient care based on 1:1 observation requirements and 15-minute safety checks, while mental health technicians record patient observations at 60-minute intervals. Although registered nurses complete weekly comprehensive head-to-toe assessments, the clinical information shared with social workers—who are responsible for coordinating discharge and community placement—is often derived primarily from non-licensed staff notes. These notes typically emphasize behavioral observations rather than clinical progress, medication adherence, or readiness for discharge.

How does this problem affect patient care and discharge planning?
This disjointed documentation structure creates gaps in clinical insight, limits the accuracy of referral packets, and delays discharge planning. The absence of a unified, nurse-driven weekly summary compromises interdisciplinary collaboration and increases the risk of incomplete or misleading patient information. A standardized weekly nursing assessment aligned with Centers for Medicare & Medicaid Services (CMS) requirements would address these deficiencies by providing a holistic, clinically grounded overview of each patient’s status.

Stakeholders

Who are the key stakeholders involved in this project, and what influence do they hold?
The success of this documentation improvement project depends on collaboration among clinical leaders, nursing staff, and administrative stakeholders. Each stakeholder contributes specialized expertise and holds varying degrees of organizational influence, ensuring that the initiative aligns with both clinical standards and institutional priorities.

These stakeholders collectively ensure that the assessment tool is clinically meaningful, operationally feasible, and compliant with regulatory standards.

Project Team Roles and Responsibilities

What responsibilities does the project manager assume in this initiative?
The project manager plays a central role in guiding the initiative from concept through implementation. Key responsibilities include coordinating stakeholder engagement, identifying workflow inefficiencies, and overseeing the development and rollout of the standardized assessment tool. The project manager also fosters accountability by monitoring timelines, tracking task completion, and addressing barriers that may impede progress.

In addition to operational oversight, the project manager serves as a coach and facilitator. By promoting collaboration, encouraging feedback, and supporting staff adaptation, the project manager helps cultivate a culture of continuous quality improvement. Two essential competencies underpinning this role are active listening and analytical thinking. These skills enable the project manager to accurately assess departmental needs, interpret data trends, and ensure the assessment tool adds meaningful clinical value.

What role does nursing education leadership play?
Susan Lynch, Director of Nursing Education, is instrumental in translating clinical expectations into a functional documentation tool. Her responsibilities include designing the assessment template based on nursing standards, leading staff training sessions, and revising institutional policies to formally integrate the new documentation process into routine practice.

Needs Assessment

How was the need for a standardized weekly nursing assessment identified?
The project team employed the “5 Whys” root cause analysis method to examine deficiencies in current nursing documentation practices. This analysis revealed that inconsistent reporting of patient behaviors and treatment progress stemmed largely from reliance on daily progress notes completed by non-licensed staff. While these notes provide valuable observational data, they lack the clinical depth required for discharge planning and interdisciplinary decision-making.

What documentation elements were identified as essential?
The needs assessment determined that a comprehensive weekly nursing assessment should include head-to-toe physical evaluations, medication adherence data, PRN medication usage, behavioral trends, activities of daily living (ADL) support, and relevant medical concerns. Incorporating these elements into a single document would improve accuracy, enhance continuity of care, and support both clinical and administrative requirements.

SWOT Analysis

What organizational factors influence project success?
A SWOT analysis was conducted to evaluate internal and external factors affecting implementation and sustainability.

This analysis guided the development of mitigation strategies to proactively address barriers to adoption.

Impact Analysis

What benefits and risks are associated with this project?
The impact analysis evaluated potential benefits and risks related to medication monitoring and nursing documentation.

With a calculated benefit-to-risk ratio of 1.57, the analysis supports project implementation, as anticipated benefits outweigh potential challenges.

Justification and Project Purpose

Why is this project necessary?
The primary purpose of this project is to implement a consolidated weekly nursing assessment that improves documentation quality and supports treatment evaluation for acute psychiatric patients. The standardized tool is designed to systematically capture patient engagement, medication usage, behavioral patterns, and medical concerns, thereby strengthening interdisciplinary collaboration.

By aligning documentation practices with CMS and Joint Commission standards, the project enhances regulatory compliance while promoting safer, more effective patient care. Existing organizational resources—including experienced nurse supervisors and a dedicated education department—further support the feasibility and sustainability of this initiative.

Review of Relevant Scholarly Sources

What does the literature say about nursing documentation in psychiatric care?
Current research consistently emphasizes the importance of high-quality nursing documentation in psychiatric settings. Wong and Muller (2023) highlight the role of detailed PRN medication documentation in reducing inappropriate pharmacologic reliance. Moldskred et al. (2021) demonstrate a direct association between improved documentation quality and patient outcomes, including discharge readiness.

Additional studies underscore the clinical relevance of nursing assessments. Ameel et al. (2019) emphasize therapeutic nursing interventions, while Schoretsanitis et al. (2020) stress the importance of monitoring antipsychotic medication levels. Barr et al. (2019) further illustrate how consistent documentation and nurse-patient rapport enhance safety and treatment effectiveness. Collectively, these findings support the implementation of a comprehensive weekly nursing assessment.

Project Environment

What regulatory standards influence this project?
CMS mandates regular documentation of patient progress in acute psychiatric settings, including weekly summaries of clinical status (Centers for Medicare & Medicaid Services [CMS], 2024). This project integrates physical assessments, medication adherence, behavioral observations, laboratory monitoring, and discharge planning into a unified format to ensure compliance and promote holistic patient care.

SMART Goal

What is the specific goal of this project?

Project Management Lifecycle

How will the project be executed?
The project follows a structured management lifecycle consisting of initiation, planning, implementation, and evaluation. During initiation, stakeholders are identified and the problem is clearly defined. The planning phase focuses on timelines, role assignments, and resource allocation. Implementation includes staff education and deployment of the assessment tool. Finally, evaluation and closure involve outcome analysis, feedback collection, and determination of next steps to ensure long-term sustainability.

References

Ameel, M., Kontio, R., & Valimake, M. (2019). Interventions delivered by nurses in adult outpatient psychiatric care: An integrative review. Journal of Psychiatric and Mental Health Nursing, 26(9–10), 301–322. https://doi.org/10.1111/jpm.12543

American Nurses Association. (2010). ANA’s principles for nursing documentation: Guidance for registered nurses. https://www.nursingworld.org

Barr, L., Wynaden, D., & Heslop, K. (2019). Promoting positive and safe care in forensic mental health inpatient settings. International Journal of Mental Health Nursing, 28(4), 793–814. https://doi.org/10.1111/inm.12588

Centers for Medicare & Medicaid Services. (2024). State operations manual Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals.

Hansmann, M. L. (2018). The top skills every healthcare process improvement leader must have. HealthCatalyst.

D156 Updated HIP Paper Template for Nursing Weekly Assessment

Moldskred, P. S., Snibsøer, A. K., & Espehaug, B. (2021). Improving the quality of nursing documentation. BMC Nursing. https://doi.org/10.1186/s12912-021-00629-9

Schoretsanitis, G., et al. (2020). Blood levels to optimize antipsychotic treatment in clinical practice. The Journal of Clinical Psychiatry, 81(3), e1–e12.

The Joint Commission. (2018). Behavioral health care standards sampler.

Wong, S., & Muller, A. (2023). Nurses’ use of PRN medication in adult acute mental healthcare settings. International Journal of Mental Health Nursing. https://doi.org/10.1111/inm.13148