D030 HIP Paper Template

Student Name

Western Governors University

D030 Leadership & Management in Complex Healthcare Systems

Prof. Name

Date

Task 1: Healthcare Improvement Project – Introduction and Project Initiation

Stakeholder Identification

How were the stakeholders identified for this healthcare improvement project?

The process of identifying stakeholders for this project began with a thorough compilation of leadership personnel, decision-makers, and staff members specializing in infection control within the organization. The primary focus was on individuals dedicated to infection prevention and the early detection of sepsis specifically among oncology patients. Following a careful evaluation of experience and roles, three pivotal stakeholders were chosen:

Stakeholder	Experience & Responsibilities	Contribution to Project
Sepsis Coordinator	Over 5 years in infection prevention; Co-Chair of Sepsis Committee	Provides leadership and expert guidance
Assistant Manager of Urgent Care	Involved in sepsis improvement initiatives; data collection; staff education	Organizes data, trains staff, implements process changes
Urgent Care Charge Nurse	Experienced ER nurse; participates in hospital committees (Nursing Standards, Policy, Skin Integrity)	Tracks project milestones, updates staff, manages timelines

The Sepsis Coordinator plays a vital leadership role, offering expert guidance grounded in extensive experience in infection prevention. The Assistant Manager of Urgent Care oversees data collection, analysis of sepsis tool effectiveness, and the education of staff regarding new screening protocols. The Urgent Care Charge Nurse contributes clinical expertise and committee involvement, aiding communication and project monitoring.

Needs Assessment

What process was used to assess the needs for the healthcare improvement project?

The project lead initiated individual meetings, either face-to-face or virtual, with each stakeholder to gather ideas for potential improvements at Moffitt Cancer Center. Each stakeholder contributed one to two project ideas. These ideas were then compiled and disseminated for group assessment. Using the Nominal Group Technique during a 30-minute Zoom session, stakeholders anonymously ranked the proposed ideas through an online questionnaire.

Following discussion and voting, the top three project ideas identified were early sepsis identification, improving care transfers, and addressing nurse burnout/employee retention. Consensus was reached to prioritize early sepsis identification because of the significant vulnerability of oncology patients to sepsis complications.

Problem Identification

What is the primary problem addressed by the project?

Moffitt Cancer Center primarily serves adult oncology patients, many of whom have compromised immune systems due to cancer treatments. Despite advances in medical care, sepsis-related mortality among cancer patients remains approximately double that of non-cancer patients (Chae, Kim, & Lee, 2020). Sepsis not only causes delays in chemotherapy but also leads to extended hospital stays and increased healthcare costs (Mert et al., 2021).

This project aims to identify the most effective sepsis screening tool tailored to oncology patients within the Urgent Care Department. Such a tool must recognize atypical infection signs unique to cancer patients, such as altered vital sign thresholds and specific laboratory markers, facilitating early and effective interventions.

Problem Description

Why is an early sepsis identification screening tool necessary at Moffitt Cancer Center?

The Infection Prevention and Sepsis Committee found several shortcomings in sepsis management within the Urgent Care setting. Chart reviews exposed repeated delays in initiating sepsis protocols for eligible patients, underscoring the urgent need for a dedicated screening tool. This tool would enable rapid diagnosis and treatment, aiming to reduce mortality rates and improve patient outcomes.

Impact Analysis

What are the potential benefits and risks associated with the project?

The impact analysis focused on two main areas: Patient Satisfaction and Decreased Length of Stay, evaluating potential benefits and risks with impact scores ranging from 1 (low) to 3 (high).

Category	Benefits (Examples)	Impact Score	Risks (Examples)	Impact Score
Patient Satisfaction	Improved communication; timely care	3	Resistance to change; training needs	2
Length of Stay	Reduced hospital stays; faster recovery	3	Implementation delays; data accuracy issues	3

The total benefit score reached 11, while the risks scored 9. This results in an impact ratio of 1.2 (benefits divided by risks), suggesting that the advantages outweigh the risks and supporting project implementation.

SWOT Analysis

How was the organizational readiness assessed?

A collaborative SWOT analysis was performed with input from all stakeholders. Each member initially drafted a SWOT focused on internal and external factors. A 45-minute group discussion followed, leading to a voting process that refined the assessment:

SWOT Component	Internal Criteria	External Criteria	Key Findings
Strengths	Strong leadership	Active stakeholder involvement	Committed leadership and engaged stakeholders
Weaknesses	Variable staff morale	Limited uptake of best practices	Concerns about burnout and knowledge dissemination
Opportunities	Training programs	External partnerships	Potential for education and collaboration
Threats	Staff turnover	Regulatory changes	Risks from turnover and evolving compliance demands

The SWOT analysis confirmed that the project is feasible while highlighting areas that require proactive management.

Ethical Considerations

What ethical standards support this healthcare improvement project?

Moffitt Cancer Center’s Code of Ethics mandates delivering high-quality, safe, and patient-centered care (Moffitt Cancer Center, 2018). This project aligns with these principles by emphasizing timely, equitable, and culturally competent care for immunocompromised oncology patients. The initiative to detect sepsis early reflects the center’s dedication to protecting vulnerable populations.

Task 2: Healthcare Improvement Project – Project Purpose and Review of Scholarly Sources

Purpose Statement

The primary objective of this project is to implement an early sepsis identification tool within the Urgent Care Department. This tool aims to accelerate response and treatment for oncology patients exhibiting sepsis symptoms by integrating the screening process into patient triage. Such prompt intervention is expected to improve clinical outcomes significantly.

Review of Relevant Scholarly Sources

Research highlights that cancer patients are at heightened risk for sepsis and experience higher mortality rates, reinforcing the need for specialized screening tools (Chae et al., 2020; Mert et al., 2021). Studies demonstrate that nurse-led sepsis protocols and community-based screening tools enhance early detection and improve patient outcomes (Baker, 2022; Moore et al., 2019). These evidences support the project’s approach and provide a robust framework for implementation.

Appendix D: SMART+C Goal Worksheet

SMART+C Criteria	Question	Answer
Specific	What is the specific project?	Implementing an early sepsis screening tool in Urgent Care to expedite intervention.
Measurable	What indicators will be measured?	Increase in timely initiation of sepsis protocols by December 2022, based on data collected.
Achievable	How feasible is the project?	Highly feasible due to supportive impact and SWOT analyses and the high risk profile of patients.
Relevant	How worthwhile is the project?	Expected to reduce mortality, shorten hospital stays, and enhance patient satisfaction.
Time-Bound	What are the project timelines?	Project initiation in June 2022 with completion by December 2022.
Challenge	What is the stretch goal?	Develop a cancer-specific sepsis screening tool using identified clinical indicators.

SMART+C Goal:
Implement an early sepsis identification tool in the Urgent Care Department to enhance sepsis protocol response and treatment times for oncology patients by December 2022.

Expected Outcome:
The project expects that collected data will enable development of an oncology-specific sepsis screening tool. This innovation aims to reduce mortality, decrease hospital length of stay, lower healthcare costs, and improve overall patient satisfaction and outcomes.

References

Baker, E. (2022). Improving sepsis recognition through use of the Sepsis Trust’s community screening tool. British Journal of Community Nursing, 27(2), 69–75. https://doi.org/10.12968/bjcn.2022.27.2.69

Chae, B.-R., Kim, Y.-J., & Lee, Y.-S. (2020). Prognostic accuracy of the sequential organ failure assessment (SOFA) and quick SOFA for mortality in cancer patients with sepsis defined by systemic inflammatory response syndrome (SIRS). Supportive Care in Cancer, 28(2), 653–659. https://doi.org/10.1007/s00520-019-04869-z

Mert, D., Merdin, A., Kandemir, N., Çakar, M. K., Dirim, E., Çeken, S., Altuntaş, F., & Ertek, M. (2021). Evaluation of risk factors and causative pathogens in bloodstream infections in cancer patients. Gulhane Medical Journal, 63(1), 42–51. https://doi.org/10.4274/gulhane.galenos.2020.1320

Moffitt Cancer Center. (2018). Code of Ethics and Professional Conduct. https://moffitt.org/about-moffitt/corporate-compliance/code-of-ethics-and-professional-conduct/

Moore, W. R., Vermuelen, A., Taylor, R., Kihara, D., & Wahome, E. (2019). Improving 3-Hour Sepsis Bundled Care Outcomes: Implementation of a Nurse-Driven Sepsis Protocol in the Emergency Department. Journal of Emergency Nursing, 45(6), 690–698. https://doi.org/10.1016/j.jen.2019.05.005