D158 Healthcare Improvement Project Paper

Implementation Approach

What was the initial step in advancing the Healthcare Improvement Project (HIP)?

The project commenced with the formation of a dedicated team composed of several organizational members focused specifically on reducing surgical cancellations. The initiation phase began with a key meeting between myself and my preceptor, which served to define the project’s scope. This scope was subsequently presented to the entire project team to gain their agreement and commitment, establishing a foundation of shared objectives.

How did the team plan for the project’s execution?

In the planning phase, the team convened every two weeks to assess the resources necessary for effective implementation. A critical output of this phase was the creation of a detailed budget. This budget was meticulously prepared using a personnel pay and hours spreadsheet to ensure financial clarity and proper allocation of resources, supporting transparency and accountability throughout the project lifecycle.

What consensus method was selected for decision-making and why?

The Nominal Group Technique (NGT) was chosen as the preferred method for group decision-making during implementation. NGT is particularly effective for small, in-person groups and follows a structured four-step process designed to foster equal participation and reduce bias:

This approach helped create a cooperative atmosphere, ultimately leading to unanimous team agreement on the HIP plan.

How does the project maintain momentum during implementation?

To keep the project on track, biweekly meetings are planned. Holding meetings too frequently could limit time for assessing implemented changes, whereas infrequent meetings might diminish focus. The project manager schedules these meetings with agendas aligned to the action plan and Gantt chart milestones. Additionally, weekly email updates help maintain ongoing communication and keep all members informed between meetings.

Were any policies reviewed or updated during the project?

Regular policy reviews were incorporated as a standing agenda item. While the hospital’s exclusion criteria policy remained unchanged, the preadmission testing guidelines were revised. Instead of a single phone call, patients now receive weekly follow-up calls, enhancing engagement. Because the project team and stakeholders largely overlapped, all policy modifications were discussed in meetings and ratified unanimously.

Action Plan

The action plan was created collaboratively, outlining five essential steps with clear responsibilities, phases, and deadlines. This structure aligns with the Gantt chart, which breaks down each step into specific subtasks to ensure precise monitoring and accountability.

The project timeline spans from January 29 to July 31, 2024, providing structured deadlines for each phase to ensure steady progress.

Gantt Chart Utilization

What is the role of the Gantt chart in the project?

The Gantt chart serves as a dynamic visual management tool, enabling the project manager and team to track tasks, deadlines, and progress comprehensively. It is regularly updated collaboratively, enhancing accountability and helping the team anticipate and prepare for upcoming activities.

Social Determinants of Health (SDOH) and Target Population

Who is the target population and what are their key social determinants?

The target for this HIP is Ortho Colorado Hospital (OCH) in Lakewood, Colorado, aiming to reduce surgical cancellations by 5% by June 30, 2024. OCH is a 48-bed facility with 17 pre-op/PACU bays, 8 operating rooms, and a workforce of 187 employees (175 clinical). The population of Lakewood exhibits diverse sociodemographic features critical to the project’s design.

How are social determinants addressed in the project?

• Education Access and Quality: Patient education materials are crafted at a sixth-grade reading level and translated into Spanish to accommodate linguistic diversity and literacy levels.

• Economic Stability: Financial challenges that may hinder adherence to care instructions are addressed through frequent patient contact and support.

• Neighborhood Environment: While Lakewood offers parks and public transit, concerns about transit safety are acknowledged, as they may impact patient mobility and recovery.

• Social and Community Support: The project leverages strong local networks such as food banks and pharmacies offering discounted medications to bolster patient wellbeing.

• Healthcare Access and Quality: Partnerships with organizations like Common Spirit Health provide access to discounted and free clinics, increasing healthcare accessibility for underserved patients.

Through clear communication, weekly nurse calls, and educational support, the project empowers patients, reducing anxiety and increasing confidence in their surgical care journey.

Force Field Analysis

What forces influence the implementation of the HIP?

What strategies are planned to manage these forces?

• Monthly executive updates on cancellation metrics to maintain leadership engagement.

• Leadership walkthroughs to build empathy and understanding with frontline staff.

• Justification for hiring additional staff to reduce workloads and improve patient communication.

• Involving staff in developing educational materials to increase ownership and reduce resistance.

Scope Statement

The project aims to enhance patient engagement through multiple phone touchpoints and by creating clear educational resources such as handouts, booklets, and classes. These materials clarify surgical requirements and milestones, promoting patient understanding and adherence throughout their surgical experience.

SMART Goal

The project’s SMART goal is to reduce surgical cancellations by 5% at Ortho Colorado Hospital by June 30, 2024. This will be achieved through enhanced patient communication, increased preadmission touchpoints, comprehensive educational materials, and focused staff training.

Key Performance Indicators (KPIs)

Communication and Training Plans

Communication

Training

Surgical, preadmission, pre-op, and operating room staff will undergo training on:

• New educational materials

• Compliance with checklists

• Enhanced preadmission communication touchpoints

Training will include four sessions per week over two weeks (May 20 – June 7, 2024), with each lasting two hours. Sessions will be held in the mornings, evenings, and virtually at the surgeon’s clinic. Competency sign-off will be required, including a walkthrough and explanation of project goals.

References

Arakawa, N., & Bader, L. R. (2022). Consensus development methods: Considerations for national and global frameworks and policy development. Research in Social and Administrative Pharmacy, 18(1), 2222–2229. https://doi.org/10.1016/j.sapharm.2021.06.024

Data USA: Lakewood, Colorado. (n.d.). Data USA. https://datausa.io/profile/geo/lakewood-co/#demographics