Quality Improvement in Healthcare Discussion

Using Evaluation Tools to Assess Quality Improvement Efforts

           Quality improvement initiatives are a constant method utilized to address new knowledge and changes in practice and require an evaluation process to assess the effectiveness or challenges of a new intervention  (Hickey & Brosnan, 2017). The balanced scorecard (BSC) is one of the most popular methods to evaluate and track organizational performance, including the consideration of linking both finance and quality outcomes (Sadeghi, Barzi, Mikhail, & Shabot, 2013).  A BSC is part of the strategic plan, aligning the appropriate metrics that support a healthcare system’s mission and vision. Both the BSC and performance dashboards are evaluation tools utilized at my workplace, and the information reported is representative of multiple departments that contribute to the organizational goals for quality improvement. The BSC lists the institutional strategic goals and tracks progress while the performance dashboards includes the hospital-acquired conditions, including fall and infections, patient and staff satisfaction results, and length of stay, morbidity, and mortality. The finance department also reports out on budget and overtime data, which represents the cost-effectiveness of the patient care delivered across the health system.

           My course project is focused on standardizing a process to address the central line-acquired bloodstream infection (CLABSI) rates across the five adult critical care intensive care units (ICUs). Due to the complex and high-acuity care provided in the ICU setting, patients often require expensive treatment modalities and excessive lengths of stay (LOS). In this situation, an ICU specific performance dashboard is particularly helpful with metrics that track mortality and morbidity, LOS, and a variety of infection types, including sepsis (Nouira et al., 2018). Hospital-acquired infection rates are also tracked and reported on the performance dashboard and provide the monthly CLABSI results for each unit, along with the Standard Infection Ratio (SIR), which measures the observed number versus the expected number of CLABSIs per 1,000 catheter days (CDC, 2019). The root cause analysis (RCA) is also reported on the performance dashboard, so you can review each incidence of CLABSI and what potential gaps in process or policy may have been missed. Compliance with the central line insertion bundle checklist is also reported and can be cross-referenced with the CLABSI rates. Other factors that could contribute to a CLABSI include the percentage of employees compliant with the hand hygiene policy and the number of patients receiving chlorhexidine gluconate (CHG) bathing treatments. The dashboards contribute to the health system’s strategic goal to become a zero harm organization and provide safe patient care and quality outcomes. They achieve this by trending data from the current or ongoing quality improvement initiatives, including my course project, to reduce CLABSI.  Plus, provide a visual information tool for employees to review data and check progress in their home units or areas of responsibility. From here, successful projects can be shared with other units and more resources added to support these initiatives. In areas with below benchmark results, the dashboards help identify where to concentrate future efforts.


Centers for Disease Control and Prevention [CDC]. (2019). FAQs about HAI progress report. Retrieved from https://www.cdc.gov/hai/data/portal/FAQs-progress-…

Hickey, J. V., & Brosnan, C. A. (2017). Evaluation of health care quality in for DNPs (2nd ed.). New York, NY: Springer Publishing Company.

Nouira, H., Ben Abdelaziz, A., Kacem, M., Ben Sik Ali, H., Fekih Hassen, M., & Ben Abdelaziz, A. (2018). Which indicators used to assess quality performance in Intensive Care Units? A systematic review of medical literature. Anaesthesia, Critical Care & Pain Medicine, 37(6), 583–587.

Sadeghi, S., Barzi, A., Mikhail, O., & Shabot, M. M. (2013). Integrating quality and strategy in health care organizations, Burlington, MA: Jones & Bartlett Publishers.