A. Discuss how to initiate a quality improvement project for this clinical problem.
In the initial stages of initiating a quality improvement (QI) project, Lauren will need to
identify the problems leading to a decrease in patient satisfaction and revenue loss and pinpoint
opportunities for improvement that stem from these issues. After identifying the problems, a written
plan would be developed that describes the structure and approach the organization will follow to
evaluate and improve systems, processes, and outcomes of care. (Shaw, 2019) It is essential to
involve all affected parties in the QI project, which fosters transparency, eliminates the “blame game,"
and promotes a sense of ownership or increased commitment among all involved. This approach also
brings diverse perspectives and expertise, leading to more effective brainstorming and
comprehensive solutions. (IHI, n.d.a) The QI team should be cross-functional, comprising staff and
leadership from the rehabilitation center, transport, and nursing staff. Lauren will lead the project and
collect data, aggregated and analyzed in the addressed problem areas, to establish improvement tools
to remedy the ongoing clinical issues at the facility. (Shaw, 2019)
1. Identify three areas of focus for quality improvement
Areas of Focus for Quality Improvement
1. Improve the timeliness of scheduled therapy sessions
2. Improve patient care and satisfaction
3. Improve communications and coordination across departments
, a. Describe the types of quantitative and qualitative data gathered for part A1,
including an example of each type of data.
Data Type
Quantitative Data
Therapy Session Start Time Track and compare scheduled therapy start
times vs. Actual therapy start times.
Duration of Therapy Sessions Total of therapy sessions that meet minimum
time requirements
Total number of therapy sessions records
reviewed
Transport Delays Documentation of delays in patient transport to
the therapy center
Qualitative Data
Staff Feedback Interviews with staff and documentation of
perceptions on how delays for therapy sessions
impact their departments.
Patient and Family Feedback Gather information on the patient and family
experience.
b. Explain your Process for gathering the data.
The first step in gathering data for the PI project is to define the goal and identify the
specific needs to be measured in order to achieve the desired results. Goals should be SMART
(Specific, Measurable, Achievable, Relevant, and Time-bound), which provides clarity, clear
direction, expectations, and accountability. (Anderton, 2023) The next step would be to plan
the data collection through identifying data sources (ex. booking systems, patient feedback,
staff observations, billing data and transport data), choosing best methods (interviews,
surveys, direct observation, and EHR system) and developing procedures such as who will
collect data, how often the data is collected, the time frame and how the collected data will
be recorded. During the data collection process, it is important that data is collected
consistently and kept simple to avoid complex manual tasks. After data is collected, it is
important to clean and organize it. Cleaning your data will help improve its accuracy and make
it easier to evaluate patterns and relationships within the data. (SafetyCulture, 2025)
2. Identify a quality improvement model that can be implemented.
In the initial stages of initiating a quality improvement (QI) project, Lauren will need to
identify the problems leading to a decrease in patient satisfaction and revenue loss and pinpoint
opportunities for improvement that stem from these issues. After identifying the problems, a written
plan would be developed that describes the structure and approach the organization will follow to
evaluate and improve systems, processes, and outcomes of care. (Shaw, 2019) It is essential to
involve all affected parties in the QI project, which fosters transparency, eliminates the “blame game,"
and promotes a sense of ownership or increased commitment among all involved. This approach also
brings diverse perspectives and expertise, leading to more effective brainstorming and
comprehensive solutions. (IHI, n.d.a) The QI team should be cross-functional, comprising staff and
leadership from the rehabilitation center, transport, and nursing staff. Lauren will lead the project and
collect data, aggregated and analyzed in the addressed problem areas, to establish improvement tools
to remedy the ongoing clinical issues at the facility. (Shaw, 2019)
1. Identify three areas of focus for quality improvement
Areas of Focus for Quality Improvement
1. Improve the timeliness of scheduled therapy sessions
2. Improve patient care and satisfaction
3. Improve communications and coordination across departments
, a. Describe the types of quantitative and qualitative data gathered for part A1,
including an example of each type of data.
Data Type
Quantitative Data
Therapy Session Start Time Track and compare scheduled therapy start
times vs. Actual therapy start times.
Duration of Therapy Sessions Total of therapy sessions that meet minimum
time requirements
Total number of therapy sessions records
reviewed
Transport Delays Documentation of delays in patient transport to
the therapy center
Qualitative Data
Staff Feedback Interviews with staff and documentation of
perceptions on how delays for therapy sessions
impact their departments.
Patient and Family Feedback Gather information on the patient and family
experience.
b. Explain your Process for gathering the data.
The first step in gathering data for the PI project is to define the goal and identify the
specific needs to be measured in order to achieve the desired results. Goals should be SMART
(Specific, Measurable, Achievable, Relevant, and Time-bound), which provides clarity, clear
direction, expectations, and accountability. (Anderton, 2023) The next step would be to plan
the data collection through identifying data sources (ex. booking systems, patient feedback,
staff observations, billing data and transport data), choosing best methods (interviews,
surveys, direct observation, and EHR system) and developing procedures such as who will
collect data, how often the data is collected, the time frame and how the collected data will
be recorded. During the data collection process, it is important that data is collected
consistently and kept simple to avoid complex manual tasks. After data is collected, it is
important to clean and organize it. Cleaning your data will help improve its accuracy and make
it easier to evaluate patterns and relationships within the data. (SafetyCulture, 2025)
2. Identify a quality improvement model that can be implemented.
