General Instructions

Advanced practice nurses apply continuous quality improvement (CQI) processes to improve client-centered outcomes. Select one of the following client-centered care initiatives that you would like to improve in your practice area: client clinical outcomes, client satisfaction, care coordination during care transitions, or specialty consultations for clients.

Include the following sections:

1. Application of Course Knowledge: Answer all questions/criteria with explanations and detail.


a.  Identify the selected client-centered care initiative and describe its application to your future practice.

b.  Select one CQI framework that can be applied to the selected initiative. Explain each step of the framework.

c.  Describe how the framework can improve client-centered care for the selected initiative.

d.  Describe how you would involve interprofessional team members in the CQI process.

care coordination during care transitions

Application of Course Knowledge:

a. Selected Client-Centered Care Initiative: For the purpose of this exercise, I will choose “care coordination during care transitions” as the client-centered care initiative to improve in my practice area.

In my future practice, I envision myself working as an advanced practice nurse in a hospital setting, particularly in a department dealing with chronic conditions or post-surgical care. Care coordination during care transitions is crucial for ensuring seamless transitions between different healthcare settings (e.g., hospital to home, hospital to long-term care facility). This initiative aims to optimize communication and collaboration among healthcare providers involved in a patient’s care to prevent adverse events, reduce hospital readmissions, and improve overall patient outcomes.

b. Selected CQI Framework: Plan-Do-Study-Act (PDSA) Cycle

Explanation of Each Step:

  1. Plan: In this step, the team identifies the problem, sets objectives, and devises a plan for improvement. This involves gathering baseline data on current care coordination processes, identifying key stakeholders, establishing goals for improvement (e.g., reducing readmission rates by a certain percentage), and developing strategies for implementation.
  2. Do: Once the plan is formulated, it is implemented on a small scale. This allows the team to test the proposed changes without significant disruption to routine operations. During this phase, communication protocols, care coordination tools, and workflow processes are adjusted as per the plan.
  3. Study: Data is collected and analyzed to evaluate the effects of the implemented changes. This involves comparing outcomes against baseline data to determine whether the interventions led to improvement. Key metrics may include readmission rates, patient satisfaction scores, and healthcare provider feedback on the effectiveness of the new processes.
  4. Act: Based on the findings of the study phase, adjustments are made to further refine the intervention. Successful strategies are scaled up for broader implementation, while unsuccessful ones are revised or abandoned. Continuous monitoring and feedback loops are established to sustain improvements over time.

c. Improving Client-Centered Care: The PDSA framework can significantly enhance care coordination during care transitions by providing a structured approach to identifying areas for improvement, implementing changes, and assessing their impact. By systematically evaluating existing processes and making targeted interventions, healthcare providers can address gaps in communication, streamline workflows, and enhance collaboration across different care settings. For example, by implementing standardized discharge protocols, ensuring timely follow-up appointments, and facilitating information sharing between hospital and community-based providers, the PDSA cycle can help optimize care transitions and improve patient outcomes.

d. Involvement of Interprofessional Team Members: Engaging interprofessional team members is essential for the success of the CQI process. In the context of improving care coordination during care transitions, collaboration among nurses, physicians, pharmacists, social workers, case managers, and other stakeholders is critical. Each team member brings unique perspectives and expertise to the table, contributing to the development and implementation of effective strategies for improvement. Strategies for involving interprofessional team members may include regular interdisciplinary meetings to discuss care coordination issues, assigning specific roles and responsibilities to each team member, and fostering a culture of open communication and mutual respect. By harnessing the collective knowledge and skills of the interprofessional team, the CQI process can drive meaningful change and ultimately improve client-centered care outcomes.

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