NHS FPX 8010 Assessment 4 Quality Improvement Proposal

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Executive Summary

The recommended program includes the Plan Do Study Act (PDSA) cycle to enhance patients and their families’ experiences in the emergency room setting of the Grand River Hospital. This is in line with the department’s strategic ambition of enhancing the experiences of patients and their families. A SWOT analysis highlighted significant strengths, including dedicated personnel and facilities that were in good condition, on which future developments could be built. NHS FPX 8010 Assessment 4 Certain opportunities include the reduction of wait times through the use of technology and the implementation of good communication strategies. But, issues such as resource scarcity and workers change are real and must be addressed. It is also necessary to pay attention to the feedback from patients in order to turn mistakes into opportunities to improve. Thus, by addressing these significant issues, it is our goal to enhance our department’s performance and rank it among the top ten departments in Ontario in terms of patient and family satisfaction. This will help in making sure that all the clients we are going to serve are going to be served to the best of our abilities and they are happy with the services that we offer.

NHS FPX 8010 Assessment 4 Quality Improvement Proposal

An acute care Improvement Proposal (QIP) is crucial in emergency rooms as it is a structured approach to identify issues, address them, and enhance the care of patients. It is especially crucial in the ER, where the working environment is hectic and tense, to constantly strive to make changes that will help enhance the patients’ outcomes, minimize the number of adverse incidents, and optimize the functioning of the facility as a whole. A good QIP enables healthcare workers to plan the way they look at present practices, identify ways of improving the practices, use approaches supported by evidence and view the changes’ impact on patients in the future. QIPs are essential for enhancing the quality of patient care in emergency departments; making patients safe, happy and satisfied with the treatment they receive. This results in improved outcomes for those individuals who require urgent care (Chartier et al. , 2022). The purpose of this evaluation is to recommend a QIP for the ER’s selected strategy goal, which is to enhance patients and their families’ experiences. The patient and family experience is defined with the aim to be in the top ten in Ontario.

The Rationale for Establishing a Strategic Priority

It enhances the effectiveness of task accomplishment since it provides a framework that guides the allocation of time and resources in the achievement of specific goals that are aligned with the general mission and vision of groups. By determining what needs to be changed for the most, e. g. making the emergency room more pleasant for the patients and their families, groups can be more effective in using their resources, and collaborate on the issues that will have the most positive impact. The primary objectives of the suggested quality improvement program include the enhancement of the quality of care provided to the patients and their families in emergency rooms. To ensure that patients and their families receive quality care and feel valued throughout their healthcare processes (Rosa et al., 2023), this project seeks to enhance patient-clinician communication, decrease barriers to care, and foster a supportive environment.

If changes are made in this area, businesses can improve the quality of patient satisfaction and increase the health of patients and the entire community (Drossman & Ruddy, 2019). This goal was set due to how patient-centered care is vital, as well as due to the fact that positive experiences in the ER can significantly influence the patients’ perceptions of the overall quality of healthcare (Walsh et al., 2022). It is crucial to understand that a focus on making the experiences of patients and their families better is the way organizations demonstrate that they are committed to delivering the highest quality of care and strive to create environments that foster healing, trust, and compassion.

The fact that one of the goals is to enhance the experience of the patients and their families in the emergency room proves that those who are there really know how crucial these experiences are when it comes to health. Understanding that positive interpersonal communication with individuals in distress can make a difference in their attitude towards care in general indicates that you possess psychological and emotional insight into the subject. By placing this aspect first, organizations demonstrate that they understand how this will impact the patient’s satisfaction, health outcomes, and interactions with society (Walsh et al., 2022). The strategy focus in this case is quite impressive as it is an indication of a commitment to attend to the present needs and to foster a culture of patient-centeredness, which includes listening and understanding the patient. This will assist in cultivating an organizational culture of whole person care and make the organization the best in Ontario in terms of patient and family satisfaction.

SWOT Analysis

Doing a SWOT analysis of Grand River Hospital’s strategic focus to enhance patient and family experience in the emergency room means considering the strengths and the weaknesses of the goal, its opportunities, and threats.

Grand River Hospital is the single largest health service provider in Waterloo Region and Guelph-Wellington hence there is ground work and support to back up planned initiatives. This is in line with the hospital’s mission and vision as it focuses on providing quality healthcare services. This provides the hospital with the solid foundation of placing patient and family experiences at the centre. The hospital also has relationships with several entities including internal teams, students, workers, and the community. This way it is ensured that different concepts and opinions are considered, which can help in finding new approaches (Grand River Hospital, n. d. ).

NHS FPX 8010 Assessment 4 Quality Improvement Proposal

Despite the fact that Grand River Hospital is listed among the best hospitals, it may be challenging for it to change the ER swiftly. If the hospital lacks some resources, for example, human resources or financial resources, then it might not be in a position to manage all patient and family experience issues. One more factor which might prevent improvement of situations in ER is organizational resistance – when people in the hospital do not want to change.

NHS FPX 8010 Assessment 4 hospital strategic plan outlines specific objectives in enhancing the experiences of the patients and their families to be among the best globally. It also demonstrates how one can get there. According to Grand River Hospital (n. d. ), with the help of collaboration with other nearby MedTech, education, and healthcare facilities, it is possible to enhance the emergency room experiences by sharing the best practices and utilizing resources effectively. It is also important to embrace new ideas because advancements in technology and patient-centered care delivery systems have made it possible to try new things that will benefit the patients and their families (Dang et al. , 2021).

New regulation or shift in health care legislation can also reduce the capacity of the hospital to consider the best interest of patients and their families. Threats can also be other centers of healthcare since some of them may have better solutions to enhance the customer experience. Furthermore, the unpredictability of the ER such as fluctuation in patient turnover and the level of concerns they present makes it difficult to always deliver outstanding experiences (Shaw, 2022).

Key Performance Indicators

The KPIs are useful for seeing how effectively the PDSA cycle is addressing quality improvement. This is even the case in the healthcare context such as the emergency department of the Grand River Hospital where improving the experience of patients and their families is one of the key strategic objectives. Patient satisfaction rate which can be obtained from polls or comment section is one of the key performance indicators. These numbers speak volumes about the satisfaction level of patients regarding their care, including communication, waiting time, and overall experience (Lee et al. , 2019). If these numbers increase, then it tells the organizer that the effort is moving in the right direction in terms of achievement of the goals.

Another such sign is the average length of stay (ALOS) in the emergency room. This means that effort is being made to deliver care more effectively and this can be beneficial to the patient as well as the result. Supervising the ALOS is useful with regards to identifying process issues and potential means by which routines may be improved. NHS FPX 8010 Assessment 4 readmissions within a given timeframe are also used as another KPI in evaluating how effective efforts aimed at enhancing quality are (Ansah et al. , 2021). Those patients who are less readmitted receive proper care as well as the necessary follow-up, which contributes to the improvement of the total experience and outcomes.

It is also important to know how many bad events or medical mistakes are happening to be able to understand how safe your patients are and the effectiveness of your quality improvement initiatives. Reducing these problems demonstrates that the care is improving and patients will have faith in the emergency room (Jarrar et al. , 2021). Finally, the following are examples of key KPIs: Staff turnover, which is an indicator of the morale of employees; Staff polls (Brown, 2020). It is evident that the morale and satisfaction of the staff will enhance the quality of the care given to patients and hence improve their experience.

Stakeholders Identification

Stakeholders’ feedback is very useful for quality improvement processes, especially at the ER in Grand River Hospital. The project gets to understand the various perspectives of the patients, the families, the staff and the community members, who are most likely to be affected by the changes proposed. This feedback helps to direct improvement efforts in a way that satisfies stakeholders’ requirements and objectives.

There are a few critical actions that need to be undertaken to cooperate with partners on the suggested quality improvement project. To start with, it is essential to introduce oneself to all the main stakeholders, including the patients, their relatives, the immediate workforce, hospital administration, and local representatives. People must be able to continue talking and communicating throughout the life cycle of the project, and clear lines of contact should be established. In addition, to get feedback, address problems and find the solution with the stakeholders, joint meetings, focus groups, polls, and other feedback tools must also be employed (Geraghty et al. , 2019).

NHS FPX 8010 Assessment 4 Stakeholder Patient

NHS FPX 8010 Assessment 4 Stakeholders GRH emergency include patients, the patient’s families, the emergency department staff including doctors, nurses, and technicians, the hospital managers, other healthcare workers in the community, and individuals from the patient support organizations. I think their support for the attempt to enhance quality is crucial for the success of this task. First, the quality of the care and experiences of the patients and their families in the emergency room influences them, thus ensuring that they are satisfied will help the program achieve its goals (An et al. , 2020). Community healthcare workers assist with managing care, while patient support groups provide a lot of valuable knowledge about patient-oriented care (Simpson et al. , 2022).

Due to the vast amount of customer feedback, there is a need to adopt a structured approach to harness all the information. To achieve this, the data collected must undergo analysis to identify areas that share the same themes that need to be enhanced. Then, action items must be prioritized according to the potential and feasibility of each. It is crucial to continuously and transparently engage all stakeholders involved in the process so that they are not only aware of what is happening but actively participate in implementing the changes being proposed (Cui, 2021). NHS FPX 8010 Assessment 4, the involvement of all staff members in the process of quality improvement will contribute to the creation of a healthy organizational culture in the emergency room based on teamwork, personal responsibility, and continuous learning. This will enhance the experiences of patients and their families, hence meeting the organization’s strategic goals.

Role of Change Theory

Lewin’s Change Theory can be used to assist Grand River Hospital’s emergency room in achieving the strategy goal of enhancing the experiences of patients and their families by creating a new and specific quality improvement program. Lewin’s theory says that change happens in three steps: They are the unfreezing, change, and refreezing (Ahmed et al. , 2022).

This could mean presenting current patient satisfaction scores and emphasizing the need to address communication, waiting time and comment concerns (NHS FPX 8010 Assessment 4). After that, the hospital may apply the Plan-Do-Study-Act (PDSA) model to implement the proposed quality improvement plan in the change stage. This means finding better methods for members of the department to communicate, implementing plans to reduce the time patients can wait, and establishing procedures for acquiring feedback from patients and addressing it (Wong et al. , 2020).

Finally, in the last stage of change management known as the refreezing stage, the hospital can ensure that the changes are made permanent by promoting new ways of thinking and carrying out activities, which are patient and family centred. This could mean providing the staff with regular training, monitoring their work on a daily basis, and ensuring that the departmental objectives include patient satisfaction as a metric (Pawaskar et al. , 2022). It is suggested to apply Lewin’s Change Theory to Grand River Hospital so that the hospital can make necessary changes to achieve the strategic goal of enhancing the patient and family experiences in the emergency department. This has its final goal as being amongst the best in Ontario for this measure.

Lewin’s Change Theory provides more structured approach to managing change, emphasizing how necessary it is to first identify what needs to be changed, and than to freeze it and make sure it stays that way. Leaders who are implementing change have to communicate the need for change, engage the employees, and manage resistance (Bonawitz et al. , 2020). Lewin’s theory can assist the change leaders to address the issues associated with change, develop organizational culture for improvement, and facilitate changes that enhance the outcomes of the patients besides boosting the performance of the organization.

Policy Recommendation

In order to contribute to the success of the planned quality improvement project that will seek to make the Grand River Hospital emergency room better for the patients and their families, the following policies may be implemented: First, the hospital should establish specific guidelines for communication and ensure that the staff members disseminate information within a short span (Farcas et al. , 2020). It could imply implementing treatment procedures that categorize patients with severity of their state so as to optimally utilize available resources, and frequently assess and modify levels of staffing to match with patient needs (Daly et al. , 2021). Moulaei and his colleagues (2023) have also suggested that the hospital should consider adopting technologies like Skype to allow for quick consultation and reduce unnecessary physical visits.

NHS FPX 8010 Assessment 4 recommended that policies should be established in order to ensure that the patients’ feedback is received and addressed appropriately and in good time. This can be achieved through providing ways in which the patient can give feedback, and in real-time, conducting surveys to determine the level of satisfaction of the patient, and lastly, providing ways in which the patient can express their concerns or even ideas. There should also be guidelines on how to handle the feedback received and the measures of responsibility in case of an issue to ensure that such incidences are addressed promptly (Liu et al. , 2020).

Second, it is the case that patients like shorter wait times, and the former way results in better use of resources and more efficient operations. Finally, replying to comments from patients, especially in a timely and effective manner, is an indication of a commitment to the well-being of the patients. This creates a positive attitude towards the hospital among the patients and their families and also enhances the perception of the hospital in the society (Liu et al. , 2020). These effects are in harmony with the suggestions because they align with the organization’s strategic direction and can enable the achievement of the goal of being among the top ten organizations in Ontario in terms of patient and family experience and total organization performance, leading to the health of the patients.


Lastly, NHS FPX 8010 Assessment 4 proposed quality improvement plan for the ER department of the Grand River Hospital that targets at enhancing patients and families’ experiences aligns with the department’s objectives. This goal is to establish the department as one of the best in Ontario for patient and family experience by using the PDSA cycle, which aims at enhancing communication, reducing waiting times, and promptly addressing feedback from patients. This project proves that the emergency room is committed to striving for improvement and delivering quality care to anyone who needs it.


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