Nursing Quality Improvement Paper

1.         Introduction

Introduction paragraph (one paragraph).

Introduce a practice issue appropriate for a quality improvement project facilitated by a MSN or DNP prepared nurse. There must be a thesis statement at the end of the paragraph that tells the reader the purpose of paper and what will be discussed.

2.         AHRQ Implementation Tool Kit

Review the AHRQ tool kit for the implementation of quality improvement and patient safety projects found at:

Describe the purpose of the AHRQ implementation tool kit.

What role with interprofessional collaboration have in the project?

3.         Problem, Aim and Review of the Literature

Based on the Organizational Analysis (OA) paper that you previously submitted this semester, use the same facility for this paper.

Use a concern that you identified from your analysis from the Hospital Compare website or a similar source; select a single area that needs improvement.

1. Quantify (measure) the practice concern for the facility that you selected for the Organizational Analysis paper based on your assessment. State the problem in a single concise measurable problem statement. For example: In XX facility, the rate for XX is XX% higher than the national benchmarks.

2. State a measurable aim statement based on the problem statement. For example:

The aim for this quality improvement project is to reduce XXX by XX% over XX months.

Review the literature for the identified concern, what has been an effective approach for other facilities?

Note: Do not describe the intervention in this section. The next steps will focus solely on the problem.

4.         How to assess readiness for change

Assume you are doing this project in the facility that you reviewed in the prior OA paper. How will you assess the facilities readiness to change? What change theory would you use to plan your work?

5.         Quality Improvement Tool

What steps will you take to understand the problem? Identify the quality improvement tool you will use (e.g. Root Cause Analysis, Fishbone cause and effect diagram, FMEA, etc.) Describe how you will complete an assessment of the problem in the organization.

6.         Quality Improvement Model and Tool kit or Bundle

Select a model (e.g., PDSA, FADE, Six Sigma, TCAB, TeamSTEPPs) for the quality improvement project. Describe the model and summarize the practice improvement initiative/intervention(s) using the steps of the model. This is the point in the paper where you describe the evidence-based intervention (with citation) based on the problem, background and investigation of the concern.

The proposed intervention must be an approved set of interventions (tools) from the AHRQ or another professional organization. Describe the toolkit you will be implementing within the structure of the quality improvement model.

There are multiple toolkits or bundles available from AHRQ and other professional resources. Choose the toolkit/bundle or structured intervention that you will plan to implement and discuss the steps for implementing the toolkit/bundle/intervention. Use appendices if needed to support your discussion.

Examples of AHRQ toolkits

Examples of toolkits: to an external site. to an external site. to an external site. to an external site. to an external site.

Examples of IHI bundles:

See IHI tool kits

7.         Quality Improvement Budget

Are there costs associated with implementing the planned intervention? Describe and estimate the costs and any savings.

8.         Measuring the work

Based on Donabedian’s work, identify and describe

1 point (a) the structure measures,

1 point (b) the process measures, and

1 point (c) the outcomes measures for the quality improvement intervention(s) for this project.

1 point What qualitative and quantitative measures will be identified to determine effectiveness of quality initiative?

1 point How would qualitative findings contribute to the project plan?

9.         Quality Improvement Visual Display

Identify and briefly describe at least two visual displays for reporting outcome data for your selected practice issue (e.g. histogram, run chart, pie chart, bar graph, etc.).

10.       Conclusion

Conclusions: Summarize the essential points of paper (one paragraph).

           Paper Guidelines & What Must Be Included:

Demonstrate Graduate Level Scholarship.

1.            Formal, scholarly writing style; no first-

person language.

2. Writing should be clear and concise.

3. Organize work by headings.

4. Writing should be free of APA errors.

5. Full paper (except reference page, appendices, and

attachments) submitted to Turnitin, with minimal similarity.

6. CON approved format for a title page, running head, introduction, and page numbers.

7. Paper to include a minimum of 10 peer- reviewed or scholarly


8. Citations and references follow APA


9. Writing should be free of grammatical and

spelling errors.

10. Paper not to exceed six (6) to seven (7) pages

(excluding title page, reference page, and any appendices).

Quality Improvement Model and Tool kit or Bundle

1.            A model (e.g., PDSA, FADE, Six Sigma, TCAB, TeamSTEPPs) for the quality improvement project. Describe the model and summarize the practice improvement initiative/intervention(s) using the steps of the model. This is the point in the paper where you describe the evidence-based intervention (with citation) based on the problem, background and investigation of the concern.

The proposed intervention must be an approved set of interventions (tools) from the AHRQ or another professional organization. Describe the toolkit you will be implementing within the structure of the quality improvement model.

There are multiple toolkits or bundles available from AHRQ and other professional resources. Choose the toolkit/bundle or structured intervention that you will plan to implement and discuss the steps for implementing the toolkit/bundle/intervention. Use appendices if needed to support your discussion.

Examples of AHRQ toolkits

Examples of toolkits: to an external site.

Links to an external site. to an external site. to an external site. to an external site. to an external site.

2.    to an external site.

Examples of IHI bundles:

See IHI tool kits

Quality Improvement: Accessible and High-Quality Care for Mental Health Needs at Alameda Hospital


Mental health needs manifest in various forms, such as anger management, anxiety and panic attacks, and control disorders. More serious mental health concerns include bipolar, major depressive disorder, and schizophrenia. All these needs, regardless of their intensity, require clinical attention. However, in many healthcare outlets in the US, access to sufficient and high-quality mental health care is a challenge. At Alameda Hospital, this challenge often arises due to inadequate skills/knowledge, lack of a priority assessment system, and high costs associated with mental health treatment. Therefore, the current paper develops a quality improvement initiative to enhance mental healthcare accessibility and quality, in turn improving patient and caregiver outcomes.

AHRQ Implementation Toolkit

The AHRQ implementation toolkit is a robust collection of practical tools and procedures for implementing hospital care quality and safety improvement initiatives. The tracking and implementation tools fall into six categories, starting with a readiness assessment. Here, the quality improvement (QI) leader must determine if their facility is ready for change by evaluating available resources and the facility’s performance of the AHRQ quality indicators. Next, the leader must apply quality indicators to the facility’s data to determine current performance and coding tips. Third, the toolkit provides resources for identifying priorities. Here, the leader can use a worksheet to develop a quality improvement plan and engage their staff members in the initiative. The fourth category of the AHRQ toolkit comprises twenty-five best practices, a charter, a gap analysis tool, and an implementation plan to enable the leader to execute evidence-based strategies in addressing a specific problem. The toolkit also contains resources for progress and sustainability monitoring and return on investment analysis. Lastly, the toolkit contains a list of other relevant tools (AHRQ, 2017). Hence, the toolkit is comprehensive and adaptable to different clinical problems and cultural settings, making it a universal resource for quality improvement.

The toolkit inspires interprofessional collaboration. Hence, the interprofessional collaboration will be instrumental in the program in several ways. First, it will promote staff education. Caregivers will acquire knowledge and skills from other disciplines, improving their competence to implement evidence-based change strategies. Networking will also be vital to the project’s success by enabling diverse professionals to share ideas for problem-solving, resulting in better clinical outcomes (Brugman et al., 2022). Lastly, interprofessional collaboration will play a motivational role in the initiative by inspiring creativity and resolve to address challenges and attain benchmark mental health quality standards.

The Problem, Aim, and Review of the Literature

Alameda Hospital has been struggling to provide high-quality mental healthcare services. The key reasons for this shortcoming include insufficient competency among caregivers, the lack of a prioritization assessment for any mental illness, and high costs. Consequently, the proportion of people who receive comprehensive mental healthcare is significantly smaller than the facility’s capacity. Over the past two years, only 24 of every 100 patients visiting the facility for mental healthcare needs have received comprehensive and sustainable care. Comparatively, according to the National Institute of Mental Health (2023), about 47.2% of all American adults with any mental illness received mental health services in 2021. While this national benchmark data still falls short of the expected standards, it is a sufficient indicator of Alameda Hospital’s inefficiency in addressing mental health needs. Therefore, this quality improvement initiative will aim to improve mental health accessibility by up to 50% within the next twelve months.

Increasing mental health access can be a daunting task for healthcare organizations. Nonetheless, various strategies have been successful in other clinical settings. First, hospitals can integrate mental health services with primary care. This integration has particularly helped alleviate depressive symptoms among individuals with other clinical needs (Moise et al., 2021). It is also economical since it reduces overall healthcare costs. Another intervention is the use of technology in mental healthcare delivery. Telemedicine and telehealth infrastructure are revolutionizing mental healthcare access. Digital platforms allow more people to access mental health services remotely and at a reasonable cost. Furthermore, according to Kemp et al. (2020), these digital platforms still offer comparable outcomes in terms of compassion and professionalism by using various safety and communication techniques. Therefore, telehealth improves mental healthcare access while upholding quality standards.

Assessing Readiness for Change

The quality improvement leader at Alameda Hospital will conduct a change readiness assessment to determine if the facility is willing and able to make systematic alterations to the mental healthcare delivery process for improved accessibility. First, the leader would evaluate the availability of resources and the capacity to acquire the missing ones. The leader must determine what equipment, personnel, or other infrastructure is necessary for the change initiative. If an item is missing, the leader must then assess the organization’s capacity to acquire it. Next, the leader should evaluate the perception and awareness of the issue. A scoping review of attitudes toward mental health among caregivers would reveal their perceptions and consequent willingness to participate in the change implementation process. Lastly, the leader would assess the facility’s sociocultural context. They will determine how the organization’s top leadership perceives mental health and the organizational goals related to care quality across different clinical spheres. The outcomes of this assessment will provide a clear illustration of hospital readiness.

The quality improvement leader can then use Roger’s diffusion of innovation theory to implement changes. The first step in this theory is imparting knowledge (Barrow et al., 2022). The leader will create awareness among the facility’s leadership on the need for change. They will also break down the process and identify the required resources and personnel. The second step is persuasion, which is employee engagement. The clinical staff will undergo a sensitization workshop to persuade them to accept the change by integrating their attitudes, experiences, and knowledge to create a positive outlook on the initiative. Next, the quality improvement leader and clinical staff must agree on whether to implement the change. This decision-making process entails negotiations to find the best solutions to the problem and the ideal implementation practices. The fourth step, implementation, entails executing evidence-based strategies to create the desired impact. Lastly, the theory states that the team must confirm that the change has the desired impact on care quality. Therefore, this theory is practical and applicable to the current care quality issue.

Quality Improvement Tool

One can understand the mental health access and quality challenges at the Alameda Hospital through general observation, data analysis, and generic surveys with stakeholders. Observing the clinical setting will help identify issues such as poor attitudes among caregivers, while data analysis will quantify the problem. Meanwhile, generic surveys will uncover competency gaps among caregivers in delivering high-quality mental health services. The Fishbone cause and effect diagram will be useful in this process. The QI leader will indicate mental health inaccessibility as the core issue. They will then identify the main categories of the possible causes of the problem, such as economic factors, limited clinical competency, lack of digital tools, etc. The leader will complete the diagram by noting the key components under each category (Cox & Sandberg, 2018). Lastly, the leader will complete the assessment by comparing the facility’s statistics related to the issue to benchmark data to reveal the need for improvement.

Quality Improvement Model and Tool kit or Bundle

The quality improvement intervention will be the integration of telehealth services in delivering mental healthcare. The QI leader will utilize the Plan-Do-Study-Act (PDSA) model to implement the intervention (McNicholas et al., 2019). First, they will plan the initiative by creating objectives and amassing the requisite resources. Secondly, they will integrate the telehealth infrastructure into the hospital’s mental health department. Trained practitioners will deliver services to patients using telehealth platforms depending on individual needs. The QI leader will then study the initial outcomes of the intervention and identify challenges. They will then develop plans to address these issues and implement interventions during the next cycle. Each PDSA cycle will last three months. Hence, there will be four cycles during the twelve-month quality improvement window.

The Substance Abuse and Mental Health Administration (SAMHSA) developed a toolkit for implementing telehealth to address serious mental illnesses and substance abuse disorders. From the literature review, telehealth is one of the ways to improve mental health accessibility and quality. Therefore, SAMHSA’s guidelines comprise a comprehensive toolkit to address the care quality issue. The toolkit’s focus population is adults with serious mental illness or substance abuse disorder. Meanwhile, the care continuum consists of several stages: screening and assessment, treatment, case management, recovery support, and crisis services. Caregivers can utilize various treatment modalities such as medication-assisted, prolonged exposure, cognitive behavioral, cognitive process, and behavioral action therapy. The delivery for all these interventions is telehealth based. First, patients can access the services via videoconferencing. This avenue allows comprehensive interaction and supports dynamic feedback. The other avenues include telephone and web-based applications. The toolkit also engages a wide range of practitioners, including clinicians, pharmacists, MAT-waivered providers, case managers, and peers (SAMHSA, 2021). Thus, it supports interdisciplinary integration.

Quality Improvement Budget

The major costs in this project relate to acquiring and integrating telehealth resources for mental healthcare and training caregivers. On the other hand, the project will provide the facility with increased revenue. Previous patients will also realize cost benefits since they will save on transport. They will also not forego their regular income since they can schedule appointments when they are off-duty. Table 1 provides estimates for these expenses and potential savings, highlighting the initiative’s long-term economic sustainability. The projections highlight that the hospital could make a net income of at least 56000 USD in the first implementation year. The continued expansion and refinement of the initiative will result in more positive financial outcomes in the subsequent years.

Table 1: Financial Budget

Financial ItemsCycle 1Cycle 2Cycle 3 Cycle 4TOTAL
ExpenditureApproximate amount (USD)
Telehealth infrastructure acquisition150,000   150,000
Telehealth system maintenance 5,0005,0005,00015,000
Staff training17,8001, 6501, 6501, 65022,750
Savings & Revenue     
Additional income25,00068, 75075,00075,000243,750
Net Income    56,000

Measuring the Work

The QI leader will use structural, process, and outcome measures to assess the project’s success. Structural measures will include increasing the uptake of telehealth in mental health by 15% among the hospital’s patients and increasing the number of peer-based and MAT-waivered practitioners by 80%. Meanwhile, the main process outcome will be doubling the facility’s mental health capacity within a year. Lastly, the key outcome measure is attaining 50% accessibility of mental health services in the first year. These measures will comprise the quantitative assessment. On the other hand, qualitative measures will include caregiver and patient experiences. These qualitative measures will help the project manager identify the general perception and acceptability of the project. Therefore, they will enable the project to attain cultural relevance and competence, enhancing its appeal to diverse sociocultural groups.

Quality Improvement Visual Display

The QI leader can display outcomes for the initiative using icon arrays and pie charts. Icon arrays would be useful in displaying the change in accessibility pre-and post-intervention. According to Albers et al. (2022), icon arrays are easy to interpret since they offer a simple visual medium to consume statistical data. For instance, in the pre-intervention column, one could depict mental health accessibility using twenty-four human icons. The post-intervention column would then show the achieved new percentage (e.g., fifty). Meanwhile, pie charts will be useful in illustrating the proportions of caregiver types pre-and post-intervention. The accompanying verbiage would help the audience understand which categories have more practitioners after the intervention due to the use of telehealth in mental healthcare delivery.


In conclusion, mental health accessibility is a major challenge at Alameda Hospital. The proposed quality improvement initiative seeks to address the problem by implementing telehealth service delivery infrastructure. This approach will reduce the demand to hire more highly-skilled caregivers and instead focus more on integrated care and the use of peers and MAT-waivered caregivers. Thus, the proposal could enhance mental health accessibility and improve clinical outcomes, patient experiences, and caregiver satisfaction.


Agency for Healthcare Research and Quality [AHRQ]. (2017).

Albers, E. A. C., Fraterman, I., Walraven, I., Wilthagen, E., Schagen, S. B., van der Ploeg, I. M., Wouters, M. W. J. M., van de Poll-Franse, L. V., & de Ligt, K. M. (2022). Visualization formats of patient-reported outcome measures in clinical practice: a systematic review about preferences and interpretation accuracy. Journal of Patient-Reported Outcomes, 6(1), 18.

Barrow, J. M., Annamaraju, P., & Toney-Butler, T. J. (2022). Change Management. StatPearls [Internet]. In StatPearls Publishing.

Brugman, I. M., Visser, A., Maaskant, J. M., Geerlings, S. E., & Eskes, A. M. (2022). The evaluation of an interprofessional QI program: A Qualitative Study. International Journal of Environmental Research and Public Health, 19(16), 10087.

Cox, M., & Sandberg, K. (2018). Modeling causal relationships in quality improvement. Current Problems in Pediatric and Adolescent Health Care, 48(7), 182–185.

Kemp, J., Zhang, T., Inglis, F., Wiljer, D., Sockalingam, S., Crawford, A., Lo, B., Charow, R., Munnery, M., Singh Takhar, S., & Strudwick, G. (2020). Delivery of compassionate mental health care in a digital technology-driven age: scoping review. Journal of Medical Internet Research, 22(3), e16263.

McNicholas, C., Lennox, L., Woodcock, T., Bell, D., & Reed, J. E. (2019). Evolving quality improvement support strategies to improve Plan-Do-Study-Act cycle fidelity: a retrospective mixed-methods study. BMJ Quality & Safety, 28(5), 356–365.

Moise, N., Wainberg, M., & Shah, R. N. (2021). Primary care and mental health: Where do we go from here? World Journal of Psychiatry, 11(7), 271–276.

National Institute of Mental Health. (2023). Mental Illness.

Substance Abuse and Mental Health Administration [SAMHSA]. (2021). Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders. Substance Abuse and Mental Health Services Administration.

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