NU712 Unit 9 QI Project Charter and Measures Example

One Aim, Seven Measures, Three Terms: A Unit 9 Project Charter and Measurement Plan for Spreading an Insulin Discharge Bundle

[Student Name]

Purdue University Global

NU712: Quality Improvement and Interprofessional Collaboration for the Doctoral Nurse

Unit 9 Project Charter and Measurement Plan

[Instructor Name]

[Date]

The hospital, units, team and figures are composite and illustrative; the guidance and studies cited are real.

Project Title

Ready at Home: Spreading an Insulin Discharge Readiness Bundle to Ten Adult Inpatient Units.

Problem Statement

In the year before the bundle, 31 of 214 patients who left the two pilot units on new insulin, about 14 percent, were seen again within a month because their glucose ran dangerously high or low. During the bundle's first year on those units, 20 of 212 returned, a little under 10 percent. The other eight adult inpatient units discharge about 400 patients a year on new insulin without the bundle. The equity analysis in Unit 7 showed that the bundle's components reached Medicaid, uninsured, older and rural patients less reliably than others.

Aim Statement

By the end of NU806, the proportion of patients discharged on new insulin from all ten adult inpatient units who return within 30 days with a glucose problem will fall from a baseline of about 14 percent on the eight spread units to 10 percent or lower, while every bundle component is delivered to at least 85 percent of patients in each payer group.

The aim carries its own equity condition, so the project cannot reach its target by helping only insured, younger, nearby patients.

An aim that can be met while the uninsured fall further behind is not the aim this project needs.

Scope

In scope. Adults on the ten inpatient units who start insulin during the stay and go home on it, including patients who restart insulin after more than a year without it.

Out of scope. Patients already on insulin before admission, patients discharged to a skilled nursing facility, who receive their insulin from facility nurses, the pediatric unit and the emergency department.

Team and Roles

The DNP student leads the project and owns the measurement plan. As sponsor, the chief nursing officer has signed off on a go-live calendar that keeps each unit's start at least eight weeks from its sepsis bundle start. The diabetes educator owns teaching content and the text follow-up queue. A clinical pharmacist owns pen access and the prior authorization step added after Unit 7. A hospitalist champion owns order-set changes. Each unit names a nurse champion, who leads a 15-minute bundle review in that unit's monthly council meeting. A data analyst from quality builds the monthly extract, and a patient advisor who started insulin two years ago reviews every patient-facing change.

Decision rules. Changes to bundle content need agreement from the educator and pharmacist and a review by the patient advisor; changes to go-live timing need the sponsor; any safety signal, such as a rise in lows after discharge, pauses the spread on the next unit until the team has reviewed it.

Timeline

NU802. Baseline data for the eight spread units, the measurement build, ethics review by the hospital's quality improvement determination process and go-live on 4 West and 3 West.

NU804. Go-live on four more units, at roughly six-week intervals, with PDSA cycles on each unit's adaptations.

NU806. Go-live on the last two units, six months of follow-up data for the earlier units, the final analysis and a report written to SQUIRE 2.0.

The Family of Measures

Each measure below lists its definition, numerator and denominator, source and frequency.

Outcome 1: 30-day glucose-related return. Numerator: in-scope patients seen in the emergency department or readmitted within 30 days of discharge with hypoglycemia, hyperglycemia or diabetic ketoacidosis coded as a primary or secondary diagnosis. Denominator: in-scope patients discharged that month. Source: the hospital's encounter data, which miss visits to other hospitals; the limitation will be reported. Monthly, by unit and payer.

Process 2: all components delivered. The proportion of in-scope patients who received all five bundle components, counted only when every one is documented. Nolan and Berwick (2006) argue that this kind of all-or-none measure reflects what the patient actually needs and pushes teams to fix the system rather than the easiest component. Monthly, by unit, payer, age group and distance.

Process 3: pen by the first insulin day. Patients whose dispensed pen is recorded by the end of the first calendar day on which insulin was given, divided by in-scope patients. Monthly, by payer.

Process 4: follow-up completed by day three. Patients with a documented text reply, call or visit by the end of the third day after discharge. Monthly, by age group.

Process 5: transition questions answered. The share of patients for whom the day-seven contact records the three confidence and meaning questions added after the Unit 8 theory application. Reported as exploratory.

Balancing 6: time from discharge order to departure. Median minutes for in-scope patients, to check that bundle work does not delay discharge. Monthly.

Balancing 7: nurse time on follow-up. Weekly minutes logged in the follow-up queue per unit, with a review triggered above three hours a week on any unit.

How the Data Will Be Displayed and Judged

Each measure will be shown on a run chart by month, with an annotation for each go-live and each tested change. Once a unit has 20 or more monthly points, the outcome and the all-components measure will move to a p-chart, since proportions with changing monthly denominators need control limits that change with them. Langley et al. (2009) describe the run chart as the improvement team's main way of learning from data over time; this plan treats the run chart as the working tool and the control chart as the confirming one. The final report will set each spread unit's return rate for the half year preceding its start beside the half year that follows, with a confidence interval, and will state honestly that a pre-post comparison cannot rule out other changes in the hospital.

Reporting

Results go to each unit council monthly, to the nursing quality committee quarterly and to the faculty committee at the end of each course. The final paper will be written to SQUIRE 2.0, so that a reader can see the hospital and its units, exactly what changed, how the change was evaluated and how each measure was defined (Ogrinc et al., 2016).

Risks

The chief risks are educator capacity, competing priorities and measure drift, meaning a slow change in how staff document the components. The text follow-up addresses the first, the go-live calendar the second and a quarterly audit of ten charts per unit the third.

Approval

The charter will be signed by the sponsor, the DNP student and the faculty project chair before NU802 week one, and revised only through the decision rules above.

References

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Nolan, T., & Berwick, D. M. (2006). All-or-none measurement raises the bar on performance. JAMA, 295(10), 1168-1170. https://doi.org/10.1001/jama.295.10.1168

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411