NU800 Unit 8 Evaluation Plan, Thresholds Set Early Example

Thresholds Written Before the First Week: An Evaluation Plan for a Glucocorticoid Hyperglycemia Bundle, With Structure, Process, Outcome and Balancing Measures, a Collector and Schedule for Each, and a Decision Table

[Student Name]

Purdue University Global

NU800: DNP Project Proposal

Unit 8 Evaluation Plan

[Instructor Name]

[Date]

The units, targets and schedules are composite; figures are bracketed.

The Framework

Measures are organized using Donabedian's model of quality, which distinguishes structure, meaning the resources and arrangements behind care, process, the actions clinicians take, and outcome, the result for patients (Donabedian, 1988). A balancing measure is added to watch for harm the change could cause elsewhere. The model suits this project because a failure to improve outcomes could arise at any of the three levels, and the plan needs to show which.

Structure Measures

The order-set trigger will be tested each week by the informatics analyst, who will review the share of qualifying glucocorticoid orders that generated glucose check orders; the threshold is [95] percent. The share of nurses and patient care technicians who completed the huddle session will be counted by the nurse educator at the end of the education weeks and monthly thereafter; the threshold is [90] percent. Meter availability will be confirmed by the unit secretaries weekly.

Process Measures

Checks before lunch and before dinner will be measured from glucometer timestamps, reported separately, as the share of eligible patient-days with each check done within [30] minutes before the tray; the threshold is [80] percent for each. The project lead will collect this weekly from the glucometer export. Escalation will be measured as the share of episodes meeting the two-reading criterion that are followed by a page within [two] hours, from paging logs and nursing notes; the threshold is [75] percent. Scheduled insulin will be measured as the share of escalated episodes followed by an NPH or other scheduled insulin order within [24] hours; this is reported without a threshold, since the decision belongs to the prescriber. Taper adjustments and discharge plans will be reviewed in every relevant chart by the project lead each week.

Outcome Measure

The primary outcome is the rate of hyperglycemic days among monitored steroid days, expressed per 100. Weekly values will be charted over time against the median of the sixteen baseline weeks. The threshold for success is a shift, at least six consecutive weeks below the baseline median, which run chart rules treat as unlikely to occur by chance (Perla et al., 2011). A secondary target is a pooled implementation rate at or below [20] per 100, from a baseline of [31].

Balancing Measure

Low-glucose days, meaning days with any reading under 70 mg/dL, will be charted each week as a rate per 100 steroid days. The threshold for concern is a shift above the baseline median, or any single week above [4] per 100, which will trigger an immediate review of NPH doses and taper adjustments.

The balancing measure is set to fire faster than the outcome measure, because a harm should stop the project sooner than a benefit should confirm it.

Decision Table

If structure and process thresholds are met and the outcome shifts down without a balancing signal, the bundle will be adopted as standard on both units and proposed for other medical units. If process thresholds are met but the outcome does not shift, the team will examine whether escalation leads to scheduled insulin, since detection without treatment would explain the pattern, and adapt the escalation step. If pre-dinner checks meet the threshold but pre-lunch checks do not, the lunch break coverage problem identified in the framework mapping will be addressed directly, by assigning checks to a named role at lunch. If structure thresholds are not met, the order set or training will be fixed before any conclusion is drawn about the bundle. If the balancing measure signals harm, NPH suggestions will be paused and reviewed with pharmacy, regardless of other results.

Reporting Schedule

Weekly run charts will be posted on both units and shared at huddles. A monthly summary will go to the nurse managers, hospitalist director and pharmacy. A final report at week [12] will present all measures, the decisions reached from the table and the lessons for the next cycle. The Health Care Data Guide's approach of displaying data over time for learning, rather than comparing two averages, underlies this schedule (Provost & Murray, 2022).

Who Sees the Data

Run charts will be shown to the staff who produce the data, not only to managers. Nurses and technicians will see the pre-lunch and pre-dinner check rates for their own unit each week at huddle, which serves both as feedback and as a way to hear why checks are being missed. Prescribers will see escalation and insulin response rates at their monthly meeting. Keeping the data visible to those whose work it measures is part of the intervention as well as the evaluation.

Limits of the Plan

The pre-post design cannot rule out other causes of change, such as a new hospitalist or a change in the mix of patients receiving steroids. The monitored patient-day denominator addresses the detection problem but will be smaller in the baseline period, so baseline rates will be less precise. And fidelity to the NPH suggestion depends on prescribers, whose decisions the plan reports but does not control.

References

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

Provost, L. P., & Murray, S. K. (2022). The health care data guide: Learning from data for improvement (2nd ed.). Jossey-Bass.