Implementation of Quality Improvement Plan

Implementation of Quality Improvement Plan

Capstone Project- Part 5 The first orders (Part 1,2, 3, 4) #226133, 226279, 226280, 226281 and the writer #1747. Location of Practice Experience: Saint Joseph Pain and Rehabilitation Center Improvement on time out process before procedures. The next step in the process is to begin identifying the challenges and impediments to implementing a quality improvement plan. In the analysis consider the individuals affected by the change as well as the cost of implementing the quality improvement plan. Post a description of some of the proposed action steps for implementing improved practice, and explain where potential challenges might compromise your proposed improvement project. Describe what resources are needed for your solution, and explain whether or not those resources are cost-effective. Continue to collaborate with the selected individuals in your practice environment as needed in the development of the Practice Experience Project, and share this information with your group. Sources have to be 5 years or less and it has to be wrote in APA 7th edition.Implementation of Quality Improvement Plan


Improving Quality by Entrenching Respect for Time-out Procedures at St. Joseph Pain and Rehabilitation Center: Challenges, Resources, and Affected Stakeholders

The quality improvement (QI) project at St. Joseph Pain and rehabilitation Center with regard to time-out procedures will be faced with challenges like any other project. Challenges to a project are barriers that threaten to derail the achievement of project goals and objectives. Then there are those internal stakeholders that will be affected by the change process intended to foster evidence-based practice or EBP. These stakeholders themselves may be the source of some of the project challenges or barriers, especially if their buy-in was not secured properly. To successfully implement the evidence-based project and overcome the project pitfalls or challenges, enough resources (human, material, and fiscal) must be available. The objective of this paper is to identify the individuals that will be affected by the practice change, state the challenges that may face the project, and determine the resources required to successfully implement the change project at St. Joseph Pain and Rehabilitation Center.

Proposed Action Steps, Individuals to Be Affected by the Change Project, and the Challenges to be Expected

The individuals who also happen to be internal stakeholders and who will be affected by the change plan in the implementation project to reduce the incidence of wrong-site surgeries are surgeons and OR nurses (AHRQ, 2019). They will be affected because they will be required to attend the planned training as well as practically go through the time-out procedure with colleagues several times over. They will be expected to shed hierarchies and place themselves at the same level with their colleagues. This will make it easier for everyone to play their part without fear in a psychologically safe environment.Implementation of Quality Improvement Plan

The proposed steps in the implementation of the evidence-based project interventions to reduce wrong-site surgeries (WSS) through strict adherence to time-out procedures can be summarized as training, role play, supervised implementation, and evaluation. The focus will be to remind the OR team of time-out details; the importance of the protocol to their professions, patient outcomes, and the reputation of the organization; and the financial impact of sentinel events. On the challenges expected during the implementation of the practice change project, these will include:

  • Resistance from the employees who will be affected by the change and who loathe close supervision.
  • Difficulties with scheduling surgeries during the period of training as the same staff will be expected to continue with ongoing surgeries.
  • Budgetary constraints when it comes to the purchase of an interactive electronic checklist system or iECS (Rothman et al., 2016).

Resources Needed

The resources needed for successful implementation of this project will be human, material, and fiscal in nature. While implementing the recommended evidence-based interventions, surgeries will be continuing as usual and therefore there will be a shortage of OR nurses to cover the shifts. This means that the organization’s nursing administration will have to organize for coverage in terms of locums and other means. This will definitely mean that the nursing resources will be stretched. Financially, the organization will have to adjust its payroll to accommodate the locums. The payroll will also have to be adjusted to reflect the extra pay of the regular nursing staff that will accumulate extra full-time equivalents or FTEs for extra hours of work done to cover the shortage. Lastly, the organization has to facilitate the resource persons from outside organizations (specifically JCAHO) who will come to do the training. Materials such as overhead projectors, note books, flip charts, and whiteboards will be needed too. Interprofessional collaboration will be encouraged with regard to effective communication, especially between the OR nurses and the surgeons.   Implementation of Quality Improvement Plan


Agency for Healthcare Research and Quality [AHRQ] (2019). Wrong-site, wrong-procedure, and wrong-patient surgery. Patient Safety Network.

Rothman, B.S., Shotwell, M.S., Beebe, R., Wanderer, M.Phil., J.P., Ehrenfeld, J.M., Patel, N., Sandberg, W.S. (2016). Electronically mediated time-out initiative to reduce the incidence of wrong surgery: An interventional observational study. Anesthesiology, 125(3), 484-494.

Implementation of Quality Improvement Plan