[Solved] Quality and Sustainability Paper Part Three – Implementation and Evaluation

Quality and Sustainability Paper Part Three – Implementation and Evaluation(WEEK SIX) 

The Quality and Sustainability Paper is a practice immersion assignment designed to be completed in three sections. This is part three of the assignment. Learners are required to provide a theoretical framework that supports the design and implementation of their evidence-based quality and/or safety program and discuss expected outcomes.

General Guidelines:

Use the following information to ensure successful completion of the assignment:

  • APA style is required for this writing assignment.
  • This assignment requires that you support your position by referencing at least eight scholarly resources.


Write a paper (2,000-2,500 words) that provides the following:

  1. Identify a quality, change, or safety theory you will use to support the implementation of your quality and/or safety program. Provide evidence that supports the use of this theory within the program you designed. Quality and Sustainability Paper Part Three – Implementation and Evaluation
  2. Provide the design of your evidenced-based quality and/or safety program that can be implemented to improve quality or safety outcomes in your identified entity.
  3. Discuss expected outcomes of your implementation and how to ensure their sustainability
Quality and Sustainability Paper Part Three - Implementation and Evaluation
Quality and Sustainability Paper Part Three – Implementation and Evaluation

Part III

Implementation and Evaluation


Institution Affiliation

Implementation and Evaluation


Upon examining the concepts of quality healthcare and patient safety and its role in nursing practice in Part I and Part II was notable for its analysis and application of the quality outcomes and creation of sustainability, the third and last part of the practice immersion exercise offers a theoretical framework that supports the design as well as the implementation of my evidence based quality improvement program.  This section also explores the expected outcomes.

Theoretical Framework Supporting the CITiT

Having identified the quality of healthcare outcome aspect to address as primarily time where the CITiT purposes to reduce WTC in less than two hours in the ED, this paper utilizes the Iowa Model as the theoretical framework to guide this EBP guided quality improvement project. This after the preceding sections of this essay has established that reducing the WTC to less than 2 hours in the ED as not only time intensive challenge but also one that calls a multifaceted approach with well-coordinated resources (Miake- lye et al, 2017). The rationale of using CITiT program is informed by the fact that while other studies prior to this have researched  on how triage methods can be used to decrease WTC and essentially reduce overcrowding but also the rate of LWBS few if any bothered to explore the effectiveness of CITiT approach. The rate of LWBS in the ED happens when there is prolonged WTC due to a confluence of several factors which amongst several others include inadequate resources, increased nurse workload and overcrowding.

Changes in healthcare in the recent past like the introduction of Medicare Access and Chip Reauthorization Act of 2015, Value based purchasing (VBP) as well as the Merit Based Incentive System (MIPS) have prodded healthcare organizations to focus on operating safer ED activities that are also efficient (Sayah et al., 2014). In view of these and healthcare policy and legislations, nurses can use the Iowa Model before they implement or pilot EBP projects to have an assurance that the proposed project or program matters in healthcare today. Conventionally, choice of the Iowa Model emphasized on selecting a project that was system wide within the organization but upon insightful revision the focus was widened to have the model utilized in sub systems like the ED besides its system wide use (Sayah et al., 2014). Suffice it then to say that the use of Iowa Model will help in evaluating whether indeed there is enough evidence at the present to continue positioning a CITiT past the initial period of implementation or even the necessity of exploring alternative methods to benchmark the expected reduction of LWBS rate as a result of reduced WTC in the WTC for P2 patients in the ED (Miake-Lye et al., 2018).

Quality and Sustainability Paper Part Three - Implementation and Evaluation
Quality and Sustainability Paper Part Three – Implementation and Evaluation

Triggering Issues and Why CITiT should be a BQHH Priority

Supporting evidence from the PICOT based literature search and subsequent review established that reducing WTC in the ED, rates of LWBS and overcrowding in this area together with enhancing the declining patient satisfaction rates were priority areas for BQHH. At the system wide level, it is important to note that overcrowding is a general hospital issue which usually begins within the ED (Aaronson et al., 2015). Similarly the facility has ongoing strategies which seek to improve patient flow across the facility. For example, doctors and specialty physicians place their own orders on admitting a patient thus eliminating the bureaucracy that delayed patient movements in the past (Davenport et al., 2017). Ward supervisors and charge nurses also facilitate placement of patients throughout the hospital further easing patient flow. Viewed from the point of an ED staff the macro level measures may help in ensuring admitted patients are allocated units to free up beds in the ED more quickly, yet patient pile up also occur at a micro level within the ED at triage (Aaronson et al., 2015). The resultant overcrowding leads to extended wait times which are directly linked to death rates which are higher, compromised quality of care, increased rates of LWBS and decreased patient satisfaction as well. Subsequently, based on the PICOT Question ‘How does emergency department wait time greater than two hours compared to those less than two hours affects the rate of LWBS (leave without being seen) or patient satisfaction rate?’ the primary purpose of this quality improvement project will be to decrease WTC for P2 patients less than two hours in order to decrease rate of LWBS and simultaneously increase patience satisfaction. The EBP guided intervention is to position a clinical inter-professional team in triage during periods of high numbers and quick patient flow.

Once the PICOT question was formulated, the search strategy involved the use of various search engines. The search engines included databases like Cochrane Database for Systematic Reviews, PubMed, ProQuest, Medline and CINAHL. The key search terms were like ED overcrowding, left without being seen, prolonged wait time, ED quality indicators, team triage, nurse led and physician led triage, patient satisfaction amongst others.  The search parameters were that those meeting the inclusion criteria for review had to be scholarly journals published in English not earlier than 2014 up to 2020. Eight articles met the inclusion criteria from journals like the Journal of Emergency Nursing, Academy of Emergency Medline and the Journal of Nursing Administration all of which provided a wide, multidisciplinary of LWBS and its allied concepts dwelling on its causes, impact on patient outcomes and strategies that can lead to its reduction. In the synthesis of literature   many studies reported that LWBS affects all sizes of health facilities ranging from community hospitals, teaching and referral hospitals not just here in the US but throughout the globe (Weng, 2019). The studies also acknowledged that causes of LWBS were multiple with a commonly reported theme the numbers of patients visiting the ED continued to increase over the years.

Critical appraisal of literature also indicated that a unique approach investigating the rate of LWBS in the ED is to concentrate on the patient’s perception of WTC metrics in the ED contrasted to the actual time intervals which may help identify non-conventional ideas that would make WTC seem shorter for patients who visit the ED (Davenport et al, 2017). Along the same vein, other studies pointed out that there was a shortage of literature on definition of ED overcrowding thus necessitating the need for a tool that determines overcrowding in the EDs experience overcrowding. A main cause of increased rates of LWBS is overcrowding which emanates from communities that lack  access to primary care  with Davenport et al. (2017) dwelling on patient perspectives. The ED quality indicators  had statistics that demonstrated that WTC decreased by more than 40%  in arrival to triage time leading to a reduction in the rate of LWBS of 5%  while the actual WTC reduced by 6 minutes (Muller, Chee & Doan, 2018). Suffice it to say that studies  on team triage of which CITiT project is modified from had findings that reported using the team triage approach  had limited impact on the general ED quality indicators  while expressing optimism that the future offers room for improving team triage of which CITiT is one such example(Broccoli et al., 2018).  Researchers like Spencer et al(2019)  reaffirmed the benefits of using team triage when they found that despite paying extra wages  in hiring more staff for team triage  the costs saving accrued in a period lasting 189 days was over $ 800 000. Burstrom et al. (2017) in their study found that the introduction of a physician led- triage resulted in improved quality within the ED while Zocchi et al2015) recommended that for hospitals to improve on their ED flow the management should also consider utilizing health technologies.

Design of the CITiT program

After offering the evidence that supports the CITiT project and the subsequent synthesis of literature after a critical appraisal this subsection details the project’s design. In the first step, the project leader will identify the stakeholders and invite them to participate in the collecting relevant literature. This will be followed by an exercise targeting to amalgamate, synthesize and collect all the literature collected form the search strategy. While this is happening, all RNs in the BQHH will have to take a triage course before they can take part in the CITiT project. It is expected that the knowledge learnt will be helpful as the bias of the team triage (Silver et al., 2016). The stakeholders will comprise the project leader, the director of surgical services and injuries as well as the analyst on ED performance.  To a have truly inter professional and multi-disciplinary team that works within the ED, a doctor and a charge nurse to represent the main ED block will be included. The project leader will then extend invitations to the manager and medical director of the ED to attend the meetings.

The measurable outcomes in this project will be the average WTC measured in minutes from the time the P2 patient arrives in the ED to discharge while the rate of LWBS will be a percentage of the patients who left before the provider could attend to them (Spencer, Stephens, Swanson-Biearman, & Whiteman, 2019). IRB approval for the project will then be sought whereby the project leader will present the findings and appraisal of literature collected before the CITiT project implementation to BQHH research council where additional changes and suggestions for the implementation will be made (Smeds-Alenius et al., 2016). Having established that enough evidence exists to warrant the initialization of team triage through CITiT project, the pilot project will be launched. Baseline data in line with the average P2 patient WTC and LWBS percentage before the implementation of the project will facilitate the comparison with data once the project is completed.

This will then be followed with the formulation of the EBP CITiT project guidelines. The project leader and the principal assistant   will be joined by the ED director to review the guidelines established on a regular basis where revisions will be done if need be. In the pilot phase the team triage will have 8 hour shift of 2 days in week. At BQHH, Sunday and Monday are the days which currently have the highest number of patients visiting the ED hence the reason why the CITiT piloting will happen. The pilot shift will be scheduled to last two months with a quick ED patient arrival from 3: 00 pm to 11: 00 p.m.  Commencing on April 2, 2020 based on past higher patient counting. After completing the pilot period, the project leader will compare the average P2 patient WTC lasting more than two hours and LWBS percentages on CITiT days against those lasting less than two hours.  This project expects that WTC lasting more than 2 hours will mostly happen during the RN only triage days while those WTC with less than hours happening mostly during the CITiT days.  A review of the pre- intervention and RN only triage will be done on Sundays and Mondays from 3-11 pm. This will happen the same months a year before the piloting of CITiT. After that the EBP CITiT will undergo necessary revisions before they are integrated into full practice.

Integration and Sustaining the Practice Change

            Upon establishing that the pilot project has indeed resulted in decreased WTC for P2 patients and LWBS rates in addition to reducing overcrowding in the ED the CITiT will be implemented on a full scale basis. To get more funding to sustain the quality improvement project will require constant monitoring of the outcomes like WTC  and rates of LWBS as well as increased patient satisfaction and that of the inter-profession team staff as well (Silver et al, 2016).


In the third and last part of the quality and sustainability paper, the Iowa model has been identified as the theory that will guide the CITiT project and the outline of the project been offered. Finally, the paper has concluded by discussing the expected outcomes which are that WTC for the P2 patients will reduce to less than 2 hours, the rates of LWBS will also decrease by more than 5% and patient satisfaction will also be established for the pilot CITiT to be implemented on a full scale within the ED.


Quality and Sustainability Paper Part Three - Implementation and Evaluation
Quality and Sustainability Paper Part Three – Implementation and Evaluation



Aaronson, E. L., Marsh, R. H., Guha, M., Schuur, J. D., & Rouhani, S. A. (2015). Emergency department quality and safety indicators in resource-limited settings: an environmental survey. International journal of emergency medicine, 8(1), 39.

Davenport, P. J., O’Conner, S. J., Szychowsky, J. M., Landry, A. Y., & Hernandez, R. (2017). The relationship between emergency department wait times and inpatient satisfaction. Health Marketing Quarterly, 34(2), 97-112

Miake-Lye, I. M., O’Neill, S. M., Childers, C. P., Gibbons, M. M., Mak, S., Shanman, R. & Shekelle, P. G. (2017). Effectiveness of interventions to improve emergency department efficiency: an evidence map.

Muller, K., Chee, Z., & Doan, Q. (2018). Using nurse practitioners to optimize patient flow in a pediatric emergency department. Pediatric Emergency Care, 34(6), 396-399.

Sayah, A., Rogers, L., Devarajan, K., Kingsley-Rocker, L., & Lobon, L. F. (2014). Minimizing ED waiting times and improving patient flow and experience of care. Emergency medichttp://emergency.comine international2014.

Sharifi, S., & Saberi, K. (2014). Hospital Management Factors for better quality outcomes. Indian Journal of Fundamental and Applied Life Sciences4(2), 508-514.

Silver, S. A., McQuillan, R., Harel, Z., Weizman, A. V., Thomas, A., Nesrallah, G., & Chertow, G. M. (2016). How to sustain change and support continuous quality improvement. Clinical Journal of the American Society of Nephrology11(5), 916-924 Quality and Sustainability Paper Part Three – Implementation and Evaluation

Smeds-Alenius, L., Tishelman, C., Lindqvist, R., Runesdotter, S., & McHugh, M. D. (2016). RN assessments of excellent quality of care and patient safety are associated with significantly lower odds of 30-day inpatient mortality: a national cross-sectional study of acute-care hospitals. International journal of nursing studies61, 117-124. Quality and Sustainability Paper Part Three – Implementation and Evaluation

Spencer, S., Stephens, K., Swanson-Biearman, B., & Whiteman, K. (2019). Health care provider in triage to improve outcomes. Journal of Emergency Nursing: JEN: Official Publication of the Emergency Department Nurses Association, 1-6.

Weng, S. J., Tsai, M. C., Tsai, Y. T., Gotcher, D. F., Chen, C. H., Liu, S. C. & Kim, S. H. (2019). Improving the Efficiency of an Emergency Department Based on Activity-Relationship Diagram and Radio Frequency Identification Technology. International journal of environmental research and public health16(22), 4478.


"Looking for a Similar Assignment? Order now and Get a Discount!

Place New Order
It's Free, Fast & Safe

"Looking for a Similar Assignment? Order now and Get a Discount!

"Looking for a Similar Assignment? Order now and Get a Discount!

Get better grades effortlessly,
It’s cheaper than you might think

Effortlessly get the essays and grades you need. You can now get any essay, on any subject and at ANY deadline with just 10 minutes of your time (or less). Your professor will love you for it!