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Thinking about the goals and timeline you developed in Module Six (module six attached)and considering major challenges in healthcare and how they can be improved, identify a patient safety or a patient quality issue (such as falls, infections, interdepartmental communications, etc.) and use the Plan-Do-Study/Check-Act (PDSA/CA) tool to describe the steps you would take for the issue you identified. Write your PDSA/CA cycle in narrative format using the Module Seven Short Paper Template. (Template attached)

Guidelines for Submission: Your short paper should be a submitted as a 3- to 4-page Microsoft Word document (in addition to title and reference pages) with double spacing, 12-point Times New Roman font, one-inch margins, and sources cited in APA format.



[Note: To complete this template, replace the bracketed text with your own content. Remove this note before you submit your paper.]

PDSA/CA Cycle for Quality Improvement [Process or Issue You Plan to Improve]

[Your Name]

Nursing, Southern New Hampshire University

IHP 604 Healthcare Quality Improvement



[Title of the Paper]: PDSA/CA Cycle

[Introduce your project. Include the following: (1) the purpose of a PDSA, (2) the context of the patient safety issue or quality issue (state the issue and the significance of the issue), and (3) the goal(s) and timeline (which you identified in the Module Six assignment).]


[The plan is a detailed description of the issue you have identified including history, data, and a narrative (explanation) as to why it is an issue.]

Brief Literature Review

[What does the literature say about your topic? Scholarly literature, process improvement papers, and research papers are necessary to validate the need for your process plan. What interventions have been attempted? Expect this part of the assignment to take at least one page.]

Recommended Actions

[How will your plan improve the process? Include in your plan the details of team building and the committees necessary. How will you collect the data?]


[This section is about the pilot. How and where did you implement your pilot plan? Include your pilot area/location for the intervention. Discuss the data collected. What is your timeframe? Plan in terms of months, quarters, or years. Do not present dates and times.]


[What does the data tell you? What was successful, and what additional challenges if any were encountered? Discuss the details. How did you/could you validate the data/results? Was the intervention successful? Why? Was the intervention not successful? Why?]


[Then what is the next step? Changes, adjustments to the plan that need to be implemented. If successful, how will you disseminate the results and implement the intervention across the organization or unit?]


[Proper APA formatting for all references and citation is required.]


Process-Improvement Goal Setting

Luz Rodriguez

Southern New Hampshire University

Process-Improvement Goal Setting

Accent Care, Inc. is an institution that offers healthcare services in the US. Specifically, it offers hospice care, personal care, facility staffing, skilled nursing, and home health services. Accent Care has approximately 24 000 employees in more than 165 offices who work diligently to enhance the quality of living of its clients (Accent Care, 2020). This paper evaluates the accreditation report of Accent Care to identify recommendations that will enhance the current level of the institution’s safety.

The accreditation report is dated June 8 2019 and focuses on Accent Care’s ability to offer quality and safe home care services. Five safety goals were evaluated. The first safety goal is how the institution improves its patient identification accuracy. The Joint Commission requires organizations to utilize two patient identifiers to enhance patient identification accuracy. Second, there is the improvement of the safety of the utilization of medication. The Joint Commission advises that organizations should reconcile medication information. Third, there is the goal of lowering the risk of any healthcare-related infections. The Joint Commission requires organizations to meet strict hand hygiene guidelines (The Joint Commission, 2019). Fourth, there is the goal of lowering the risk of clients harming themselves due to falling down. The Joint Commission advises organizations to have a working fall reduction program. Finally, there is the goal that requires the institution to point out the safety risks, which identify with its target patient population. The Joint Commission requires organizations to reveal risks that are tied to home oxygen.

In all these five categories, The Joint Commission (2019) came up with the conclusion that Accent Care adhered to all the relevant guidelines it requires of healthcare institutions, which offer home-based care. Accent Care met all the National Patient Safety Gals, which The Joint Commission. (2019) has established. Consequently, The Joint Commission (2019) accredited Accent Care to offer home care in New York.

Based on the results of this accreditation report, it is clear that Accent Care I an institution that offers high-quality home care services. Its accreditation implies that it meets the bare minimum standards developed by The Joint Commission (2019). Nevertheless, regardless of how good an institution is, there is always room for improvement. In this regard, the table below reveals three goals that address recommendations to enhance quality at the organization.

Table 1: Three goals that address recommendations to enhance quality at Accent Care

Technology Issues1. Physiological monitoring: The institution should have active home telemonitoring services, which can remotely monitor the client’s vital signs (National Academies Press, 2015). This ensures that the primary physician knows how the client is progressing without having to be in the same physical location.2. Sensory and Cognitive Activity: Use of active technologies to come up with reminders and alerts for the automatic dispensation of medication.Commencement:Beginning of a client’s home-based care periodCompletion:The end of a client’s home-based care period
Process Improvement1. Creation of customized care: Care should be patient-focused where a client takes part in the formulation of his/her treatment and care program (IISE, 2015).2. Culture competency: Workers should be trained on culture-competent care to ensure they are well equipped to offer services that are aligned with the culture-related needs of their patients.Commencement:Beginning of a client’s home-based care periodCompletion:The end of a client’s home-based care period
Performance Improvement1. Analysis of data and outcomes: There should be a comprehensive review of the treatment progress of each client. The objective is to measure how well the client’s needs were met with the intent of identifying any weaknesses to eradicate.2. Appraisal of Employees: Employees should give regular feedback on their job-related experiences to collaboratively identify challenges and formulate recommendations on how to deal with them.Commencement:Beginning of a client’s home-based care periodCompletion:The end of a client’s home-based care period.


Accent Care. (2020). An accent on exceptional care. Accent Care. https://accentcare.com/about/

IISE. (2015, December 30). Healthcare systems process improvement conference – Denis A. Cortese – Cerner tech talk. [Video] YouTube. https://www.youtube.com/watch?v=nKa9NyCGGxw%29

National Academies Press. (2015, August 4). The future of home health care: Workshop summary. NCBI. https://www.ncbi.nlm.nih.gov/books/NBK315926/

The Joint Commission. (2019, June 8). Accreditation quality report: Accent Care of New York, Inc. The Joint Commission. apps.jointcommission.org/QualityCheckHistory/pdfgen.aspx?hcoid=103952&x=pdf&yr=2019&ver=1&hst=Y