NURSING EDUCATION FIELD EXPERIENCE

QUALITY IMPROVEMENT FORM ;

NCQA Quality Improvement Activity Form (an electronic version is available on NCQA’s Web site)
Activity Name:
Section I: Activity Selection and Methodology
A.    Rationale. Use objective information (data) to explain your rationale for why this activity is important to members or practitioners and why there is an

opportunity for improvement.

B.    Quantifiable Measures. List and define all quantifiable measures used in this activity. Include a goal or benchmark for each measure. If a goal was

established,
list it. If you list a benchmark, state the source. Add sections for additional quantifiable measures as needed.
Quantifiable Measure #1:     Team Cohesiveness

QUALITY IMPROVEMENT FORM
NCQA Quality Improvement Activity Form (an electronic version is available on NCQA’s Web site)
Activity Name:
Section I: Activity Selection and Methodology
A.    Rationale. Use objective information (data) to explain your rationale for why this activity is important to members or practitioners and why there is an

opportunity for improvement.

B.    Quantifiable Measures. List and define all quantifiable measures used in this activity. Include a goal or benchmark for each measure. If a goal was

established,
list it. If you list a benchmark, state the source. Add sections for additional quantifiable measures as needed.
Quantifiable Measure #1:     Team Cohesiveness
Numerator:
Denominator:
First measurement period dates:
Baseline Benchmark:
Source of benchmark:
Baseline goal:

Quantifiable Measure #2:    Safe Staffing (mainly in the Constant Care Unit [CCU])
Numerator:
Denominator:
First measurement period dates:
Benchmark:
Source of benchmark:
Baseline goal:
Quantifiable Measure #3:     Staff Retention
Numerator:
Denominator:
First measurement period dates:
Benchmark:
Source of benchmark:
Baseline goal:
C.    Baseline Methodology.

C.1    Data Sources.
[    ] Medical/treatment records
[    ] Administrative data:
[    ] Claims/encounter data    [    ] Complaints    [    ] Appeals    [    ] Telephone service data     [    ] Appointment/access data
[    ] Hybrid (medical/treatment records and administrative)
[    ] Pharmacy data
[    ] Survey data (attach the survey tool and the complete survey protocol)
[    ] Other (list and describe):
_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

C.2    Data Collection Methodology. Check all that applies and enter the measure number from Section B next to the appropriate methodology.
If medical/treatment records, check below:
[    ] Medical/treatment record abstraction
If survey, check all that apply:
[    ] Personal interview
[    ] Mail
[    ] Phone with CATI script
[    ] Phone with IVR
[    ] Internet
[    ] Incentive provided
[    ] Other (list and describe):
_______________________________________________
_______________________________________________    If administrative, check all that apply:
[    ] Programmed pull from claims/encounter files of all eligible members
[    ] Programmed pull from claims/encounter files of a sample of members
[    ] Complaint/appeal data by reason codes
[    ] Pharmacy data
[    ] Delegated entity data
[    ] Vendor file
[    ] Automated response time file from call center
[    ] Appointment/access data
[    ] Other (list and describe):
_________________________________________________________________
_________________________________________________________________

C.3    Sampling. If sampling was used, provide the following information.
Measure    Sample Size    Population    Method for Determining Size (describe)    Sampling Method (describe)

C.4    Data Collection Cycle.
Data Analysis Cycle.
[    ] Once a year
[    ] Twice a year
[    ] Once a season
[    ] Once a quarter
[    ] Once a month
[    ] Once a week
[    ] Once a day
[    ] Continuous
[    ] Other (list and describe):
_________________________________________________________
_________________________________________________________    [    ] Once a year
[    ] Once a season
[    ] Once a quarter
[    ] Once a month
[    ] Continuous
[    ] Other (list and describe):
_________________________________________________________
_________________________________________________________
C.5    Other Pertinent Methodological Features. Complete only if needed.

D.    Changes to Baseline Methodology. Describe any changes in methodology from measurement to measurement.
Include, as appropriate:
•    Measure and time period covered
•    Type of change
•    Rationale for change
•    Changes in sampling methodology, including changes in sample size, method for determining size and sampling method
•    Any introduction of bias that could affect the results
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

Section II: Data / Results Table
Complete for each quantifiable measure; add additional sections as needed.
#1 Quantifiable Measure: Team Cohesiveness
Time Period
Measurement Covers
Measurement
Numerator
Denominator    Rate or Results    Comparison Benchmark    Comparison
Goal    Statistical Test and Significance*
Baseline:
Remeasurement 1:
Remeasurement 2:
Remeasurement 3:
Remeasurement 4:
Remeasurement 5:
#2 Quantifiable Measure: Safe Staffing
Time Period
Measurement Covers
Measurement
Numerator
Denominator    Rate or Results    Comparison Benchmark    Comparison
Goal    Statistical Test and Significance*
Baseline:
Remeasurement 1:
Remeasurement 2:
Remeasurement 3:
Remeasurement 4:
Remeasurement 5:
#3 Quantifiable Measure: Staff Retention
Time Period
Measurement Covers
Measurement
Numerator
Denominator    Rate or Results    Comparison Benchmark    Comparison
Goal    Statistical Test and Significance*
Baseline:
Remeasurement 1:
Remeasurement 2:
Remeasurement 3:
Remeasurement 4:
Remeasurement 5:
*    If used, specify the test, p value, and specific measurements (e.g., baseline to remeasurement #1, remeasurement #1 to remeasurement #2, etc., or baseline to

final remeasurement) included in the calculations. NCQA does not require statistical testing.
Section III: Analysis Cycle
Complete this section for EACH analysis cycle presented.
A.    Time Period and Measures That Analysis Covers.

B.    Analysis and Identification of Opportunities for Improvement. Describe the analysis and include the points listed below.
B.1  For the quantitative analysis, include the analysis of the following:
•    Comparison with the goal/benchmark
•    Reasons for changes to goals
•    If benchmarks changed since baseline, list source and date of changes
•    Comparison with previous measurements
•    Trends, increases or decreases in performance or changes in statistical significance (if used)
•    Impact of any methodological changes that could impact the results
•    For a survey, include the overall response rate and the implications of the survey response rate

B.2  For the qualitative analysis, describe any analysis that identifies causes for less than desired performance (barrier/causal analysis) and include the following:
•    Techniques and data (if used) in the analysis
•    Expertise (e.g., titles; knowledge of subject matter) of the work group or committees conducting the analysis
•    Citations from literature identifying barriers (if any)
•    Barriers/opportunities identified through the analysis
•    Impact of interventions

Section IV: Interventions Table
Interventions Taken for Improvement as a Result of Analysis. List chronologically the interventions that have had the most impact on improving the measure. Describe

only the interventions and provide quantitative details whenever possible (e.g., “hired 4 UM nurses” as opposed to “hired UM nurses”). Do not include intervention

planning activities.
Date Implemented (MM / YY)    Check if
Ongoing

Interventions

Barriers That Interventions Address

Section V: Chart or Graph (Optional)Attach a chart or graph for any activity having more than two measurement periods that shows the relationship between the timing of

the intervention (cause) and the result of the remeasurements (effect). Present one graph for each measure unless the measures are closely correlated, such as average

speed of answer and call abandonment rate. Control charts are not required, but are helpful in demonstrating the stability of the measure over time or after the

implementation.

Advanced Nursing Practice Field Experience
Change Investigation Proposal Form
Provide a brief description of the change you will investigate and your plans for the investigation.

1. Brief description of the change you will be investigating:

Safe staffing in the Constant Care Unit (CCU), team integration/cohesiveness and staff retention are the subjects I will be investigating.  In the current setting, CCU

is separated from the Medical Surgical floor and this seems to cause a rift between the two units working together, consistently and cohesively.  Some of this is from

past behaviors of seasoned staff and some may be attributed to the separation of the two units.  It is believed that bringing the two units together will increase the

cohesiveness of staff, which will, in turn, will increase the safety factor of staffing and lead to staff retention.

2. Proposed process for conducting the investigation:

Talking with management, house supervisors and staff members, both seasoned and new, to gain an insight on what they have observed.  Also, to ask for their

solutions to this problem.  The information will then be gathered and reviewed as to the validity of said proposals, as well as, comments garnered.

The proposal above is approved by:

Change Leader Signature     Print Name    Title/Organization
E-mail Address     Contact Telephone Number     Date

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