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Quality Improvement Plan
Bachelor of Science in Health Information Management
Christian Caldwell
05/18/2026
A.
,To initiate a successful QI project at this facility, we must shift staff away
from subjective frustrations toward an objective, data-driven approach.
, Some steps Lauren should take include initiating the project and forming a
team. The team should include representatives from every touchpoint of the
problem, including physical, occupational, and speech therapists;
transporters; nursing staff; and nursing aides. The team needs a clear,
unified understanding of the issue.
The next step is to collect data. Lauren accurately recognized that the
current complaints are highly subjective. To frame out a strategy, she must
gather hard data to determine exactly where the system is breaking down.
The team should map the exact workflow of a patient getting to therapy.
This includes the time the Transporter is dispatched, the time they arrive at
the unit, the time required for nurses' aides to prepare the patient, and the
actual arrival time in the rehab department.
The final step would be to perform a root cause analysis. Once baseline data
is collected, Lauren can lead the team in identifying the root cause and
developing solutions.
A1.
Some areas Lauren is facing are a systemic breakdown that impacts
operations, clinical care, and staff relations.
a.
To successfully transition her team away from the highly subjective
frustrations currently driving the conflict, Lauren must gather both
quantitative and qualitative data. Quantitative data is measurable,
numerical, and objective. This will be the backbone of Lauren's report,
proving whether and how often the problem occurs and quantifying its
financial and clinical impact. Qualitative data is descriptive and
observational. While quantitative data tells Lauren what is happening,
qualitative data tells her why it is happening. It provides context to the
numbers.
b.
For Lauren to gather Quantitative data, she will need the exact variance
between when a patient is scheduled for therapy, when the Transporter
arrives, when the patient is ready, and when the patient arrives at rehab.
Lauren will also need the actual duration of the therapy sessions to
determine whether they meet the 45–60-minute standard. Lauren can
obtain this information from the EHR and scheduling software; these