Western Governors University
, D159: Evidence-Based Measures for Evaluating Healthcare Improvements
Project Reports
In collaboration with the project team, the team decided on three data elements that
would help with the success of the Healthcare Improvement Project (HIP). The three data
elements are (1) the number of patients that cancel surgery for the month/the number of patients
scheduled for the month, (2) reasons for the surgical cancellations, and (3) all staff are educated
on the new process using a competency checklist.
The first data element is gathering the number of patients who cancel surgery per month
and the number of patients scheduled for surgery for the month. The project manager will work
with the clinic staff and hospital schedulers to receive the cancellations by email in a template
format so that all the information needed for the HIP is appropriate. The email information will
be placed into a spreadsheet that will be kept up to date and reviewed weekly. At the end of the
month, the surgical report will be pulled to show how many surgeries we had scheduled so that
the project manager can calculate the percentage of cancellations. This data element is essential
to the HIP because it will give the foundation in which the team will know if the improvements
being made are working. It provides us with the percentage of cancellations per month.
The second data element is gathering the reasons for cancellations. The project manager
will work with the clinic staff, hospital schedulers, the preadmission testing nurses, and the pre-
operative nurses, as they are sometimes the ones to receive the reasons for the cancellations. The
project manager will collect this data in the same email format as the surgical cancellations. The
template allows for a space for the reason to be documented. The reason for surgical
cancellations will be placed in the spreadsheet and reviewed weekly. At the end of the month, the