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FPX9901 Assessment 2: Quality/Performance Improvement Framework

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FPX9901 Assessment 2: Quality/Performance Improvement Framework

Quality and performance improvement (QI/PI) models assist organizations in healthcare settings

improve their operations and outcomes. The objective of this project is to resolve an identified

issue by developing a structured QI/PI framework using evidence-based models. The framework

is designed to promote measurable improvements in quality and safety by analyzing current

issues, proposing solutions, and establishing evaluation methods. The aim is to provide a strong

basis for implementing a project plan enhancing patient outcomes, compliance, and efficiency

into use.

Current Practice Needing Improvement

Imperial Health Psychiatric currently lacks a consistent medication safety procedure, which

increases medication errors and adverse drug events (ADEs).The root causes contributing to this

problem include inconsistent medication reconciliation, inadequate pharmacist engagement, and

inadequate staff training in the administration of medications. These can lead to medication

inconsistencies, presenting substantial concerns to patient safety. Recent internal audits indicate

a 20% rise in medication errors over the previous year, with 75% of patient files lacking

adequate reconciliation data. Moreover, 60% of nursing personnel expressed uncertainty about

medication administration protocols, highlighting substantial deficiencies in competence and

compliance with safety measures. Research shows that structured electronic medication

reconciliation and pharmacist-led verification can reduce medication errors by up to 50%

(Alqenae et al., 2020). However, Imperial Health Psychiatry currently lacks these standardized

practices, making it difficult to ensure consistent and accurate medication management.

The gap between current practices and the best practices is apparent in the lack of rigorous

medication reconciliation and pharmacist oversight. The organization need to implement

electronic reconciliation methods, provide staff training, and include pharmacist-led verification

processes to minimize medication errors. The lack of such metrics results in workflow

inefficiencies, increased risk of adverse drug events, and compromised patient safety. Best

practices, such as those outlined in the MATCH Toolkit (AHRQ, 2023) and IHI Medication

Safety Toolkit (IHI, 2019), emphasize these improvements. Addressing these gaps through

structured interventions will enhance medication safety, reduce preventable ADEs, and align the

organization with national patient safety standards. Implementing evidence-based solutions will

lead to better patient outcomes and improved compliance with regulatory guidelines.

QI/QP Framework that will Support and Guide the Project

Achieving a 20% reduction in medication errors within 12 weeks requires the implementation of

strategic interventions, such as standardized computerized medication reconciliation, enhanced

staff training, and more pharmacist-led verification. Enhanced patient safety and a decrease in

errors can be achieved by establishing explicit guidelines for medication reconciliation and

ensuring that staff members are proficient in administering medication. Interdisciplinary

collaboration will also improve workflow efficiency and create a culture of accountability by

promoting stronger adherence to medication safety protocols.

Regular formative assessments will point out areas requiring improvement and offer continuous

insights on the efficacy of the interventions. While pharmacist logs will check compliance with

verification systems, weekly audits of electronic health records (EHRs) will assess adherence to

medication reconciliation guidelines. Staff competency will be evaluated by utilizing the IHI

Medication Safety Toolkit to evaluate post-training evaluations and training completion records

to address knowledge gaps. Medication errors incident reports will be monitored to ascertain

whether the strategies that have been implemented are having a quantifiable effect. Research
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supports these evaluation strategies as studies show that combining pharmacist-led treatments

with the MATCH Toolkit (AHRQ, 2023) greatly lowers medication discrepancies, therefore

enhancing general patient safety (Schnipper et al., 2021).

The project will be guided by the Plan-Do-Study-Act (PDSA) framework. The PDSA

framework is a cyclical, iterative model that is employed in the healthcare sector to facilitate

continuous quality enhancement. The Plan phase is comprised of the following: the

identification of an issue, the establishment of objectives, and the development of an intervention

plan. The intervention is implemented on a limited scale during the Do phase. The analysis of

data and the evaluation of effectiveness are the methods by which outcomes are evaluated during

the Study phase. In the Act phase, the intervention is enhanced based on the outcomes and the

effective enhancements are scaled. This model encourages the adoption of data-driven decision-

making and sustainable adjustments in clinical practice.

Using the PDSA model will provide a methodical, iterative way to implement, assess, and

improve the quality improvement project. Each step of the PDSA cycle will provide a

methodical approach for resolving medication safety issues and enable required changes

depending on real-time data. Studies show how well PDSA promotes continuous improvements

in quality in healthcare settings, therefore guaranteeing that interventions stay flexible and

sustainable over time (Manandi et al., 2023). Using this model to the process of medication

reconciliation will help to encourage adherence to national patient safety standards and a data-

driven strategy to reduce medication errors and improve general healthcare outcomes.

How QI/PI Data will be Collected and Analyzed

Measuring Imperial Health's progress toward lower medication errors calls both thorough

collection of data and analysis. Medication errors rates, adherence to electronic medication
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reconciliation guidelines, pharmacist-led verification compliance, staff training completion rates,

and medication reconciliation time per patient are the main data points needed for this project.

During the 12-week implementation period, these data elements will be collected through

pharmacist logs, incident reports, staff training records, and electronic health record (EHR)

audits to monitor the efficacy of interventions.

A structured data management system in the hospital's encrypted EHR, pharmacy system, and

Learning Management System (LMS) will record and organize data collected. While

pharmacist-led verification logs will be kept to track compliance, weekly reconciliation audits

will evaluate documentation completeness. LMS documentation of staff training attendance and

competence assessments will help evaluate changes in medication safety knowledge. HIPAA-

compliant encryption and role-based access restrictions will help to preserve data security and

confidentiality, therefore guaranteeing that only authorized staff members—including the

Quality & Risk Manager, Nurse Educator, Health Informatics Specialist, and Pharmacist Lead—

have access.

The collected data will be analyzed using percentage reduction analysis for medication errors,

descriptive statistics for compliance rates, and trend analysis for adherence to reconciliation

protocols. While staff real-time comments will direct required changes, weekly comparisons of

pre- and post-intervention data will show progress. These approaches will guarantee

continuous monitoring, which will allow data-driven improvements in medication safety as well

as long-term sustainability of such improvements.

Proposed QI/PI Changes and Expected Outcomes

The proposed QI changes emphasize the use of computerized medication reconciliation,

pharmacist-led medication verification, and staff training using the IHI Medication Safety
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Toolkit. The interventions aim to decrease medication errors by 20% within 12 weeks through

the standardization of reconciliation procedures, enhancement of pharmacist engagement, and

elevation of nurse competency in the administration of medications. Essential metrics for

assessing actual improvements include weekly monitoring of medication errors rates, compliance

audits for reconciliation procedures, pharmacist verification records, staff training completion

percentages, and time efficiency in medication reconciliation. Analyzing pre- and post-

intervention data will provide insight into the implications of the changes on patient safety.

The feasibility of these interventions is further enhanced by leadership support, interdisciplinary

collaboration and integration of current EHR systems. Contextual issues, including staff

opposition to workflow changes, time limitations for training, and restricted pharmacist

availability, may provide problems. Overcoming these obstacles with targeted education,

leadership involvement, and phased implementation will improve the outcomes. Studies show

that comparable MATCH Toolkit-based initiatives have decreased medication disparities by as

much as 50% (AHRQ, 2023). Implementing these systematic improvements will improve

medication safety, ensure adherence to national standards, and establish a sustainable culture of

patient safety at Imperial Health Psychiatry.

How Changes in Quality or Performance will be Evaluated

Evaluating the efficacy of the quality improvement interventions at Imperial Health

Psychiatry will include a review of quantitative data analysis, compliance audits, and feedback

from stakeholders. The main evaluation tools are electronic health record (EHR) audits,

pharmacist verification logs, staff training assessments, and incident reports about medication

errors. Weekly assessment of medication reconciliation compliance, pharmacist participation,

and staff proficiency will provide immediate insights into the effectiveness of the interventions.
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The outcome evaluation will be dependent on key criteria, such as a 20% decrease in

medication errors within 12 weeks, 85% adherence to electronic medication reconciliation

methods, enhanced pharmacist-led verification rates, and elevated staff competence as assessed

by post-training assessments. The efficiency of the workflow will be evaluated by monitoring the

duration required to complete medication reconciliation. Continuous stakeholder feedback from

nurses, pharmacists, and administrators will provide essential adjustments, which

will promote the long-term sustainability of medication safety improvements.