NURS FPX 6016 Assessment 2

NURS FPX 6016 Assessment 2

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

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Determining the success rate of programs intended to raise the bar for the treatment of patients and operations in healthcare is the evaluation of efforts to improve quality in the healthcare industry. The approach of identifying areas for improvement involves the systematic observation of and assessment of critical performance metrics, including efficiency, safety, and patient outcomes. By taking advantage of data-driven assessments and feedback, healthcare organizations may make improvements to their methods, implement treatments based on research, and monitor their progress over time. By providing a more secure, successful, and efficient treatment, this iterative method guarantees that healthcare treatments are constantly enhanced to meet the highest quality standards (Backhouse & Ogunlayi, 2020). This assessment’s fundamental objective is to examine quality-improvement strategies aimed at solving healthcare-related challenges.

Quality Improvement Initiative

St. Mary’s Hospital is currently using a quality improvement effort to enhance the safety of patients as well as minimize medication errors. In this pursuit, two widely recognized approaches for improving hospital quality—Lean and Six Sigma—are used (Rathi et al., 2021). Lean procedure, which emphasizes efficiency and waste reduction, is being used to boost the delivery of medication. The hospital meticulously examines each step of this procedure, spots any bottlenecks, and cuts any unnecessary motion. Using barcode technology to scan prescription drugs and link them with patient identities is a critical first step in reducing prescription errors. In order to enhance communication and minimize miscommunications among medical workers, visual management technologies such as Kanban boards are also being used to track prescription orders and administration schedules (Muscad, 2023).

NURS FPX 6016 Assessment 2 Quality Improvement Initiative Evaluation

Conversely, the Six Sigma methodology places a high emphasis on making decisions based on data and using precise problem-solving techniques. In order to minimize prescription errors, St. Mary’s Hospital is using Six Sigma methods by conducting extensive Root Cause Analyses (RCA). These evaluations go completely into the underlying issues, which may include insufficient training, poor communication, or structural flaws. Following identifying the underlying issues, Six Sigma’s DMAIC (Define, Measure, Analyze, Improve, Control) methodology is used to develop and implement solutions. For example, improving the accuracy of medication prescriptions might include modernizing and supporting training programs.

Overall, the Lean and Six Sigma approaches used by St. Mary’s Hospital’s quality improvement program demonstrate a commitment to improving patient safety by streamlining medication delivery processes and addressing root causes of errors. It is expected that this comprehensive approach would improve healthcare outcomes as well as offer a more secure environment for patients.

  • Knowledge Gaps, Missing Information, and Areas of Uncertainty

There are a lot of unanticipated events and knowledge gaps in the improvement of the quality initiative at St. Mary’s Hospital. First off, since the program only quantifies the extent of prescription errors after the initiative, it is difficult for one to assess its effectiveness. It is also problematic for us to monitor the program’s advancement since we have yet to determine when these adjustments will be implemented. The project’s sources of financing should be mentioned in the piece, which might have an impact on how long it is available. Other information about the exact outcomes attained and any unexpected difficulties encountered during the implementation procedure would enhance the assessment of the initiative’s overall impact.

National State and Accreditation Benchmarks

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Patient safety and the productivity of the systems for delivering drugs have both improved at St. Mary’s Hospital as a result of the Quality Improvement Program. We could assess the effectiveness of nationally recognized standards and outcome measurements from the US medical system. One of the most crucial indicators of a project’s success is patient safety, which has been closely monitored by two nationally recognized organizations, the Agency for Healthcare Research and Quality (AHRQ) and the Leapfrog Group (Gangopadhyaya et al., 2023). Since the Lean method has been used to streamline drug distribution processes, there has likely been a reduction in errors related to drugs. This project aims to decrease reported incidents related to medication delivery, and AHRQ’s dedication to improving safeguards for patients is in line with the goal at hand.
The concentration on data-driven decisions and solutions in the Six Sigma methodology is also connected to national quality improvement criteria. Monitoring the incidence of medication errors over time allows one to gauge the effectiveness with which the Six Sigma project employed DMAIC-based solutions and conducted Root Cause Analysis (RCA). The program’s noteworthy glory, as per the norms set by accrediting bodies such as The Joint Commission, is the reduction of mistakes and continuous process improvement (Wadhwa & Huynh, 2023).
Additionally, the HIMSS criteria for improving drug distribution processes via technology are complied with while employing barcode scanning instruments and visual monitoring devices. Success in this area may be defined as tracking drug administration accuracy, evaluating the efficacy of physician-to-physician interactions, and seeing greater adherence to medication distribution schedules (Sulkers et al., 2018).
In summary, since the St. Mary’s Hospital Quality Improvement Initiative conforms to generally accepted national standards and outcome indicators, it is headed in the right direction. By focusing on patient safety, lowering pharmaceutical errors, and improving medication administration methods, the initiative displays a desire to deliver top-notch medical treatments that meet or exceed the expectations set by government and accrediting authorities in the USA. Regular monitoring and assessment of the above benchmarks and indicators of results will be required to ensure the program’s lasting effectiveness.

  • Underlying Assumptions

The St. Mary’s Hospital Quality Improvement Initiative research advances the belief that using technologies alongside Six Sigma and Lean methodologies would greatly reduce prescription errors and improve patient safety. Additionally, it is assumed that these methods will enhance healthcare workers’ coordination and teamwork. The research project also claims that training materials can be updated effectively to improve prescribing accuracy. Finally, the established benchmarks and result metrics provide as trustworthy indicators of the initiative’s achievement and compliance with international and national standards.

Inter-professional Perspectives and Actions

NURS FPX 6016 Assessment 2 Inter-professional Perspectives and Actions

For the reason for the St. Mary’s Hospital quality improvement project to function with greater effectiveness and provide positive outcomes, interprofessional opinions, and actions are crucial. Under the Lean procedure, which emphasizes performance and eliminating mistakes, working together among nurses, pharmacists, and executives would be important (Waszyk-Nowaczyk et al., 2022). Teams of experts are able to assess the medicine supply chain, spot obstacles, and terminate redundant duties. With the aid of pharmacy and nursing staff, barcode scanning technology could drastically decrease medication errors by ensuring accurate patient identification (Barakat & Franklin, 2020). Visual management responses, such as Kanban boards and other similar systems, may enhance teamwork and communication and reduce the probability of miscommunications and misunderstandings when used by the whole team (Muscad, 2023).

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For the Six Sigma technique to effectively enhance processes and enable data-driven choice-making, interprofessional collaboration is essential (McDermott et al., 2022). A root-cause analysis, or RCA, that incorporates feedback from several healthcare professionals may identify the main root causes of pharmaceutical errors, such as poor training or communication breakdowns. Collaborative groups of professionals may then use the DMAIC paradigm from Six Sigma to develop and implement solutions. For example, physicians, pharmacists, and educators might work collectively to enhance educational efforts, guaranteeing that medical personnel are well-versed in and proficient in administering medicines (Dilles et al., 2021).

  • Knowledge Gaps

Investigating deeply and completing knowledge discrepancies may aid in our understanding of the St. Mary’s Hospital Quality Improvement Initiative. Part of this is revealing the specific Lean and Six Sigma approaches being used as well as the expected results. In order to bring about any alteration, data about drug mistake rates and the efficiency of interprofessional collaboration must be gathered. For a comprehensive evaluation of the initiative’s performance, it would be very helpful to know the resources allocated for educational programs and the feedback mechanisms implemented for continued enhancement.

Indicators and Protocols

To raise the quality of the program results at St. Mary’s Hospital, we suggest using additional measurements and practices that are in line with Lean and Six Sigma principles. In the beginning, a measurable assessment of progress over time would be possible with the use of KPIs of medication mistakes, such as the Medication Error Rate и Medication Error severity rating (Rosdia, 2021). To ensure that progress is being achieved and to identify areas that need more focused effort, these KPIs may be frequently monitored (May Hassan ElLithy et al., 2023).

In addition, the hospital may implement an exhaustive incident reporting mechanism that would enable healthcare professionals to record drug errors and near misses without worrying about facing reprisals. The environment of transparency may facilitate a proactive approach to error prevention by helping to spot issues before they cause detriment to patients (Mutair et al., 2021). Thirdly, St. Mary’s Hospital may benefit via a comprehensive Continuous Quality Improvement (CQI) program aimed at encouraging ongoing observation and evaluation of practices related to pharmaceutical distribution. Periodic CQI meetings allow interdisciplinary teams to review data, identify trends, and swiftly implement corrective actions to guarantee long-lasting gains (O’Donnell & Gupta, 2020).

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To inspire a culture of ongoing growth and development, the hospital should also invest in the healthcare personnel’s education and training programs. By taking part in frequent competency assessments and ongoing education connected to best practices and the most relevant pharmaceutical safety study, staff members may stay up on the latest developments and be productive in their roles. Including these other uses and practices will make the quality program simpler to implement, lead to fewer prescription errors, and ultimately enhance the protection of patients at St. Mary’s Hospital (Schenk, 2023).

Pros and Cons of the Recommendations

The suggestions that have been provided for bettering St. Mary’s Hospital’s quality program contain benefits and drawbacks. On a positive note, measuring progress while recognizing areas for improvement is made easier when key performance indicators, or KPIs, are used. This method based on data empowers the hospital to allocate resources successfully and to make informed decisions (Insightsoftware, 2023). By attracting attention to near-misses, an incident reporting mechanism may promote transparency and aid in preventing errors. To ensure that improvements are sustained over time, continuous quality enhancement ( CQI ) meetings facilitate the evaluation and resolution of faults as they emerge (Yang & Liu, 2021). Finally, funding for training and education increases employee competency and enhances patient safety (Lacerenza et al., 2018).

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However, there can be negatives to consider. Medical personnel may unknowingly feel under pressure to meet targets as a result of the focus on KPIs, which might lead to underreporting of incidents or a preference for quantity over quality. The accident reporting system is helpful, but if it needs to be established with staff concerns about responsibility and consequences in mind, it may encounter resistance. Attending CQI meetings may take time, diverting resources away from direct patient care. In a busy hospital environment, delivering training programs may be difficult due to their high cost and the need for staff time for instruction. A thorough plan and effective communication are needed to reduce these potential drawbacks and ensure the success of the quality program’s execution (Farra et al., 2019).


In order to broaden its patient safety, the St. Mary’s Hospital quality enhancement program research by highlighting the need for data-driven techniques, transparency, regular evaluation, and staff training. The positive effects of fewer medication errors and higher levels of care far outweigh any potential drawbacks or problems. St. Mary’s Hospital is prepared to provide enhanced outcomes for patients and higher standards of care by taking these suggestions to heart and making an ongoing dedication to continuous enhancement.


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Barakat, S., & Franklin, B. D. (2020). An evaluation of the impact of barcode patient and medication scanning on nursing workflow at a UK teaching hospital. Pharmacy, 8(3), 148.

Dilles, T., Heczkova, J., Tziaferi, S., Helgesen, A. K., Grøndahl, V. A., Van Rompaey, B., Sino, C. G., & Jordan, S. (2021). Nurses and pharmaceutical care: Interprofessional, evidence-based working to improve patient care and outcomes. International Journal of Environmental Research and Public Health, 18(11), 5973.

Farra, S. L., Gneuhs, M., Hodgson, E., Kawosa, B., Miller, E. T., Simon, A., Timm, N., & Hausfeld, J. (2019). Comparative cost of virtual reality training and live exercises for training hospital workers for evacuation. Computers, Informatics, Nursing: CIN, 37(9), 446–454.

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Lacerenza, C. N., Marlow, S. L., Tannenbaum, S. I., & Salas, E. (2018). Team development interventions: Evidence-based approaches for improving teamwork. American Psychologist, 73(4), 517–531.

May Hassan ElLithy, Salah, H., Lamyaa Samir Abdelghani, Assar, W., & Corbally, M. (2023). Benchmarking of medication incidents reporting and medication error rates in a JCI Accredited University Teaching Hospital at a GCC Country. Saudi Pharmaceutical Journal, 31(9), 101726–101726.

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O’Donnell, B., & Gupta, V. (2020). Continuous Quality Improvement. PubMed; StatPearls Publishing.

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