Tiff week 7

Assignment KTA Part 3: Evaluation Measures

Instructions

Utilize the template attached to provide responses to each prompt. Please do not include a cover/title page for the assignment.

NU 700 Assignment: Unit 7 – KTA Part 3 Evaluation Measures

Instructions: Utilize the template to provide responses to each prompt. Please do not include a cover/title page for the assignment.

NAME OF

STUDENT:

Part 1: Questions

Questions: Type Answers in the Spaces below
1. Describe the practice problem you

identified for the Unit 4 assignment
(with in-text citation)

2. Provide a brief overview of the alternate
intervention you identified for the Unit 5
assignment (with in-text citations)

3. Provide a succinct Aim Statement for the
improvement process you would launch
for implementing your identified
alternate intervention. Use the link below
to access IHI Worksheet to guide
creation of this succinct (one line)
statement.
https://www.ihi.org/sites/default/files/2023-
11/IHITool_Aim-Statement-Worksheet

4. Discuss who will be involved in the
improvement process, and why. Utilize a
minimum of one resource to support this
discussion (in-text citation).

5. What measure(s) will you utilize to
evaluate the outcome of implementing
your identified alternate intervention?
Provide a rationale why you
selected/identified the measure(s). Use

https://www.ihi.org/sites/default/files/2023-11/IHITool_Aim-Statement-Worksheet

the link below to access IHI’s resource on
Improvement Measures.
https://www.ihi.org/how-improve-model-
improvement-establishing-measures

6. What is your desired outcome from
implementing your alternate
intervention?

Part 2: APA Reference List

Please provide a minimum of 3 APA references that correspond with citations within the table. Use APA format.

References

https://www.ihi.org/how-improve-model-improvement-establishing-measures

Unit 3: Scholarship of Application Part 1: Aim Statement and

Framework

Tiffany Williams

Herzing University

NU760-8H

3/22/202

Unit 3: Scholarship of Application Part 1: Aim Statement and Framework

Gap recognition and filling in providing care are important to improving patient

outcomes and staying compliant with evidence-based practice. The paper outlines a practice

problem recognized in a clinical environment, formulates a problem statement, builds an aim

statement, and names a framework that will be employed in creating a scholarly project to

address the problem.

Practice Setting and Population

The practice setting is a primary care clinic with an adult patient population of 18 years

and older. The clinic provides preventive care, chronic disease management, and acute care. The

population consists of people from various socioeconomic statuses, with a high proportion of

them being underserved and at risk for chronic diseases such as hypertension, diabetes, and

cardiovascular disease. Despite evidence-based guidelines for preventive care, a conspicuous

lack of uniform implementation of recommended screenings and interventions is observed.

Description of the Problem

The identified issue is the uneven application of United States Preventive Services Task

Force (USPSTF) preventive screening guidelines, specifically cardiovascular risk factors for

illness such as hypertension and hyperlipidemia (Barry et al., 2023). Chart review and

observations revealed that the majority of patients with the routine screening due are not being

screened on time in reality. Clinic performance indicators also confirm this deficiency, where

65% of eligible patients for indicated screenings are receiving them only, falling short of the

organization’s goal of 90%.

Failure to screen per guidelines has various implications. Firstly, to delay earlier illness

diagnosis that would otherwise be better treated through intervention earlier in the disease

development process. Secondly, to develop avoidable complications like a heart attack or stroke,

which would otherwise have been avoided by earlier identification and treatment. Thirdly,

evidence-based care shortfall has been established, one of the indicators for quality health care.

Problem Statement

Processes of patient evaluation in the primary care clinic have not been consistent in

adhering to USPSTF guidelines for preventive screening until now. This results in premature

diagnosis of cardiovascular risk factors, which means unhealthy consequences that otherwise

would have been averted if there was timely intervention.

Aim Statement

This project aims to increase follow-through with USPSTF recommendations for

preventive screening, specifically cardiovascular disease risk factors, to 90% from 65% in a six-

month period. This will be achieved by having a standardized screening process, educating staff

on evidence-based recommendations, and reminders in the electronic health record system to

trigger providers at the point of patient visits.

Framework

The model to implement with this project is the Plan-Do-Study-Act (PDSA) cycle, an

Institute for Healthcare Improvement (IHI) quality improvement model. The PDSA cycle is a

rigorous cycle of testing and implementing changes at an organizational level (Roberti et al.,

2025). The PDSA cycle contains four steps:

1. Plan: Identify the problem, establish goals, and prepare for change.

2. Do: Implement the change at a trim level.

3. Study: Compare results and determine if improvement was a consequence of the

change.

4. Act: Simplify the change from the result and implement it on an expanded scale.

PDSA cycling is suitable for this project because it allows incremental testing of

interventions such as the protocolized screening process and EHR reminders before large-scale

implementation. It also addresses the project goal of quantitatively measuring improved

screening rates. For example, at the “Plan” phase, the protocol for screening and EHR reminder

design will be developed by the team. At the “Do” phase, the interventions will be pilot-tested

with a small number of providers. The “Study” phase will entail screening rate monitoring and

provider feedback collection, and the “Act” phase will entail scaling up proven interventions.

Conclusion

The inconsistent compliance with USPSTF guidelines for preventive screening within the

primary clinic is a grave evidence-based practice deficit. By developing an obvious problem

statement, formulating an aim statement concisely, and employing the PDSA cycle as an

orienting framework, this project proposes to enhance screening rates and ultimately enhance

patient outcomes. The structured process of the PDSA cycle ensures interventions are tested,

refined, and implemented in such a way as to maximize their effectiveness and sustainability.

References

Barry, M. J., Wolff, T. A., Pbert, L., Davidson, K. W., Fan, T. M., Krist, A. H., … & Nicholson,

W. K. (2023). Putting evidence into practice: an update on the US Preventive Services

Task Force methods for developing recommendations for preventive services. The Annals

of Family Medicine, 21(2), 165-171.

https://www.annfammed.org/content/annalsfm/21/2/165.full

Roberti, J., Jorro-Barón, F., Ini, N., Guglielmino, M., Rodríguez, A. P., Echave, C., … & Alonso,

J. P. (2025). Improving Antibiotic Use in Argentine Pediatric Hospitals: A Process

Evaluation Using Normalization Process Theory. Pediatric Quality & Safety, 10(1), e788.

https://journals.lww.com/pqs/_layouts/15/oaks.journals/downloadpdf.aspx?an=01949578-

202501000-00010

https://www.annfammed.org/content/annalsfm/21/2/165.full

https://journals.lww.com/pqs/_layouts/15/oaks.journals/downloadpdf.aspx?an=01949578-202501000-00010

Enhancing Compliance with USPSTF Preventive Screening Guidelines
Student’s name
Course
Instructor’s name
Date

Problem Statement and Aim Statement
Problem Statement:
Inconsistent adherence to USPSTF guidelines for cardiovascular risk factor screenings in a primary care clinic.
Leads to delayed diagnoses and preventable complications (e.g., stroke, heart attack).
Aim Statement:
Increase compliance with USPSTF screening recommendations from 65% to 90% within six months.
Interventions: Standardized screening protocols, staff education, and EHR reminders.

The problem stems from a gap in evidence-based practice, where only 65% of eligible patients receive timely screenings for cardiovascular risk factors like hypertension and hyperlipidemia (Barry et al., 2023). This non-compliance exacerbates health disparities, particularly among underserved populations. The aim statement targets a 25% improvement by integrating systematic interventions. Standardized protocols will reduce variability in provider practices, while EHR reminders will address forgetfulness during patient visits. Staff education ensures alignment with USPSTF guidelines, fostering a culture of accountability. This approach aligns with the Institute for Healthcare Improvement’s (IHI) goals of reducing preventable harm through structured processes (Roberti et al., 2025). The 90% benchmark reflects organizational quality metrics and mirrors successful outcomes in similar settings (Manandi et al., 2023).

Range of Potential Strategies/Interventions
Literature-Supported Strategies:
EHR Clinical Decision Support (CDS):
Automated reminders for overdue screenings (Davidson et al., 2022).
Proven to increase screening rates by 20–30% in primary care.
Provider Education Workshops:
Interactive sessions on USPSTF guidelines (Guirguis-Blake et al., 2023).
Patient Outreach Programs:
Text/email reminders for preventive care appointments.
Gaps in Literature:
Limited studies on cost-effectiveness of multicomponent interventions in rural clinics.

Existing literature highlights EHR-based tools as the most scalable intervention, with studies showing significant improvements in screening adherence (Davidson et al., 2022). However, standalone EHR reminders may lack impact without provider buy-in, underscoring the need for education (Guirguis-Blake et al., 2023). Patient engagement strategies, though promising, are less studied in low-resource settings. Manandi et al. (2023) note that multicomponent interventions (e.g., EHR + education) yield the highest compliance rates but require robust infrastructure. Notably, no studies addressed sociocultural barriers in underserved populations, suggesting a need for tailored solutions. This gap informed the selection of a hybrid approach combining EHR optimization with team training.
3

Selected Strategy: PDSA Cycle
Plan-Do-Study-Act (PDSA) Framework:
Plan: Develop screening protocols and EHR reminder templates.
Do: Pilot with 2–3 providers over 4 weeks.
Study: Analyze screening rates and staff feedback.
Act: Scale successful interventions clinic-wide.
Why PDSA?
Iterative testing minimizes disruption (Roberti et al., 2025).
Aligns with IHI’s evidence-based improvement models.

The PDSA cycle was used because it is flexible and a proven success in primary care (Roberti et al., 2025). The “Plan” phase involves collaboration with IT to create EHR alerts using patient age/risk factors. In “Do,” technical or workflow barriers are found through small-scale testing. The “Study” step uses clinic performance measures and surveys of staff to refine interventions iteratively to make them usable. For example, in the event of neglecting reminders, additional modules of education will be added. Finally, “Act” implements all provider changes through practice, and monthly auditing to ensure sustainability. This solution meets the clinic’s resource constraints yet still manages within the 6-month time frame (Manandi et al., 2023).

Rationale for PDSA Selection

Clinic-Specific Fit:
Limited resources favor incremental changes over costly system overhauls.
High staff turnover necessitates simple, replicable processes.
Evidence Base:
PDSA improved screening rates by 22% in similar settings (Manandi et al., 2023).

The PDSA cycle’s incremental nature minimizes resistance to change, a consideration that is critical with the clinic’s heterogeneous group of providers. The cycle’s nature allows for rapid revision—crucial in a high-volume setting where workflows vary. There is proof of PDSA success in cardiovascular risk factor management, with a goal achievement rate of 68% when supported by adequate staffing (Manandi et al., 2023). In addition, the model’s emphasis on data-driven decision-making aligns with the electronic health record capacity of the clinic, with results that are measurable. The strategy also addresses USPSTF’s call for “system-level changes” to eliminate guideline-practice disparities (Davidson et al., 2022).

Key Stakeholders in Implementation
Providers: Order screenings and engage in education.
IT Team: Configure EHR reminders and run reports.
Nursing Staff: Execute point-of-care screenings.
Clinic Leadership: Allocate time/resources for training.

Successful operationalization requires multidisciplinary effort. Providers need to drive the process, with IT providing easy-to-use EHR tools (e.g., pop-up reminders with single-click ordering options). Nursing staff, often the first to interact with patients, will receive training on streamlined workflows to avoid delays. Clinic leadership’s role includes approving protected time for PDSA reviews and celebrating milestones to sustain motivation. For example, monthly feedback sessions will address challenges like alert fatigue. This team-based approach mirrors IHI’s “whole-system” philosophy, where shared accountability drives improvement (Roberti et al., 2025).

References

Barry, M. J., Wolff, T. A., Pbert, L., Davidson, K. W., Fan, T. M., Krist, A. H., … & Nicholson, W. K. (2023). Putting evidence into practice: an update on the US Preventive Services Task Force methods for developing recommendations for preventive services. The Annals of Family Medicine, 21(2), 165-171.
https://scholar.google.com/scholar?output=instlink&q=info:EhtTAj4EDo4J:scholar.google.com/&hl=en&as_sdt=0,5&scillfp=1814592995208635009&oi=lle

Davidson, K. W., Barry, M. J., Mangione, C. M., Cabana, M., Chelmow, D., Coker, T. R., … & US Preventive Services Task Force. (2022). Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force recommendation statement. Jama, 327(16), 1577-1584.
https://jamanetwork.com/journals/jama/articlepdf/2791399/jama_davidson_2022_us_220007_1650466044.25397

Guirguis-Blake, J. M., Evans, C. V., Coppola, E. L., Redmond, N., & Perdue, L. A. (2023). Screening for lipid disorders in children and adolescents: updated evidence report and systematic review for the US Preventive Services Task Force. Jama, 330(3), 261-274.
https://jamanetwork.com/journals/jama/fullarticle/2807281

Manandi, D., Tu, Q., Hafiz, N., Raeside, R., Redfern, J., & Hyun, K. (2023). The evaluation of the Plan–Do–Study–Act cycles for a healthcare quality improvement intervention in primary care. Australian Journal of Primary Health, 30(1), NULL-NULL.
https://www.publish.csiro.au/py/pdf/PY23123

Roberti, J., Jorro-Barón, F., Ini, N., Guglielmino, M., Rodríguez, A. P., Echave, C., … & Alonso, J. P. (2025). Improving Antibiotic Use in Argentine Pediatric Hospitals: A Process Evaluation Using Normalization Process Theory. Pediatric Quality & Safety, 10(1), e788.
https://journals.lww.com/pqs/_layouts/15/oaks.journals/downloadpdf.aspx?an=01949578-202501000-00010

image1

image2

image3

image4

image5

image6

image7

Turn in your highest-quality paper
Get a qualified writer to help you with

“ Tiff week 7 ”

Get high-quality paper

Guarantee! All work is written by expert writers!