Date of Conferral
2022
Degree
Doctor of Nursing Practice (DNP)
School
Nursing
Advisor
Lynda Crawford
Abstract
This project was an evaluation of a quality improvement (QI) initiative conducted in a large medical enterprise to address the problem of poor performance of their hospitals in accreditation surveys. The desired outcome was to evaluate whether an innovative plan of correction process was impactful in reducing the negative outcomes of regulatory and accreditation surveys. The practice-focused question guiding this project addressed the effect of the pre-accreditation evaluation and a plan of correction process in this QI initiative on reducing requirements for improvement (RFI) and condition-level deficiencies (CLD) cited in a recent The Joint Commission survey review. This project was grounded in Kotter’s model for change. Comparative analyses of sets of RFI and CLD data obtained from the reports produced after the surveys measured differences in accreditation outcomes prior to and after the implementation of the plan of correction process. Of the hospitals that participated in the QI initiative through the 30-day plan of correction call, two (13%) received at least one CLD, compared to all six (100%) of the hospitals that did not participate. The number of RFIs for the facilities who completed at least through the 30-day call were significantly lower (p = .017) than the number of RFIs in facilities that did not. This project will help guide hospital leadership to make informed preparations for improved regulatory and accreditation outcomes. Improved accreditation outcomes will indicate enhanced patient safety, positive patient outcomes, and a higher quality of patient care.
Recommended Citation
Pierson, Carla, "Evaluation of Action Plan Management Strategy to Improve Survey Readiness and Decrease Negative Accreditation Findings" (2022). Walden Dissertations and Doctoral Studies. 12513.
https://scholarworks.waldenu.edu/dissertations/12513
