Date of Conferral



Doctor of Nursing Practice (DNP)




Oscar Lee


Improving the role the nurse plays in health care delivery should be embodied in the performance improvement initiatives to successfully improve the quality of care that is delivered. The purpose of this evidence-based practice project was to collect performance improvement data and present it to staff who, in turn, used the information to improve practice and influence patient safety outcomes. The practice-focused question addressed what would occur if a tool that allowed frequent data trending was used to measure effectiveness of care and thereby influence key outcome measures. Duffy's quality caring model provided a framework for the study to support the need for the development of a dashboard for staff and to ensure that staff were informed as they developed interventions to improve patient outcomes. Publicly available data published by the Centers for Medicare/ Medicaid (CMS) for the Quality Star Report were explored to inform the project. Workgroups, comprised of volunteers from leadership and staff providing care at the bedside, were formed to implement practice changes based on the dashboard reports. By bringing the data to the attention of nurses within the organization, improvements were made in the overall score for safety of care from below national average (25th percentile of the reported 3,647 hospitals across the nation) to the same as national average (47th percentile) as reported by CMS. Through staff involvement, social change occurred as strategies were hardwired to improve categories of the Quality Star Report and ultimately patient care. The project showed that quality improvement tools can assist in empowering staff to understand the data needed to implement process improvement strategies.