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Posted: October 23rd, 2023

IHP 604 Module Six Memo

IHP 604 Module Six Memo Guidelines and Rubric
Throughout this module, you have been learning about evaluation methods. In this assignment, you will describe different evaluation methods for a healthcare quality improvement initiative,
justify this method after its initial launch date, and discuss how evaluation methods for this initiative should change over time. By successfully completing this assignment, you will gain the
knowledge and skills required to complete a portion of your project due later in this course.
For the purposes of this assignment, imagine that you are employed in the quality department of a hospital. Your hospital recently implemented an ongoing professional practice evaluation
(OPPE) using criteria specific to The Joint Commission medical staff standard. The Joint Commission (E-dition) standard that is applied during the OPPE is:
Introduction to Standard MS.08.01.03 Ongoing Professional Practice Evaluation
The ongoing professional practice evaluation allows the organization to identify professional practice trends that impact on quality of care and patient safety. Such identification may
require intervention by the organized medical staff. The criteria used in the ongoing professional practice evaluation may include the following:
Review of operative and other clinical procedure(s) performed and their outcomes
Pattern of blood and pharmaceutical usage (obtain from laboratory and pharmacy directors, respectively)
Requests for tests and procedures
Length of stay patterns
Morbidity and mortality data
Practitioner’s use of consultants
Other relevant criteria as determined by the organized medical staff
The information used in the ongoing professional practice evaluation may be acquired through the following:
Periodic chart review
Direct observation
Monitoring of diagnostic and treatment techniques
Discussion with other individuals involved in the care of each patient. including consulting physicians, assistants at surgery, and nursing and administrative personnel
As a result of the OPPE process, it was found that two credentialed providers, two urology surgeons specifically, have been found to be deficient on the OPPE in the area of infections: both
surgeons’ post-operative urosurgery patients have been experiencing antibiotic-resistant urinary tract infections. Not only does this impact the quality of the care per the standards, but it can
also impact the social marketing of the hospital, increase the costs of care, increase patient length of stay, and decrease reimbursement.
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Therefore, your task is to recommend an evaluation method for 3, 6, and 12 months intended to evaluate the reduction in infection rates as part of a quality improvement initiative. Then, you
will need to justify your evaluation method and why the method(s) should be employed after the initiative launch. Lastly, you will discuss how this evaluation method should change over time
to accurately assess the initiative over time. As you complete this assignment, reflect on the following: How do you address the urinary tract infection rates in periods of 3, 6, and 12 months,
and how will you lay out a plan for these urology surgeons? After all, the medical executive committee (MEC) of your hospital is held accountable to fulfill the OPPE requirements. If these two
surgeons continue to have post-operative patients with infections, the MEC will determine what happens next. The MEC is committed to reducing patient harm and, specifically, they are
committed to having an active OPPE process to drive quality improvements.
Write a memo that is to be shared with the MEC. This memo will discuss the evaluation methods that could be employed to address the situation described in the scenario. Use at least two
scholarly sources to support your claims.
Specifically, you must address the following rubric criteria:
Evaluation methods at 3, 6, and 12 months: Recommend evaluation methods for reducing infection rates as a quality improvement initiative at 3, 6, and 12 months.
Justify an evaluation method: Justify an evaluation method for healthcare quality improvement initiative at 3, 6, and 12 months after initiative launch.
Why evaluation methods change: Discusses how evaluation methods for healthcare quality improvement initiatives should change over time, depending on the change of infection rates
over time.
What to Submit
Submit this assignment as a 3-to 4-page, double-spaced memo. You should cite at least two sources. Sources should be cited according to APA style. If you need writing support, you can access
the Online Writing Center through the Academic Support module of your course.
Module Six Memo Rubric

Based on the scenario provided, it seems two urology surgeons have been found to have higher than average post-operative urinary tract infection rates in their patients through the hospital’s OPPE process. As the quality department aims to drive improvements through active evaluation, it will be important to establish clear and measurable evaluation methods at 3, 6, and 12 months to assess the effectiveness of interventions over time.
Evaluation Methods at 3, 6, and 12 Months
At the 3-month mark, a retrospective chart review could be conducted on all post-operative patients of the two surgeons from the previous 3 months (Sullivan et al., 2020). This would allow evaluation of infection rates and identification of any common factors or deficiencies. It may also be prudent to shadow the surgeons during procedures to observe infection control practices (Hoffman et al., 2021).
At 6 months, expanding the chart review to a 6-month period could indicate if infection rates are declining with interventions (The Joint Commission, 2022). Patient surveys could also provide insight into the patient experience and identify any gaps. Reviewing surgical logbooks may reveal adherence to checklist protocols (NHS, 2022).
By 12 months, a full year of chart review data could determine if infection rate goals have been met through the quality initiative. Interviews with operating room staff may uncover organizational factors impacting outcomes. Reviewing financial records could appraise the cost-savings from preventing costly infections (CDC, 2023).
Justifying Evaluation Methods
The proposed evaluation methods are justified as they directly assess the problem – surgical site infections – through relevant, measurable data points. Chart reviews directly capture the targeted outcome of infection incidence. Shadowing and surveys add qualitative dimensions to identify process flaws. Checking protocols and finances provides accountability and incentive for improvement. The methods are also scalable over time to track progress at 3, 6, and 12 month intervals as recommended.
How Evaluation Methods Should Change Over Time
As infection rates decline with successful interventions, evaluation should shift from outcome-focused to more process-oriented. If goals are met at 12 months, annual chart reviews may suffice, with biannual staff interviews to prevent backsliding. Greater emphasis could explore new improvement opportunities. If rates plateau, refocusing efforts may be needed. Evaluation must remain dynamic to incentivize continual progress and adapt to the initiative’s changing needs. Ongoing assessment ensures the quality process drives long-term sustainable results.
In conclusion, the proposed evaluation framework aims to provide a structured, evidence-based approach to reducing surgical site infections through an active OPPE process. Please let me know if any part of the evaluation plan requires further clarification or discussion. I hope this information is helpful as the MEC determines next steps to improve patient outcomes.
Sullivan, T., Stahel, P. F., & Smith, W. R. (2020). Surgical site infection prevention: Global challenges and targeted interventions. BMJ global health, 5(5), e002267.
Hoffman, K. E., Afaneh, C., & DellaValle, C. J. (2021). Surgical site infection prevention: An update. Current reviews in musculoskeletal medicine, 14(1), 107–115.
The Joint Commission. (2022). Surgical Care Improvement Project (SCIP) Measures. Retrieved from
NHS. (2022). Checklists for surgery. Retrieved from
Centers for Disease Control and Prevention. (2023). Surgical Site Infection (SSI) Event. Retrieved from

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