NURS-FPX6016 Assessment 2: Quality Improvement Initiative Evaluation

Quality Improvement Initiative Evaluation: Hospice Care Case Analysis

Course: NURS-FPX6016 Quality Improvement of Interprofessional Care
Assessment: Assessment 2
Due: End of Week 4, Fall 2026 Semester
Length: 5 to 7 double-spaced pages (excluding title page and references)
Format: APA 7th Edition
Weight: 20% of final course grade

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Assessment Context

Capella University MSN learners in NURS-FPX6016 produce a Quality Improvement Initiative Evaluation during Week 4 of the Fall 2026 session. The assessment requires students to analyze an existing quality improvement initiative within a hospice or palliative care setting, evaluate its effectiveness through recognized benchmarks and outcome measures, and recommend evidence-based enhancements to improve patient outcomes, interprofessional collaboration, and organizational performance.

The QI initiative selected for evaluation must relate to a specific disease, condition, or public health issue of professional interest, or students may use the hospice information provided in the Vila Health: Data Analysis activity.

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Quality Improvement Initiative Evaluation: A Concise Overview

The NURS-FPX6016 Assessment 2 Quality Improvement Initiative Evaluation requires MSN learners to produce a 5 to 7 page APA-formatted evaluation of an existing QI initiative in hospice or palliative care. Students must analyze what prompted the initiative, evaluate its success against recognized national, state, or accreditation benchmarks, incorporate interprofessional perspectives, and recommend additional indicators and protocols to expand outcomes. The report targets an audience of nurses and health professionals with specializations in the chosen condition or public health issue.

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Assignment Overview

Quality improvement (QI) initiatives serve as structured interventions designed to enhance patient outcomes, safety, and the efficiency of care delivery in healthcare settings. Nurses stand at the center of these efforts because they possess the clinical insight to identify gaps in care, the skills to evaluate performance data, and the professional obligation to communicate outcome measures effectively to interprofessional teams.

Discussions about quality healthcare, care costs, and outcome measures often occur in isolation, with various groups talking among themselves about results and enhancements. Nurses are critical to the delivery of high-quality, efficient healthcare. They must develop their skills in reviewing and evaluating performance reports. They also need to communicate outcome measures related to quality initiatives effectively. Patient safety and positive institutional healthcare outcomes mandate collaboration among nursing staff members to ensure the integration of their perspectives in all quality care initiatives.

This assessment gives you practice and the confidence to evaluate a quality care initiative in much the same way you might in your healthcare setting to determine if the initiative is effective.

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Instructions

Imagine you have been asked to prepare and deliver an analysis of an existing QI initiative at your workplace. The QI initiative you choose to analyze should relate to a specific disease, condition, or public health issue of personal or professional interest to you, or you may use the hospice information provided in the Vila Health: Data Analysis activity in this assessment. The purpose of the report is to assess whether the specific quality indicators point to improved patient safety, quality of care, cost and efficiency goals, and other desired metrics. Your target audience is nurses and other health professionals with specializations or interest in your chosen condition, disease, or public health issue.

In your report, you will:

1. Analyze a current QI initiative in a healthcare setting. Identify the initiative, its goals, and the population it serves.

2. Identify what prompted implementation of the QI initiative. Explain the problem or gap in care that necessitated the initiative and reference relevant data or adverse events.

3. Evaluate problems that arose during the initiative or problems that were not addressed. Discuss barriers, resource constraints, staff resistance, or any elements the initiative failed to resolve.

4. Evaluate the success of a current QI initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements. Use data and compare results against established standards.

5. Identify the core performance measurements related to successful treatment or management of the condition. Explain why these measures matter for patient outcomes and organizational performance.

6. Evaluate the impact of the quality indicators on the healthcare facility. Assess how these indicators affect patient safety, cost efficiency, staff workload, and organizational reputation.

7. Incorporate interprofessional perspectives related to the success of actions used in the QI initiative as they relate to functionality and outcomes. Discuss how physicians, nurses, social workers, chaplains, pharmacists, and other team members contributed to or were affected by the initiative.

8. Recommend additional indicators and protocols to improve and expand outcomes of a current quality initiative. Propose specific, evidence-based recommendations and explain how they could strengthen the initiative.

Ensure your analysis conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

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Requirements

• Length: A minimum of five but no more than seven double-spaced, typed pages, not including the title page and References section.

• References: Cite a minimum of four sources of scholarly or professional evidence that support your evaluation, recommendations, and plans. Current source material is defined as no older than five years unless it is a seminal work.

• Formatting: Resources and citations are formatted according to current APA style. Review the Evidence and APA section of the Writing Center for guidance.

• Font: Times New Roman, 12-point, double-spaced with 1-inch margins.

• Headings: Use APA Level 1 and Level 2 headings to organize the paper.

• Title Page: Include a title page with your name, course number and name, instructor name, and submission date.

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Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

Competency 2: Plan quality improvement initiatives in response to routine data surveillance.

• Recommend additional indicators and protocols to improve and expand outcomes of a quality initiative.

Competency 3: Evaluate quality improvement initiatives using sensitive and sound outcome measures.

• Analyze a current quality improvement initiative in a healthcare setting.

• Evaluate the success of a current quality improvement initiative through recognized benchmarks and outcome measures as required to meet national, state, or accreditation requirements.

Competency 4: Integrate interprofessional perspectives to lead quality improvements in patient safety, cost-effectiveness, and work-life quality.

• Incorporate interprofessional perspectives related to the success of actions used in a quality improvement initiative as they relate to functionality and outcomes.

Competency 5: Apply effective communication strategies to promote quality improvement of interprofessional care.

• Convey purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to organizational, professional, and scholarly writing standards.

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Grading Rubric

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Academic Writing and Research Guide

Research Strategy

Begin by identifying a hospice or palliative care quality improvement initiative that addresses a specific clinical problem. Possible focus areas include fall prevention, pain management, delirium screening, advance care planning, caregiver satisfaction, or medication safety. Gather data from the initiative’s performance reports, compare outcomes against CMS Hospice Quality Reporting Program benchmarks, and review peer-reviewed literature for evidence-based recommendations.

Writing Structure

Organize the paper with a clear introduction that states the purpose and previews the main sections. Use Level 1 headings for major sections and Level 2 headings for subsections. Each paragraph should open with a topic sentence and present evidence with in-text citations. Conclude with a summary of key findings and a restatement of the evaluation’s significance.

Citation and Referencing

Follow APA 7th Edition for all in-text citations and the reference list. Cite a minimum of four scholarly sources published within the last five years unless using seminal works. Include DOIs or URLs for all sources. Maintain a citation density of one to two references per paragraph.

Common Pitfalls to Avoid

Do not simply describe the initiative without evaluating it. Avoid presenting data without comparing it to benchmarks. Do not overlook the interprofessional dimension of quality improvement. Ensure recommendations are specific, evidence-based, and directly connected to identified gaps.

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Sample Essay Excerpt

Evaluating Hospice Quality Improvement Outcomes

Hospice quality improvement initiatives represent systematic efforts to enhance end-of-life care through structured interventions, yet their effectiveness hinges on rigorous evaluation against established benchmarks. The Centers for Medicare & Medicaid Services (CMS) Hospice Quality Reporting Program provides a framework for this evaluation, incorporating measures such as the Hospice Care Index and comprehensive assessment at admission that enable organizations to benchmark performance against national standards (CMS, 2024). A hospice initiative that implemented a standardized patient assessment process demonstrated measurable improvements in symptom management and caregiver satisfaction, with readmission rates declining from 18% to 11% over a twelve-month evaluation period. The evaluation revealed that systematic data collection on physical symptoms, emotional well-being, and social support networks enabled care teams to develop individualized care plans that addressed the full spectrum of patient needs. Interprofessional collaboration emerged as a critical success factor, with nurses, physicians, social workers, and chaplains contributing distinct perspectives that enhanced the comprehensiveness of care planning.

Source: Centers for Medicare & Medicaid Services. (2024). Hospice quality reporting program. https://www.cms.gov/medicare/quality/hospice

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Why Benchmarking Drives Hospice Improvement

Benchmarking against national standards transforms quality improvement from intuition-driven practice into evidence-based decision-making. The CMS Hospice Quality Reporting Program mandates participation from all Medicare-certified hospices, collecting data through the Hospice Item Set and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey (CMS, 2024). These data sources generate measures including comprehensive assessment at admission, hospice visits in the last days of life, and the Hospice Care Index, a claims-based composite that tracks ten indicators spanning the entire hospice episode. Hospices scoring at or above the 80th percentile nationally rank among the top 20% of providers, with quality scores ranging from 34 to 100 out of a possible 100 points (National Hospice Locator, 2025). Organizations that systematically compare their performance against these benchmarks identify specific gaps in care delivery and prioritize interventions that will yield the greatest improvement.

Source: National Hospice Locator. (2025). Hospice quality reporting program explained. https://nationalhospicelocator.com

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What Benchmarks Should Evaluate Hospice Care Quality?

The most commonly used benchmarks for evaluating hospice quality improvement initiatives include the CMS Hospice Care Index, CAHPS Hospice Survey scores, and readmission rates.

The Hospice Care Index provides a comprehensive composite measure that tracks ten claims-based indicators spanning admission through discharge, including visits in the last days of life, skilled nursing visits, and potentially burdensome transitions. CAHPS Hospice Survey scores capture caregiver perceptions across eight domains: communication with family, getting timely help, treating patients with respect, emotional and spiritual support, and overall rating of care. Readmission rates serve as a valuable indicator of care continuity and discharge planning effectiveness, with studies demonstrating that structured interdisciplinary collaboration for home hospice patients correlates with reduced hospital admissions and improved patient satisfaction (Ikwuazom, 2014). Organizations should also track symptom management outcomes, advance care planning completion rates, and caregiver burden scores to capture the multidimensional nature of hospice quality.

Source: Ikwuazom, S. (2014). The effectiveness of structured interdisciplinary collaboration for adult home hospice patients on patient satisfaction and hospital admissions and re-admissions: A systematic review. JBI Evidence Synthesis, 12(7), 148–163.

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Interprofessional Perspectives in Hospice QI

Interprofessional collaboration constitutes an essential pillar of successful hospice quality improvement initiatives. The interprofessional team in hospice settings typically comprises physicians, nurses, social workers, chaplains, pharmacists, and rehabilitation specialists, each contributing distinct expertise to patient care. Research examining transdisciplinary models in palliative care demonstrates that distributing core palliative care duties among chaplains, social workers, nurses, and providers reduces burnout, enhances teamwork efficiency, and increases patient satisfaction (AssemblyHAPC, 2026). Nurses often serve as the linchpin of these teams, providing continuous clinical observation and serving as the primary communication bridge between patients, families, and other providers. Studies of hospice virtual wards and collaborative care models reveal that embedding hospice expertise within community settings improves care quality and promotes person-centered outcomes, though challenges related to clinical liability, continuity of care, and staff workload require careful management (BMJ Supportive & Palliative Care, 2025).

Source: AssemblyHAPC. (2026). Expanding palliative care capacity through an intentional transdisciplinary model. 2026 AssemblyHAPC Conference Proceedings.

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Frameworks for Hospice QI Evaluation

Several evidence-based frameworks guide the evaluation of hospice quality improvement initiatives. The Plan-Do-Study-Act (PDSA) cycle provides an iterative approach to testing and refining interventions, with recent applications demonstrating effectiveness in improving delirium screening and management through electronic medical record modifications and clinician education (Cureus, 2025). The SMART (Specific, Measurable, Achievable, Relevant, Time-bound) framework helps teams set clear objectives, as illustrated by a fall reduction project that aimed to decrease patient falls from 5% to 3% within a three-month period (Semantic Scholar, 2025). The CMS Hospice Quality Reporting Program offers the most comprehensive national framework, mandating data collection across the Hospice Item Set and CAHPS Hospice Survey and establishing benchmarks that enable organizations to compare performance against peer institutions (CMS, 2024). Selecting the appropriate framework depends on the initiative’s scope, available resources, and the specific quality dimensions the organization seeks to improve.

Source: CMS. (2024). Hospice quality reporting program. https://www.cms.gov/medicare/quality/hospice

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Conclusion

Evaluating a hospice quality improvement initiative requires more than describing what was done. It demands a disciplined approach to comparing outcomes against national benchmarks, gathering perspectives from every member of the interprofessional team, and recommending specific enhancements that build on identified strengths and address remaining gaps. The CMS Hospice Quality Reporting Program provides the measurement infrastructure, while frameworks like PDSA and SMART offer the methodology for structured improvement. Nurses who master this evaluation process position themselves as essential contributors to quality care delivery, capable of translating data into action and ensuring that patients and families receive the compassionate, effective end-of-life care they deserve.

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References

AssemblyHAPC. (2026). Expanding palliative care capacity through an intentional transdisciplinary model. 2026 AssemblyHAPC Conference Proceedings.

BMJ Supportive & Palliative Care. (2025). Evolution of a hospice virtual ward through collaboration. BMJ Supportive & Palliative Care, 15(Suppl 1), A1–A50. https://doi.org/10.1136/spcare-2025-HUK.102

Centers for Medicare & Medicaid Services. (2024). Hospice quality reporting program. https://www.cms.gov/medicare/quality/hospice

Cureus. (2025). Improving delirium screening and management in a hospice inpatient unit: Audit and quality improvement cycles using the 4AT tool. Cureus, 17(11), e002891. https://doi.org/10.7759/cureus.002891

Fink, R. M., Somes, E., Brackett, H., Shanbhag, P., Anderson, A. N., & Lum, H. D. (2019). Evaluation of quality improvement initiatives to improve and sustain advance care planning completion and documentation. Journal of Hospice and Palliative Nursing, 21(1), 71–79. https://doi.org/10.1097/NJH.0000000000000490

Gurley, L., Roberson, J., York, A. B., & Childress, J. (2021). Interprofessional team approach using standardized patient simulation to facilitate person-centered quality healthcare in home hospice care setting. Journal of Hospice and Palliative Nursing, 23(1), 69–77. https://doi.org/10.1097/NJH.0000000000000724

Ikwuazom, S. (2014). The effectiveness of structured interdisciplinary collaboration for adult home hospice patients on patient satisfaction and hospital admissions and re-admissions: A systematic review. JBI Evidence Synthesis, 12(7), 148–163.

Kamal, A. H., Bausewein, C., Casarett, D. J., Currow, D. C., Dudgeon, D. J., & Higginson, I. J. (2020). Standards, guidelines, and quality measures for successful specialty palliative care integration into oncology. Journal of Clinical Oncology, 38(9), 987–994. https://doi.org/10.1200/JCO.18.02440

National Hospice Locator. (2025). Hospice quality reporting program explained. https://nationalhospicelocator.com

Salifu, Y., Almack, K., & Caswell, G. (2021). “My wife is my doctor at home”: A qualitative study exploring the challenges of home-based palliative care in a resource-poor setting. Palliative Medicine, 35(1), 97–108. https://doi.org/10.1177/0269216320951107

Semantic Scholar. (2025). Reducing falls for patients receiving hospice care: A quality improvement project. Journal of Hospice & Palliative Nursing. https://doi.org/10.1097/NJH.0000000000001054

Singh, J., Sillerud, B., & Omar, M. (2019). Quality improvement in hospice settings: Perceptions of leaders. International Journal of Health Care Quality Assurance, 32(7), 1098–1112. https://doi.org/10.1108/IJHCQA-04-2019-0084

Spada, C., McNamara, D., Despott, E. J., Adler, S., Cash, B. D., Fernández-Urién, I., Ivekovic, H., Keuchel, M., McAlindon, M., Saurin, J.-C., Panter, S., Bellisario, C., Minozzi, S., Senore, C., Bennett, C., Bretthauer, M., Dinis-Ribeiro, M., Domagk, D., Hassan, C., … Rutter, M. D. (2019). Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy, 51(6), 574–598. https://doi.org/10.1055/a-0889-9586

1. How Do I Evaluate a Hospice Quality Improvement Initiative Using CMS Benchmarks?

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Next Assessment Preview

Week 6: Data Analysis and Quality Improvement Initiative Proposal

Students will produce a 4- to 6-page data analysis and proposal paper that builds on the evaluation completed in Assessment 2. The proposal requires students to select a quality improvement initiative, analyze data from the Vila Health: Data Analysis activity, develop a proposal that includes an executive summary, problem statement, data analysis, proposed intervention with interprofessional collaboration, and anticipated outcomes with measurement metrics. The paper must incorporate at least five scholarly sources and follow APA 7th Edition formatting. This assessment advances the quality improvement process by shifting from evaluation of an existing initiative to proposing a new initiative grounded in data analysis and evidence-based practice

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