Leading Organizations for Quality Improvement Initiative

Leading Organizations for Quality Improvement Initiative

This is a graded discussion: 100 points possible

due Jan 17

Discussion Responses


Read a selection of your colleagues’ responses and respond to two of your colleagues who selected a different quality improvement model than you. Suggest an additional strategy on how your colleague may implement the quality improvement model they selected in their healthcare organization or nursing practice.




Laura Assanga Eyong

Plan-Do-Study-Act (PDSA)


A methodical and formal approach to the efficient examination of practice performance to guide efforts toward quality improvements is offered by quality improvement models. Several models of quality improvement can be applied. Quality improvement models are available to assist in data gathering and analysis to evaluate the efficacy of process changes, notwithstanding their differences in design. Improving efficiency, boosting patient safety, and encouraging clinical outcomes all depend on an understanding of and a foundation in the various quality improvement models for quality improvement activities (Knudsen et al., 2019). The PDSA cycle is one of the most well-known and often applied quality improvement models. The plan-do-study-act cycle is shortened to the PDSA cycle. According to Abuzide et al. (2023), the PDSA cycle is a four-stage iterative problem-solving paradigm that may be used to implement change and improve processes. To increase clarity on the intended aim of the quality improvement endeavor, it is necessary to ask and respond to several questions for this quality improvement model to be effective. The first question concerns the goals of the QI project, and the second one asks how a healthcare setting may recognize that the change brought about by the QI initiative is an improvement. To ensure that the process or system improves as planned by the quality improvement project, the third question asks what adjustments are necessary (Connelly, 2021).

First Stage

The planning stage is the first in the PDSA cycle. This step involves putting together a team that is well-versed in a particular issue or that has recognized a chance for development. After a quality improvement team has been created in the planning stage, it is vital to determine roles and responsibilities, establish meeting schedules, and set timelines (Connelly, 2021). To identify areas for improvement, the planning step also involves a description of the current system, method, or context (Katowa-Mukwato et al., 2021). Questions like “What is the current practice” and “What are the major steps in the process” should serve as a guide during the planning stage. What people are involved, what is done well, and what can be done better. The planning phase provides a forum for ideation around potential enhancements to the different systems or processes (Knudsen et al., 2019).

Second Stage

The doing stage is the second phase of the PDSA cycle. This phase comprises carrying out a plan of action to initiate the opportunities that have been identified. The team can record issues with the action plan’s execution, note any unanticipated consequences, and make broad observations using this stage as a platform (Connelly, 2021). This stage should be more of an experiment and should comprise a single department before the quality improvement program is scaled out to the complete healthcare setting as well as to additional healthcare settings.

Third Stage

The study stage is the third phase of the PDSA cycle. The study offers a way to assess the efficacy of the quality improvement project by using the objective statement from the planning stage and data gathered from the doing stage (Abuzied et al., 2023) Essential questions that enable an assessment of the quality improvement project efficacy ought to direct this phase. Analyzing trends and unintended side effects of the quality improvement program is crucial, as is determining whether and to what extent the initiative produced improvements. Several tools, including Pareto charts, run charts, control charts, and many more, can be used at this stage to visually review and assess the success of the quality improvement project (Knudsen et al., 2019).

Fourth  Stage

The action stage is the last and fourth phase of the PDSA. At this point, there is enough structure in place to consider the quality improvement project and its results. Should the quality improvement project be deemed successful, the enhancement ought to be standardized and used more frequently within the healthcare environment. On the other hand, the team is recommended to return to the earlier phases to plan, create, implement, and test a new and alternative strategy that would be more effective if the quality improvement program was deemed to be less successful (Katowa-Mukwato et al., 2021).


As was previously noted, the PDSA cycle is an iterative quality improvement model. Healthcare facilities can go back and review previous phases in their efforts to develop more intelligent and effective quality improvement initiatives to close gaps in treatment or take advantage of opportunities (Abuzied et al., 2023) Adopted as a continuous process, the PDSA cycle can assist firms in implementing and refining their quality improvement programs over time. Because the PDSA cycle promotes ongoing improvement, it can help mitigate the effects of unfavorable events. To eliminate unfavorable events and improve patient outcomes, efficiency, and safety, quality improvement teams can go back to earlier phases and create better plans or modify the ones that have already been created (Connelly, 2021).


Abuzied, Y., Alshammary, S. A., Alhalahlah, T., & Somduth, S. (2023). Using FOCUS-PDSA Quality Improvement Methodology Model in Healthcare: Process and Outcomes. Global Journal on Quality and Safety in Healthcare,6(2), 70-72.

Connelly, L. M. (2021). Using the PDSA model correctly.Medsurg Nursing,30(1), 61-54.

Katowa-Mukwato, P., Mwiinga-Kalusopa, V., Chitundu, K., Kanyanta, M., Chanda, D., Mwelwa, M. M., … & Carrier, J. (2021). Implementing Evidence-Based PracticeNursing using the PDSA model: Process, lessons, and implications. International Journal of Africa Nursing Sciences14, 100261.

Knudsen, S. V., Laursen, H. V. B., Johnsen, S. P., Bartels, P. D., Ehlers, L. H., & Mainz, J.(2019). Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC health services research,19, 1-10



Janie Marie Fleming


I have selected Root Cause Analysis (RCA) as the quality improvement model for discussion. RCA is a systematic method used to identify the underlying causes of an issue or problem within a healthcare setting (Chuang & Howley, 2013). In my healthcare organization, implementing RCA would involve a structured process to investigate adverse events, near misses, or persistent problems affecting patient care. Firstly, a dedicated team comprising healthcare professionals and relevant stakeholders would be assembled to conduct the analysis. The team would utilize tools such as fishbone diagrams and the “5 Whys” technique to delve deep into the root causes of the identified issue.

Once the root causes are identified, the next step involves developing and implementing corrective actions to address these underlying factors. This may involve changes to protocols, processes, or staff training. Continuous monitoring and evaluation would be essential to assess the effectiveness of the implemented changes and ensure sustained improvement over time. RCA can be integrated into the organizational culture by promoting a blame-free environment where healthcare professionals feel comfortable reporting incidents for analysis without fear of retribution (Latino, 2015). Regular training and education on the RCA process would empower staff at all levels to actively participate in identifying and addressing issues, fostering a culture of continuous improvement within the healthcare organization.

Applying RCA in Nursing Practice

In my nursing practice, applying RCA would mean systematically investigating any adverse events or issues affecting patient care. This could include incidents related to medication errors, communication breakdowns, or patient safety concerns. By utilizing the RCA model, I would collaborate with the healthcare team to identify the root causes contributing to these events. Subsequently, implementing changes to nursing protocols, communication strategies, or incorporating additional training would be crucial to prevent the recurrence of similar issues. Emphasizing a culture of learning from mistakes rather than assigning blame is fundamental in encouraging open communication and ensuring the ongoing improvement of patient care in my nursing practice (Nicolini, Waring & Mengis, 2011).


In conclusion, the implementation of Root Cause Analysis (RCA) in both healthcare organizations and nursing practice stands as a pivotal strategy for driving quality improvement. By adopting a systematic approach to investigate and understand the underlying causes of adverse events or persistent issues, healthcare professionals can develop targeted and effective corrective actions. In the organizational context, RCA fosters a culture of continuous improvement by encouraging collaboration, transparency, and ongoing evaluation of implemented changes. Similarly, in nursing practice, applying RCA ensures a proactive approach to identifying and addressing issues, leading to enhanced patient safety and care quality. Embracing RCA not only facilitates the resolution of specific problems but also contributes to the broader goal of creating resilient and adaptive healthcare systems that prioritize continuous learning and improvement.


Chuang, S. and Howley, P.P. (2013), Beyond root cause analysis: An enriched system-oriented event analysis model for wide application. Syst. Engin., 16: 427-438. https://doi.org/10.1002/sys.21246

Latino, R.J. (2015), How is the effectiveness of root cause analysis measured in healthcare? Journal of Healthcare Risk Management, 35: 21-30. https://doi.org/10.1002/jhrm.21198

Nicolini D, Waring J, Mengis J. The challenges of undertaking root cause analysis in health care: A qualitative study.  Journal of Health Services Research & Policy. 2011;16(1_suppl):34-41. doi:10.1258/jhsrp.2010.010092


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