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NSG 542 Phoenix eCQM as a Quality Improvement Initiative Discussion Paper

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In this assignment, you will write a proposal to use an eCQM as a quality improvement initiative. In this proposal, you will present a plan for incorporating an eCQM into the EHR implementation and optimizing the EHR to provide clinical decision support for the quality measure. This initiative will also fulfill one of the meaningful use requirements of an EHR system. You will offer an implementation plan for the process change and address the risks involved. You will identify how it will be monitored and maintained.

Read Continuous Quality Improvement (CQI) Strategies to Optimize your Practice. You will use the CQI concepts, strategies, and techniques that are contained in the primer.

Select one of the following eCQMs to use as the basis for this assignment:

  • HIV Screening – CMS349v2
  • Colorectal Cancer Screening – CMS130v8
  • Controlling High Blood Pressure – CMS165v8
  • Preventive Care and Screening: Screening for Depression and Follow-up Plan – CMS002v9
  • Diabetes: Eye Exam – CMS131v8

Select an appropriate CQI strategy (PDSA, Lean, Six Sigma, Baldrige) to achieve the aims of the initiative.

Explain your rationale for your choice and how the strategy would be used to achieve the aims.

Define all possible stakeholders for the selected eCQM. Select your ideal team from the list of stakeholders.

Note: This is a hypothetical so you can list job titles rather than names.

Complete a Performance Measure Data Definition worksheet for this measure.

Find the meaningful use value set in AHRQ USHIK.

Establish measures for this initiative by locating industry benchmarks for your eCQM. How will you measure change, and will you know that the changes are an improvement? Can the benchmark data be used to measure and indicate improvement?

Complete a Performance Measure Workflow Alignment worksheet for this measure.

Create a workflow diagram depicting the ideal information flow for the eCQM from the point of capture through reporting the data and indicate which agencies that data will be reported to. The diagram will include when the data is captured, by whom, at what point of the patient visit, etc.

Determine an appropriate CDS tool to integrate into the workflow. Explain the rationale for selecting it and why you located at the point you placed it in (5 rights of clinical decision support).

Develop a plan for testing, monitoring, and maintaining this CQI.

Write a proposal for incorporating this initiative into an organization’s EHR implementation in which you will include:

  • A summary of the initiative objectives, including eCQM rationale
  • The desired outcomes resulting from this change (e.g., initiative goals, target benchmark, etc.)
  • CQI strategy that will be employed
  • Implementation plan
  • Testing and monitoring plan
  • Details of how a CDS will be incorporated into the EHR and how it will facilitate meaningful use
  • Risk assessment and change management plans
  • Training support (i.e., who will need training and how will they be trained?)

Include any completed worksheets and workflow diagrams in the proposal as appendices.

Note: The proposal should be approximately 5-6 pages long, excluding the title page, references page, and all appendices, and should include a minimum of 3 professional references to support your work.

Cite your references according to APA guidelines.