6-2 memo: evaluation methods | IHP604 | Southern New Hampshire University


 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.

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.

Guidelines for Submission

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. 



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