HQ002 Measurement and Evaluation of Quality Outcomes
Phillip March 27, 2024 No Comments

HQ002 Measurement and Evaluation of Quality Outcomes

HQ002 Measurement and Evaluation of Quality Outcomes



NURS 6231 Healthcare Systems and Quality Outcomes

Prof. Name


Healthcare Quality Dashboard

All organizations should have a dashboard for their staff to view. This is a great way to show progress of quality and performance improvements. A dashboard is essentially a way to keep track of performance and it allows everyone to acknowledge where things are going well or where there are problems (Centers for Medicare and Medicaid Services, n.d.). This paper discusses the dashboard created for Community General Hospital and how it can help patient outcomes.

Quality Measures Chosen

On the dashboard, there are seven quality measures I have chosen to be present. These are serious complications, readmissions after discharge, average time spent in the emergency department, stroke symptoms followed up by brain scans within 45 minutes, staff vaccination status, surgical site infections and complications for knee and hip replacements.

Each of these measures are important to the organization for different reasons. For starters, serious complications are huge because we need to minimize these at all costs. Not only can this essentially take a life, but it does extend a patient’s length of stay. Readmissions after discharge is important because organizations lose money for a readmission within 30 days (U.S. Centers for Medicare & Medicaid Services, 2022). Readmissions are extremely important to avoid because they reflect poor hospital quality as well.

Time spent in the emergency department is huge because patient’s want to feel cared for. The longer they are sitting in the emergency department not receiving care, the more they feel neglected. Also, if a patient needs to be admitted, and they are waiting in the emergency department for three hours to be transferred to a floor, it can affect their outlook on the quality of care they believe they will receive. This can also cause patients to leave against medical advice. All stroke patients must have a scan of the brain done when they are brought to the hospital.

NURS 6231 Assessment 2 HQ002 Measurement and Evaluation of Quality Outcomes

According to Northwestern Medicine. (n.d.), brain scans are done to show abnormalities of the brain and can show if it is a hemorrhage or ischemic stroke. This is important because a hemorrhagic stroke shows a brain bleed right away, and this determines tissues plasminogen activators (tPA) cannot be used. If there are no signs of a hemorrhagic stroke, tPA can be initiated within three hours of onset of symptoms. This is important to the dashboard because every minute counts in stroke patients, and to have a scan done within the door to scan time is essential in a positive recovery. Staff vaccinations plays a role for not only healthcare workers but patients as well.

Having the vaccinations up to date will allow the spread of infection to decrease, creating a safe and healthy environment for workers and patients. Surgical site infections are big because if this infection happens it can be ruled as a hospital acquired infection or HAI’s. One of the main goals in healthcare is to keep HAIs to a minimum. This can cause a lot of issues for the patient, but also the organization because they are not reimbursed if an infection happens on them. Another big surgery is hip and knee replacements. When someone is choosing a hospital to get these big surgeries done at, they do investigate the complications. Not only does this effect patients length of stay, but it puts them at risk for greater complications and is alarming to future surgery patients.

Triple/Quadruple Aim

The Quadruple aim is the Triple aim with one more subsection added. Their four goals are improving the health of populations, enhancing the experience of care for everyone, reducing the cost of healthcare, and pursuing health equity (Institute for Healthcare Improvement, 2017). The Triple aim is represented on the measures by acknowledging how they can improve their care. Although there are many positives on the dashboard meaning they are providing effective quality of care to patients, there are and will be some negatives.

The best way to create more positives is acknowledging there is an issue in area and figure out how to fix it. For example, the readmission after discharge rate is high. What they can do is figure out what they are missing while discharging a patient. Is it not effective communication? Are they lacking explanations? The dashboard created is aiming to improve health, create low-cost healthcare, and create a good experience for patients.


Most displays on the dashboard are done by bar graphs. I chose this because it is the easiest to read and show comparison. According to Government of Canada (2021), bar graphs are useful to compare different categories if there are not too many categories to compare. Choosing this way to display was optimal in allowing for a quick result for readers. It is straight to the point, and easy to comprehend.

Communicating Dashboards

Communicating dashboards to the organization is important because it is one of the reasons it is created. A few good ways to communicate it is by sending it to all staff members via email, posting them on the unit and discussing them during morning meetings. Making the staff aware of these dashboards are essential because it allows them to know what areas they are doing well in and what areas need some change. The purpose of the dashboard is to show progress of quality and performance improvements.

Leadership Tool

According to Randell, Alvarado, McVey, Ruddle, Doherty, Gale, Mamas, and Dowding (2020), these dashboards are also used to provide feedback to the team. Using this as a leadership tool can be done by implementing change throughout the team to increase the negative areas. Healthcare workers can see the trends and identify areas that need work along with feedback provided to them on how to change or implement new ways to do better. The leaders can look at these dashboards over time and see the trend if they are increasing after their implementations and feedback, or if there is something else missing!


Dashboards are a great way to show progress of quality and performance improvements to an organization. A dashboard is created to show areas that are doing well, and areas that may need some change. This allows everyone to implement change, stay up to date and work together to create the best patient care. Dashboards are set up in ways that are easy to read and play an essential role in helping improve workflows and employees’ performances.


Centers for Medicare and Medicaid Services. (n.d.). Instructions to develop a dashboard. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/InstrDevDshbddebedits.pdf

Government of Canada. (2021, September 2). Bar Chart. 5.2 Bar chart. https://www150.statcan.gc.ca/n1/edu/power-pouvoir/ch9/bargraphdiagrammeabarres/5214818-eng.htm

Institute for Healthcare Improvement. (2017, November 28). The triple aim or the quadruple aim. Institute for Healthcare Improvement. https://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy

Northwestern Medicine. (n.d.). Computed Tomography (CT) scan for stroke. Northwestern Medicine. https://www.nm.org/conditions-and-care-areas/tests/computed-tomography-ctscan-for-stroke#:~:text=CT%20scans%20can%20show%20areas,a%20stroke%20has%20taken

NURS 6231 Assessment 2 HQ002 Measurement and Evaluation of Quality Outcomes

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