San Diego State University School of Nursing
NURS 622 Syllabus
Quality Improvement and Program Evaluation in Nursing Systems
Organizations
Spring 2015
Faculty:
Willa Fields, DNSc, RN, FHIMSS
Home/office: 858-756-5642
Mobile: 619-925-0450
Email: willa.fields@sbcglobal.net
Do NOT text the instructor
12/22/2014
Quality Improvement and Program Evaluation in Nursing Systems
Organizations
N622
Spring 2015
Schedule Number: 22335
COURSE INFORMATION
Class Days: Thursdays
Class Times: 1:00 to 3:40
Class Location: Hepner Hall 134
Professor: Willa Fields, DNSc, RN, FHIMSS
Contact Information:
Office Hours Days: Thursdays
Office Hours Times (and by appointment): 4:00-6:30
Office Hours Location: Adams Humanities 3151
Home/Office: 858-756-5642
Mobile: 619-925-0450
Email: willa.fields@sbcglobal.net
Do NOT text the instructor
Course Overview
This course provides evaluation theories and concepts within a nursing care delivery system and
health care organization. Concepts of quality management, consistent with accreditation criteria
and professional standards of practice are presented.
The integrating theme of this course is the leadership role of the nurse in achieving performance
excellence within a framework of systems thinking. The focus will be on expanding knowledge
in all the domains of quality and developing the necessary skills to translate this knowledge into
practice in the student’s healthcare organization.
Upon completion of the course, the student will be able to:
1. Discuss the evolution of healthcare quality concepts and efforts to ensure quality of care;
2. Explore the social, governmental, regulatory, and professional pressures that have driven the
healthcare quality field
3. Discuss the Institute of Medicine’s (IOM) white paper on Errors in Hospitals and mandate
for patient safety;
4. Discuss professional standards and accreditation requirements for healthcare systems;
5. Discuss the transformation process necessary to ensure Magnet Hospital status, accreditation,
and quality recognition, such as the Baldrige Award;
6. Define the concept of quality from multiple perspectives;
7. Identify research and evaluation methods to assess healthcare quality;
8. Apply quality improvement concepts and methods;
9. Compare and contrast the processes of quality improvement, program evaluation, and
traditional research methods.
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10. Develop an organized strategy and plan for assessing and improving an organizational
project important to the students’ current or past organization.
Enrollment Information
Prerequisites: Acceptance into the School of Nursing graduate program.
Course Materials
Required Textbooks
 American Psychological Association. (2010). Publication Manual of the American
Psychological Association (6th ed.) Washington, DC: Author.
o APA Publication Manual Online Tutorials:
http://www.apastyle.org/learn/index.aspx
 Lighter, D. (2011). Advanced Performance Improvement in Health Care. Boston: Jones
and Bartlett.
 Hines, S., Luna, K., Lofthus, J., et al. (2008). Becoming a High Reliability Organization:
Operational Advice for Hospital Leaders. (Prepared by the Lewin Group under Contract
No. 290-04-0011.) AHRQ Publication No. 08-0022. Rockville, MD: Agency for
Healthcare Research and Quality. Available free online:
http://archive.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/hroadvice/hroadvice.pdf
 AHRQ (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
(AHRQ Publication No. 08-0043). Agency for Healthcare Research and Quality,
Rockville, MD. Available free online: http://www.ahrq.gov/qual/nurseshdbk/
Required Hardware and Software
 Access to a Windows or Macintosh multimedia computer. Preferably one that meets the
SDSU minimum computing standards (see http://edweb2.net/ldt/currentstudents/computer-requirements/ ) In addition, the following will be needed to support
course participation:
 E-mail system
 Microsoft Word
 Microsoft PowerPoint
 High-speed connection to the Internet
Recommended Hardware and Software
 Backup system for computer files
 USB headset for participating in remote sessions
Blackboard Student Support: http://www-rohan.sdsu.edu/dept/its/blackboard/student/
Netiquette: http://wwwrohan.sdsu.edu/dept/its/blackboard/student/gettingstarted/netiquette.html
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Course Structure and Conduct
Lecture-Discussion in Seminar format; directed readings and discussion; audio-visual
presentations; guest speakers; written and oral assignments; and role playing.
All students are expected to attend the first class session, and at least four additional sessions on
campus. If you are unable to attend a session on campus, you can remotely participate through
Blackboard (USB headset required to verbally participate) or listen to the recorded session at a
more convenient time. Participation will be monitored through Blackboard discussions and
recorded session data.
This course is intended to enable students to translate quality improvement theory and
knowledge into practice. Real life examples are used to explain and illustrate technically
complex concepts. An action-learning approach will be utilized to explore managerial and
organizational issues related to healthcare quality. Course content will include lecture-discussion
and review of concepts. Practice is crucial in any improvement effort. The assignments allow
students to refine their understanding of and familiarity with the theories and processes
addressed in the course. The first evaluation component focuses students on conducting an
organizational assessment based on a national program such as the National Baldrige or Magnet
Criteria to document their organization's current reality. The student may choose the evaluation
program. The second component requires the student to propose a Quality Improvement Project
that addresses an opportunity or weakness identified in the organizational assessment
assignment. Students will also present application of a performance improvement tool. Students
may use current work setting or student clinical practicum site for assignment completion.
This course may require students to participate in field trips, research or studies that include
course work that will be performed off-campus. Participation in such activities may result in
accidents or personal injury. Students participating in the event are aware of these risks, and
agree to hold harmless San Diego State University, the State of California, the Trustees of the
California State University and Colleges and its officers, employees and agents against all
claims, demands, suits, judgments, expenses and costs of any kind on account of their
participation in the activities.
Students using their own vehicles to transport other students to such activities should have
current automobile insurance.
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Assignments
Class Participation
Purpose: The purpose of class participation is to facilitate the student’s ability to analyze,
synthesize, apply, and critique class content with professional experiences and literature based
evidence. Class participation will be through in-class and on Blackboard discussions.
Requirements: The student is expected to actively participate in class by making substantive
contributions to the content covered.
Preparation: Review literature related to weekly class content.
Grade: 5% Evaluation will be based on attendance (on campus and remotely), quality of student
participation in class discussions, and demonstration of the ability to analyze, synthesize, apply,
and critique discussed concepts.
Conference/Webinar Write-up
Purpose: To expose students to Quality Improvement content available through webinars and
professional conferences.
Requirements: Attend a professional conference or webinars of at least two and a half hours in
length that is related to the course content. Email a summary of the presentation, what you
learned from the experience, and how the session/s related to the course content to
willa.fields@sbcglobal.net no later than the last day of class by 1:00 PM.
If uncertain about appropriateness of webinar/conference, email the instructor.
Grade: 5% Pass/Fail determination will be based on instructor evaluation of meeting the above
requirements. Late submissions will not be accepted.
Quality Improvement Tool Presentation
Purpose: To practice using a new Quality Improvement Tool (e.g. brainstorming, fishbone
diagram, etc.).
Requirements: Use a Quality Improvement Tool you have never used for a work or personal
problem. Present in 5 minutes or less, utilizing PowerPoint slides, a description of the tool used,
why/how you used it, evaluation of the tool’s effectiveness, and lessons learned in using the tool.
Email the presentation to willa.fields@sbcglobal.net the day before your presentation.
Grade: 10% Evaluation will be based on instructor and peer ratings of the presentation. Peers
will use the Peer Evaluation Form. A half letter grade will be deducted for each three minutes
over the allotted 5 minutes.
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Organizational Assessment Paper
Purpose: To practice completing an organizational assessment based on the Baldrige National
Quality Program Healthcare Criteria for Performance Excellence, Magnet, or other process as a
means of documenting current reality in the student’s own organization/unit or clinical practicum
site.
Requirements: Choose an organizational assessment program (e.g. Baldrige, Magnet, etc.) and
assess the area per the program’s criteria. For Baldrige use materials at
http://www.nist.gov/baldrige/ as a guide. Sample assessment papers from past terms are available
on Blackboard. Paper must include an introduction, purpose statement for the paper, an overview
of the organizational unit being assessed, description of the assessment criteria/process, results of
the assessment, recommendations for action, and conclusion. Depending on the assessment
program chosen, provide an overview of the program and focus on key elements of the
assessment.
The paper is to be prepared in APA format and supported with evidence-based literature.
Email the paper to willa.fields@sbcglobal.net on or before the last day of class by 1:00 PM.
Grade: 60% The paper will be evaluated on the clarity of writing, presentation of the overall
concept to be discussed, organization of the content into topical sub-headings, and incorporation
of evidence-based literature addressing managerial actions/recommendations to address the
problem/issue. Evidence of critical thinking and analysis about what others in the field are doing
and/or recommending is expected, as well as your own interpretation, inferences and rationale
about the problem. Correct spelling, punctuation, sentence/paragraph construction, and APA
style or in the students organization performance improvement methodology are expected. See
NURS 622 Grading Sheet for point distribution. Late papers will be accepted, but the overall
grade of the paper will be dropped five points for each day late.
Quality Improvement Proposal Presentation
Purpose: The Quality Improvement Proposal presentation is to simulate a presentation to a healthcare
executive team. The presentation is to demonstrate the student’s ability to synthesize quality improvement
learning from the reading materials and class discussions and identify a quality improvement project from
the results presented in the organizational assessment paper.
Requirements: Proposal should be based on recommendations from the organizational assessment paper
and grounded in evidence-based literature. You are NOT to present a proposal on something that is
currently in process.
In 10 minutes or less, utilizing PowerPoint slides, describe a quality improvement proposal: problem
being addressed, proposed solution, plan for implementation, costs for implementation, and evaluation
criteria. It is the student’s responsibility to be aware of the elapsed time.
Email the presentation to willa.fields@sbcglobal.net the day before your presentation.
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Grade: 10% Evaluation will be based on instructor and peer ratings of the presentation. Peers will use
the Peer Evaluation Form. A half letter grade will be deducted for each three minutes over the allotted 10
minutes.
Course Assessment and Grading
GRADING SCALE
A = 93-100, A-=90-92
B+=87-89, B=83-8, B-=80-82
C+=77-79, C=73-76, C-=70-72
D+=67-69, D=63-66
F=62 or less
Rounding points are at the instructor’s discretion.
REQUIREMENT
PERCENT OF GRADE
Class participation
5%
Tool Presentation
10%
Quality Improvement Presentation
20%
Organizational Assessment Paper
60%
Webinar/Conference Summary
5%
DUE DATE
ongoing
arranged
arranged
5/7
5/7
All assignments are due by 1:00 PM. Assignments submitted on the due date and after 1:00 PM will be
considered late. Five points will be deducted from grade for each day late.
Other Course Policies
STUDENT DISABILITY SERVICES
If you are a student with a disability and believe you will need accommodations for this class, it is your
responsibility to contact Student Disability Services at (619) 594-6473. To avoid any delay in the receipt
of your accommodations, you should contact Student Disability Services as soon as possible. Please note
that accommodations are not retroactive, and that I cannot provide accommodations based upon disability
until I have received an accommodation letter from Student Disability Services. Your cooperation is
appreciated.
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PLAGIARISM
Students are responsible for abiding by the University policy on plagiarism, written below and
found at http://arweb.sdsu.edu/es/catalog/2013-14/Graduate/060070_University%20Policies.pdf. Papers with plagiarized content will have the grade reduced by
25 points. I also strongly encourage you to take the paraphrasing and plagiarism tutorials on the
SDSU library website: http://library.sdsu.edu/guides/sub2.php?id=336&pg=354.
Plagiarism
Plagiarism is defined as the act of incorporating ideas, words, or specific substance of
another, whether purchased, borrowed, or otherwise obtained, and submitting same to the
university as one's own work to fulfill academic requirements without giving credit to the
appropriate source. Plagiarism shall include but not be limited to (a) submitting work,
either in part or in whole, completed by another; (b) omitting footnotes for ideas,
statements, facts, or conclusions that belong to another; (c) omitting quotation marks
when quoting directly from another, whether it be a paragraph, sentence, or part thereof;
(d) close and lengthy paraphrasing of the writings of another; (e) submitting another
person's artistic works, such as musical compositions, photographs, paintings, drawings,
or sculptures; and (f) submitting as one's own work papers purchased from research
companies.
Disciplinary Action
Cheating and plagiarism in connection with an academic program at the university may
warrant two separate and distinct courses of disciplinary action that may be applied
concurrently in response to a violation of this policy: (a) academic sanctions, such as
grade modifications; and (b) punitive sanctions, such as probation, suspension, or
expulsion.
Academic sanctions are concerned with the student's grades and are the responsibility of
the instructor involved. Punitive sanctions are concerned with the student's records and
status on campus and shall be the responsibility of the university president or designated
representative. The Coordinator of Judiciary Procedures shall be the president's
representative in matters of student discipline.
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WEEKLY SCHEDULE
All web sites tested and functioning on December 22, 2014
DATE
1/22
TOPIC/CLASS ACTIVITIES
Introductions
Identify personal goals and priorities
for N622
Course Overview
Introduction to Performance
Improvement
1/29
2/5
National Activities in Performance
Improvement
Quality Improvement Methods and
Tools
Quality Improvement Methods and
Tools (cont)
ASSIGNMENT (to be completed prior to class
session)
Lighter readings:
 Chapter 1: The Business Case for Quality
Patient Safety and Quality: An Evidence-Based
Handbook for Nurses.
 Chapter 1: Defining Patient Safety…
http://www.ahrq.gov/qual/nurseshdbk/docs/Mit
chellP_DPSQ.pdf
Lighter readings:
 Chapter 3: Process Tools
 Chapter 5: Essentials of Statistical Thinking and
Analysis
Patient Safety and Quality: An Evidence-Based
Handbook for Nurses.
 Chapter 44: Tools and Strategies…
http://www.ahrq.gov/qual/nurseshdbk/docs/Hug
hesR_QMBMP.pdf
Lighter readings:
 Chapter 2: Teams in Healthcare Performance
Improvement
Team Collaboration
Error Reporting
QI Methodologies
Sign up for class presentations
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Patient Safety and Quality: An Evidence-Based
Handbook for Nurses.
 Chapter 33: Professional Communication and
Team Collaboration
http://www.ahrq.gov/qual/nurseshdbk/docs/O'D
anielM_TWC.pdf
 Chapter 35: Error Reporting…
http://www.ahrq.gov/qual/nurseshdbk/docs/Wol
fZ_ERED.pdf
DATE
2/12
ASSIGNMENT (to be completed prior to class
session)
TOPIC/CLASS ACTIVITIES
Culture of Safety
High Reliability Organization
Measurement in Quality
Improvement
Student Quality Improvement Tool
Presentations
Lighter readings:
 Chapter 4: Medical Informatics and Information
Resources for Quality Improvement
Web Sites of Interest
 NQF ABCs of Measurement:
http://eoplugin.commpartners.com/NQF/10102
5/ABC%27s%20of%20Measurement%20Publi
cation.pdf
 AHRQ Culture of Safety:
http://www.ahrq.gov/qual/patientsafetyculture
 The Commonwealth Fund:
http://www.commonwealthfund.org
 Hines, S., Luna, K., Lofthus, J., et al. (2008).
Becoming a High Reliability Organization:
Operational Advice for Hospital Leaders.
(Prepared by the Lewin Group under Contract
No. 290-04-0011.) AHRQ Publication No. 080022. Rockville, MD: Agency for Healthcare
Research and Quality.
http://archive.ahrq.gov/professionals/qualitypatient-safety/qualityresources/tools/hroadvice/hroadvice.pdf

Nurse Sensitive Measures:
http://www.nursingworld.org/MainMenuCatego
ries/ThePracticeofProfessionalNursing/PatientS
afetyQuality/Research-Measurement/TheNational-Database/Nursing-SensitiveIndicators_1.aspx
Patient Safety and Quality: An Evidence-Based
Handbook for Nurses.
 Chapter 45: AHRQ Quality Indicators
http://www.ahrq.gov/qual/nurseshdbk/docs/Far
quharM_IS.pdf
Bring Peer Evaluation Forms to class
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DATE
2/19
TOPIC/CLASS ACTIVITIES
The Joint Commission
 National Patient Safety Goals
 Core Measures
Student Quality Improvement Tool
Presentations
2/26
Just Culture
Change Management
3/5
Student Quality Improvement Tool
Presentations
National Baldrige Award
Guest Speaker: 1:00
 Jason Broad, Sr. Director, Sharp
HealthCare
ASSIGNMENT (to be completed prior to class
session)
Web sites:
 The Joint Commission:
http://www.jointcommission.org/
 National Patient Safety Goals:
http://www.jointcommission.org/PatientSafety/
NationalPatientSafetyGoals
 Medicare Hospital Compare:
http://www.medicare.gov/hospitalcompare/sear
ch.html
Bring Peer Evaluation Forms to class
Lighter readings:
 Chapter 6: Approaches to Improvement…
 Chapter 7: Six Sigma…
Bring Peer Evaluation Forms to class
Lighter readings:
 Chapter 8: Alignment and Integration…
Bring to class your organization’s:
 Quality/Performance Improvement Plan
 Organizational Chart for Quality
 Model for Quality/Performance Improvement
Baldrige Web Site to review:
 http://www.nist.gov/baldrige/
3/12
CQI Applications:
Public Health Guest Speaker: 1:00
 K. Michael Peddecord, Dr.P.H.,
Professor Emeritus, SDSU
Comparison of QI and Research
3/19
Student Quality Improvement Tool
Presentations
CQI Applications:
Bring Peer Evaluation Forms to class
Primary Care Guest Speaker: 1:00
 Vicki DeBaca, Vice President,
Sharp Reese Stealy
Student Quality Improvement Tool
Presentations
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Bring Peer Evaluation Forms to class
DATE
3/26
No face
to face
class
session
TOPIC/CLASS ACTIVITIES
Attend a professional conference or
at least two and a half hours of a
Webinar related to patient safety,
quality measurement, or
improvement.
ASSIGNMENT (to be completed prior to class
session)
Write a brief summary of what you learned from
the conference/webinar and how the content related
to the course objectives.
Spring Break No Class 4/2
4/9
Catch-up
4/16
CQI Applications:
Acute Care Guest Speaker: 1:00
 MaryAnn Cone, COO, Sharp
Grossmont Hospital
Patient Safety and Quality: An Evidence-Based
Handbook for Nurses.
 Chapter 38: Medication Reconciliation
http://www.ahrq.gov/qual/nurseshdbk/docs/Bar
nsteinerJ_MR.pdf
Medication Reconciliation
4/23
Quality Improvement Proposal
Presentations
Intersection: Quality and Health IT
Quality Improvement Proposal
Presentations
Bring Peer Evaluation Forms to class
Organizational Assessment Paper Due
Patient Safety and Quality: An Evidence-Based
Handbook for Nurses.
 Chapter 47: Patient Safety and Health
Information Technology
http://www.ncbi.nlm.nih.gov/books/NBK2644/
Health IT and Patient Safety:
http://www.iom.edu/Reports/2011/Health-IT-andPatient-Safety-Building-Safer-Systems-for-BetterCare.aspx
Bring Peer Evaluation Forms to class
4/30
5/7
Quality Improvement Proposal
Presentations
Quality Improvement Proposal
Presentations
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Bring Peer Evaluation Forms to class
Bring Peer Evaluation Forms to class
NURS 622
Organizational Assessment Paper Grading Sheet
Student Name:
Possible
Points
Description
APA Style
Citations written correctly per APA Manual
5
References listed correctly per APA Manual
5
Paper formatted per APA Manual
2
Correct use of APA headings
3
Content
Introduction
5
Purpose statement
5
Organizational Unit Overview
10
Assessment Criteria and Process Description
15
Assessment Results
10
Recommendations
10
Conclusion
10
Clear writing style, use of good grammar and punctuation
10
Content grounded in current evidence
10
TOTAL POSSIBLE POINTS:
100
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Your
Score
Peer Evaluation Form
Class Presentations
Presenter: ______________________
Date: _______________
Presentation Title: _____________________________________________
Please complete the following information about your classmate’s presentation. This information
will be used to provide positive feedback and areas for growth for executive level presentations.
Thank You.
Please rate the presentation in the
following areas.
Needs
Improvement
1
2
Excellent
3
Innovative ideas
Logically and clearly developed
Synthesized classroom and evidencedbased materials
Included relevant and current references
Professional and articulate presentation
PowerPoint slides enhanced material
Answered questions well
Please comment on what you particularly liked about the presentation?
What areas could the presenter improve upon?
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4
5
NA