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As a nurse leader, you will be called upon to collect and analyze data, then to use the data to drive change.
For this assignment, you will be presented with two sets of data. Both sets are representative of the occurrence of pressure ulcers in long-stay nursing home patients.
One set of data (NHQDR) represents national data as compared to the state of Georgia.
The second data set (Medicare.gov) is specific for the nursing home in Georgia where you are the supervisor. View and interpret the data specific to pressure injury rates.
After you interpret the data in Part 1, you will create a staff in-service to address the identified concerns in Part 2.
Access the data by scanning the QR code to the right.
If you are unable to use the QR code, the data is available here.
Rubric
Data-Driven Process Improvement
Data-Driven Process Improvement
Criteria Ratings Pts
This criterion is linked to a Learning OutcomePart 1: Data interpretation
10 pts
Exemplary
Through the lens of a leader, learner interprets national and local data citing specific examples of how the data compares to each other. Examples of strengths and weaknesses (at least one example of each) of the data are identified and discussed. This submission represents an analytical interpretation of data.
7 pts
Proficient
Learner interprets national and local data citing an example of how the data compares to each other. Examples of strengths or weaknesses (at least one example of each) of the data are identified and briefly discussed. This submission could benefit from the inclusion of additional details, examples, or discussion.
4 pts
Developing
Despite an attempt, appropriate interpretations and strengths and weaknesses of data of national and local data are not achieved.
0 pts
Does not meet expectations
Learner did not attempt to interpret the data sets.
10 pts
This criterion is linked to a Learning OutcomePart 1: ‘Never Event’
10 pts
Exemplary
Through the lens of a leader, learner accurately and thoroughly defined a ‘Never Event’ and discussed how this would affect their facility. Submission reflects an understanding of the impact of data on facilities.
7 pts
Proficient
Learner accurately defined a ‘Never Event’ and briefly discussed how this would affect their facility. Submission could benefit from the inclusion of additional details, examples, or discussion.
4 pts
Developing
Learner accurately defined a ‘Never Event’, but the discussion of how this affects the facility is missing.
0 pts
Does not meet expectations
A ‘Never Event’ is inaccurately defined or this section is missing.
10 pts
This criterion is linked to a Learning OutcomePart 2: In-service creation
10 pts
Exemplary
Through the lens of a leader, the learner researches and designs an in-service to address the pressure injury rate at the facility. At a minimum, these items are included: the proper use of barrier cream, 6 or more complications of immobility, 6 or more interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. Learner is specific and descriiptive in the responses to each prompt. This submission represents content mastery of pressure injury prevention.
7 pts
Proficient
Learner researches and designs an in-service to address the pressure injury rate at the facility. All required items were included, but one or more of these items lacked the required number of examples: the proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. While each item is present, the submission could benefit from the inclusion of additional, details, or examples.
4 pts
Developing
The learner researches and designs an in-service to address the pressure injury rate at the facility. One or two of these items were not addressed or lacked the required number of examples: proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. The submission could benefit from the inclusion of all required criteria, details, or examples.
0 pts
Does not meet expectations
Three or more of these items were not addressed or lacked the required number of examples: proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients.
10 pts
This criterion is linked to a Learning OutcomePart 2: Follow-up plan
10 pts
Exemplary
Through the lens of a leader, a specific in-service evaluation plan is identified and discussed. A plan for if the in-service is not effective is also identified and discussed. Specific examples are included. This submission represents insight into a data-driven process improvement plan evaluation.
7 pts
Proficient
The learner identified and briefly disussed an in-service evaluation plan and also a plan if the in-services is deemed unsuccessful. All required items were included, but one of these items lacked discussion and insight into an evaluation plan.
4 pts
Developing
The learner identified and briefly disussed an in-service evaluation plan and also a plan if the in-services is deemed unsuccessful. All required items were included, but both of these items lacked discussion and insight into an evaluation plan.
0 pts
Does not meet expectations
An evaluation plan is not identified.
10 pts
This criterion is linked to a Learning OutcomeProfessionalism of writing
5 pts
Exemplary
The submission represents a professional writing submission. Complete sentences are used, and the paper is free of grammatical and spelling errors. APA 7th edition formatting is consistently followed, and a reference page (author, publication year, source) and in-text citations are utilized to give credit to source(s).
3 pts
Proficient
Complete sentences are used, and the paper contains 1-2 grammatical and spelling errors. APA 7th edition formatting is consistently followed, and a reference page (author, publication year, source) and in-text citations are utilized to give credit to source(s).
2 pts
Developing
Complete sentences are used, but the paper contains 3-4 grammatical or spelling errors. Use of APA 7th Edition guidelines are generally present; however, reference(s) are incorrectly formatted (missing author, publication year, and/or source).
0 pts
Does not meet expectations
Question responses are not all phrased in complete sentences and/or contain numerous (5 or more) grammatical or spelling errors. APA 7th Edition guidelines are not followed for in-text citations and/or reference(s) (missing author, publication year, and/or source). Submission could benefit from use of the Writing Center.Data-Drive Process Improvement: Quality and Safety Data
National Data (NHQDR):
image.png
https://datatools.ahrq.gov/nhqdr/?_gl=1%2Agtuph6%2A_ga%2AMjA4MTQ0NjIzLjE2OTk1NDIzMDA.%2A_ga_1NPT56LE7J%2AMTY5OTg5MTc1NC4zLjEuMTY5OTg5NDY3Mi4wLjAuMALinks to an external site.
Links to an external site.Data query -> State Categories -> Georgia -> Measure -> High-Risk, long-stay nursing home patients with pressure ulcer
Data for your nursing home in Georgia (Medicare.gov):
image.png
https://www.medicare.gov/care-compare/details/nursing-home/115343?state=GA&measure=nursing-home-quality-of-careLinks to an external site.
Long-Stay Quality Measures
Using the data provided to you, answer the following questions. Record your answers on a Word document.
As the supervisor of this nursing home, how do you interpret this data? What is it telling you? Give specific examples in your comparison of the data sets.
What are the strengths and weaknesses of the data? Give at least one example of each.
“Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care setting” (National Quality Forum, 2016) is considered a ‘Never Event’. What is a ‘Never Event’? What does that mean to your facility? (https://psnet.ahrq.gov/primer/never-events#:~:text=The%20term%20%22Never%20Event%22%20was,surgery%E2%80%94that%20should%20never%20occurLinks to an external site..)
Rubric
Data-Driven Process Improvement
Data-Driven Process Improvement
Criteria Ratings Pts
This criterion is linked to a Learning OutcomePart 1: Data interpretation
10 pts
Exemplary
Through the lens of a leader, learner interprets national and local data citing specific examples of how the data compares to each other. Examples of strengths and weaknesses (at least one example of each) of the data are identified and discussed. This submission represents an analytical interpretation of data.
7 pts
Proficient
Learner interprets national and local data citing an example of how the data compares to each other. Examples of strengths or weaknesses (at least one example of each) of the data are identified and briefly discussed. This submission could benefit from the inclusion of additional details, examples, or discussion.
4 pts
Developing
Despite an attempt, appropriate interpretations and strengths and weaknesses of data of national and local data are not achieved.
0 pts
Does not meet expectations
Learner did not attempt to interpret the data sets.
10 pts
This criterion is linked to a Learning OutcomePart 1: ‘Never Event’
10 pts
Exemplary
Through the lens of a leader, learner accurately and thoroughly defined a ‘Never Event’ and discussed how this would affect their facility. Submission reflects an understanding of the impact of data on facilities.
7 pts
Proficient
Learner accurately defined a ‘Never Event’ and briefly discussed how this would affect their facility. Submission could benefit from the inclusion of additional details, examples, or discussion.
4 pts
Developing
Learner accurately defined a ‘Never Event’, but the discussion of how this affects the facility is missing.
0 pts
Does not meet expectations
A ‘Never Event’ is inaccurately defined or this section is missing.
10 pts
This criterion is linked to a Learning OutcomePart 2: In-service creation
10 pts
Exemplary
Through the lens of a leader, the learner researches and designs an in-service to address the pressure injury rate at the facility. At a minimum, these items are included: the proper use of barrier cream, 6 or more complications of immobility, 6 or more interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. Learner is specific and descriiptive in the responses to each prompt. This submission represents content mastery of pressure injury prevention.
7 pts
Proficient
Learner researches and designs an in-service to address the pressure injury rate at the facility. All required items were included, but one or more of these items lacked the required number of examples: the proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. While each item is present, the submission could benefit from the inclusion of additional, details, or examples.
4 pts
Developing
The learner researches and designs an in-service to address the pressure injury rate at the facility. One or two of these items were not addressed or lacked the required number of examples: proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. The submission could benefit from the inclusion of all required criteria, details, or examples.
0 pts
Does not meet expectations
Three or more of these items were not addressed or lacked the required number of examples: proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients.
10 pts
This criterion is linked to a Learning OutcomePart 2: Follow-up plan
10 pts
Exemplary
Through the lens of a leader, a specific in-service evaluation plan is identified and discussed. A plan for if the in-service is not effective is also identified and discussed. Specific examples are included. This submission represents insight into a data-driven process improvement plan evaluation.
7 pts
Proficient
The learner identified and briefly disussed an in-service evaluation plan and also a plan if the in-services is deemed unsuccessful. All required items were included, but one of these items lacked discussion and insight into an evaluation plan.
4 pts
Developing
The learner identified and briefly disussed an in-service evaluation plan and also a plan if the in-services is deemed unsuccessful. All required items were included, but both of these items lacked discussion and insight into an evaluation plan.
0 pts
Does not meet expectations
An evaluation plan is not identified.
10 pts
This criterion is linked to a Learning OutcomeProfessionalism of writing
5 pts
Exemplary
The submission represents a professional writing submission. Complete sentences are used, and the paper is free of grammatical and spelling errors. APA 7th edition formatting is consistently followed, and a reference page (author, publication year, source) and in-text citations are utilized to give credit to source(s).
3 pts
Proficient
Complete sentences are used, and the paper contains 1-2 grammatical and spelling errors. APA 7th edition formatting is consistently followed, and a reference page (author, publication year, source) and in-text citations are utilized to give credit to source(s).
2 pts
Developing
Complete sentences are used, but the paper contains 3-4 grammatical or spelling errors. Use of APA 7th Edition guidelines are generally present; however, reference(s) are incorrectly formatted (missing author, publication year, and/or source).
0 pts
Does not meet expectations
Question responses are not all phrased in complete sentences and/or contain numerous (5 or more) grammatical or spelling errors. APA 7th Edition guidelines are not followed for in-text citations and/or reference(s) (missing author, publication year, and/or source). Submission could benefit from use of the Writing Center.
Submit Parts 1 and 2 at the same time as part of the same project.
Give credit to your sources using APA 7th edition format.
Use both in-text citations and a reference page.
Please visit the Writing Center if you need assistance.

image.png
Rubric
Data-Driven Process Improvement
Data-Driven Process Improvement
Criteria Ratings Pts
This criterion is linked to a Learning OutcomePart 1: Data interpretation
10 pts
Exemplary
Through the lens of a leader, learner interprets national and local data citing specific examples of how the data compares to each other. Examples of strengths and weaknesses (at least one example of each) of the data are identified and discussed. This submission represents an analytical interpretation of data.
7 pts
Proficient
Learner interprets national and local data citing an example of how the data compares to each other. Examples of strengths or weaknesses (at least one example of each) of the data are identified and briefly discussed. This submission could benefit from the inclusion of additional details, examples, or discussion.
4 pts
Developing
Despite an attempt, appropriate interpretations and strengths and weaknesses of data of national and local data are not achieved.
0 pts
Does not meet expectations
Learner did not attempt to interpret the data sets.
10 pts
This criterion is linked to a Learning OutcomePart 1: ‘Never Event’
10 pts
Exemplary
Through the lens of a leader, learner accurately and thoroughly defined a ‘Never Event’ and discussed how this would affect their facility. Submission reflects an understanding of the impact of data on facilities.
7 pts
Proficient
Learner accurately defined a ‘Never Event’ and briefly discussed how this would affect their facility. Submission could benefit from the inclusion of additional details, examples, or discussion.
4 pts
Developing
Learner accurately defined a ‘Never Event’, but the discussion of how this affects the facility is missing.
0 pts
Does not meet expectations
A ‘Never Event’ is inaccurately defined or this section is missing.
10 pts
This criterion is linked to a Learning OutcomePart 2: In-service creation
10 pts
Exemplary
Through the lens of a leader, the learner researches and designs an in-service to address the pressure injury rate at the facility. At a minimum, these items are included: the proper use of barrier cream, 6 or more complications of immobility, 6 or more interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. Learner is specific and descriiptive in the responses to each prompt. This submission represents content mastery of pressure injury prevention.
7 pts
Proficient
Learner researches and designs an in-service to address the pressure injury rate at the facility. All required items were included, but one or more of these items lacked the required number of examples: the proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. While each item is present, the submission could benefit from the inclusion of additional, details, or examples.
4 pts
Developing
The learner researches and designs an in-service to address the pressure injury rate at the facility. One or two of these items were not addressed or lacked the required number of examples: proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients. The submission could benefit from the inclusion of all required criteria, details, or examples.
0 pts
Does not meet expectations
Three or more of these items were not addressed or lacked the required number of examples: proper use of barrier cream, complications of immobility, interventions to prevent immobility complications, and the proper ergonomics while moving or repositioning clients.
10 pts
This criterion is linked to a Learning OutcomePart 2: Follow-up plan
10 pts
Exemplary
Through the lens of a leader, a specific in-service evaluation plan is identified and discussed. A plan for if the in-service is not effective is also identified and discussed. Specific examples are included. This submission represents insight into a data-driven process improvement plan evaluation.
7 pts
Proficient
The learner identified and briefly disussed an in-service evaluation plan and also a plan if the in-services is deemed unsuccessful. All required items were included, but one of these items lacked discussion and insight into an evaluation plan.
4 pts
Developing
The learner identified and briefly disussed an in-service evaluation plan and also a plan if the in-services is deemed unsuccessful. All required items were included, but both of these items lacked discussion and insight into an evaluation plan.
0 pts
Does not meet expectations
An evaluation plan is not identified.
10 pts
This criterion is linked to a Learning OutcomeProfessionalism of writing
5 pts
Exemplary
The submission represents a professional writing submission. Complete sentences are used, and the paper is free of grammatical and spelling errors. APA 7th edition formatting is consistently followed, and a reference page (author, publication year, source) and in-text citations are utilized to give credit to source(s).
3 pts
Proficient
Complete sentences are used, and the paper contains 1-2 grammatical and spelling errors. APA 7th edition formatting is consistently followed, and a reference page (author, publication year, source) and in-text citations are utilized to give credit to source(s).
2 pts
Developing
Complete sentences are used, but the paper contains 3-4 grammatical or spelling errors. Use of APA 7th Edition guidelines are generally present; however, reference(s) are incorrectly formatted (missing author, publication year, and/or source).
0 pts
Does not meet expectations
Question responses are not all phrased in complete sentences and/or contain numerous (5 or more) grammatical or spelling errors. APA 7th Edition guidelines are not followed for in-text citations and/or reference(s) (missing author, publication year, and/or source). Submission could benefit from use of the Writing Center.

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