Key Project Elements

Readmissions for heart failure are still a significant problem in health care, especially in underserved populations. This evidence-based practice (EBP) quality improvement (QI) initiative proposes a nurse-led nurse-led transitional care model to decrease 30-day readmissions at Jackson North Medical Center. The project aims to connect evidence, clinical expertise, and patient needs to improve continuity of care to support patient outcomes and goals of the healthcare system related to safety, quality, and financial sustainability. The paper outlines the site selection process, the key stakeholders, a practice issue, and the framework of translation used to aid implementation: Key Project Elements.

Site Selection

Description of the Three Healthcare Settings

Three sites are proposed for the EBP-QI initiative: Jackson North Medical Center (JNMC), Memorial Hospital Miramar (MHM), and Chen Senior Medical Center (CSMC), which also serve communities in or near Miami Gardens, Florida. JNMC is a public hospital in the Jackson Health System with a mission to provide high-quality, accessible care to medically underserved, racially diverse populations, regardless of ability to pay.

As a private, not-for-profit hospital in the Memorial Healthcare System, MHM serves mostly insured families in a suburban area, and its mission is to provide patient and family-centered care. Lastly, CSMC is a for-profit primary care facility under the ChenMed network specializing in preventive geriatric care for Medicare Advantage beneficiaries with a mission to deliver personalized, VIP-level healthcare to seniors.

Additional Relevant Site Information

The Office of Clinical Transformation at JNMC has existed and supports evidence-based quality initiatives and inter-departmental communication necessary for a successful project. Although MHM has fewer heart failure cases, it boasts advanced clinical technologies and a high-performing nursing staff committed to innovation. CSMC runs a smaller clinic model with an elderly population that is highly engaged in chronic disease management but has weak inpatient capabilities. The presence and absence of these organizational features matter regarding each site’s capacity to adopt, implement, and sustain EBP-QI projects.

Strengths and Weaknesses Comparison

The hospital, JNMC, is highly viable because of the large number of heart failure patients and the Office of Clinical Transformation, which has successfully implemented QI projects such as reducing central line infections in the past. One weakness is that it depends on county funding, which can slow down the allocation of resources. Next, while MHM is good at using tools such as an electronic discharge planning tool, is magnet-designated for nursing, and has a low patient heart failure caseload, it overestimates the scope of its intervention. Lastly, while CSMC has efficient chronic disease protocols such as weekly seniors’ medication reviews, it does not provide inpatient services, and care transition infrastructure has not been developed, reducing implementation feasibility.

Selected Site and Rationale

Jackson North Medical Center was selected because of its alignment with the project’s aims, infrastructure to support implementation, and access to a high-risk patient population. Population needs, institutional support, scalability, and potential for measurable outcomes were considered in making the decision, making JNMC the most viable and impactful site.

Stakeholders

Department That Leads QI Initiatives

At JNMC, the Office of Clinical Transformation leads QI initiatives. Oversees hospital vast performance improvements, planning implementation, and evaluation of these efforts. It works with other clinical departments and administrative leaders to ensure projects tie to institutional priorities and evidence-based standards. When the Office of Clinical Transformation is unavailable, the Chief Nursing Officer (CNO) or Director of Performance Improvement can approve and guide QI projects inside the hospital structure.

Titles/Roles of Relevant Stakeholders

Within multiple organizational levels, stakeholders are key. The Chief Executive Officer (CEO) is responsible for finalizing all institutional initiatives and allocating necessary resources at the executive level. The Chief Nursing Officer (CNO) approves clinical practices, and the nursing staff must be prepared and aligned with the project goals.

The Director of Performance Improvement leads the evaluation process, and continuous monitoring of outcomes is maintained. Other executive stakeholders include the Chief Quality Officer, responsible for ensuring that the initiative complies with government standards and enhances patient safety, and the Medical Director, who provides clinical oversight.

Nurse managers help manage the workflow integration and ensure that staff complies at the mid-level. Case managers for heart failure are key to identifying eligible patients, discharging patients, and coordinating follow‐up care. Discharge planners will ensure the patients get appropriate resources when discharged, and clinical educators will provide training on the new protocols.

Hands-on education and patient monitoring will be provided by the staff nurses, who are at the bedside daily (Patel & Bechmann, 2023). Moreover, patients and families are direct stakeholders who directly impact the initiative’s effectiveness and sustainability by participating in education and adhering to care plans.

Practice or Organization Issue

Practice or Organization Issue Selected

The practice issue selected is the persistent 30-day rate of readmissions to the hospital of heart failure patients at JNMC. This is a chronic condition that affects a large portion of the hospital’s patient population and, when not properly managed post-discharge, is fatal to the patient’s health. Avoidable rehospitalizations are common among many patients experiencing barriers of low health literacy, financial straits, and limited follow-up care (Coyne & Dieperink, 2025). In addition to decreasing patient quality of life, these readmissions can strain hospital revenue and, under value-based reimbursement programs such as those from the Centers for Medicare & Medicaid Services (CMS), these hospitals receive financial penalties.

Why This Issue Makes Sense as the Focus of an EBP-QI Initiative

The issue is quite suitable as an EBP-QI initiative. The most recent literature contains evidence indicating that using transitional care models decreases heart failure readmissions. In multiple hospital systems, nurse-led transitional care interventions decreased readmissions (Sakashita et al., 2025).

Discharge education in a structured form has improved medication adherence and symptom monitoring (Aremu et al., 2022). Dhaliwal and Dang (2024) also noted that telehealth follow‐ups help maintain continuity of care, reducing the probability of rehospitalization. These studies show that structured intervention can dramatically improve patient education, caregiver participation, and schedule follow-up outcomes.

Also, there is more evidence to support this initiative’s basis. Improving self-management and reducing complications are enhanced by involving caregivers in discharge planning (Haverfield et al., 2024). Further, Ciapponi et al. (2021) found that pharmacologic education to the patient during discharge minimizes medication errors and increases patient confidence in accomplishing their health care task, which minimizes the readmission rate. For JNMC’s diverse, high-risk patient population, a nurse-led transitional care program founded on this evidence would immediately address the ‘root causes’ of readmissions. Moreover, this initiative aligns perfectly with the organization’s strategic goals of quality, safety, and financial sustainability and will benefit individual patient outcomes.

Translation Framework/Model

Translation Framework/Model Identified and Described

The Iowa Model of Evidence-based Practice supports the evidence-based practice (EBP) quality improvement (QI) initiative to promote quality care as the framework for this initiative. This provides a systematic way of addressing clinical problems, critically reviewing the best available evidence before piloting new practices and evaluating outcomes before widespread implementation. Developed for nursing practice in the first place, this is now popularly used throughout various healthcare fields (Chiwaula et al., 2021).

The EBP model commences with a trigger, whether a problem in practice or new knowledge, which starts the process of EBP. This promotes stakeholder collaboration, organizational readiness, and ongoing feedback; all are efficient elements of hospital-based QI initiatives like reducing 30-day readmissions.

Rationale for Framework Selection

All three have strong statements about integrating research into frontline clinical practice. However, compared with other frameworks, such as the Knowledge-to-Action (KTA) Framework and the Johns Hopkins EBP Model, the Iowa Model was preferred because of its emphasis on system integration. Unlike the KTA model, which is more theoretical while being policy-oriented, the Iowa Model is a practical, easy-to-follow, and bedside nurse-led change model tailored for direct bedside nursing change (Cullen et al., 2022).

This is particularly helpful at Jackson North Medical Center, where resources are limited, and it encourages forming interdisciplinary teams and evaluating feasibility earlier in the process. In addition, its cycle structure ensures long-term sustainability and iterative improvement, both of which are critical to the success of the transitional care program.

Steps and Processes in the Iowa Model           

The Iowa Model consists of a 7-step process. The first step is the issue identification—in this case, there are high readmission rates. Second, the leadership of the nurses, the case managers, and the quality improvement staff create a team or combine to form a team of stakeholders. Thirdly, relevant research must be collected, and its strength and applicability must be critically appraised.

Fourth, the team evaluates the intervention’s feasibility in the organization (Cullen et al., 2022). Fifth, a nurse-led transitional care model is piloted, including structured education at discharge and post-discharge follow-up by telephone. Sixth, the outcome is measured by monitoring readmission rates, patient satisfaction, and adherence to follow-up. Finally, if the intervention is successful, the intervention is incorporated into standard practice and disseminated within the Jackson Health System to achieve a broader impact.

Conclusion

Conclusively, Jackson North Medical Center’s EBP-QI initiative provides a targeted, evidence-based solution to reducing heart failure readmissions. Using the Iowa model, engaging key stakeholders and existing transitional care gaps, the project attempts to improve outcomes for a vulnerable population. The successful implementation of the project has the potential to advance the hospital’s mission of providing equitable and effective care to its patients by leading to the sustenance of changes in practice, increased patient satisfaction, and improved disease management and quality of care.

References

Aremu, T. O., Oluwole, O. E., Adeyinka, K. O., & Schommer, J. C. (2022). Medication adherence and compliance: Recipe for improving patient outcomes. Pharmacy, 10(5), 1–5. https://doi.org/10.3390/pharmacy10050106

Chiwaula, C. H., Kanjakaya, P., Chipeta, D., Chikatipwa, A., Kalimbuka, T., Zyambo, L., Nkata, S., & Jere, D. L. (2021). Introducing evidence-based practice in nursing care delivery, utilizing the Iowa model in the Kamuzu Central Hospital, Malawi intensive care unit. International Journal of Africa Nursing Sciences, 14(14), 100272. https://doi.org/10.1016/j.ijans.2020.100272

Ciapponi, A., Nievas, S. E. F., Seijo, M., Rodríguez, M. B., Vietto, V., Perdomo, H. A. G., Virgilio, S., Fajreldines, A. V., Tost, J., Rose, C. J., & Elorrio, E. G. (2021). Reducing medication errors for adults in hospital settings. Cochrane Database of Systematic Reviews, 2021(11). https://doi.org/10.1002/14651858.cd009985.pub2

Coyne, E., & Dieperink, K. B. (2025). Effective health communication to reduce avoidable readmission: Enhancing understanding for patients and families. Nursing Open, 12(3). https://doi.org/10.1002/nop2.70187

Cullen, L., Hanrahan, K., Edmonds, S. W., Reisinger, H. S., & Wagner, M. (2022). Iowa implementation for sustainability framework. Implementation Science, 17(1), 1–20. https://doi.org/10.1186/s13012-021-01157-5

Dhaliwal, J. S., & Dang, A. K. (2024, June 7). Reducing hospital readmissions. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK606114/

Haverfield, M. C., De Leon, G., Johnson, A., Jackson, V. L., Basu, G., & Dodge, J. (2024). Transforming the discharge conversation through support and structure: A scoping review. International Journal of Nursing Studies Advances, 6, 100203. https://doi.org/10.1016/j.ijnsa.2024.100203

Patel, P., & Bechmann, S. (2023). Discharge planning. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557819/

Sakashita, C., Endo, E., Ota, E., & Oku, H. (2025). Effectiveness of nurse-led transitional care interventions for adult patients discharged from acute care hospitals: A systematic review and meta-analysis. BMC Nursing, 24(1). https://doi.org/10.1186/s12912-025-03040-w

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EBP, IS, AND QI
Evidence-based practice (EBP) involves a reliance on science to produce evidence that is then used to inform nursing practice and implementation. EBP can be defined as the process of reviewing and analyzing current scientific evidence with the goal of translating this evidence, along with clinical experience and patient preference, into clinical practice. EBP is the cornerstone of clinical practice.

Implementation science (IS) began in the early 2000s when researchers and practitioners recognized the importance of generating knowledge to promote translation of evidence into practice for improvements in the quality and safety of healthcare. Implementation knowledge consists of a growing number of empirical studies, as well as theories, frameworks, and models supporting the understanding of factors associated with successful implementation of evidence-based interventions (Tabak, Khoong, Chambers, & Brownson, 2012).

How does quality improvement (QI) fit into all this? Batalden and Davidoff (2007) described QI as “the combined and unceasing efforts of everyone—healthcare professionals, patients and their families, researchers, payers, planners and educators—to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development” (p. 2).

The overarching concept of QI means that we use select theories, frameworks, and models from implementation science to translate evidence into practice to improve quality. As a DNP-prepared nurse, you may not actually do the research, but it is your responsibility to be able to find the highest quality and most current evidence to support the practice changes with which you are involved.

Note: You will begin your Assignment this week, but you will not submit it until Week 6. Over the next 3 weeks you will learn more about the concepts required to complete this Assignment, including evidence-based practice (EBP), implementation science (IS), and quality improvement (QI).

Also Note: This Assignment is hypothetical in nature and is unrelated to your Practicum and DNP Project. However, the work you put in on this Assignment will help prepare you for the Practicum and DNP Project coming later in your program.

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Remember: This is a two-part Assignment consists of a written paper and a PowerPoint presentation.

To Prepare

• Review the Learning Resources in Weeks 4, 5, and 6 that address evidence-based practice (EBP), implementation science (IS), and quality improvement (QI).
• Review the Learning Resources that address how to use PowerPoint and create narrated PowerPoint presentations.
• Identify three sites within your community that would benefit from an evidence-based practice (EBP) quality improvement (QI) project.
• Based on your professional experience, consider practice or organization issues that would make sense as the focus of an evidence-based practice (EBP) quality improvement (QI) project initiative. Select one on which to focus for this Assignment. Note: You should consider practice or organization issues that you are particularly interested in or passionate about.
• Search the Walden Library and/or the internet to identify at least five recent, peer-reviewed articles (published within the last 5 years) to support the development of a QI project that applies EBP to address the specific practice or organization issue you selected.
• Based on the practice or organization issue you selected, consider the key stakeholders who would be involved in a QI initiative at each of the three sites you selected. For each site, research the website and any other available information to identify:
  • A department that leads QI initiatives or, if one does not exist, an employee within the organization who would be in charge of approving such initiatives
  • Titles/roles of relevant stakeholders (including the highest level of required approval to the healthcare associates who might help implement changes in daily patient care)
• Select one of the three potential sites you identified that you think is the best option. Consider the factors on which you based your decision, as well as the mechanics of your decision-making process.
• Based on the practice or organization issue and the site you selected, consider various translation frameworks/models that may be a good fit for your evidence-based practice (EBP) quality improvement (QI) initiative.
• Select one translation framework/model that you think is the best fit. Then, consider the steps or processes required for an evidence-based practice (EBP) quality improvement (QI) initiative that follows this framework/model to translate research and evidence to improve practice. Note: Utilize the Week 5 Learning Resources and Discussion to help you with this.
• Begin outlining how you would present the elements of your proposed evidence-based practice (EBP) quality improvement (QI) initiative to key stakeholders of the site you selected in order to gain their approval. Note: You will use the College of Nursing PowerPoint Template document, provided in the Learning Resources, to develop this presentation to stakeholders.
  

  Key Project Elements

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Note: This is a two-part Assignment consisting of a written paper and a PowerPoint presentation.