NRS-465: Capstone Change Project Evaluation
Instructions: Complete the table and questions that follow to develop an evaluation plan for your proposed project. Use the Topic 5 Implementation Plan assignment and associated faculty feedback as a starting point. Students will have 3-5 objective (goal) and outcome pairs for which an evaluation plan will be developed.
Part I: Evaluation Plan
| Project Objective (Goal) | Measurable Project Outcome | What data will be collected to measure this outcome? | What tool will be used to collect the data? | Who will be responsible for collecting data? |
| 1. Improve Adherence to Standardized Infection Control Protocols Among Surgical Staff Within 30 Days | In the first 30 days, the compliance of staff members with infection control practices will increase to 90%. | The results of the weekly compliance audit from surgical units shall be ensured to be collected to track adherence rates: NRS-465: Capstone Change Project Evaluation
Sample audit questions may include: 1. Is appropriate hand hygiene behavior observed in patient care? Yes/No 2. Is appropriate use of PPE utilized in all surgical procedures? Yes/No 3. Was sterile field maintenance observed for each operation? Yes/No. |
Information on adherence to protocol will be gathered through observation checklists and compliance audit forms. These tools will capture specific infection control practices, including hand hygiene, PPE use, and sterilization (Babore et al., 2024). | Data collection will be managed by the Infection Control Nurse, who will conduct weekly compliance audits and review completed checklists. |
| 2. Reduce Surgical Site Infection Rates by 20% within 30 days postoperatively | SSI rates will be reduced by 20% from baseline data collected prior to the institution of the new protocol. | Infection incidence data by month will be abstracted from postoperative patient records to measure the change in infection rates (Zabaglo & Sharman, 2024).
Sample data points from infection reports include the following: 1. How many SSIs occurred in patients within 30 days post-surgery? 2. Were infections associated with non-compliance to protocols? Yes or No. 3. What percentage of surgeries showed adherence to the standardized protocol? |
Data on SSI will be collected and analyzed using Electronic Health Records and infection tracking software. These systems have proven to provide reliable, timely information on patient outcomes and make trend analysis easier. | The Infection Control Team shall provide data on infections, analyzing them for accuracy and consistency in reporting. |
| 3. Improve Patient Knowledge and Involvement with Infection Prevention by Education for Wound Care after Operations | 85% of the patients will demonstrate awareness of infection-prevention measures as measured in a post-education survey after their educational session. | Results on patient questionnaires about their understanding of infection prevention practices, including wound care, will be collected and reviewed.
Sample Survey Questions: 1. Do you know what the proper treatment of your wound is? Yes or No 2. Is it significant for you to keep your wound dry and covered? Yes or No 3. What are complications/ early signs of infection that you should bring to the attention of your nurse/doctor? Specify. |
The patient education questionnaires will be tailored to assess the knowledge retention and application of infection prevention practices (Abalkhail et al., 2021). | The Patient Educator will also be responsible for administering and collating results from the questionnaires and ensuring that feedback is integrated into ongoing education. |
| 4. Consistent use of antibacterial sutures and wound-edge protectors in all eligible surgeries | During the evaluation period, 95% of eligible surgeries will use a combination of antimicrobial sutures and wound-edge protectors. | Surgical procedure logs will indicate the use of these materials in operations, thus serving as a clear record of adherence to the intervention (Toru et al., 2023)
Some examples of log data to capture would include: 1. Was an antibacterial suture utilized in the surgical procedure? Yes/No. 2. Was the use of wound-edge protectors in the surgical procedure? Yes/No. 3. If no, state the reason it was not utilized. |
The operating room team shall track surgical logs and material usage records, which shall serve as the main monitoring tools to track compliance. | The Operating Room Nurse will monitor and report on the use of antibacterial sutures and wound-edge protectors. |
| 5. Use of Statistical Process Control (SPC) charts for monitoring the trends in infection control as a basis for managerial decision making. | Trends in SSI rates will be identified and analyzed using SPC charts, and if automation ensures > 95% of the deviation will be handled within one week (Baker et al., 2020). | Data points from SSI trend analyses will be gathered on a weekly basis.
Sample Trend analysis data points include: 1. Was there a deviation from baseline SSI rates? Yes or No. 2. Were interventions implemented in a timely manner for identified deviations? Yes or No. 3. What changes were made to address the trends? Specify. |
SPC charts have, therefore, been established in the hospital’s health information system. | The quality Improvement Team will be responsible for data collection. |
Part II: Communication Plan
| How will the data collected be communicated to the team?
|
| Good communication ensures that all the stakeholders are always updated with the progress or results of the evaluation plan. The following will be used as strategies for the dissemination of information:
Weekly Updates The Infection Control Nurse will complete weekly summaries of the compliance rates and preliminary trends in SSI rates. These will be emailed to the surgical team, infection control staff, and hospital administrators weekly. Key metrics are included in each week’s update: the percentage of adherence to protocols and the number of surgical procedures using the recommended materials (Sartelli et al., 2020).
Bi-Weekly Multidisciplinary Team Meetings: The team is multidisciplinary and includes representatives of nursing, surgery, infection control, and patient education. It meets every two weeks. This team will review SSI trends and compliance data resulting from patient education. Discussions cover reviewing barriers, solving problems, and refining the intervention strategies.
· Attendance and minutes of all meetings will be recorded for reference and accountability purposes. · The real-time data presentation will use visual aids like SPC charts and dashboards. · In subsequent meetings, actionable plans will be developed, and progress will be monitored.
Monthly Staff Meetings The Infection Control Team will also be presenting data at monthly staff meetings. Graphs and charts will visually identify trends in compliance rates, infection rates, and patient education outcomes. These presentations will facilitate discussions about challenges, successes, and opportunities for improvement.
Real-Time Dashboards A digital dashboard integrated into the hospital’s health information system will provide real-time data on compliance rates, infection trends, and other relevant metrics. This will be made available to all stakeholders to ensure transparency and allow timely interventions (Rabiei & Almasi, 2022).
Final Report At the end of the 30-day evaluation period, a comprehensive report summarizing the results of the intervention will be prepared. It shall include a detailed analysis of each objective, a visual representation of data, and recommendations for sustaining improvement in infection control practices. The final report shall then be presented to the leadership and shared with the larger health team to inform future quality improvement initiatives. |
References
Abalkhail, A., Al Imam, M. H., Elmosaad, Y. M., Jaber, M. F., Hosis, K. A., Alhumaydhi, F. A., Alslamah, T., Alamer, A., & Mahmud, I. (2021). Knowledge, Attitude and Practice of Standard Infection Control Precautions among Health-Care Workers in a University Hospital in Qassim, Saudi Arabia: A Cross-Sectional Survey. International Journal of Environmental Research and Public Health, 18(22), 11831. https://doi.org/10.3390/ijerph182211831
Baker, A. W., Nehls, N., Ilieş, I., Benneyan, J. C., & Anderson, D. J. (2020). Use of optimised dual statistical process control charts for early detection of surgical site infection outbreaks. BMJ Quality & Safety, 29(6), 517–520. https://doi.org/10.1136/bmjqs-2019-010586
Babore, G. O., Eyesu, Y., Mengistu, D., Foga, S., Heliso, A. Z., & Ashine, T. M. (2024). Adherence to infection prevention practice standard protocol and associated factors among healthcare workers. Global Journal on Quality and Safety in Healthcare, 7(2), 50–58. https://doi.org/10.36401/jqsh-23-14
Toru, H. K., Aizaz, M., Orakzai, A. A., Jan, Z. U., Khattak, A. A., & Ahmad, D. (2023). Improving the quality of general surgical operation notes according to the Royal College of Surgeons (RCS) guidelines: A closed-loop audit. Cureus. https://doi.org/10.7759/cureus.48147
Rabiei, R., & Almasi, S. (2022). Requirements and challenges of hospital dashboards: a systematic literature review. BMC Medical Informatics and Decision Making, 22(1). https://doi.org/10.1186/s12911-022-02037-8
Sartelli, M., Pagani, L., Iannazzo, S., Moro, M. L., Viale, P., Pan, A., Ansaloni, L., Coccolini, F., D’Errico, M. M., Agreiter, I., Amadio Nespola, G., Barchiesi, F., Benigni, V., Binazzi, R., Cappanera, S., Chiodera, A., Cola, V., Corsi, D., Cortese, F., & Crapis, M. (2020). A proposal for a comprehensive approach to infections across the surgical pathway. World Journal of Emergency Surgery, 15(1). https://doi.org/10.1186/s13017-020-00295-3
Zabaglo, M., & Sharman, T. (2024, March 5). Postoperative Wound Infection. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560533/
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Question 
The purpose of this assignment will be to develop an evaluation plan for your capstone change project.Review your implementation plan including the objectives and outcomes and review your required resources. Then, develop a process to evaluate the intervention if it were implemented.Use the “Capstone Change Project Evaluation Plan” template to complete the assignment.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
NRS-465: Capstone Change Project Evaluation
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite.
Client’s Notes:
- Enhancing Infection Control Practice in surgical wounds patient
- PICOT: In hospitalized patients with surgical wounds (P), how does the implementation of a standardized infection control protocol (I) compared to the usual infection control practices (C) affect the rate of surgical site infections (O) within a 30-day postoperative period(T)?