MSN support page for a 7–10 slide quality improvement proposal that interprets HAI dashboard data and communicates a structured QI strategy.
This assessment requires a 7–10 slide PowerPoint proposal that interprets dashboard data and communicates a quality improvement initiative to address a selected health care issue.
A Quality Improvement Initiative Proposal
Student’s Name
Course
The Problem
Hospital-acquired infections (HAIs) are a significant risk to patient safety in the United States. About 1 out of every 31 hospitalized patients gets at least one HAI (CDC, 2026).
National Scope
It is estimated that 687,000 HAIs were identified in U.S. acute care hospitals in 2015. Although HAI rates have been reduced in recent years, they continued to escalate greatly throughout the Covid-19 pandemic and are just beginning to re-stabilize to pre-pandemic levels (CDC, 2026).
Financial Impact
The benefits of HAI prevention in the United States include $25 – $31.5 billion in reduced healthcare costs per year, fewer hospital stays and deaths.
1 in 31
hospitalized patients has an HAI daily
687K+
HAIs in U.S. acute care hospitals (2015 estimate)
~72,000
patients die during hospitalizations due to HAIs
Key Findings
↓ 10% CAUTI reduction (2023–2024)
↓ 9% CLABSI reduction (2023–2024)
↓ 11% C. diff reduction (2023–2024)
↑ 8% SSI (hysterectomy) INCREASE
The SIR is used as a benchmark with a score below 1.0 being better than the national baseline.
Data Source: CDC NHSN 2024 Annual HAI Progress Report, Healthgrades Patient Safety Methodology (2026)
Identified Concern
The rate of HAIs, such as CAUTIs and CLABSIs, continue to be higher than the benchmark in many acute care hospitals. The overall performance of the school has improved over time, but there are significant differences between the best and worst schools.
Benchmark Requirement
The HHS National Action Plan (2024-2028) includes continued efforts to decrease the rates of CAUTI, CLABSI, C. diff, MRSA, and SSI with the goal of achieving SIR < 1.0 as the national target for these rates. These are measured and publicly reported on CMS Hospital Compare and Healthgrades star ratings (HHS, 2024).
Data Quality
NHSN data is risk adjusted and represented by a network of more than 38,000 facilities that is validated. The 3-year rolling MedPAR data is assessed against AHRQ Patient Safety Indicators, providing reliability and comparability across settings, and then used by Healthgrades.
The goal is to implement a structured bundle-based intervention program to achieve SIR ≤ 0.80 for CAUTI and CLABSI within 12 months.
Simulated baseline estimates that are consistent with peer-reviewed literature – to be verified with local NHSN data pull.
PDSA Cycle Framework
PLAN
Conduct root cause analysis for HAI; create protocol for the bundle and staff education plan; establish baseline metrics.
DO
Implement CAUTI/CLABSI prevention bundles; roll out hand hygiene training; implement audit checklists.
STUDY
Review monthly NHSN SIR data, review compliance audit and use run charts to identify gaps.
ACT
Maintain successful changes; adjust to strategies if target not achieved; start next PDSA cycle.
01
HAI Prevention Bundles
Use HHS Daily Necessity Assessment checklists for AHRQ-recommended CAUTI/CLABSI bundles.
02
Hand Hygiene Audits
Multiple Mode programme using covert observations, electronic monitoring and instant feedback. Evidence shows 47% to 80%+ improvement (Kumar et al., 2022; Chitamanni et al., 2023).
03
Audit & Feedback
Moderate evidence exists for audit and feedback, or provider reminder systems (PRS) to increase adherence and lower infection rates (Tuma et al., 2023).
04
Staff Education
Interprofessional simulation training and competency checks and just in time learning modules addressing identified knowledge gaps.
RN
Registered Nurses
Assessment of CAUTI need every day; central line care and maintenance per bundle; hand hygiene audit; patient and family education: infection prevention.
IP
Infection Prevention Specialist
Compile and monitor NHSN data; perform root cause analysis; create and revise bundle protocols; give real-time quality control feedback.
MD
Physicians / APPs
Promoted timely removal of catheter and central line, antibiotic stewardship, involvement in PDSA planning sessions, and leadership in surgical site infection review.
Rx
Pharmacist
Support for antibiotic stewardship program; review surgery patients' antibiotic timing for prophylaxis; identify high-risk patients to target.
QS
Quality & Safety Officer
Monitor reporting on the dashboard; prepare monthly trend reports for the SIR; report to leadership; maintain regulatory and accreditation standards.
NL
Nursing Leadership
Encourage and promote a culture of safety in your organization; invest in training; reward high-performing units; include QI in the annual performance review.
Patient Safety
One HAI prevented = one patient spared additional suffering, extended hospital stay and risk of death.
Preventing CAUTI decreases the risk for sepsis, and preventing CLABSI decreases the risk for bloodstream infection and transfer to the ICU.
Patients at highest-safety hospitals have much lower rates of complications (Healthgrades, 2026).
Facilities with SIR < 1.0 are eligible for consideration to be recognized by the Healthgrades Patient Safety Excellence Award.
Cost-Effectiveness
It is estimated that HAIs cost the U.S. health care system $25-$31.5 billion per year.
Prevention is a direct CMS financial priority as they are not reimbursed for certain HAIs.
With a 10% reduction in CAUTI rates you can actually see the cost savings per 1000 catheter-days.
The return on investment for bundle training and audit systems is high and yields benefits within 12–18 months.
Work-Life Quality
Less HAIs lighten the emotional load of nurses caring for patients who could have been prevented from developing complications.
Clear protocols and check lists minimize the cognitive burden and decision fatigue at the bedside.
Staff morale and job satisfaction is enhanced by recognition of unit level improvement.
When doctors and nurses work as a team, it fosters a collaborative team atmosphere and helps minimize burnout and employee turnover.
Communication is a common thread that holds all successful QI efforts together.
SBAR Communication Tool
When you need to communicate with physicians and charge nurses when you are escalating your concern for HAI or reporting a compliance issue, the Situation–Background–Assessment–Recommendation (SBAR) structure is a good way to keep your communication succinct and complete.
Situation: Daily huddles, incident escalation, handoff communication.
CUS Assertion Tool
I'm Concerned – I'm Uncomfortable – This is a Safety Issue. Encourages everyone on the team to raise safety concerns without barriers — especially if the line/catheter is not removed in a timely fashion.
Use case: Bedside Safety Concerns and Interprofessional escalation
Monthly Data Dashboards
HAI SIR trend reports shared to all units on shared EHR dashboard and sent to unit leaders and medical staff by email.
Interprofessional Huddles
Short 10-minute safety meetings at the beginning of the shift, following a short agenda (yesterday, today, and prevention).
Visual Management Boards
Whiteboards showing compliance in real time within the unit, for shared accountability and visible progress, such as hand hygiene, bundle adherence.
Simulation Debriefing
Structured debriefs following a simulation reinforce good communication skills and pinpoint system-level impediments to compliance, based on the TeamSTEPPS principles.
Phase 1
Months 1–2
Foundation
Baseline NHSN data pull & analysis
Employees training & simulation training
Bundle protocol finalization
Audit tool development
Phase 2
Months 3–6
Implementation
Ensure CAUTI & CLABSI bundles are launched.Ensure CAUTI & CLABSI bundles are launched.
Start hand hygiene covert audits.Implement hand hygiene covert audits.
Daily huddles initiated
SBAR/CUS training complete
Phase 3
Months 7–9
Evaluation
Mid-cycle NHSN SIR review
PDSA Step: Study
Stakeholder feedback sessions
Any protocol refinement as needed
Phase 4
Months 10–12
Sustainment
Comprehensive 12-month SIR outcome report
Praise successes and acknowledge deficits;
Policy integration & standardization
Submit for Healthgrades evaluation.
The statistics are alarming: 1/31 hospitalized patients gets an HAI every day and it is preventable.
This PDSA-based project will focus on CAUTI, CLABSI, and hand hygiene compliance with the goal of achieving measurable targets in keeping with HHS 2024-2028 national targets.
Operational foundation includes the evidence-based bundle protocols, structured audits and interprofessional communication tools (SBAR, CUS).
Sustained success relies on interprofessional engagement, for example, nurses, physicians, pharmacists, infection prevention and quality leaders.
Expected results: 12-month SIR < 0.80 for CAUTI/CLABSI, ≥ 80% hand hygiene compliance, measurable patient safety and cost savings.
"If you can't measure it, you can't improve it." — AHRQ
Centers for Disease Control and Prevention. (2026). 2024 national and state healthcare-associated infections progress report. U.S. Department of Health & Human Services. https://www.cdc.gov/healthcare-associated-infections/php/data/progress-report.html
Healthgrades. (2026). Patient safety excellence award: Methodology. RVO Health. https://www.healthgrades.com/quality/ratings-awards/method/healthgrades-patient-safety-methodology
Kumar, A., Kumar, R., Gupta, A. K., Kishore, S., Kumar, M., Ahmar, R., Prakash, J., & Sharan, S. (2022). Improvement of hand hygiene compliance using the Plan-Do-Study-Act method: Quality improvement project from a tertiary care institute in Bihar, India. Cureus, 14(6), e25590. https://doi.org/10.7759/cureus.25590
Pavani Chitamanni, Ahreen Allana, & Hand, I. (2023). Quality Improvement Project to Improve Hand Hygiene Compliance in a Level III Neonatal Intensive Care Unit. Children (Basel), 10(9), 1484–1484. https://doi.org/10.3390/children10091484
U.S. Department of Health and Human Services. (2024). National HAI targets & metrics: National action plan to prevent health care-associated infections 2024–2028. https://www.hhs.gov/oidp/topics/health-care-associated-infections/targets-metrics/index.html
Tuma, P., Vieira Junior, J. M., Ribas, E., Silva, K. C. C. D., Gushken, A. K. F., Torelly, E. M. S., de Moura, R. M., Tavares, B. M., Prandini, C. M., Borem, P., Delgado, P., Ue, L. Y., de Barros, C. G., Vernal, S., Petenate, A. J., Teixeira, A. M., Martins, A., Toniolo, A. do R., Brenner, A., & Pedroso, A. C. (2023). A National Implementation Project to Prevent Healthcare-Associated Infections in Intensive Care Units: A Collaborative Initiative Using the Breakthrough Series Model. Open Forum Infectious Diseases, 10(4). https://doi.org/10.1093/ofid/ofad129
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