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Phase 2: Defining the Problem and the Project Outcome
Table of Contents
Defining the Problem
As you assess the problem or opportunity for improvement, you will find it helpful to be able to concisely and clearly communicate the project focus to your mentor, organizational leaders, and other stakeholders. A concise statement to describe the problem and the opportunity for improvement help you to effectively communicate the problem, and its importance.
Concise Description of the Problem and its Importance
Here are some tips regarding the development of a problem statement to convey your points:
The problem statement or statement of need should:
- Represent a problem which can be solved, or a situation which can be improved
- Clearly describe the problem
- Clearly convey the importance to all stakeholders
- Clarify your intention and what you hope to achieve
When writing a problem statement or statement of need, there is no need to worry about defining a specific outcome or output. Those steps will come later in the planning process. The main idea with a problem statement or statement of need is to communicate in a succinct manner the essence of the problem which you plan to address, and why it is important. As you develop the problem statement, keep in mind the scope of your project and timeframe available.
Helpful Reminders
Components of a well-written problem statement or statement of need include:
- Succinct description of the problem (need, or situation to be improved)
- Location of the problem (unit, organization, etc.)
- Timeframe
- Size/scope/implications of the problem
Another way to envision the problem statement is to consider the following:
- Who – who does the problem affect?
- What – what is the problem/need and its impact?
- When – when does or did the problem/need occur?
- Where – where does this problem/need occur?
- Why – why is it important to fix the problem?
Make the Connection
As you read through the examples provided below, think about the similarities that are shared across each one. For example, while they each address a different problem, they contain similar elements to allow for a succinct, clear description of the problem and its impact on health outcomes and healthcare delivery:
Example A
The ACA established new community benefit requirements for nonprofit hospitals which include a Community Health Needs Assessment (CHNA) to be completed every three years. Priority needs must be determined and a strategic plan implemented to address each of the needs identified. Rural County Hospital must comply with this legislative requirement in order to maintain tax-exempt status. As such, a CHNA and strategic plan must be completed by 12/31/2021 in order to submit to the IRS (Form 990) with taxes for fiscal year 2021.
Note – In this example, there is a legislative mandate which serves as primary rationale for the need. Financial bottom line is the driving factor (maintaining tax-exempt status).
Example B
Unit 6 West reported an increase in CAUTI rates from 11% to 27% during the first quarter (January through March 2020). One of the National Patient Safety Goals is the prevention of infection. The increased infection rate results in additional medical treatment, compromised health status, and in some cases prolonged the hospital stays. As a result, a staff development course is needed regarding guidelines to prevent infections of the urinary tract that are caused by catheters.
Note – In this example, there is an increased rate of infection on the unit and compromised health, coupled with the NPSG, to validate the need.
Example C
At Hillside Hospital, Unit 3 South serves a large patient population suffering from chronic congestive heart failure. During the second quarter (April through June 2020), the 30-day readmission rate for this population increased from 9% to 19%. Recent healthcare legislation (ACA) requires the Centers for Medicare and Medicaid Services (CMS) to reduce reimbursements to hospitals with notable readmission rates within a 30-day period. As a result, Hillside Hospital could experience reimbursement penalties due to extensive readmissions within the 30-day period. A strategic plan to address discharge planning, care coordination, and home maintenance to manage CHF is needed to promote health outcomes and prevent reimbursement penalties.
Note – In this example, there is compromised health and an increased readmission rate, which may result in financial penalties, which serve as validation of need.
Defining the Outcome for the Planned Change Practicum Project
In order to effectively direct planned change, it is imperative that the problem or opportunity for improvement be clearly defined. Equally important is the development of a clear outcome statement to convey the desired end result of the planned change project.
Intended End Result
An outcome statement is a comprehensive statement that conveys the intended end result achieved through the work of the planned change initiative. This end result is most often a reflection of the improvement in health outcomes or improved healthcare delivery that will be realized through the planned change initiative.
Scope and Feasibility
In addition to accurately conveying the intended end-result, project outcomes must align with the time available for project planning, implementation, and evaluation. For example, if you have 8 weeks to plan, implement, and evaluate project outcomes, those outcomes must be do-able within that timeframe. To position the project for success, it is imperative that you establish project outcomes that are feasible to be achieved within the scope of time and resources available.
SMART Criteria
Effective outcome statements include SMART characteristics (
S
pecific,
M
easureable,
A
ction-oriented,
R
ealistic, and
T
ime-specific). A well-written outcome statement will also:
- Define what you intend to accomplish through the planned change project. This clear statement of the desired result will keep the efforts focused on what you hope to achieve.
- State the target date for the accomplishment to be successfully completed.
- Identify who will be involved.
- Clarify the indicator for successful achievement.
Think About It
Take a look at these examples, and consider – do they demonstrate SMART criteria? Can they be measured to determine successful achievement?
- 20% increase in the number of patients receiving the flu vaccine at Mercy Clinic by 12/31/2020 (baseline = 160 patients accepting the vaccine)
- 25% decrease in the number of patients readmitted with CHF at Fairfield Hospital by the end of the second quarter, 6/30/2020 (baseline = 16 patients readmitted during the first quarter)
- 20% decrease in the number of teen pregnancies at Judson High School by 6/1/2020 (baseline = 15 pregnancies)
Helpful Reminders
As you learn about how to write a clear, effective, and accurate outcome statement, it is also important to note that
an outcome is
not
:
- A description of an activity or intervention which the nurse or other health care professional will implement
- A product or output that will be developed by the nurse or other health care professional (such as a new policy, protocol, or staff development session).
Rather, the outcome statement is a
description of the desired end-state
which will be achieved through the planned change project.
Practicum Application and Activities
As you clarify the problem revisit the PICOT question that you developed regarding this problem. Does the PICOT question seem appropriate? How might that PICOT question facilitate quality improvement at the microsystem level? How can you “move the needle” to improve quality through this planned change practicum project?
After defining the problem to be addressed through a planned change project, it is essential that you define the intended outcome. As you consider the scope of your practicum experience, you will want to identify an outcome that is measurable and feasible within the time available.
Review the
Johns Hopkins Appendix B
located in the
MSN Toolbox
area of the course. Proceed with the following activities. Document your practicum-related activities on the Practicum Log:
- Prepare a plan with specific talking points to meet with faculty (and practicum mentor if available) regarding your definition of the problem and the project outcome.
- Meet with mentor to discuss clarification of the problem and the project outcome.
-
Complete
Johns Hopkins Appendix B
. - Validate your work on Phase 2 with your faculty (and practicum mentor if available) as needed.
- Revise your work as necessary.
-
Submit the
Johns Hopkins Appendix B
document with your time log, once Phase 2 is completed.
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Phase 2: Defining the Problem and the Project Outcome Table of Contents Defining the Problem As you assess the problem or opportunity for improvement, you will find it helpful to be able to concisely
Johns Hopkins Nursing Evidence-Based Practice Appendix BQuestion Development Tool 1. What is the problem? Enter text 2. Why is the problem important and relevant? What would happen if it were not addressed? Enter text 3. What is the current practice? Enter text 4. How was the problem identified? (Check all that apply) ☐Safety and risk-management concerns ☐Quality concerns (efficiency, effectiveness, timeliness, equity, patient-centeredness) ☐Unsatisfactory patient, staff, or organizational outcomes ☐Variations in practice within the setting ☐Variations in practice compared to community standard ☐Current practice that has not been validated ☐Financial concerns 5. What are the PICO components? P – (Patient, population, or problem) I – (Intervention) C – (Comparison with other interventions, if foreground question) O – (Outcome measures to determine success) 6. Initial EBP question ☐Background ☐Foreground Enter text 7. List possible search terms, databases to search, and search strategies. Enter text 8. What evidence must be gathered? (Check all that apply) ☐Publications (e.g., EBSCOHost, PubMed, CINAHL, Embase) ☐Standards (regulatory, professional, community) ☐Guidelines ☐Organizational data (e.g., QI, financial data, local clinical expertise, patient/family preferences) ☐Position statements 9. Revised EBP question (Revisions in the EBP question may not be evident until after the initial evidence review; the revision can be in the background question or a change from the background to a foreground question) Enter text 10. Outcome measurement plan What will we measure? (structure, process, outcome measure) How will we measure it? (metrics are expressed as rate or percent) How often will we measure it? (frequency) Where will we obtain the data? Who will collect the data? To whom will we report the data? Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Enter text here. Directions for Use of the Question Development Tool Purpose This form is used to develop an answerable EBP question and to guide the team in the evidence search process. The question, search terms, search strategy, and sources of evidence can be revised as the EBP team refines the EBP question. What is the problem, and why is it important? Indicate why the project was undertaken. What led the team to seek evidence? Ensure that the problem statement defines the actual problem and does not include a solution. Whenever possible, quantify the extent of the problem. Validate the final problem description with practicing staff. It is important for the inter-professional team to take the time together to reflect, gather information, observe current practice, listen to clinicians, visualize how the process can be different or improved, and probe the problem description in order to develop a shared understanding of the problem. What is the current practice? Define the current practice as it relates to the problem. Think about current policies and procedures. Observe practices. What do you see? How was the problem identified? Check all the statements that apply. What are the PICO components? P (patient, population, problem) e.g., age, sex, setting, ethnicity, condition, disease, type of patient, or population I (intervention) e.g., treatment, medication, education, diagnostic test, or best practice(s) C (comparison with other interventions or current practice for foreground questions; is not applicable for background questions, which identify best practice) O (outcomes) stated in measurable terms; may be a structure, a process, or an outcome measure based on the desired change (e.g., decrease in falls, decrease in length of stay, increase in patient satisfaction) Initial EBP question A starting question (usually a background question) that is often refined and adjusted as the team searches through the literature: Background questions are broad and are used when the team has little knowledge, experience, or expertise in the area of interest. Background questions are often used to identify best practices. Foreground questions are focused, with specific comparisons of two or more ideas or interventions. Foreground questions provide specific bodies of evidence related to the EBP question. Foreground questions often flow from an initial background question and literature review. List possible search terms, databases to search, and search strategies. Using PICO components and the initial EBP question, list search terms. Terms can be added or adjusted throughout the evidence search. Document the search terms, search strategy, and databases queried in sufficient detail for replication. What evidence must be gathered? Check the types of evidence the team will gather based on the PICO and initial EBP question. Revised EBP question Often, the question that you start with may not be the final EBP question. Back- ground questions can be refined or changed to a foreground question based on the evidence review. Foreground questions are focused questions that include specific comparisons and produce a narrower range of evidence. Measurement plan Measures can be added or changed as the review of the literature is completed and the translation planning begins: A measure is an amount or a degree of something, such as number of falls with injury. Each measure must be converted to a metric, which is calculated before and after implementing the change. Metrics let you know whether the change was successful. They have a numerator and a denominator and are typically expressed as rates or percent. For example, a metric for the measure falls-with-injury would be the number of falls with injury (numerator) divided by 1,000 patient days (denominator). Other examples of metrics include the number of direct care RNs (numerator) on a unit divided by the total number of direct care staff (denominator); the number of medication errors divided by 1,000 orders. © 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing
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