Vila Health™
Data Analysis
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Introduction
Email from Sienna Pope
Hospice Adverse Event Data 2014-2015
Interviews with Stakeholders
Email Response to Sienna Pope
Conclusion
Credits
Introduction
Quality improvement initiatives are a critical tool in the ongoing effort to improve patient care at
health care organizations. But without data, many QI initiatives would fail — or the problem
behind them might never be detected. That’s why data, and the dashboards that present data in a
comprehensible fashion, are essential for QI efforts to succeed.
In this activity, you will assume the role of a quality assurance analyst at St. Anthony Medical
Center. You will be offered both a dataset that you can use to outline a quality improvement
initiative, and input from stakeholders who can help you contextualize the data.
Educational Goals
After completing the activity, you will be prepared to:
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Analyze data to identify a health care issue or area of concern.
Outline a QI initiative proposal based on a selected health issue and supporting data
analysis.
Integrate interprofessional perspectives to lead quality improvements in patient safety,
cost effectiveness, and work–life quality.
Email from Sienna Pope
QI Data For You
From: Sienna Pope, Director of Medical Support Services
To: Prudencia Nganghi
Prudencia,
Hi! I heard through word of mouth that you were looking for some possible areas of
improvement in the hospital. I’ve got some data from SAMC’s in-home hospice program that
might be useful.
I realize that you may not be familiar with the hospice program, so I also set up some meetings
with a few people with a stake in the program. I’m hoping they can give you some context for
the data you’re looking at.
Let me know if you need anything!
Sienna Pope,
Director of Medical Support Services
Hospice Adverse Event Data 2014-2015
Per Vila Health policy, these figures include near misses as well as events that resulted in some
level of harm or potential harm to the patient. This is a summary of the data; a downloadable
spreadsheet that provides all the data you will need for your presentation is also available below.
Pain Level 7-10 More
Unit - Year
LOS Less than 7 Days
IPU Admission
Hospice 2014
50
47
13
Hospice 2015
46
27
17
Download XLS
than 24 Hours
Interviews with Stakeholders
Here is a list of stakeholders that you had the opportunity to interview.
1. Roger Goldenberg
Director of Hospice Services
2. Jackie Sandoval
Chief Nursing Officer
3. David Brooks
Quality Assurance Director
4. Owen Welch
CFO
Owen Welch
CFO
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What is the current state of the hospice program’s physical plant?
Well, the current technology — secure laptops with remote access to the EHR — is
working, although I think there’s always something better out there. We’re thinking about
experimenting with video conferencing to improve care on site; for example, when a
physician isn’t available but another is available by video link, that’s an opportunity to
improve care. I’ve heard of technology that pushes electronic alerts to hospice nurses so
that they can coach caregivers to deliver better care. But of course, we can’t have
everything.
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Do you feel that the hospice program is resourced adequately?
Well, of course, as with any offsite program like this, you start to have staff issues when
staff are stretched too thin. So are they having to spend too much time traveling to
patient’s homes, or feeling that their patient census is too high to give each patient the
care they really need? I like to think that we’ve balanced care loads among our hospice
nurses pretty well. But we can’t know if we’re wrong — absent adverse events, which we
really don’t want — unless our nurses tell us.
Roger Goldenberg
Director of Hospice Services
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What are the overall goals of the hospice program?
Well, given the unique mission of hospice, we take a different tack from other practices.
Since we’re providing end-of-life care, our goal is comfort care, not urgent or life-saving
care. That means we treat the symptoms, not the disease. Unlike other units, the patient is
a recipient of care, but so is the family.
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What is your approach to meeting those goals?
We use a holistic approach, in that we try to address not just physical, but also emotional,
psychological, and spiritual needs. With each patient, there’s an interdisciplinary team
that delivers care at home. When symptoms arise that need more aggressive management
than home care can provide, we do temporary inpatient admissions.
Jackie Sandoval
Chief Nursing Officer
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Roger Goldenberg mentioned that an interdisciplinary team is an important part of the
hospice approach. Who do you consider to be part of that team?
Many different roles, actually. Of course the nurse, a hospice physician, and a social
worker are going to be involved. Often home health aides are part of the team, as well as
the volunteer coordinator and the chaplain. Depending on the patient and their
circumstances, sometimes music, art, or physical therapists are also engaged in the
patient’s care.
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What would you consider to be quality-related “red flags” as far as the data categories?
One big problem we see in hospice is that patients are referred too late — that is, too
close to their end of life. So they aren’t able to receive all of the benefits of being in the
hospice program. So length of stay is something you’ll want to look at. Then, of course,
the effectiveness of pain and symptom management.
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How do hospice nurses document and communicate data between their on-site location
and the rest of the team?
All of our hospice nurses carry laptops so they can live-chart patient-related data, just like
inpatient nurses on site use connected devices to update the EHR. In some homes, where
wi-fi isn’t available, those nurses just take notes on their laptops on site and then chart
later.
David Brooks
Quality Assurance Director
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What are the processes that the hospice program uses to ensure safety?
We’ve got processes and procedures in place for managing movement for patients who
are at risk of falls, for maintaining sanitary conditions, for managing medical waste (for
example, if a patient has a catheter in place), and for safe storage of pain and other
medications. And we have processes for pain assessment, which are also part of our
protocol for assessing the need for an IPU admission.
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What about quality?
That’s somewhat reflected in our adverse event reporting. Obviously, we’re not
delivering quality care if all we do is prevent adverse events. But our processes are
geared to prevent those events and make sure we’re helping the patient to face the end of
life as comfortably as possible. So our nurses monitor pain levels, symptom levels, and
the patient’s overall level of comfort, as well as that of the family and caregivers. They
ask a lot of specific and general questions to get at the patient’s quality of life, from their
own perspective and from that of their loved ones.
Email Response to Sienna Pope
QI Data For You
From: Sienna Pope, Director of Medical Support Services
To: Prudencia Nganghi
I hope you got what you needed from Jackie, David, Roger, and Owen. Can you send me an
email and let me know what your initial thoughts are? It doesn’t have to be anything formal, just
your ideas about what the data suggest, and whether there are any QI initiatives that you would
recommend based on what you’re seeing. If there are, make sure you explain how the initiatives
you recommend might affect the different roles on the hospice team.
Thanks!
— Sienna
Your reply to Sienna's email should summarize what you’ve learned during this activity. It might
also be helpful to articulate any questions or research you plan to do. The reply will be available
in your activity log and can be used as a pre-writing activity for the unit assignment.
Email you sent
Conclusion
Having met with some stakeholders, you should now have a solid understanding of what the data
you gathered is telling you. You should be able to use this information to complete your
assignment in the course.
Credits
Subject Matter Expert:
Marylee Bressie
Interactive Design:
Lori Olson, Estelle Domingos, Mark Bune, Marc Ashmore
Interactive Developer:
Peter Hentges
Instructional Design:
Stephen Sorenson
Media Instructional Design:
Holly Dolezalek
Project Management:
Nakeela Hall
Assessment 3
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Data Analysis and Quality Improvement Initiative Proposal
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Details
Attempt 1Available
Attempt 2
Attempt 3
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Overview
Prepare an 8–10-page data analysis and quality improvement initiative
proposal based on a health issue of professional interest to you. The
audience for your analysis and proposal is the nursing staff and the
interprofessional team who will implement the initiative.
"A basic principle of quality measurement is: If you can't measure it, you
can't improve it" (Agency for Healthcare Research and Quality, 2013).
Health care providers are on an endless quest to improve both care quality
and patient safety. This unwavering commitment requires hospitals and
care givers to increase their attention and adherence to treatment
protocols to improve patient outcomes. Health informatics, along with new
and improved technologies and procedures, are at the core of virtually all
quality improvement initiatives. The data gathered by providers, along
with process improvement models and recognized quality benchmarks, are
all part of a collaborative, continuing effort. As such, it is essential that
professional nurses are able to correctly interpret, and effectively
communicate information revealed on dashboards that display critical care
metrics.
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By successfully completing this assessment, you will demonstrate your
proficiency in the following course competencies and assessment criteria:
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Competency 2: Plan quality improvement initiatives in response to
routine data surveillance.
• Outline a QI initiative proposal based on a selected health
issue and supporting data analysis.
Competency 3: Evaluate quality improvement initiatives using
sensitive and sound outcome measures.
• Analyze data to identify a health care issue or area of concern.
Competency 4: Integrate interprofessional perspectives to lead
quality improvements in patient safety, cost effectiveness, and worklife quality.
• Integrate interprofessional perspectives to lead quality
improvements in patient safety, cost effectiveness, and worklife quality.
Competency 5: Apply effective communication strategies to promote
quality improvement of interprofessional care.
• Apply effective communication strategies to promote quality
improvement of interprofessional care.
• Communicate evaluation and analysis in a professional and
effective manner, writing content clearly and logically with
correct use of grammar, punctuation, and spelling.
Reference
Agency for Healthcare Research and Quality. (2013). Preventing falls in
hospitals. Retrieved from
https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallp
xtk5.html#tiptop
Competency Map
CHECK YOUR PROGRESSUse this online tool to track your performance and
progress through your course.
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Questions to Consider
As you prepare to complete this assessment, you may want to think about
other related issues to deepen your understanding or broaden your
viewpoint. You are encouraged to consider the questions below and
discuss them with a fellow learner, a work associate, an interested friend,
or a member of your professional community. Note that these questions
are for your own development and exploration and do not need to be
completed or submitted as part of your assessment.
Reflect on QI initiatives focused on measuring and improving patient
outcomes with which you are familiar.
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How important is the role of nurses in QI initiatives?
What quality improvement initiatives have made the biggest
difference? Why?
When a QI initiative does not succeed as planned, what steps are
taken to improve or revise the effort?
Toggle Drawer
Resources
Required Resources
MSN Program Journey
Please review this guide for your degree program. It can help you stay on
track for your practicum experience, so you may wish to bookmark it for
later reference.
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MSN Program Journey | Transcript.
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Suggested Resources
The resources provided here are optional. You may use other resources of
your choice to prepare for this assessment; however, you will need to
ensure that they are appropriate, credible, and valid. The Nursing Masters
(MSN) Research Guide can help direct your research, and the Supplemental
Resources and Research Resources, both linked from the left navigation
menu in your courseroom, provide additional resources to help support
you.
Capella Resources
Capella provides a thorough selection of online resources to help you
understand APA style and use it effectively.
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APA Module.
Capella Multimedia
Use this media piece if you do not have access to dashboard metrics to
complete the final assessment.
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Vila Health: Data Analysis | Transcript.
Quality Improvement Examples and Results
These resources explore the effectiveness and lessons learned from
various quality improvement initiatives.
Ohde, S., Terai, M., Oizumi, A., Takahashi, O., Deshpande, G. A.,
Takekata, M., . . . Fukui, T. (2012). The effectiveness of a
multidisciplinary QI activity for accidental fall prevention: Staff
compliance is critical. BMC Health Services Research, 12, 197.
• Berman, J., Nkabane, E. L., Malope, S., Machai, S., Jack, B., & Bicknell,
W. (2014). Developing a hospital quality improvement initiative in
Lesotho. International Journal of Health Care Quality
Assurance, 27(1), 15–24.
These articles showcase examples of strategic QI projects.
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Nazir, A., Dennis, M. E., & Unroe, K. T. (2015). Implementation of a
heart failure quality initiative in a skilled nursing facility: Lessons
learned. Journal of Gerontological Nursing, 41(5), 26–33.
• Schoenfelder, S. L., Wych, S., Willows, C. A., Harrington, J., Christoffel,
K. K., & Becker, A. B. (2013). Engaging Chicago hospitals in the babyfriendly hospital initiative. Maternal and Child Health Journal, 17(9),
1712–1717.
This resource evaluates a QI initiative based on a communication strategy.
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Wysham, N. G., Mularski, R. A., Schmidt, D. M., Nord, S. C., Louis, D. L.,
Shuster, E., . . . Mosen, D. M. (2014). Long-term persistence of quality
improvements for an intensive care unit communication initiative
using the VALUE strategy. Journal of Critical Care, 29(3), 450–454.
Benchmarks for Quality Indicators
These databases provide recognized benchmarks for quality indicators.
Montalvo, I. (2007). The national database of nursing quality
indicators. Online Journal of Issues in Nursing, 12(3), 1–11.
• The Joint Commission. (2017). National patient safety goals.
Retrieved from
https://www.jointcommission.org/standards_information/npsgs.as
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Assessment Instructions
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Preparation
In this assessment, you will propose a quality improvement (QI) initiative
proposal based on a health issue of professional interest to you. The QI
initiative proposal will be based on an analysis of dashboard metrics from
a health care facility. You have one of two options:
Option 1
If you have access to dashboard metrics related to a QI initiative proposal
of interest to you:
• Analyze data from the health care facility to identify a health care
issue or area of concern. You will need access to reports and data
related to care quality and patient safety. If you work in hospital
setting, contact the quality management department to obtain the
data you need.
• You will need to identify basic information about the health care
setting, size, and specific type of care delivery related to the topic
that you identify. You are expected to abide by HIPAA compliance
standards.
Option 2
If you do not have access to a dashboard or metrics related to a QI initiative
proposal:
• You may use the hospital data set provided in the media piece titled
Vila Health: Data Analysis. You will analyze the data to identify a
health care issue or area of concern.
• You will follow the same instructions and provide the same
deliverables as your peers who select Option 1.
Instructions
Analyze dashboard metrics related to the selected issue.
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Provide the selected data set in the proposal.
• Assess the stability of processes or outcomes.
• Delineate any problematic variations or performance failures.
Evaluate QI initiatives on the selected health issue with existing
quality indicators from other facilities, government agencies, and
non-governmental bodies on quality improvement.
• Analyze challenges that meeting prescribed benchmarks can
pose for a heath care organization and the interprofessional
team.
Outline a QI initiative proposal based on the selected health issue
and data analysis.
• Identify target areas for improvement.
• Define what processes can be modified to improve outcomes.
• Propose strategies to improve quality.
• Define interprofessional roles and responsibilities as they
relate to the QI initiative.
• Provide recommendations for effective communication
strategies for the interprofessional team to ensure the success
of the QI initiative. Briefly reflect on the impact of the
proposed initiative on work-life quality of the nursing staff
and interprofessional team.
• Integrate relevant sources to support arguments, correctly
formatting citations and references using current APA style.
Note: Remember, you can submit all, or a portion of, your draft to
Smarthinking for feedback, before you submit the final version of your
analysis for this assessment. However, be mindful of the turnaround time
for receiving feedback, if you plan on using this free service.
The numbered points below correspond to grading criteria in the scoring
guide. The bullets below each grading criterion further delineate tasks to
fulfill the assessment requirements. Be sure that your Quality
Improvement Initiative Evaluation addresses all of the content below. You
may also want to read the scoring guide to better understand the
performance levels that relate to each grading criterion.
8. Analyze data to identify a health care issue or area of concern.
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Identify the type of data you are analyzing (from your
institution or from the media piece).
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Discuss why the data matters, what it is telling you, and what
is missing.
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Analyze dashboard metrics and provide the data set in the
proposal.
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Present dashboard metrics related to the selected issue.
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Delineate any problematic variations or performance failures.
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Assess the stability of processes or outcomes.
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Evaluate the quality of the data and what can be learned from
it.
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Identify trends, outcome measures and information needed to
calculate specific rates.
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Analyze what metrics indicate opportunities for quality
improvement.
9. Outline a QI initiative proposal based on a selected health issue and
supporting data analysis.
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Identify benchmarks aligned to existing QI initiatives set by
local, state, or federal health care policies or laws.
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Identify existing QI initiatives related to the selected issue,
and explain why they are insufficient.
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Identify target areas for improvement, and define what
processes can be modified to improve outcomes.
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Propose evidence-based strategies to improve quality.
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Evaluate QI initiatives on the selected health issue with
existing quality indicators from other facilities, government
agencies, and non-governmental bodies on quality
improvement.
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Analyze challenges that meeting prescribed benchmarks can
pose for a heath care organization and the interprofessional
team.
10. Integrate interprofessional perspectives to lead quality
improvements in patient safety, cost effectiveness, and work-life
quality.
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Define interprofessional roles and responsibilities as they
relate to the data and the QI initiative.
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Explain how you would you make sure that all relevant roles
are fully engaged in this effort.
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Explain what non-nursing concepts would you incorporate
into the initiative?
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Identify how outcomes to measure the effect of the
intervention affect the interprofessional team.
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Briefly reflect on the impact of the proposed initiative on
work-life quality of the nursing staff and interprofessional
team. Describe how work-life quality is improved or enriched
by the initiative.
11. Apply effective communication strategies to promote quality
improvement of interprofessional care.
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Identify the kind of interprofessional communication
strategies that will be effective to promote and ensure the
success of this performance improvement plan or quality
improvement initiative.
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In addition to writing, identify communication models (like
CUS, SBAR) that you would include in your initiative proposal.
12. Communicate evaluation and analysis in a professional and effective
manner, writing content clearly and logically with correct use of
grammar, punctuation, and spelling.
13. Integrate relevant sources to support arguments, correctly
formatting citations and references using current APA style.
Submission Requirements
Length of submission: 8–10 double-spaced, typed pages, not
including title and reference page.
• Number of references: Cite a minimum of five sources (no older than
seven years, unless seminal work) of scholarly, peer-reviewed, or
professional evidence that support your evaluation,
recommendations, and plans.
Note: Faculty may use the Writing Feedback Tool when grading this
assessment. The Writing Feedback Tool is designed to provide you with
guidance and resources to develop your writing based on five core skills.
You will find writing feedback in the Scoring Guide for the assessment,
once your work has been evaluated.
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Data Analysis and Quality
Improvement Initiative Proposal
Scoring Guide
VIEW SCORING GUIDEUse the scoring guide to enhance your learning.How to
use the scoring guide
Data Analysis and Quality Improvement Initiative
Proposal Scoring Guide
CRITERIA
NONPERFORMANC
E
BASIC
PROFICIENT
DISTINGUISH
ED
Analyze data
to identify a
health care
issue or area
of concern.
Does not
analyze data to
identify a
health care
issue or area
of concern.
Attempts to
analyze data,
but misses
trends or
opportunities
for quality
improvement,
or fails to
persuasively
link data to a
health care
issue or area
of concern.
Analyzes data
to identify a
health care
issue or area
of concern.
Analyzes data
to identify a
health care
issue or area
of concern,
and evaluates
the quality of
the data.
Outline a QI
initiative
proposal based
on a selected
health issue
and supporting
data analysis.
Does not
outline a QI
initiative
proposal based
on a selected
health issue
and supporting
data analysis.
Attempts to
outline a QI
initiative
proposal, but
proposal is
missing
benchmarks, is
not evidencebased, is
impractical, or
is not clearly
linked to the
selected health
issue or
supporting
data analysis.
Outlines a QI
initiative
proposal based
on a selected
health issue
and supporting
data analysis.
Outlines a QI
initiative
proposal based
on a selected
health issue
and supporting
data analysis,
and identifies
knowledge
gaps,
unknowns,
missing
information,
unanswered
questions, or
areas of
uncertainty
(where further
information
could improve
the proposal).
CRITERIA
NONPERFORMANC
E
BASIC
PROFICIENT
DISTINGUISH
ED
Integrate
interprofession
al perspectives
to lead quality
improvements
in patient
safety, cost
effectiveness,
and work-life
quality.
Does not
integrate
interprofession
al perspectives
to lead quality
improvements
in patient
safety, cost
effectiveness,
and work-life
quality.
Attempts to
integrate
interprofession
al
perspectives,
but misses
relevant roles
or concepts, or
fails to
consider key
interprofession
al perspectives
related to
patient safety,
cost
effectiveness,
or work-life
quality.
Integrates
interprofession
al perspectives
to lead quality
improvements
in patient
safety, cost
effectiveness,
and work-life
quality.
Integrates
interprofession
al perspectives
to lead quality
improvements
in patient
safety, cost
effectiveness,
and work-life
quality, and
identifies
assumptions
on which the
suggestions
are based.
Apply
effective
communicatio
n strategies to
promote
quality
improvement
of
interprofession
al care.
Does not
suggest
communicatio
n strategies to
promote
quality
improvement
of
interprofession
al care.
Suggestions
for
communicatio
n strategies are
not sufficient
to promote
quality
improvement
of
interprofession
al care.
Applies
effective
communicatio
n strategies to
promote
quality
improvement
of
interprofession
al care.
Applies
effective
communicatio
n strategies to
promote
quality
improvement
of
interprofession
al care, and
identifies
assumptions
on which the
suggestions
are based.
Communicate
evaluation and
analysis in a
professional
and effective
Does not
communicate
evaluation and
analysis in a
professional
and effective
Attempts to
communicate
evaluation and
analysis in a
professional
and effective
Communicates
evaluation and
analysis in a
professional
and effective
manner,
Communicates
evaluation and
analysis in a
professional
and effective
manner.
CRITERIA
NONPERFORMANC
E
BASIC
PROFICIENT
DISTINGUISH
ED
manner,
writing
content clearly
and logically
with correct
use of
grammar,
punctuation,
and spelling.
manner,
writing
content clearly
and logically
with correct
use of
grammar,
punctuation,
and spelling.
manner, but
content is not
consistently
clear and
logical, or
errors in use of
grammar,
punctuation,
or spelling
distract from
the message.
writing
content clearly
and logically
with correct
use of
grammar,
punctuation,
and spelling.
Content is
clear, logical,
and
persuasive;
grammar,
punctuation,
and spelling
are without
errors.
Integrate
relevant
sources to
support
arguments,
correctly
formatting
citations and
references
using current
APA style.
Does not
integrate
relevant
sources to
support
arguments,
correctly
formatting
citations and
references
using current
APA style.
Sources lack
relevance or
are poorly
integrated, or
citations or
references are
incorrectly
formatted.
Integrates
relevant
sources to
support
arguments,
correctly
formatting
citations and
references
using current
APA style.
Integrates
relevant
sources to
support
assertions,
correctly
formatting
citations and
references
using current
APA style.
Citations are
free from all
errors.
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