D030 HIP Paper Template

Grace J.
January 15, 2026January 15, 2026
D030, MSN, Western Governors University

Student Name

Western Governors University

D030 Leadership & Management in Complex Healthcare Systems

Prof. Name

Date

Task 1: Healthcare Improvement Project – Introduction and Project Initiation

Stakeholder Identification

How were the stakeholders identified for this healthcare improvement project?

The identification of stakeholders for this project began by compiling a detailed list of leadership figures, decision-makers, and staff with expertise in infection control within the organization. The main focus was on individuals dedicated to infection prevention and early detection of sepsis in oncology patients. After careful evaluation, three key stakeholders were selected based on their experience and roles:

Stakeholder	Experience & Responsibilities	Contribution to Project
Sepsis Coordinator	Over 5 years in infection prevention; Co-Chair of Sepsis Committee	Provides leadership and expert guidance
Assistant Manager of Urgent Care	Involved in sepsis improvement initiatives; data collection; staff education	Organizes data, trains staff, implements process changes
Urgent Care Charge Nurse	Experienced ER nurse; participates in hospital committees (Nursing Standards, Policy, Skin Integrity)	Tracks project milestones, updates staff, manages timelines

The Sepsis Coordinator plays a critical leadership role with deep knowledge of infection prevention. The Assistant Manager of Urgent Care handles data collection, statistics on sepsis tool effectiveness, and staff education related to new screening processes. Lastly, the Urgent Care Charge Nurse leverages clinical experience and committee involvement to support communication and monitor project progress.

Needs Assessment

What process was used to assess the needs for the healthcare improvement project?

The project lead engaged each stakeholder individually through in-person or virtual meetings, soliciting suggestions for improvement opportunities at Moffitt Cancer Center. Stakeholders proposed one to two project ideas each. These were compiled and shared for group evaluation. A 30-minute Zoom meeting was held where stakeholders anonymously ranked ideas using the Nominal Group Technique via an online questionnaire.

Following discussion and voting, the top three ideas identified were: early sepsis identification, improving transfers of care, and preventing nurse burnout/employee retention. Consensus was reached to focus on early sepsis identification due to the high vulnerability of oncology patients to sepsis complications.

Problem Identification

What is the primary problem addressed by the project?

Moffitt Cancer Center cares for adult oncology patients, many with compromised immune systems from cancer therapies. Despite medical advances, sepsis-related mortality among cancer patients is twice that of non-cancer patients (Chae, Kim, & Lee, 2020). Sepsis frequently causes chemotherapy delays, longer hospitalizations, and elevated healthcare costs (Mert et al., 2021).

The project seeks to identify the most effective sepsis screening tool tailored for oncology patients in the Urgent Care Department. This tool must detect atypical infection signs unique to cancer patients, such as different vital sign thresholds and laboratory markers, to enable timely intervention.

Problem Description

Why is an early sepsis identification screening tool necessary at Moffitt Cancer Center?

The Infection Prevention and Sepsis Committee identified multiple areas needing improvement in sepsis management within Urgent Care. Chart reviews revealed frequent delays in initiating sepsis protocols for eligible patients. These findings highlighted the need for a dedicated screening tool to support rapid diagnosis and treatment, ultimately aiming to reduce mortality and improve patient outcomes.

Impact Analysis

What are the potential benefits and risks associated with the project?

The impact was evaluated considering two categories: Patient Satisfaction and Decreased Length of Stay. Both categories included examples of benefits and risks, each rated from 1 (low) to 3 (high) impact.

Category	Benefits (Examples)	Impact Score	Risks (Examples)	Impact Score
Patient Satisfaction	Enhanced communication; timely care	3	Resistance to change; staff training demands	2
Length of Stay	Shorter hospital stays; faster recovery	3	Implementation delays; data accuracy issues	3

The total benefit score was 11, while risks totaled 9. With an impact ratio of 1.2 (benefits ÷ risks), the analysis suggests that benefits outweigh risks, supporting the project’s adoption.

SWOT Analysis

How was the organizational readiness assessed?

A SWOT analysis was conducted collaboratively with stakeholders. Each member drafted a preliminary SWOT focusing on internal factors (leadership, morale) and external factors (stakeholder involvement, knowledge uptake). A 45-minute group discussion and voting refined these findings:

SWOT Component	Internal Criteria	External Criteria	Key Findings
Strengths	Strong leadership	Active stakeholder involvement	Committed leadership and engaged stakeholders
Weaknesses	Variable staff morale	Limited uptake of best practices	Concerns about staff burnout and knowledge dissemination
Opportunities	Training programs	External partnerships	Opportunities for education and collaboration
Threats	Staff turnover	Regulatory changes	Risk of turnover and evolving compliance demands

This analysis confirmed the project’s feasibility and highlighted areas needing proactive management.

Ethical Considerations

What ethical standards support this healthcare improvement project?

Moffitt Cancer Center’s Code of Ethics emphasizes providing high-quality, safe, and patient-centered care (Moffitt Cancer Center, 2018). The project aligns with this by focusing on timely, equitable, and culturally competent care, especially for immunocompromised oncology patients. Early sepsis detection embodies the center’s commitment to protecting vulnerable populations.

Task 2: Healthcare Improvement Project – Project Purpose and Review of Scholarly Sources

Purpose Statement

The project’s primary aim is to implement an early sepsis identification tool within the Urgent Care Department to accelerate response and treatment for oncology patients showing sepsis symptoms. This integration into triage processes is intended to enhance clinical outcomes through prompt intervention.

Review of Relevant Scholarly Sources

Research consistently highlights the increased risk and mortality associated with sepsis in cancer patients, underscoring the necessity for specialized screening tools (Chae et al., 2020; Mert et al., 2021). Nurse-led sepsis protocols and community screening tools have been shown to improve early recognition and outcomes (Baker, 2022; Moore et al., 2019). These findings validate the project’s focus and provide evidence-based guidance for its implementation.

Appendix D: SMART+C Goal Worksheet

SMART+C Criteria	Question	Answer
Specific	What is the specific project?	Implementing an early sepsis screening tool in Urgent Care to expedite intervention.
Measurable	What indicators will be measured?	Increase in timely initiation of sepsis protocols by December 2022, based on collected data.
Achievable	How feasible is the project?	Highly feasible due to supportive impact and SWOT analyses and patient risk profile.
Relevant	How worthwhile is the project?	Expected to reduce mortality, shorten hospital stays, and enhance patient satisfaction.
Time-Bound	What are the project timelines?	Project to start in June 2022 and complete by December 2022.
Challenge	What is the stretch goal?	Develop a cancer-specific sepsis screening tool using identified clinical indicators.

SMART+C Goal:

To implement an early sepsis identification tool in the Urgent Care Department to improve sepsis protocol response and treatment times for oncology patients by December 2022.

Expected Outcome:

The project anticipates that collected data will facilitate the creation of an oncology-specific sepsis screening tool. This will contribute to decreased mortality rates, shorter hospital stays, reduced healthcare costs, and improved patient satisfaction and outcomes.

References

Baker, E. (2022). Improving sepsis recognition through use of the Sepsis Trust’s community screening tool. British Journal of Community Nursing, 27(2), 69–75. https://doi.org/10.12968/bjcn.2022.27.2.69

Chae, B.-R., Kim, Y.-J., & Lee, Y.-S. (2020). Prognostic accuracy of the sequential organ failure assessment (SOFA) and quick SOFA for mortality in cancer patients with sepsis defined by systemic inflammatory response syndrome (SIRS). Supportive Care in Cancer, 28(2), 653–659. https://doi.org/10.1007/s00520-019-04869-z