Module Components

• Overview
• Assignments

Topics

• Quality Improvement vs Research
• DNP Project Proposal
• REDCap

NDNP 810 DNP Project Identification

Module 4: DNP Project Proposal

DNP Project Proposal

Problem Description

• Problem should be significant: The statement of the problem must convince the reader that the proposed project is important and worth doing. Describe who is affected by the problem, how extensive the problem is, causes and health outcomes of the problem internally to the site and the barriers that exist in solving the problem. All external evidence should be supported by citation of sources.
• Broad to narrow approach: When describing the problem, it is best to move from a broad (external) to narrow (internal) approach. For example, when describing it broadly, you may want to present national, regional, or state data on the problem, if available. Then move to a narrower discussion of the problem – e.g., at the city, organizational or unit level.
• Health disparities: If the problem has had an impact on health disparities of any vulnerable populations, be sure to identify what they are.
• Use primary sources: When presenting the data, it is essential to use primary (not secondary) sources whenever possible to support significance of problem. For example, if the data is reported to have come from the World Health Organization or the Centers for Disease Control, then the references should have come directly from these sources, and not from a review article in a journal.
• Protect anonymity: It is essential that you protect the anonymity of the organization in which you are going to carry out your project in the introduction and throughout the manuscript. Therefore, when discussing internal evidence or data from the organization in the proposal, use a description that will not directly identify them, but will generally give the reader an idea of the context of the problem. For example, you might say “Medication reconciliation has been identified as a potential patient safety issue by the primary care providers in the organization

Specific Aims and Availability Knowledge

Available knowledge refers to the scientific evidence in the literature to support your intervention to achieve your project aim. Ideally, available knowledge is in the form of research evidence, however, some projects may include practice evidence from similar published quality Improvement initiatives or gray literature. Provide a concise synthesis summary to convince your reader of the evidence to support your intervention in your population and setting to achieve your desired outcome. Reference the level and quality of the evidence.

In the closing paragraph of this section, include a one-sentence purpose statement, or statement of the practice change to be implemented to address the problem and the main process and outcome goals. For example, “The purpose of this DNP project is ….

• to implement and evaluate the effectiveness of a childhood obesity screening and referral program in a population health setting
• to implement and evaluate a health policy toolkit to support xxxx policy initiative.

Take care not to confuse the purpose statement with the goals of the project. The purpose statement is focused more on what you plan to implement and not what you expect to happen after you implement it – those are the goals. Follow the purpose statement with the anticipated outcomes or intended effects of the initiative. It is advisable to focus on the key goals of the initiative that will be measured.

Rationale

This section of the DNP Scholarly Project Proposal should include a discussion of the theoretical framework chosen to guide the quality improvement project. The description of the framework should be understood by anyone, even those who are completely unfamiliar with the framework. Theoretical frameworks serve as an organizing scheme or lens through which to view the problem.

• All UMSON DNP Scholarly Projects are expected to use a Quality Improvement Framework to underpin the initiative – refer to Module 3 for Frameworks to consider
• Some projects may lend themselves to a Middle Range Practice Theory, which may be included but not required
• For example, a student is implementing a mentoring program to achieve advanced professional development
• The theory posits 6 concepts associated with development and the project involves the addition of all 6 concepts
• If the project involved the addition of 1 of the 6 concepts, it would not be appropriate to use the practice theory as the basis of the project

This framework description should be followed by a brief discussion of how the components of the framework will be used in planning strategies and the execution of the project. This is regarded as project leverage.

Context

One important issue to present in a QI project proposal is context, including the setting, participants, team members, as well as the current structures and process relevant to the issue. This type of writing differs significantly from the methods section of research studies. In writing up research studies, the authors go to great lengths to describe how they have controlled for contextual factors to ensure that they have eliminated any bias that may have influenced the outcomes. However, with QI, the project is implemented in a real-world setting. It is impossible to control the implementation context. But it is critical to understand and characterize the context so that you will have insights into what contextual elements facilitated or were barriers to the implementation effectiveness. These insights will help you and others in future implementation efforts. The purpose of this process is to sensitize readers to the contextual factors that should be carefully considered when introducing the QI intervention in other settings

Intervention

Strategies and tactics are specific actions that are expected to achieve a certain goal or aim. Implementation leaders will be more effective if their implementation plan includes multiple types of strategies and tactics. Too often leaders’ default to only one strategy, education. Education is the first stage when disseminating an innovation. However, leaders need to utilize other strategies and tactics as well. Since implementation is context specific, there is no one list of strategies and tactics that apply to every initiative.

Be creative and identify strategies and tactics that are considered a good fit for your organization and the goals you’re trying to achieve. The success of your DNP Project depends on how willing people are to work with you. You do not have the ability to dictate that others change. You can however lead in a manner that influences, persuades, and supports others in their efforts to improve outcomes.

Consider the ABCDE acronym below to guide the identification of possible strategies and tactics for your DNP project (Bingham & Main, 2010; Powell et al., 2015). Refer to this link for a detailed list of suggested implementation strategies and tactics

A = Accountability
B = Buy-In for the right outcomes
C = Collaboration, Communication, and Changes in structures
D = Data
E = Education

Timeline

A Gantt Chart is used to schedule, organize and coordinate project activities. Once items are entered, the timeline for the activities display on a bar chart. Use of this type of timeline serves as a valuable tool for the Project Lead and can be shared with all team members to visualize the project and track progress.

Attached is an example of a Gantt Chart created in an Excel Spreadsheet which lists generic tasks associated with all DNP Projects. Students may use this as a template and customize to reflect additional tasks specific to your project:

• Add your start and end dates and responsible person for each listed task
• Add additional tasks relevant to your own project. For instance,
• if your project involves IT, when do you need to start and complete that process?
• if your project involves a new policy or purchase of supplies and equipment, when do you need to start and end that process?
• If your project requires additional site authorizations, when will you obtain those approvals?

For more detail, view the QI Brief video on Project Management Essentials

• Quality & Safety Briefs on Blackboard under the Community Tab - Select UMSON QI Quality & Safety Briefs Series then Modules
• 3.5   Project Management Essentials (this has instructions on how to do a Project GANTT Chart)

Barriers and Facilitators

The team will need to consider the psychological, physical, and procedural barriers it has to address in order to accomplish its aim. Barriers to improvement come in many forms. Psychological barriers such as fear of change, fear of failure, grief over loss of familiar processes, or fear of loss of control or power can be significant impediments to overcome. Other common barriers include the following:

• Inexperience with quality improvement, lack of support or buy-in
• Deficient knowledge or ability, lack of training
• Inadequate staffing levels and/or resources.
• Limited information technology systems.
• Outdated or misguided organizational policies.

Sustainability is the process of hard-wiring or locking in the structure, process, or outcome improvements that were made during the quality improvement’s (QI) implementation phase. Sustainability is how you work to ensure that your work is continued on after you.
A variety of features may contribute to sustainable change in an organization dependent upon the objectives of the DNP project. The following are some examples:

• the engagement of senior leaders in the administration early in the planning of the project
• the inclusion of mentors or champions from the organization to facilitate the change and continue processes
• the integration of documentation of the practice change into the Electronic Health Record
• the availability of financial resources for maintaining the process improvement beyond the project end
• a clear need for the practice changes to occur within the organization
• insertion of newly developed processes as part of new staff orientation and/or organizational policies
• establishment of an ongoing sustainability measurement plan for collection of outcomes and quality improvement activity data (e.g., structure, process, and outcome measures, frequency of chart audits, ongoing use of benchmarks and target goals.

Measurment

In planning data collection, students should collect structure, process and possibly outcome measures. Structure measures indicate whether the system itself has been changed (e.g., a change in the electronic medical record to record an intervention or an increase in the number of providers who have demonstrated competency in an assessment or procedure). These measures do not require a validated tool since the measurement of achievement is typically “yes or no;” yes, the resource was obtained, yes, the training was completed, yes, a policy was approved.

Process measures demonstrate the practice change itself was being done (e.g., the percentage of times the process change has been documented as being implemented in the electronic health record). Students are expected to utilize validated instruments to measure process and how consistently or reliably your intervention was applied. if you are unable to identify a process measure that has gone through validity and reliability testing then it is important to share details about the process measures you created. It is also important you describe in your limitations section the limitations of the measures you used. For example, if the measure(s) were not endorsed by National Quality Form or have not gone through formal testing, this should be outlined as a limitation of your project.

Outcome measures reflect the impact of that process change on patient outcomes (the fall rate on a unit). Outcome measures are often seen as the “gold standard” in measuring improvement, but there are reasons why the student may not be able to collect outcomes in a DNP project. First, DNP students should be implementing interventions that have already been shown to be efficacious -- Therefore you do an iterative literature review. The student does not necessarily have to provide additional evidence to support the intervention based on outcomes. Secondly, because of the short implementation phase for DNP projects (i.e., a maximum of 15 weeks), it may not be possible to demonstrate how the change in a process(es) altered an outcome(s). A reason to capture outcome measures is to assure that the change made does not adversely impact a key process or result in unintended consequences.

Ethics

Quality Improvement, just as research, is conducted ethically in accordance with key principles of beneficence, nonmaleficence, autonomy, and justice. There should be assurances that the initiative poses no threat of physical or psychological harm to participants, protects privacy and confidentiality, and is inclusive and conducted with honesty and integrity.

All UMSON DNP Projects are reviewed by the UMSOM IRB for determination that the project is non-human subject’s research. Students will prepare and submit an IRB application in NDP 811 detailing the project and the planned actions to comply with ethical responsibilities. This process, determination, and your subsequent compliance provides assurance that you and your DNP Project meets your ethical duty. A simple way of stating this in your writing is:

• Non-human Subject’s Research determination from the Human Research Protections Office (HRPO) of the UMSOM Institutional Review Board (IRB) will be obtained prior to project implementation.

Analysis

The majority of DNP Projects aim to demonstrate change over time, (hopefully favorable and sustained) typically aggregated on a weekly basis. One could display data in a tabular form with frequencies or percentages such as 20% screening rates in week 1 and 35% in week 2. This illustrates change but is this variability due to your project intervention or random.

Interpreting the pattern of variability in your data set will be necessary to determine if the variability is common-cause or special-cause (Ogrinc, G.S., et al. (2018). Fundamentals of health care improvement: A guide to improving your patients’ care (3rd Ed.). The Joint Commission and Institute for Healthcare Improvement pgs. 93 - 96).

• Common-cause refers to random variation. Think about this like random error in research
• Special-cause refers to something that significantly effects variation in data. Think about this like effect in research
• The source of special-cause variation may be intentional (ie, your project intervention) or a situational contextual factor (ie, work-force shortage due to COVID)

You’ll learn more about interpreting Run Charts as you progress with your project. For now, suffice it to say that DNP projects will most often use descriptive quantitative statistics (frequencies, percentages, means, medians) to draw inferences, with Run Charts to illustrate change over time. Some projects may involve qualitative methods if the data is non-numerical, such as information gathered through interviews or narrative replies by participants. In these instances, students are required to identify individuals skilled in qualitative analysis to draw inferences from this type of data.

Review this Run Chart video as a review of this concept presented in NRSG 795.