NUR 630 Benchmark – Outcome and Process Measures

Benchmark – Outcome and Process Measures

Healthcare organizations implement multidimensional measures to ensure care that matches the desired outcomes. Continuous quality improvement (CQI) in a culture that prioritizes innovation and efficiency is critical to achieving optimal quality and safety goals. In healthcare, the primary objective of quality improvement is to standardize care processes and organizational structures to minimize variations and enhance outcomes (CMS.gov, 2024). It necessitates joint strategies, including effective leadership, innovative procedures, technology adoption, and a culture of collaboration. As the improvements occur, healthcare leaders and professionals use quality indicators to measure progress. Quality measures are tools that organizations use to quantify or evaluate the impact of processes, outcomes, and systems linked with providing high-quality care (Jazieh, 2020). The purpose of this paper is to discuss the outcome and process measures that can be used for CQI.

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Process Measures

Healthcare delivery involves many processes designed to achieve the best outcomes for patients, care providers, and the organizations. Continuous improvement requires timely and adequate data from the relevant process measures. According to Fleisher (2024), process measures have a causal link with vital patient outcomes and provide valuable feedback regarding performance. Consequently, improving process measures provides an incredible opportunity for achieving the most desirable patient outcomes. The rate of patient falls among older adults in the emergency department (ED) is a process measure that can be used for CQI. Thatphet et al. (2021) found that fall rates among older adults have been increasing over time, threatening their quality of life and health outcomes. A multidimensional intervention is highly recommended to address this safety and care quality concern in the ED. The other process measure that can be used for CQI is compliance with hand hygiene protocols among nurses. Hand hygiene is a standard infection control process whose adherence often falls below the desired rates (Bredin et al., 2022). Improving compliance would lead to a proportional improvement in care quality, patient safety, and the overall condition of the care environment.

Outcome Measures

Healthcare processes should lead to beneficial outcomes, which are evident through improvements in patient health. Fleisher (2024) stated that outcome measures indicate the actual results of care in terms of a patient’s health over time. Consequently, outcome measurement relates directly to the patient’s health status. The implication is that outcome measures are centered on the immediate results of a particular evidence-based intervention, rather than the overall success of the care cycle (Fleisher, 2024). A suitable outcome measure for CQI is the 30-day all-cause readmission rate in the intensive care unit (ICU). According to Lahijanian and Alvarado (2021), hospital readmissions refer to unplanned admissions within a specified timeframe following discharge from an earlier or initial hospital stay. Common risk factors include the emergence of new health issues, treatment-related complications, and the recurrence of the primary condition. Another suitable outcome measure for CQI is the rate of hospital-acquired infections (HAIs). Also known as nosocomial infections, HAIs occur during the course of receiving medical care in a hospital. Their rates are inversely proportional to the level of care quality, underlining the need for multidimensional measures to prevent their occurrence.

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Description of Why Each Measure Was Chosen

The various process and outcome measures were chosen due to their influence on care quality and impact on other aspects, such as healthcare costs and trust in the care system. Regarding patient falls, their occurrence hampers care quality since they increase injuries, mental health problems, ED visits, and mortality rates. Patient falls also pose a significant financial burden, as hospitals spend approximately $67.7 billion annually to treat falls and fall-related injuries among geriatric patients (Thatphet et al., 2021). Hand hygiene was chosen since it promotes preventive care. Compliance with the established guidelines is vital in hospitals to reduce the incidence of HAIs, mortality, and extended hospitalizations (Bredin et al., 2022). Improving adherence implies a commitment to protecting patients and care providers as well as ensuring care quality that matches the expected standards.

All-cause readmissions were chosen since they are a reliable measure of the causal link between care processes and patient outcomes. As Lahijanian and Alvarado (2021) mentioned, approximately 20% of patients in the United States are readmitted within 30 days of discharge. This readmission rate indicates poor care quality due to unaddressed factors, including ineffective care transitions, unsafe clinical environments, and inadequate follow-up care. HAIs indicate the need to implement strategies like hand hygiene, bundled care, and surveillance programs to prevent prolonged hospitalizations and mortality (Hajiyeva et al., 2025). The prevention and proper control of these conditions are critical in healthcare settings to improve care quality and reduce operational costs.

Explanation of How Data Would Be Collected for Each Measure

Data to guide healthcare professionals in quality improvement can be quantitative, qualitative, or a combination of both. An effective way to collect data on the rates of patient falls among older adults is to utilize administrative data. This data from electronic health records (EHRs) contains vital information on the incidence of falls, their causes, and patient demographics, among other components. Data on hand hygiene compliance would be collected via direct observation or self-reported compliance (Bredin et al., 2022). Covert observation would be effective, where healthcare professionals are observed anonymously. Readmission data can be extracted from EHRs. Medical records can also be reviewed to provide a comprehensive picture of contributing factors and other variables that help nursing professionals address care quality concerns. Data on the rates of HAIs would be collected from EHRs.

Explanation of How Success Would Be Determined

Success would be determined by analyzing data to make informed decisions. The most effective way is descriptive statistics. Here, incidence data before and after a quality improvement intervention would be analyzed to assess whether a significant change occurred. A suitable example is calculating and comparing the averages (mean data) of HAIs, readmissions, and falls. The success of a hand hygiene compliance program, such as staff training, can be determined through knowledge assessments combined with feedback and observable changes in hand-washing practices. A positive change in each aspect would indicate a successful intervention (quality improvement program).

Data Driven, Cost-Effective Solutions

Feasible, data-driven, and cost-effective solutions include automating processes and mitigating risk. In this era of technology, quality improvement processes and data collection procedures can be automated to reduce costs and enhance efficiency. For instance, data analytics has been instrumental in analyzing large datasets to inform data-driven practices. The primary purpose of risk mitigation is to save costs associated with quality improvement and data collection processes. It achieves this critical goal by fostering a proactive approach to issues that increase harm and hamper care quality.

Conclusion

CQI is crucial in healthcare settings to ensure that services and care quality meet the desired standards. Effective decision-making regarding CQI requires accurate data. Process measures for CQI include the rates of patient falls and compliance with hand hygiene protocols. Appropriate outcome measures include the rates of readmissions and HAIs in a department or the entire organization. Valuable in quality improvement, process measures reflect an organization’s ability to comply with actions that improve patient outcomes. Outcome measures reflect the patient’s health status.

References

Bredin, D., O’Doherty, D., Hannigan, A., & Kingston, L. (2022). Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis. Journal of Hospital Infection, 130, 20-33. https://doi.org/10.1016/j.jhin.2022.08.013

CMS.gov. (2024). Quality measurement and quality improvement. https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/mms/quality-measure-and-quality-improvement-

Fleisher, L. A. (2024). Miller’s anesthesia, 2-volume set E-book. Elsevier.

Hajiyeva, A., Jarl, J., & Saha, S. (2025). The effectiveness of quality management interventions in reducing hospital-associated infections in adult patients: a systematic literature review. International Journal of Infectious Diseases, 154, 107837. https://doi.org/10.1016/j.ijid.2025.107837

Jazieh, A. R. (2020). Quality measures: Types, selection, and application in health care quality improvement projects. Global Journal on Quality and Safety in Healthcare, 3(4), 144–146. https://doi.org/10.36401/JQSH-20-X6

Lahijanian, B., & Alvarado, M. (2021). Care strategies for reducing hospital readmissions using stochastic programming. Healthcare (Basel, Switzerland), 9(8), 940. https://doi.org/10.3390/healthcare9080940

Thatphet, P., Kayarian, F. B., Ouchi, K., Hogan, T., Schumacher, J. G., Kennedy, M., & Liu, S. W. (2021). Lessons learned from emergency department fall assessment and prevention programs. Cureus, 13(7), e16526. https://doi.org/10.7759/cureus.16526

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Assessment Traits

Benchmark

Requires Lopeswrite

Assessment Description

In a 1,000-1,250-word paper, consider the outcome and process measures that can be used for CQI. Include the following in your essay:

At least two process measures that can be used for CQI.
At least one outcome measure that can be used for CQI.
A description of why each measure was chosen.
An explanation of how data would be collected for each (how each will be measured).
An explanation of how success would be determined.
One or two data-driven, cost-effective solutions to this challenge.

Use a minimum of three peer-reviewed scholarly references as evidence.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Benchmark Information

This benchmark assignment assesses the following programmatic competency:

MSN Leadership in Health Care Systems

6.5: Generate data-driven, cost-effective solutions to organizational challenges.

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Benchmark – Outcome and Process Measures – Rubric

Rubric Criteria

Total120 points

Criterion	1. Unsatisfactory	2. Insufficient	3. Approaching	4. Acceptable	5. Target
Process Measures Process Measures	0 points Two process measures are not present.	8.58 points Two process measures are incomplete or not applicable.	9.9 points NA	11.22 points NA	13.2 points Two process measures are present.
Outcome Measures Outcome Measures	0 points One outcome measure is not present.	8.58 points One outcome measure is incomplete or not applicable.	9.9 points NA	11.22 points NA	13.2 points One outcome measure is present.
Description of Why Each Measure Was Chosen Description of Why Each Measure Was Chosen	0 points A description of why each measure was chosen is not present.	9.36 points A description of why each measure was chosen is present, but lacks detail or is incomplete.	10.8 points A description of why each measure was chosen is present.	12.24 points A description of why each measure was chosen is present and detailed.	14.4 points A description of why each measure was chosen is present and thorough.
Explanation of How Data Would Be Collected for Each Measure Explanation of How Data Would Be Collected for Each Measure	0 points An explanation of how data would be collected for each measure is not present.	9.36 points An explanation of how data would be collected for each measure is present, but lacks detail or is incomplete.	10.8 points An explanation of how data would be collected for each measure is present.	12.24 points An explanation of how data would be collected for each measure is present and detailed.	14.4 points An explanation of how data would be collected for each measure is present and thorough.
Explanation of How Success Would Be Determined Explanation of How Success Would Be Determined	0 points An explanation of how success would be determined is not present.	9.36 points An explanation of how success would be determined is present, but lacks detail or is incomplete.	10.8 points An explanation of how success would be determined is present.	12.24 points An explanation of how success would be determined is present and detailed.	14.4 points An explanation of how success would be determined is present and thorough.
Data Driven, Cost-Effective Solutions (C6.5.) (B) Data Driven, Cost-Effective Solutions (C6.5.) (C6.5)	0 points One or two data-driven, cost-effective solutions to this challenge are not present.	9.36 points One or two data-driven, cost-effective solutions to this challenge are incomplete or not applicable.	10.8 points One or two data-driven, cost-effective solutions to this challenge are present.	12.24 points One or two data-driven, cost-effective solutions to this challenge are detailed.	14.4 points One or two data-driven, cost-effective solutions to this challenge are present and thorough. Solutions provided are appropriate for the task.
Scholarly Sources	0 points Peer-reviewed, scholarly sources are not present.	3.9 points Two or three peer-reviewed, sources are present, but are not scholarly. Limited research is present.	4.5 points A minimum of three peer-reviewed, scholarly sources are present.	5.1 points A minimum of three peer-reviewed, scholarly sources are present. Sources address all of the requirements stated in the assignment criteria.	6 points A minimum of three peer-reviewed, scholarly sources are present. Sources are distinctive and address all of the requirements stated in the assignment criteria.
Thesis Development and Purpose Thesis Development and Purpose	0 points Paper lacks any discernible overall purpose or organizing claim.	5.46 points Thesis is insufficiently developed or vague. Purpose is not clear.	6.3 points Thesis is apparent and appropriate to purpose.	7.14 points Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.	8.4 points Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.
Argument Logic and Construction Argument Logic and Construction	0 points Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.	6.24 points Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.	7.2 points Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.	8.16 points Argument shows logical progressions. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.	9.6 points Clear and convincing argument that presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.
Mechanics of Writing Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.	0 points Errors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout.	3.9 points Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent.	4.5 points Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.	5.1 points Few mechanical errors are present. Suitable language choice and sentence structure are used.	6 points No mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.
Format/Documentation Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc.,	0 points Appropriate format is not used. No documentation of sources is provided.	3.9 points Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.	4.5 points Appropriate format and documentation are used, although there are some obvious errors.	5.1 points Appropriate format and documentation are used with only minor errors.	6 points No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.

Criterion

1. Unsatisfactory

2. Insufficient

3. Approaching

4. Acceptable

5. Target

Process Measures

0 points

Two process measures are not present.

8.58 points

Two process measures are incomplete or not applicable.

9.9 points

11.22 points

13.2 points

Two process measures are present.

Outcome Measures

0 points

One outcome measure is not present.

8.58 points

One outcome measure is incomplete or not applicable.

9.9 points

11.22 points

13.2 points

One outcome measure is present.

Description of Why Each Measure Was Chosen

0 points

A description of why each measure was chosen is not present.

9.36 points

A description of why each measure was chosen is present, but lacks detail or is incomplete.

10.8 points

A description of why each measure was chosen is present.

12.24 points

A description of why each measure was chosen is present and detailed.

14.4 points

A description of why each measure was chosen is present and thorough.

Explanation of How Data Would Be Collected for Each Measure

0 points

An explanation of how data would be collected for each measure is not present.

9.36 points

An explanation of how data would be collected for each measure is present, but lacks detail or is incomplete.

10.8 points

An explanation of how data would be collected for each measure is present.

12.24 points

An explanation of how data would be collected for each measure is present and detailed.

14.4 points

An explanation of how data would be collected for each measure is present and thorough.

Explanation of How Success Would Be Determined

0 points

An explanation of how success would be determined is not present.

9.36 points

An explanation of how success would be determined is present, but lacks detail or is incomplete.

10.8 points

An explanation of how success would be determined is present.

12.24 points

An explanation of how success would be determined is present and detailed.

14.4 points

An explanation of how success would be determined is present and thorough.

Data Driven, Cost-Effective Solutions (C6.5.) (B)

Data Driven, Cost-Effective Solutions (C6.5.) (C6.5)

0 points

One or two data-driven, cost-effective solutions to this challenge are not present.

9.36 points

One or two data-driven, cost-effective solutions to this challenge are incomplete or not applicable.

10.8 points

One or two data-driven, cost-effective solutions to this challenge are present.

12.24 points

One or two data-driven, cost-effective solutions to this challenge are detailed.

14.4 points

One or two data-driven, cost-effective solutions to this challenge are present and thorough. Solutions provided are appropriate for the task.

Scholarly Sources

0 points

Peer-reviewed, scholarly sources are not present.

3.9 points

Two or three peer-reviewed, sources are present, but are not scholarly. Limited research is present.

4.5 points

A minimum of three peer-reviewed, scholarly sources are present.

5.1 points

A minimum of three peer-reviewed, scholarly sources are present. Sources address all of the requirements stated in the assignment criteria.

6 points

A minimum of three peer-reviewed, scholarly sources are present. Sources are distinctive and address all of the requirements stated in the assignment criteria.

Thesis Development and Purpose

0 points

Paper lacks any discernible overall purpose or organizing claim.

5.46 points

Thesis is insufficiently developed or vague. Purpose is not clear.

6.3 points

Thesis is apparent and appropriate to purpose.

7.14 points

Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.

8.4 points

Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

Argument Logic and Construction

0 points

Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.

6.24 points

Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.

7.2 points

Argument is orderly, but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.

8.16 points

Argument shows logical progressions. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.

9.6 points

Clear and convincing argument that presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

Mechanics of Writing

Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.

0 points

Errors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout.

3.9 points

Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent.

4.5 points

Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.

5.1 points

Few mechanical errors are present. Suitable language choice and sentence structure are used.

6 points

No mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.

Format/Documentation

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc.,

0 points

Appropriate format is not used. No documentation of sources is provided.

3.9 points

Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.

4.5 points

Appropriate format and documentation are used, although there are some obvious errors.

5.1 points

Appropriate format and documentation are used with only minor errors.

6 points

No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.

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