Student Name

Capella University

NURS-FPX8020 Doctoral Executive Leadership in Contemporary Nursing

Professor name

Submission Date

Quality Improvement Proposal

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Hi everyone! My name is Joseph Major. My quality improvement proposal would be to create the Department of Population Health (DPH) at NYU Langone Hospitals to be of a very high standard today.

Slide 2

Proposals for health care quality improvement are those that are systematic and evidence-based, designed to enhance the effectiveness of an organization and the outcomes of the care it provides. A complete knowledge of a QI project will determine specific challenges identified in an organization and evidence-based interventions/solutions based on research that will improve the quality of healthcare at all levels within an organization (Puri et al. 2023). The goals for improvement will be achieved by sustainable actions, with a pathway being established by quantifiable objectives and well-defined implementation strategies. QI Project will help direct and hold the healthcare organization accountable for clinical and operational excellence, providing a roadmap for the organization to follow.

The Rationale for Establishing a Strategic Priority

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Establishing evidence-based strategies and priorities is vital to help improve quality in healthcare through better guidance. The quality improvement effort was recommended by the NYU Langone Division of Public Health. The program is aimed at enhancing the well-being of mothers and children in the most vulnerable neighborhoods around New York City, including Sunset Park, Red Hook, and Hempstead. The initiative aims to reduce the gap with respect to access to prenatal care and developmental assistance for healthy child development. Evidence supports how providing early interventions in support of maternal and child health can produce better long-term health outcomes, while parent engagement programs can have a significant positive impact on developmental trajectories of families living at or below the poverty level (Kunthamas et al., 2023; Bos et al., 2024). ParentChild+ aims to retain 90% of families for two years and increase their understanding of child development by 85% in the same time (NYU Langone Health, 2025). With evidence-based strategies and priorities for resource use established in DPHS, the use of the department’s resources can be directed towards interventions that have the greatest potential.

Implications and Consequences

One key component in evaluating the viability and sustainability of a quality improvement project is to study downstream effects and outcomes. The maternal/child health improvement effort under DPH has many benefits, such as reduced health inequities, better developmental outcomes, and increased community trust (Kunthamas et al., 2025). However, there are also several potential negative consequences to the creation of new communities with limited programmatic infrastructure and/or significant data gaps and where provision of services may strain existing resources (Rasikh et al., 2024). Without addressing the data gaps, it is probable that the service delivery to the new population will be inequitable and will not work.

SWOT Analysis

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A strengths, weaknesses, opportunities, threats (SWOT) analysis provides an organized way for evaluating both internal and external factors impacting the viability of a strategic quality improvement initiative. Strong and weak points, opportunities, and threats associated with the maternal and child health improvement effort in the DPH can be examined, aiding in the informed decision-making process. (Teoli et al., 2023). You’ll analyze evidence-based information in the context of the politics of the organization, current strategic priorities, and community health.

Strengths

There are a variety of internal strengths that support the Department of Public Health’s (DPH) quality improvement effort. The programs directly affect maternal/child health outcomes and are based on a portfolio of evidence-based programs (e.g., ParentChild+ and Greenlight, NYU Langone Health, 2025). The program’s retention rate, as indicated by the documented retention of 90% of all participating families, and 85% percent increase in parents’ knowledge, indicates a measurable impact. The DPH has nine main family care centers in Brooklyn that are able to implement and expand the evidence-based initiative (NYU Langone Health, 2025), serving 40,000 people every year. The DPH, therefore, has strong internal assets that place it well for success in the implementation of a high-impact, evidence-based quality improvement initiative.

Weaknesses

Internal constraints impact the implementation of quality improvement initiatives. Documented information gaps in the new service areas of Uniondale, Roosevelt, and Mastic Beach are limiting tailored maternal/child health interventions (NYU Langone Health, 2025). Variability in program reach throughout Long Island presents barriers in service delivery (NYU Langone Health, 2025). In addition, no consistency in the ways that data are shared with community partners, making it difficult to routinely monitor and improve key performance indicators.

Opportunities

There are great opportunities to improve maternal and child health priorities within the DPH due to a variety of external conditions that provide an opportunity to advance the priorities within New York State’s Prevention Agenda to align with the state’s Prevention Agenda priorities, as well as providing an opportunity for financial support for expansion, both through policies that support programs (NYU Langone Health, 2025). Furthermore, because virtual primary care and digital health technologies are also becoming more common in communities, there are other ways to reach individuals who are not well served by close, face-to-face care within their communities (Maita et.al., 2024). Finally, working with advocacy groups and community stakeholders will add to the outreach and ability of the initiative to be culturally responsive to the communities served.

Threats

There are external risk factors that may be a challenge for the initiative to continue. Many of these social determinants will continue to be obstacles for families in neighborhoods such as Sunset Park, Red Hook, and Hempstead, making it difficult for them to take part in current programs (NYU Langone Health, 2025). Additionally, there will be an external risk factor – the economic burden of adverse weather – with further barriers to participation in communities. (Allen et al., 2025). Also, funding sources will continue to shift, a nd new regulations will be developed that will have a negative effect on DPH’s infrastructure and threaten the effort.

Key Performance Indicators

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Key performance indicators need to be set to measure quality improvement effectiveness. For instance, DPH has multiple outcomes to measure the success or failure of their maternal and child health program. Indicators for this include the ability for a family retention rate of 90% completion, and a completely different set of indicators for measuring an increase in knowledge regarding the education of enrolled parents, with the goal being that 85% of parents meet educational benchmarks (NYU Langone Health, 2025). There are also numerous other metrics to track, such as prenatal care utilization in Sunset Park, Red Hook, Hempstead, and the engagement time of community health workers with community residents in Uniondale and Roosevelt (NYU Langone Health, 2025). Once set, the measurable performance indicators will allow DPH to systematically monitor improvement.

Table 1

Balanced Scorecard for the Maternal and Child Health Quality Improvement Initiative, Department of Population Health, NYU Langone Hospitals 2025–2027

Note. BSC = Balanced Scorecard; DPH = Department of Population Health; FQHC = Federally Qualified Health Center. All data and program benchmarks are derived from the NYU Langone Hospitals Service Plan 2025–2027.

Stakeholders Identification

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However, the key to the successful implementation of quality initiatives is engagement and identification of key stakeholders. In the current quality effort, DPH will be engaging community health workers, program managers/directors within the DPH, members of the NYU Langone Audit Committee (NYU Langone Health, 2025), and stakeholder groups, which will include mothers/caregivers generally living in Sunset Park in Brooklyn, Hempstead, and other locations. The key leadership will be Research Professor Sue A. Kaplan, Vice President Kathleen Hopkins, and other leadership will be provided by the advocacy groups that support the community, and other groups that operate under the auspices of the New York State Prevention Agenda (NYU Langone Health, 2025). The sum of all the contributions by each stakeholder will be the source of value-added and the basis for the resource base, as every contribution supports their distinctiveness.

Document the process of collaborating with stakeholders. Describe how to work with stakeholders.

Stakeholders need to play a meaningful role in quality improvement activities to be able to participate in organized stakeholders’ meetings, regular communication, and community engagement. Field-based partners will create interventions which reflect the reality of their communities, and will compile data from their work with underprivileged populations (Kidger et al., 2025). Moreover, formal processes, such as public involvement and interprofessional team meetings, can ensure there is equal contribution from all stakeholders to the development of quality improvement processes (El-Awaisi et al., 2024). To be successful and to be able to continue serving the community’s needs, the overall collaboration needs to be open, organized, and committed by all stakeholders.

Leveraging Stakeholder Feedback

Collecting stakeholder participation can assist in improving quality, as well as creating sustained momentum for making ongoing improvements to the program. At the community level, multiple approaches to collecting input will be provided via community health assessments, as well as through program evaluation tools and through existing communication networks to provide ongoing feedback on the implementation of the initiative (Koo & Yang, 2025). Participant feedback, both from program participants and frontline staff, will be used to get first-hand information on how well programs achieved the intended outcomes (Atiku et al., 2024). Input from outside organizations (counterpart agencies, regulatory agencies, etc.) will also be useful in identifying other elements that will aid in the review and enhancement of the program.

Role of Change Theory

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By creating and establishing a framework, contemporary change theory will guide a structured approach to establishing an understanding of how to implement change, improve quality of care, and implement quality of care improvement initiatives in health care organizations. According to Lewin, there are three phases to creating change: unfreeze, change, and refreeze. These phases will be a helpful tool that will support an evidence-based approach to supporting change at DPH (Adam, 2022). The first step (unfreezing) will involve stakeholders creating awareness of barriers to better maternal and child health outcomes (Azasi et al., 2026). The second step (changing) will involve implementing existing processes and methods to carry out specific interventions (including community health workers) and the development of new methods to collect data on maternal and child health outcomes. The third step (refreezing) will involve implementing new processes for developing benchmarks for workflow and performance, and developing and institutionalizing ways to continue engaging stakeholders in the ongoing operational processes of DPH.

Interpretation of Theory

Lewin’s Change Theory can be applied to the health care industry to comprehend how change occurs as it relates to enhancing the quality of care provided in maternal and child health services. The ‘unfreezing’ phase to facilitate change in maternal and child health service delivery involves: critically examining the existing maternal and child health service delivery assumptions and practices with stakeholders; mapping the gaps in reaching the maternal and child health program and collecting data (Singh et al., 2024). During the ‘change’ phase, further support for leadership, resources, and staff education/training is needed to implement new intervention protocols for the underserved communities (Xue et al., 2025). The final step of Lewin’s change theory is ‘refreezing,’ which deals with institutionalizing the new procedures by changing policies.

Policy Recommendation

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Evidence-based policy recommendations are essential to ensure that quality improvement efforts are sustained. To support NYU Langone’s maternal and child health emphasis area, a standardized data sharing policy with all community partners will help reduce the lack of information in the new expanded areas of service delivery (Susha et al., 2023). Structured training protocols and established benchmarks for frequency of contact/communication in a revised policy on deployment of CHWs will enhance program consistency and improve accountability for CHWs in providing the services (Dimmer et al., 2024). An organization’s goal for 90% family retention and an 85% increase in family knowledge should be met with the development and implementation of a formal family engagement policy that identifies retention strategies (NYU Langone Health, 2025). The recommendations are designed to facilitate organizational support operations and to align them with the departmental strategic priorities.

Policy Implications and Justification

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Improving the quality of programs requires policies and evidence; if there are any entities involved in making large changes to organizations or the systems they operate within, standardizing data sharing will allow the DPH to establish maternal/child health programs from evidence produced by many different organizations. Revised community health worker deployment policy helps workers deliver programs to meet expectations and provides equitable resources to underserved communities (Endalamaw et al., 2024). A formal family engagement policy is for developing institutionalized retention strategies for the sustainability of the system (Pieper et al., 2025). The proposed policy changes will ensure the basis for organizations to implement systematic improvement of measurable outcomes and provide equity and sustainability.

Conclusion

Slide 10

The DPH’s proposed quality improvement initiative is an evidence-based strategy for attaining the health of mothers and children in underserved communities. However, specific identification of key performance indicators, performing a SWOT analysis, and involving stakeholders will be a starting point for addressing the main areas of disparity and for organizing equity across the organization. Lewin’s Change Theory will be introduced as a model for the implementation of the initiative and will serve as a sustainable structure of change to ensure that improvements that will be brought about by the new policies and workforce development will be embedded in the NYU Langone Health (NYULH) community health mission.