Capella University

NURS FPX 8020 Assessment 3 Quality Improvement Proposal
Capella University, DNP, NURS-FPX8020

NURS FPX 8020 Assessment 3 Quality Improvement Proposal

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NURS FPX 8020 Assessment 3 Quality Improvement Proposal Student Name Capella University NURS-FPX8020 Doctoral Executive Leadership in Contemporary Nursing Professor name Submission Date   Quality Improvement Proposal Slide 1 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 Slide 3 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 Slide 4 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 Slide 5 Key performance indicators

NURS FPX 8020 Assessment 2 Strategic Plan Development
Capella University, DNP, NURS-FPX8020

NURS FPX 8020 Assessment 2 Strategic Plan Development

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NURS FPX 8020 Assessment 2 Strategic Plan Development Student Name Capella University NURS-FPX8020 Doctoral Executive Leadership in Contemporary Nursing Professor name Submission Date   Strategic Plan Development Strategic planning is essential for health care organizations to set the framework for allocating resources, improving patient outcomes, and responding effectively. The voice of front-line staff in health care organizations is also crucial during the strategic planning process because they are directly engaged in the community, have operational knowledge and experience in programmer implementation and the uptake of evidence-based programmers. Such experience and dedication towards patients ensures that the strategic objectives of health care organizations are true to the actual health care delivery and reflect the actual health care needs of the population that has been neglected (Laari & Duma, 2023). To achieve the highest possible impact for the organization and for population health outcomes in the long term, it is helpful to involve frontline staff in a comprehensive strategic planning process. The purpose of the assessment is to develop a strategic plan for the Department of Population Health (DPH) at NYU Lang one Hospital, through the Balanced Scorecard approach. Departmental Strategic Priorities The ability of an organization to provide sustainable, equitable health care is the most important strategic priority. The Department of Population Health at NYU Langone Hospitals, since 2013, has been the architect of the Community Service Plan. Thus, ongoing funding is a key financial priority to support more than 40,000 people a year at NYU Langone Hospitals (NYU Lang one Health, 2025). DPH has a solid federal reimbursement policy in place and is consistent with New York State Prevention Agenda funding policies. Operating sustainable finances for DPH will enable community programs to continue to serve and will enable DPH to adapt to the evolving population health needs. An important thing a Healthcare Department can do is to enhance the health status of vulnerable groups. There are disparities among communities that are experiencing the same situation, but some communities are worse off or worse than others. Areas such as Sunset Park, Red Hook, and Hempstead have a higher number of underprivileged people due to a lack of prenatal Care and Early Childhood Development programs available (NYU Langone Health, 2025). If parents retain 90% of the information and their knowledge increases 85% over two years, it will show that these programs are viable projects (NYU Langone Health, 2025). DPH is working to show a commitment to health disparities by improving health outcomes for underserved populations in the area of maternal and child health. Better patient safety outcomes and reducing unnecessary patient harm can be achieved by the improvement of internal clinical processes. Fall Prevention and Exercise for the Elderly (E4E) is one of the eight major internal processes initiatives identified by the NYU Langone Hospitals’ DPH Program to improve clinical practice and includes an 8-week provider-led intervention spread across Brooklyn and Long Island (NYU Langone Health, 2025). The fall prevention and exercise for seniors program falls under the highest priority of an intervention, as falls contribute to more emergency room visits and increased healthcare costs in all the communities served by DPH (NYU Langone Health, 2025). The program is considered a quality improvement project, allowing it to be undertaken as scheduled since it has a clear structure of interventions and is aimed at reducing the rate of falls by 35-40% among those who participate in the project (NYU Langone Health, 2025). By enhancing the process inside the DPH, the overall culture of safety for patients and families at DPH has also been improved. One of the key objectives of DPH is to make long-term investments in workforce development. The goal will help DPH grow in providing care that is responsive to community needs. One way that DPH is going to achieve the goal is through the Community Health Worker (CHW) Research and Resource Center, which will increase the capacity of the frontline workforce in Sunset Park, Red Hook, Uniondale, Roosevelt, and Mastic Beach (NYU Langone Health, 2025). CHWs fill the gap between the population and DPH’s clinical programs, ensuring that the population has access to prevention and intervention services, which narrows the Health Disparity gap. The initiative is feasible, as the DPH already has existing training programs, as well as evidence of how many people have been served in the Reach and Impact Report from September 2023 to August 2024 (NYU Langone Health, 2025). DPH will continue to develop a competent and culturally competent workforce to meet the evolving health needs of the community through 2027. Effects of Organizational Policies Departmental strategic priorities are greatly affected by the policies of an organization, which can either enable or limit the execution. The Financial Assistance Policy at DPH, NYU Langone hospitals, for instance, is designed to increase access to under-resourced communities all over Brooklyn and Long Island by offering sliding-scale care and assisting with Medicaid enrollment (NYU Langone Health, 2025). NYULH’s focus on health equity and priorities in New York State Prevention Agenda shapes the policy landscape for DPH’s community-based services (NYU Langone Health, 2025). The policies create an enabling environment (policy alignment) that can help to scale up the departmental goals and serve as infrastructure for the sustained implementation of DPH programs in the long term. However, a number of organizational limitations may hinder the DPH’s strategic goals. Evidence of data gaps in the extended service areas of Uniondale, Roosevelt, and Mastic Beach suggests that there are policy-level challenges to collecting data and, as a result, limits to the ability to create interventions that are solely based on evidence (NYU Langone Health, 2025). Further, DPH has not yet established a consistent standard for data sharing agreements with all community partners, which reduces its capacity to analyze data and to offer a consistent measure of the impact of the program (NYU Langone Health, 2025). Continuing to address policy-level barriers with data governance changes and further community engagement through increased protocols will further support DPH’s implementation of its strategic goals. Alignment of Departmental Strategic

NURS FPX 8020 Assessment 1 Strategic Plan Appraisal
Capella University, DNP, NURS-FPX8020

NURS FPX 8020 Assessment 1 Strategic Plan Appraisal

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NURS FPX 8020 Assessment 1 Strategic Plan Appraisal Student Name Capella University NURS-FPX8020 Doctoral Executive Leadership in Contemporary Nursing Professor name Submission Date   Strategic Plan Appraisal Appraising a strategic plan is a vital management process that will help healthcare organizations to evaluate their achievements against their objectives and then adjust to the changing environment. Systematic evaluation will help organizations to allocate resources effectively, detect their performance gaps, and inform decision-making at all levels of leadership with evidence (Huebner & Flessa, 2022). The accountability mechanisms are further reinforced through ongoing strategic review, and activities are aligned with their broader organizational goals (Stanikzai & Mittal, 2025). The strategic focus of NYU Langone Hospital is discussed by looking at data integrity, stakeholder involvement, and the overall measurement of the hospital’s core performance metrics. Strategic Plan Analysis One of the key factors of a strategic plan’s effectiveness and coherence over the long term is how closely it is aligned with the mission and vision of the organization. The NYU Langone Hospitals’ plan for 2025-2027 is deeply grounded in the institution’s triple mission of caring, teaching, and discovery – as well as a shared vision of health equity – among the communities. The six priority areas of the plan (digital access, health and housing, healthy eating and food security, tobacco prevention, maternal and child health, and weather-related health effects) directly address the social determinants of health that impact underserved communities in Brooklyn, Long Island, and beyond (NYU Langone Health, 2025). Health and housing, healthy eating and food security, seem to be the highest priorities in the plan and are the most programmatic in terms of investment, including the Healthy Food Initiative (NYU Langone Health, 2025), the Health x Housing Lab, and the Health & Housing Consortium. Along with maternal and child health, there are also several programs related to early childhood intervention occurring throughout, such as PlayReadVIP, ParentChild+, ParentCorps, and Greenlight, which demonstrate that early childhood intervention is a key element of the organization’s health strategy (NYU Langone Health, 2025). Finally, a strategic plan is a plan with clear priorities that makes sure that the priorities are translated into action. SWOT A strengths and weaknesses analysis and external opportunities and threats (SWOT) is a strategic method of assessing the internal strengths and weaknesses and external opportunities and threats of an organisation. A “SWOT” analysis involves a business identifying its strengths, weaknesses, opportunities and threats, which will help it to make strategic decisions and plan competitively (Farag, 2025). In terms of inpatient hospital sites, the NYU Langone Hospitals show significant strengths with seven facilities; in ambulatory sites, the Hospitals have more than forty sites, and in terms of Federally Qualified Health Centers, the Hospitals have nine primary care centers throughout Brooklyn (NYU Langone Health, 2025). Its ability to educate and discover is further bolstered by the affiliation with NYU Grossman School of Medicine and NYU Grossman Long Island School of Medicine, both of which provide full tuition scholarships (NYU Langone Health, 2025). The internal weaknesses identified are documented information gaps that hinder the organization’s capacity to comprehensively evaluate community health needs, especially in new service areas, including Uniondale, Roosevelt, Shirley, Mastic, and Mastic Beach (NYU Langone Health, 2025). Opportunities out of the box involve alignment with New York State Prevention Agenda priorities and growing community-based virtual primary care (NYU Langone Health, 2025) and digital access programs. Brooklyn and Long Island (NYU Langone Health, 2025) are faced with numerous threats, including social determinants of health issues such as housing insecurity, food insecurity, and tobacco use, as well as weather impacts on underserved communities. By performing the comprehensive SWOT analysis, healthcare organizations can identify strengths to build upon, weaknesses to address, opportunities to exploit, and threats to mitigate, to move health outcomes in the direction of improving equitable health in the community. The SWOT findings from the NYU Langone Hospitals directly connected to strategic decision-making to maximize the effective utilization of the site’s strengths, such as their seven inpatient facilities, more than forty ambulatory sites, and academic affiliations with NYU Grossman School of Medicine, to better serve community health programs that are equitable. New service areas were coupled with documented data gaps, which led to investments in data collection, and external opportunities that support New York State Prevention Agenda priorities led to program development. Housing instability, food insecurity, and tobacco use were the remaining 3 priority threats that influenced the focus of the 6 intervention areas that the organization prioritized for 2025-2027 The data for the SWOT of NYU Langone Hospital in the table below is taken from NYU Langone Health (2025) Strengths · Seven inpatient facilities, forty+ ambulatory sites, and a nine-center Federally Qualified Health Center network ensure broad, accessible care delivery. · Academic affiliations with two medical schools offering full-tuition scholarships strengthen the organization’s mission. Weaknesses · Documented information gaps limit the ability to fully assess health needs in newly expanded service areas. · Inconsistent programmatic reach across newer communities constrains equitable service delivery. Opportunities · Alignment with New York State Prevention Agenda priorities supports expansion of evidence-based community health programs. · Growth in virtual primary care and digital access initiatives offers potential to reduce barriers Threats · Persistent housing instability and food insecurity continue to disproportionately burden underserved populations · Weather-related health risks and high tobacco use rates present ongoing challenges. Validity of Data and Analytical Strategies Assessing the validity of data and analytical processes to understand the way community needs are utilized to inform actionable priorities is a fundamental part of understanding how organizations turn community needs into actionable priorities. Valid data and strong analysis ensure that the research will yield accurate results, promoting reliable conclusions and data-informed decisions (Shaheen et al., 2023). Data from community health needs assessments, public health surveillance, and program-level outcome measures from particular neighborhoods such as Sunset Park, Red Hook, the Lower East Side, Chinatown, and Hempstead were likely used to develop NYU’s key performance indicators (NYU’s KPIs) (NYU Langone Health, 2025). Some of the indicators are

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