NR584 Week 7: Applying Quality Improvement (QI) to Clinical Practice
Assigned Topic: Catheter-Associated Urinary Tract Infections (CAUTI)
General Instructions
Carefully read the assignment guidelines and rubric and complete each section of the assignment below using your assigned topic. Assume the role of a member of a QI team in charge of reviewing facility policies and procedures related to your assigned topic. Using the topic assigned to you, answer the following questions to explore and apply the QI process to improve client safety and care outcomes.
Section 1: Identify
- Describe your assigned topic and why it is a concern in healthcare.
Catheter-associated urinary tract infections (CAUTIs) represent a persistent challenge in healthcare, contributing to preventable patient harm, prolonged hospital stays, and increased healthcare costs. These infections occur when pathogens enter the urinary tract through an indwelling catheter, often as a result of extended catheter use, breaks in sterile technique, or inadequate maintenance. Forrester et al. (2022) note that beyond the clinical implications, CAUTIs can significantly affect patient comfort, dignity, and overall recovery, making prevention a critical priority in safe, high-quality care.
- Summarize a current policy or procedure at your facility related to this issue. How is this issue currently addressed?
Current facility policy emphasizes sterile insertion techniques, maintenance of a closed drainage system, routine perineal care, and documentation of catheter necessity. Daily assessments are expected to determine whether continued catheterization remains clinically justified. Despite these guidelines, catheter removal often depends on provider orders, which may delay timely discontinuation.
- What inconsistencies exist between your facility’s current policies, actual nursing practice, and best evidence related to your assigned topic? What evidence (data, observation, incident reports) suggests a need for improvement?
Gaps between policy, practice, and best evidence are evident. Inconsistent documentation of catheter necessity, variation in adherence to aseptic technique, and delayed removal practices continue to be observed. Internal audit data indicate a rise in CAUTI rates from 2.1 to 3.8 infections per 1,000 catheter days over six months, accompanied by compliance rates below 70% for daily necessity documentation. These findings highlight a clear opportunity for improvement and reinforce the need for a structured quality improvement approach.
Section 2: Analyze
- Review national safety resources related to your topic. Name at least two national organizations or initiatives (e.g., Centers for Medicare & Medicaid Services (CMS), Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control and Prevention (CDC), Institute for Health (IHI), National Patient Safety Goals (NPSG)) and summarize the guidance they provide related to your topic.
The Centers for Disease Control and Prevention (CDC) recommends limiting catheter use, ensuring aseptic insertion, maintaining a closed drainage system, and prioritizing early removal (Halinski, 2024). Similarly, the Agency for Healthcare Research and Quality (AHRQ) promotes nurse-driven removal protocols, standardized care bundles, and continuous monitoring to reduce infection rates and improve patient outcomes(Valdez, 2022).
- Present and interpret data from your organization to justify your need for change. Use real or hypothetical data (e.g., rates, trends, benchmarks).
Organizational data further underscores the urgency for change. Facility-reported CAUTI rates exceed national benchmarks of approximately 1.0–2.0 infections per 1,000 catheter days. A review of recent trends demonstrates a steady increase in infection rates, alongside suboptimal compliance with catheter care protocols. For example, documentation audits reveal only 65% adherence to daily necessity assessments. These patterns suggest that current practices are insufficient and that targeted interventions are necessary to align care delivery with established best practices.
Section 3: Plan
- State a clear, measurable QI goal related to your topic (e.g., “Reduce CAUTIs by 25% within 6 months”).
The proposed quality improvement goal is: Reduce CAUTI rates by 30% within six months through implementation of a nurse-driven catheter removal protocol and a standardized CAUTI prevention bundle.
- Describe a proposed change to the current policy or procedure to support QI related to your topic.
To support this goal, revisions to the current policy will include authorization for nurse-driven catheter removal based on clearly defined clinical criteria. In addition, a standardized prevention bundle will be introduced, incorporating daily necessity checklists, strict adherence to aseptic insertion techniques, and electronic health record prompts to encourage timely reassessment.
- Which evidence-based strategies support your proposed changes? Include at least one scholarly source to support your plan.
Reducing catheter duration remains the most effective method for preventing CAUTIs, while standardized care bundles improve consistency and reliability in practice. Research indicates that nurse-driven protocols significantly decrease catheter days and associated infection rates (Baker et al., 2022). Consistent use of reminders and documentation tools has also been shown to enhance compliance and sustain improvements in patient safety outcomes.
Section 4: Act
- Which stakeholders need to be involved in implementing this change?
The stakeholders include bedside nurses, nurse leaders, infection prevention specialists, physicians, quality improvement teams, and information technology personnel.
- What leadership and communication strategies would you use to gain buy-in and support implementation?
I would use open communication through staff meetings, performance dashboards, and real-time feedback, which fosters awareness and encourages participation.
- How would you educate staff about the new or revised procedure?
Education would be delivered through structured training sessions, skills validation, and simulation-based learning to reinforce proper catheter insertion and maintenance techniques. Visual aids, quick-reference tools, and integration of updated practices into staff orientation programs would support ongoing education.
Section 5: Sustain
- How will you monitor the impact of the change? What data will you collect and how often?
Monitoring the impact of the change would occur through monthly EHR audits, tracking CAUTI rates, catheter utilization ratios, and daily necessity documentation compliance. Run charts would display trends. Data would guide real-time feedback and quarterly performance reviews to sustain improvement.
- What criteria will you use to evaluate success? Include short-term and long-term outcomes.
Short-term indicators include increased compliance with catheter care protocols and reductions in catheter days. Long-term outcomes focus on sustained decreases in CAUTI rates, improved patient safety, and enhanced quality of care.
- How will you ensure the improvement is sustained over time?
Sustainability will be achieved by embedding revised protocols into standard operating procedures, integrating prompts into the electronic health record, and conducting routine audits with feedback. Ongoing leadership support, continuous education, and reinforcement of best practices will help maintain progress. A sustained commitment to safety and accountability ensures that improvements are not only achieved but consistently upheld over time.
References
Baker, S., Shiner, D., Stupak, J., Cohen, V., & Stoner, A. (2022). Reduction of catheter-associated urinary tract infections: a multidisciplinary approach to driving change. Critical Care Nursing Quarterly, 45(4), 290-299. https://doi.org/10.1097/CNQ.0000000000000429
Forrester, J. D., Maggio, P. M., & Tennakoon, L. (2022). Cost of health care–associated infections in the United States. Journal of Patient Safety, 18(2), e477-e479. https://doi.org/10.1097/PTS.0000000000000845
Halinski, C. (2024). Infection prevention and control: The importance of hygiene in dialysis care. In Principles of Nursing in Kidney Care: Under the Auspices of EDTNA/ERCA and EKPF (pp. 225-242). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-031-30320-3_14
Valdez, B. C. L. (2022). Nurse-Driven Protocol for Urinary Catheter Removal (Doctoral dissertation, Grand Canyon University). https://www.proquest.com/openview/60369e57f44d315f64d55c9164a9e135/1?pq-origsite=gscholar&cbl=18750&diss=y
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Purpose
The purpose of this assignment is to explore the quality improvement (QI) process and its impact on client safety and care outcomes. Through this process, students will develop skills in identifying and using national safety resources, interpreting data to justify the need for change, and applying leadership and collaboration strategies to implement and sustain improvements in healthcare settings.
Course Outcomes
This assignment enables the student to meet the following course outcomes:
- CO 1: Examine competencies and underpinnings to continuously improve the safety and quality of healthcare. (POs 1, 5)
- CO 2: Evaluate quality and safety initiatives to advance healthcare outcomes and equity across healthcare settings. (POs 1, 5)
- CO 3: Appraise ethical, legal, regulatory, and professional standards for quality management and safety across healthcare settings. (POs 3, 4)
- CO 4: Apply advocacy for quality and safety initiatives to advance healthcare outcomes and equity. (PO 5)
- CO 5: Compare system-level emergency preparedness plans to protect patient, population, and provider safety. (POs 1, 5)
Preparing the Assignment
Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.
General Instructions
Complete this assignment assuming the perspective of a member of a QI team in charge of reviewing facility policies and procedures related to an assigned topic. Your assigned topic is based on the first letter of your last name in the chart below.
| Last Name | Topic |
| A – E | Falls with Injury |
| F – J | Hospital-Acquired Pressure Ulcers (HAPUs) |
| K – O | Catheter-Associated Urinary Tract Infections (CAUTI) |
| P – T | Central Line-Associated Bloodstream Infections (CLABSI) |
| U – Z | Ventilator-Associated Events (VAE) |
Complete the assignment by following the steps below.
- Download the Applying Quality Improvement (QI) to Clinical Practice template Download pplying Quality Improvement (QI) to Clinical Practice templateOpen this document with ReadSpeaker docReader. Use of this template is required. If the template is not used, a 10% deduction will be applied. See the rubric. Save the template and include your name in the file name.
- Identify your assigned topic from the chart based on the first letter of your last name. Using the correct topic is required. If the correct topic is not used, a 10% deduction will be applied. See the rubric.
- Complete the template using your assigned topic.
- Follow APA grammar, spelling, word usage, and punctuation rules consistent with formal, scholarly writing.
- Provide resources from at least three scholarly resources. Include in-text citations in APA format when applicable.
- No more than one short direct quote (15 words or less) may be used in this assignment.
- First person should not be used within this assignment.
- Abide by Chamberlain University’s academic integrity policy.
Include the following sections (detailed criteria listed below and in the grading rubric).
Section 1: Identify
- Describe your assigned topic and why it is a concern in healthcare.
- Summarize a current policy or procedure at your facility related to this issue. How is this issue currently addressed?
- What inconsistencies exist between your facility’s current policies, actual nursing practice, and best evidence related to your assigned topic? What evidence (data, observation, incident reports) suggests a need for improvement?
Section 2: Analyze
- Review national safety resources related to your topic. Name at least two national organizations or initiatives (e.g., CMS, AHRQ, CDC, IHI, NPSG) and summarize the guidance they provide related to your topic.
- Present and interpret data from your organization to justify your need for change. Use real or hypothetical data (e.g., rates, trends, benchmarks).
Section 3: Plan
- State a clear, measurable QI goal related to your topic (e.g., “Reduce CAUTIs by 25% within 6 months”).
- Describe a proposed change to the current policy or procedure to support QI related to your topic.
- Which evidence-based strategies support your proposed changes? Include at least one scholarly source to support your plan.
Section 4: Act
- Which stakeholders need to be involved in implementing this change?
- What leadership and communication strategies would you use to gain buy-in and support implementation?
- How would you educate staff about the new or revised procedure?
Section 5: Sustain
-
- How will you monitor the impact of the change? What data will you collect and how often?
- What criteria will you use to evaluate success? Include short-term and long-term outcomes.
- How will you ensure the improvement is sustained over time?