D031 Task 2 Innovation Proposal and Evaluation Example

A Nurse-Led Transition Package After Heart Failure Discharge: Innovation Proposal, Adoption Plan and Evaluation Against a 22.6 Percent Readmission Baseline

[Author Name]

Master of Science in Nursing, Western Governors University

D031 Advancing Evidence-Based Innovation in Nursing Practice

Task 2

[Course Instructor]

August 11, 2026

Model document written by our desk. The hospital, the staffing and every figure in it are composites; no real organization, employer, colleague or patient is described.

Practice Problem and Baseline

The setting is a composite 240-bed community hospital whose cardiac telemetry service discharges roughly fifteen adults with a primary diagnosis of heart failure each month. In the twelve months ending December 31, 2025, the service recorded 186 heart failure discharges and 42 all-cause readmissions inside 30 days, a readmission rate of 22.6 percent. Thirty-one of the 42 returns arrived between day 8 and day 21, and 27 of them carried a documented weight gain of at least 2 kg since discharge. National payment policy already treats this figure as a performance measure rather than a local curiosity, so the problem is clinical and financial at the same time (Centers for Medicare & Medicaid Services, 2024).

A review of 40 consecutive discharge records from the same period describes the process as it currently runs. Written instructions were present in 38 of the 40 records, but teach-back was documented in 9. A follow-up appointment inside 7 days was arranged for 14. A daily weight log was issued to 11, and 3 of those records show the patient able to state a weight change that should trigger a call. Medication reconciliation was complete at discharge in 36 records, yet 12 patients had not filled a new prescription 72 hours later. The gap is not knowledge of heart failure care inside the hospital; it is the handoff into the first fourteen days at home.

The aim statement fixes the target before any solution is chosen: reduce 30-day all-cause readmission after a heart failure discharge from 22.6 percent to 17 percent or below by March 31, 2027, without lengthening average stay. Stakeholders are the telemetry nursing staff, the hospitalist and cardiology groups, case management, pharmacy, the outpatient heart failure clinic, informatics, and the finance office that owns the readmission penalty forecast. Patients and family caregivers sit inside the plan rather than beside it, since the change asks them to weigh themselves daily and to call on a stated rule rather than on how they feel.

The Proposed Innovation and Its Evidence Base

The proposal is a nurse-led transition package delivered by one experienced registered nurse working across the telemetry service and the outpatient clinic. It has four parts: structured teach-back before discharge, with the patient stating a weight change and the action it triggers; a digital scale issued at discharge and paired to a shared log; a nurse telephone contact at 48 hours and again at day 7 following a written script that checks weight trend, diuretic dose, symptoms and the booked appointment; and a standing route into the outpatient clinic inside 7 days that does not need a physician referral to book. Nothing in the package requires new technology beyond scales and a flag in the existing record.

The evidence behind each part was appraised by level rather than counted. Multi-component transitional care packages sit at the strongest levels available for this question, systematic reviews of randomized trials, and they consistently outperform any single element used alone; a call by itself, a booklet by itself or an appointment by itself carries far weaker support (Melnyk & Fineout-Overholt, 2023). The federally maintained discharge redesign toolkit supplies the operational detail trials rarely publish, including scripted contact and reconciliation steps that nursing staff can run without a physician present (Agency for Healthcare Research and Quality, 2017). Where the evidence is thin, this proposal says so: issuing scales rests on reasoning about early volume overload rather than on trial evidence of the same strength.

Appraisal also sets limits. Reported effects on 30-day readmission are real but modest, and most published gains come from packages run with fidelity for a year or more rather than from a launch month. Trial populations skew toward patients with a telephone, stable housing and a caregiver at home, which describes roughly two thirds of this service's discharges. Nothing in the appraised evidence supports a nurse call substituting for an outpatient visit, so the package keeps both rather than trading one for the other. The proposal therefore predicts a rate near 17 percent rather than a halving of the figure, and it names the patients it is least likely to reach.

Adoption Plan

Adoption runs in three phases against named dates. From September 1 to October 31, 2026, the package runs with eight volunteer telemetry nurses on day shift, which is where the early adopters already sit. Diffusion of an innovation depends more on what those first users tell their colleagues than on how the change is announced (Rogers, 2003). From November 1, 2026 to January 31, 2027, it extends to every shift on the telemetry service. From February 1, 2027, it covers heart failure discharges from any inpatient service. Each phase closes with a review that can hold the change where it is, adjust the script, or stop the spread altogether.

Resources are stated rather than implied. The nurse role is 0.6 full-time equivalent at roughly 62,000 dollars a year including benefits; 150 digital scales at 38 dollars each cost 5,700 dollars in the first year; scripting, teach-back training and record changes take an estimated 90 hours of informatics and educator time. Training is four hours per nurse in two sittings, and completion is recorded by a return demonstration of teach-back rather than by an attendance sheet. Against a baseline of 42 readmissions a year, avoiding nine of them recovers the recurring cost at any defensible estimate of what one readmission costs, which is the argument the finance office will ask for first.

Three barriers are predictable. Nursing time at discharge is the first, answered by moving teach-back into the discharge conversation that already happens rather than adding a step beside it. Telephone reach is the second; the plan allows two attempts per contact and a text message fallback, and it records the reach rate rather than assuming it. Physician ownership is the third, answered by giving the cardiology group the monthly data and a standing invitation to change the script. A named executive sponsor and a monthly report to the quality committee keep the change from depending on the enthusiasm of one nurse.

Evaluation Plan: Telling Whether It Worked

Evaluation names three kinds of measure and the source of each. The outcome measure is 30-day all-cause readmission after a heart failure discharge, drawn from the same billing extract that produced the 22.6 percent baseline, so the before and after figures are built the same way. Process measures are the share of discharges with documented teach-back and a stated weight trigger, the share reached at 48 hours and at day 7, and the share seen in the outpatient clinic inside 7 days. The balancing measure is average length of stay, watched because a package added at discharge can quietly hold patients an extra day.

Data is read monthly on a run chart rather than as a single before and after comparison, because a rate built on roughly fifteen discharges a month swings widely by chance alone and one low month proves nothing (Langley et al., 2009). The decision rule is set in advance: eight consecutive readings below the baseline, or six consecutive readings below 17 percent, count as a signal rather than noise. If the outcome measure has not moved by June 30, 2027 while the process measures sit above 80 percent, the honest conclusion is that the package was delivered as designed and did not work in this setting, which is a finding rather than a failure.

Results are written up in the structure used for improvement reporting, which asks for the context, the intervention as it was actually delivered, the measures and the reasoning that links them (Ogrinc et al., 2016). Two limits belong in that report. Pharmacist coverage at discharge changed during the same period, so improvement cannot be assigned to this package alone. Readmission to another hospital stays invisible in the billing extract, which understates the true rate at both ends of the comparison. Sustainment is defined as the package surviving without its sponsor: scripts inside the standard workflow, scales in the supply chain, and the monthly chart owned by the quality committee.

References

Agency for Healthcare Research and Quality. (2017). Re-Engineered Discharge (RED) toolkit. U.S. Department of Health and Human Services. https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html

Centers for Medicare & Medicaid Services. (2024). Hospital Readmissions Reduction Program (HRRP). U.S. Department of Health and Human Services. https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing and healthcare: A guide to best practice (5th ed.). Wolters Kluwer.

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992.

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press.