From One Aim to Nine Change Ideas: A Driver Diagram for Morning Discharges, the Theory It Makes Explicit and a Family of Measures Built for Improvement Rather Than Judgment
[Student Name]
University of Phoenix
DNP/730: Organizational and Systems Leadership
Week 5 Assignment
[Instructor Name]
[Date]
The units and measures are composites written for a model paper.
Four PDSA cycles on 5 East raised discharges before noon from 9% to 21%. To spread the work to 5 West and sustain it, the team needs a shared picture of how the pieces fit. This paper builds a driver diagram and a family of measures.
Why Make the Theory Explicit
Reed et al. (2014) describe the action effect method, a structured approach for articulating the program theory of a quality improvement initiative. It produces a diagram linking the overall aim to contributing factors and then to specific interventions, with measure concepts attached. They argue that a well-articulated theory guides execution and evaluation, focuses other methods such as PDSA cycles and serves as a communication tool to engage stakeholders.
The Aim
Across both medical units, raise the share of patients leaving before noon from 9% to 30% within a year, with no rise in readmissions at 30 days. The aim echoes a published program in which discharges before noon rose from 11% to 38% and the ratio of observed to expected length of stay fell (Wertheimer et al., 2014).
Primary Drivers
Our system map and PDSA cycles point to four primary drivers: early identification of patients likely to leave tomorrow; readiness of discharge tasks before the morning, including prescriptions, teaching and equipment; prioritization of discharges in morning workflows across professions; and timely departure logistics, including family pickup and transport.
Secondary Drivers and Change Ideas
Under early identification: a shared definition of ready for discharge and an afternoon huddle; change ideas include a 3 p.m. multidisciplinary huddle and a whiteboard column for tomorrow. Under task readiness: pharmacy, teaching and therapy completed the day before; change ideas include evening prescription filling and teaching begun the evening before. Under prioritization: rounding order and case management timing; change ideas include seeing identified discharges first and case managers arranging placements the prior afternoon. Under logistics: family and transport; change ideas include calling families the evening before and a morning transport block.
The diagram is not a picture of what we will do; it is a set of claims about what causes what, each of which could be wrong.
Building the Diagram Together
The diagram was drafted in a 90-minute session with the working group, using sticky notes on a wall. Each profession added the factors they believed delayed discharge, and the group clustered them into drivers. Building it together produced a theory everyone recognized and gave each profession a visible place in it, which matters for engagement.
What the Diagram Leaves Out
Some factors were placed outside the diagram because the team could not influence them directly, such as insurer authorization times. Naming them in a box labeled external constraints keeps them visible without pretending the team controls them. Some may become targets later through negotiation with partners.
Testing the Theory
Every arrow is a hypothesis. For example, we predict that evening prescription filling increases discharges before noon because waiting for prescriptions delays departure. If filling prescriptions early does not change departure times, the link is wrong or another bottleneck dominates.
Three Purposes of Measurement
Solberg et al. (1997) distinguish three faces of performance measurement: for improvement, for accountability and for research. Measurement for improvement aims to learn and uses small, frequent samples that are just good enough; measurement for accountability aims to judge or compare and requires precise, standardized data; measurement for research aims to generate generalizable knowledge and requires rigorous design. Confusing these purposes, for example using improvement data to judge individuals, undermines both learning and trust.
When Accountability Measures Are Needed
The operations council will eventually want discharge timing reported monthly for comparison across units. That is an accountability use, requiring stricter definitions and complete data. Keeping the weekly team measures separate from the monthly council report lets each serve its own purpose without distorting the other.
Our Measures Are for Improvement
Our measures are designed for learning, reviewed weekly by the team and not used to evaluate individual nurses or physicians. This distinction, communicated clearly, protects the candor the PDSA cycles need.
Outcome Measures
The primary outcome is the weekly percentage of discharges before noon on each unit. A secondary outcome is the median time from admission decision to bed for medical patients in the emergency department.
Process Measures
Each process measure matches a primary driver: the share of next-day departures named on the 3 p.m. list; the percentage of discharge prescriptions filled by 8 a.m.; the percentage of identified patients seen first on rounds; and the percentage of families contacted the evening before.
Balancing Measures
Balancing measures detect harm: 30-day readmissions, patient-reported readiness for discharge on the follow-up call and nurse-reported workload on the morning shift.
Why Not Measure Everything
The team proposed more than 20 possible measures. Collecting all of them would consume the analyst's time and overwhelm the run chart wall. Choosing one process measure per primary driver keeps the family small enough to review in ten minutes each week and ensures every measure tests a specific link in the theory.
Data Sources and Burden
Most measures come from existing systems: discharge times from bed management, prescription times from pharmacy, family contact from a checkbox in the discharge note. Only the rounding-order measure requires manual tally, done by the charge nurse on a card at the huddle. Low collection burden is essential for measures that must run for a year.
Operational Definitions
Each measure has an operational definition. A discharge before noon is a discharge order time and departure time from the unit before 12:00 p.m., taken from the bed management system. Identification counts only if the patient's name appears on the huddle list by 3:30 p.m. the prior day.
Displaying Measures
The wall of charts is reviewed standing up, in ten minutes, at the weekly team meeting.
Measures are displayed on run charts, one per measure, with outcome and process charts side by side so the team can see whether process changes precede outcome changes.
Linking Measures to Decisions
Each measure has a decision attached. If identification drops below 70%, the team reviews the huddle. If prescription readiness falls, pharmacy is consulted. If readmissions rise, the team pauses spread and reviews cases. Measures that lead to no decision are dropped at the quarterly review.
Using the Diagram
The diagram hangs in both units' conference rooms and is updated as tests change our understanding. Reed et al. (2014) describe the diagram as a communication tool; staff use it to see how their piece fits.
Conclusion
A driver diagram built with a structured method for program theory links the aim of morning discharges to four primary drivers, their secondary drivers and specific change ideas, each a testable hypothesis. Measures are matched to each driver and designed for improvement rather than accountability, with outcome, process and balancing measures defined operationally and displayed over time.
References
Reed, J. E., McNicholas, C., Woodcock, T., Issen, L., & Bell, D. (2014). Designing quality improvement initiatives: The action effect method, a structured approach to identifying and articulating programme theory. BMJ Quality and Safety, 23(12), 1040-1048. https://doi.org/10.1136/bmjqs-2014-003103
Solberg, L. I., Mosser, G., & McDonald, S. (1997). The three faces of performance measurement: Improvement, accountability, and research. The Joint Commission Journal on Quality Improvement, 23(3), 135-147. https://doi.org/10.1016/S1070-3241(16)30305-4
Wertheimer, B., Jacobs, R. E. A., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154
How this DNP 730 Week 5 example is structured
The DNP/730 Week 5 work usually develops a driver diagram and measures. This paper shows how the diagram makes the team's theory of change visible and testable and how each measure is matched to a link in that theory. Students search this week as DNP 730 Week 5, DNP730 Wk 5 or DNP/730 Wk 5; all three are the same assignment.
DNP/730 Week 5 questions, answered
What does DNP/730 Week 5 usually ask for?
Many sections ask students to build a driver diagram for an improvement aim and define outcome, process and balancing measures.
What is a driver diagram?
A visual display of a team's theory of improvement, linking an aim to primary drivers, the main factors that must change, secondary drivers that influence them and specific change ideas to test.
How does measurement for improvement differ from measurement for accountability?
Improvement measures are practical, frequent and just good enough to guide learning; accountability measures must be precise and comparable for judgment; research measures must be rigorous enough to generalize.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.