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Queen’s Institute of Healthcare Improvement


The following is a fictional case study based on current occurrences in Ontario’s healthcare system.


Your team must formulate a solution to the case described by using the information given as well as your own research to inform your opinions. You will pitch this solution to a panel of judges in the form of a 10-minute oral presentation.


Guiding questions are included on the page below to inform your answers.


For several decades now, the province of Ontario has been experiencing understaffing of registered nurses (RNs) and other nursing staff. This staffing crisis was exasperated during and following the COVID-19 pandemic, which caused 75% of RNs in the province to report experiencing burnout, excessive stress, or depression. This crisis has led the province to resort to drastic measures in recent years, such as large scale emergency department closures and massive surgical wait-times. It is estimated that by the year 2028, the province will be over 30,000 nurses short of the desirable nurse-to-patient ratio, which could cost the government over $20 billion to correct. This crisis has not only created a financial burden but has created deficits in patient safety and care as RNs take on more patients to accommodate for the growing lack of staff. 

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Hope Valley Hospital islocated in a large urban city in Southern Ontario and services an area of approximately 500,000 patients. Following the COVID-19 pandemic, the hospital is experiencing unsustainably high RN shortages. RNs that remain employed by the hospital work longer hours and support more patients than ideal as a result. Currently, nurses at Hope Valley are reporting a high degree of burnout, work-related anxiety, and/or depression. As part of its ongoing quality improvement initiative, the hospital randomly selects a number of patients per week to complete a voluntary patient experience survey. This survey was first implemented over 15 years ago and continues to be used to date. This quantitative, ranking-based survey asks patients to rank their experiences 1 to 5 in several domains, including but not limited to:

  • Emotional Support: did the patient feel supported by their care team and other hospital staff?

  • Staying Informed: was the patient informed/educated on their health and treatment options by their care team?

  • Involvement of Loved Ones: were the patient’s loved ones adequately informed and involved in their care?

  • Respect: were physicians and nurses respectful of the patient’s preferences and unique situation?

  • Comfort: was the patient assisted in being as physically comfortable as possible within the hospital environment?

  • Overall Experience: was the patient’s stay generally a positive experience?

Over the past 18 months, Hope Valley administrators have noticed a drastic decline in all scores, especially patient-reported Emotional Support and Overall Experience scores. This finding shadows a stark decline in patient outcomes, with Hope Valley seeing a greater patient mortality rate and longer patient stays over the past year. Other nearby public hospitals which also suffer from staffing issues have reported similar findings. You are a quality improvement expert who has been hired to assist the hospital in rectifying the decline in patient care quality as a result of the hospital’s staffing issues

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With patient safety and healthcare quality improvement in mind, create an intervention strategy to help rectify this hospital’s QI crisis.


Use the following questions to guide your thinking and answers. Note that providing answers to each question in your presentation is not mandatory, however you may want to use these questions to inform the content of your answer


  • What, precisely, must the hospital work to correct? What are the major problems Hope Valley is facing, and what are the more minor problems?

  • Who are the stakeholders involved in this crisis, and how might you go about gathering their experiences and opinions to inform your intervention strategy?

  • What is physician-to-patient or nurse-to-patient ratio and why is it so important for health?

  • What is the most efficient way to correct an understaffing problem at a public hospital?

  • Is it more important for the hospital to implement drastic short-term changes or slower, more comprehensive long-term changes?

  • Moving forward, is the existing patient survey enough to inform any changes that result from your intervention strategy?

  • Is there any legislature surrounding patient rights which could help inform your intervention strategy?


  • Is it more important for the hospital to approach its crisis from the perspective of (a) helping patients receive better care, or (b) helping nurses combat burnout and depression?

  • Are there additional supports (i.e., non-nursing staff) which could be leveraged to alleviate the burden placed on nurses during this time? What might the consequence of relying on additional supports be?

  • Will you implement a way to track the changes that result from your intervention strategy over time, and how will you accomplish this?

Questions about specifics related to this case or the event should be directed to


Information used to formulate this case was adapted from the following 2010 report. It is within the rules of the competition to consult this document and any additional resources you can find.

Reference: Quigley, Denise D., Shelley H. Wiseman, and Donna O. Farley, Improving Hospital Inpatient Nursing Care: A Case Study of One Hospital's Intervention to Improve the Patient's Care Experience. Santa Monica, CA: RAND Corporation, 2010.


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