Lippincott NursingCenter Pocket Card - May 2021

Quality Improvement Initiative

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Overview (Flynn, Scott, Rotter, & Hartfield, 2017)

The goal of healthcare quality improvement (QI) is to achieve and sustain changes that produce better care and health systems, thus positively affecting patient outcomes. QI is the application of tools and methods to implement, test, and improve effective quality improvement practices. QI efforts should be based on sound evidence, rigorous assessment, implementation, adoption, evaluation, dissemination, and sustainability. Improvement science is a new field where scientific evidence is provided as a base for health care QI by incorporating QI research and implementing and scientifically evaluating QI interventions. 
 
The QI movement in healthcare gained momentum after the report by the Institute of Medicine (IOM), To Err is Human: Building a Safer Healthcare System. The report estimated that medical errors caused between 44,000 and 98,000 patient deaths annually with an estimated cost of $38 billion per year (IOM, 2000). Progress has been slow with unintended medical errors estimated to be the third leading cause of death in the U.S. in recent years (Makary & Daniel, 2016). With nurses at the frontline of patient care, we are strategically positioned to lead significant QI initiatives. We can nimbly bridge the gap between improving science research and implementing actions into patient care. 

Transformational Leadership (McFadden, Stock, Gowen, 2015)

Transformational leadership (TFL) is based on charisma inspiration and has been recognized as the most effective leadership style when compared to transactional leadership (based on rewards and punishment) and laissez-faire leadership (based on lack of leadership). TFL transforms organizations by empowering through inspirational motivation and encouraging innovation by giving followers a clear sense of purpose and a role model for conduct.

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Quality Improvement Teams (Kurnik, n.d.)

Team-led processes are preferable to management-led processes, considering the following:

  • Suggestions and ideas are submitted from the bottom up, creating a sense of ownership and enthusiasm for the initiative.
  • Solutions that are easiest to implement are identified quickly, resulting in immediate process improvements.
  • Teamwork is emphasized and team members feel valued.
  • Team members work closely with the issues and have a vested interest in resolving issues through process improvements.
Composition of an ideal QI team:
  • Assemble a team that is knowledgeable about the process and diverse in thinking styles.
  • Appoint a team leader.
  • Restrict team size – less than eight members is ideal.
  • Ensure convenient meeting times and locations.
  • At first meeting, inform team of expectation for attendance, participation, and time requirements.
  • Appoint a recorder that will document ideas and record attendance at meetings.

Define, Measure, Analyze, Improve, and Control (DMAIC)

DMAIC is well-established methodology for process and quality improvement that aims to create innovative, targeted solutions and influence change (Christopher et. al 2014, Kurnik, n.d.).
  • Define Phase
    • Clarify the purpose and scope of the project while conveying a deep understanding of the problem.
    • Develop the team and assign responsibilities based on individual strengths.
    • Identify key stakeholders to ensure ownership and accountability throughout the project.
    • Develop a team charter to clearly define goals.
  • Measure Phase
    • Develop a detailed process map.
    • Develop an audit tool or identify a metric that is representative of the process performance.
  • Analyze Phase
    • Audit current processes (retrospectively and prospectively).
    • Review all data collected and consider chart/graph for ease of understanding.
    • Brainstorm solutions.
    • Focus on actual problems to solve.
  • Improve and Control Phase
    • Conduct a best practice review.
    • Develop a pilot.
    • Assign resources to improvement tasks along with a timeline for task completion. Consider assigning outside the team to identify the best person to execute the task (i.e., has authority to effect change).
    • Consider using a metric control chart to track actions, assignees, target completion dates, actual completion dates, and task status on a weekly basis and address obstacles.
    • Create a system to ensure that critical tasks continue without the team’s ongoing support so that process improvement initiatives are not lost.

Quality Improvement Tools (Harkness & Pullen, 2019)

Many tools have been developed and utilized to assist in the quality improvement process. 

Model for Improvement/Plan-Do-Study-Act (PDSA)
PDSA is a systematic approach to reassess processes and improve outcomes. Three main questions form the improvement plan.
  • What are we trying to accomplish? This sets the vision for the program.
  • How will we know that a change is an improvement? This outlines the steps to achieve the desired outcome.
  • What changes can be made that will result in improvement. This generates ideas for testing.
Pilot the PDSA program on a small scale, analyze the data, refine the program, and repeat until the desired outcome is achieved.
 
Lean Process Improvement
Lean is a systematic method to identify and eliminate waste by implementing value-added processes based on customers’ perceptions of satisfaction. It answers the question: “What changes can we make that will result in improvement?” Key definitions include:
  • Value: what the customer is willing to pay for
  • Nonvalue added: a process that does not add value but must be done
  • Waste: what the customer is not willing to pay for
Six Sigma
Six Sigma is a process to decrease variation and is similar to the DMAIC process described above. Steps include the following:
  • Define: set goals that are consistent with customer demands and the organization’s strategy.
  • Measure: evaluate the current process and set a baseline for comparison. Utilize statistical tools such as descriptive statistics, run charts, and Pareto charts.
  • Analyze: verify cause and effect and identify ways to achieve goals.
  • Improve: optimize the process based on analysis. Implement and evaluate the plan and transition it into the standard processes.
  • Control: ensure the variances are corrected before they result in defects. Identify and communicate processes through ongoing data collection and evaluation.
Root Cause Analysis (RCA)
RCA is a retrospective, systematic approach to discern the causes of an adverse event and identify system weaknesses that can be improved to prevent the error from occurring again. The RCA process involves:
  • Identifying what occurred
  • Reviewing what could have or should have happened
  • Determining the causes
  • Developing causal statements
  • Generating recommended actions to prevent recurrence
  • Writing a summary and sharing it with administration, staff and all involved in the event 
Frontline Dyad
Frontline dyad is a bottom-up approach which utilizes a small team of two frontline staff members to identify both clinical and nonclinical issues in daily work. It involves a timeline, design benefits, specific actions, and design/test strategies. The team or dyad is responsible for the work and must show significant improvement in 30 days or less.
 
Failure Mode and Effects Analysis (FMEA)
FMEA is used to assess possible failures and prevent them as opposed to reacting to adverse events after mistakes have been made. The analysis prompts teams to review, evaluate, and record steps in the process:
  • Failure mode - What could go wrong?
  • Failure causes - Why would the failure happen?
  • Failure effects - What would be the consequences of each failure?
Nurses at every level of practice should participate in QI initiatives, be aware of key elements in the QI process, promote a culture of QI, and serve on QI teams (Harkness & Pullen, 2019).
 
 
 
References:
Christopher, D.A., Trotta, R.L., Yoho, M.A., Strong, J., & Dubendorf, P. (2014). Using process improvement methodology to address the complex issue of falls in the inpatient setting. Journal of Nursing Care Quality, 29(3), 204-214. https://doi.org/10.1097/NCQ.0000000000000053
 
Flynn, R., Scott, S.D., Rotter, T., & Hartfield. (2017). The potential for nurses to contribute to and lead process improvement science in health care. Journal of Advanced Nursing, 73(1), 97-107. https://doi.org/10.1111/jan.13164
 
Harkness, T.L., Pullen, R.L. (2019). Quality improvement tools for nursing practice. Nursing Made Incredibly Easy, 17(3), 47-51. https://doi.org/10.1097/01.NME.0000554602.68360.ed  

Institute of Medicine. (2000). To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. https://doi.org/10.17226/9728.
 
Kurnik, R. (n.d.) Process improvement teams power six sigma success. https://www.isixsigma.com/implementation/teams/process-improvement-teams-power-six-sigma-success/
 
Makary, M.A. & Daniel, M. (2016). Medical error- the third leading cause of death in the US. BMJ, 352: i2139.  https://doi.org/10.1136/bmj.i2139
 
McFadden, K.L., Stock, G.N., & Gowen, C.R. (2015). Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety. Health Care Management Review, 40(1), 24-34.  https://doi.org/10.1097/HMR.0000000000000006