Healthcare Improvement
Advanced nursing graduates (whether MSN or DNP) seek realistic care delivery strategies. For interventions to be an organizational “fit”, the cost of improvement has to be balanced with the benefits. For example, while it may be helpful to hire an “extra” advanced practice nurse to improve the triage process, it may not be cost justified. One aspect of the role of the advanced practice nurse is to argue convincingly for best practice. However, in order to argue effectively, one must understand business and financial acumen. Careful consideration must be given to additional resources (human, structural, costs) associated with implementation of quality improvement plans. New costs incurred by the organization are heavily weighed against the benefits. Think about this important concept for one a moment. If someone were to ask for money from your dwindling bank account, what would make you write that check when you have many other competing needs??? The advanced practice nurse’s argument has to be based on more than one’s passion and stronger than one’s feelings that “it is simply the right thing to do”.
Business Case for Health Care Quality Improvement.pdf
Although a bit older (2013), this article does a nice job of describing how to make the business case for quality improvement. The next article describes how a budget was developed for a quality improvement project.
Budgeting monitors.pdffile:///C:/Users/mayow/Downloads/Budgeting%20monitors.pdf
Change
Before embarking on the quality improvement journey, it is important to understand the complexity of change. This unit advances knowledge about change theory as an underpinning for quality improvement (Deming, Juran, Rogers, Lewin, Prochaska, Kotter, etc.).
Listen to John Kotter explain what it really takes for change to occur:
Overview
Advanced nursing practice roles are evolving rapidly from a need for leaders to improve quality and safety in healthcare settings.Transforming healthcare requires specialized expertise, including knowledge of evidence-based practice, leadership skills, and the ability to translate the evidence into practice. Advanced practice nurses are expected to possess the advanced leadership skills and knowledge required to redesign healthcare and improve outcomes. So far in this course we have discussed how to assess organizational readiness for change and the leadership required to facilitate change in complex systems. The focus of this unit is the development of quality improvement skills. According to the American Association for Colleges of Nursing (AACN), MSN and DNP of Nursing Practice graduates should be proficient in quality improvement strategies and have the ability to facilitate and sustain change within our organizations (p. 10).
Module 4 provides students an opportunity to analyze a broad array of quality improvement models, strategies and tools used in quality improvement. Students learn the importance of measuring outcomes and using data to determine effectiveness of improvement activities. Finally, students apply change theory as the underpinning for healthcare improvement.
Objectives
Upon completion of this unit the student will:
- Demonstrate proficiency in quality improvement strategies for creating and sustaining change.
- Integrate change theory as an underpinning for innovation and quality improvement activities.
- Demonstrate understanding of balancing costs with quality.
- Identify process and outcome measures to evaluate effectiveness of quality efforts.
- Select appropriate visual presentation to display outcome data.
The following table represents a crosswalk of the unit objectives with the DNP and MSN Essentials.
Click The Essentials for Doctoral Education for Advanced Nursing Practice or The Essentials of Master’s Education in Nursing published by the American Association for Colleges of Nursing for more details about the Essentials.
| Module Four objectives and Assignments | ||
|
1. Demonstrate proficiency in quality improvement strategies for creating and sustaining change |
II-1, 2a, 2b, 2d, 2e; III-2,3 | I-6; II-3; III-1, 2, 3, 4, 5,6, 7, 8 |
| 2. Assess change theory as an underpinning for innovation and quality improvement activities | I-1, 3 | VII-1 |
| 3. Formulate an understanding of balancing costs with quality | II-2b, d | VI-1 |
| 4. Formulate process and outcome measures to evaluate effectiveness of quality efforts | II-1, 2b, 2d, 2e; III-2,3 | I-6; II-3; III-1, 2 |
| 5. Select appropriate visual presentation to display outcome data. | II-1, III 2, 3 | I-6; II-3; III-1, 2 |
| Paper: Quality Improvement | II-1, 2a, 2b, 2d, 2e; III-2,3 | I-6; II-3; III-1, 2, 3, 4, 5,6, 7, 8; VI-1 |
Readings
Polancich, S., Roussel, L. A., & Miller, A. (2017). Quality improvement and safety science: Historical and future perspectives. In Hall, & Roussel (Eds), Evidenced-based practice: An integrative approach to research, administration, and practice (2nd ed., pp.213-230). Burlington, MA: Jones and Bartlett.
Geary, M. E. & Roussel L. (2017). Improvement science: Impact on quality and patient safety. In Hall, & Roussel (Eds), Evidenced-based practice: An integrative approach to research, administration, and practice (2nd ed., pp.231-246). Burlington, MA: Jones and Bartlett.
Clanton, C. (2017) Introduction to evidence-based research. In Hall & Roussel (Eds.), Evidenced-based practice: An integrative approach to research, administration, and practice (2nd ed., pp.283-297). Burlington, MA: Jones and Bartlett.
Klenpell, R., &Alexandrov, A. W. (2019). Integrative review of APRN outcomes and performance improvement research. In Tracey and O’Grady (Eds.), Hamric and Hanson’s Advanced practice nursing: An integrative approach (6th ed., pp.585-606).
Outcome Measures
Although outcome measures is the last point of this keynote discussion, trust me, deciding what one is going to measure to determine if the quality improvement effort makes a difference and how the data is to be collected occurs early in the process. Outcome measures are generally a re-evaluation of the baseline data that informed you there was a problem to begin with. So, before one implements change, determining how the change is going to be evaluated (outcome) has to be determined. Data is powerful! As noted in the QI overview video, determining the effectiveness of quality improvement efforts informs us as to how we should proceed. In other words, the project outcomes will help one decide if the implemented change was successful, or not. If not successful, one would critically analyze the change process. Was the planning poor? Implementation flawed? Was the organization ready? The analysis of change processes and outcomes will inform the change team whether the practice or process is ready to be spread outside the original testing site or whether the practice or implementation strategy should be revised or even aborted. Okay, now let’s talk a little more about the different types of quality measures (structure, process, and outcome).
Structure, process, and outcome measures have significant value in determining effectiveness of QI labors. Donabedian (2005) proposed using structure, process, and outcomes measures to evaluate care. Structure measures refer to settings, administration, staffing, materials, etc. Process measures are the means to the end. Process measures are linked to the desired outcome, but in and of themselves do not measure the effectiveness of the intervention. An example of a process measure would be determining staff compliance in implementing a best practice protocol. Specifically, what percentage of time did the nurses elevate the HOB as indicated in the protocol. Outcome measures are the desired outcomes of a quality improvement project such as the rate of patient falls per patient days or the rate of ventilator associated pneumonia per patient days. As stated earlier, it is essential to consider measurement outcomes during the planning phase of QI. A comparison of baseline outcome measures (whether structure or process measures) determines whether interventions implemented through quality improvement plans are successful or not. I cannot emphasize enough the importance of your understanding of outcome measurement. Please take time to carefully review the Donabedian article and any other resources needed for you to conceptualize this important part of quality improvement.
Displaying Data
The careful collection of quality improvement process and outcome data is important. Visual displays of these data are grasped faster and more easily than summary statistics or analysis. Poorly displayed data can nullify even the most compelling results. The following visual graphs are common and effective aids for displaying data. Click on the links below to learn more about histograms, pareto diagrams, and run charts. You will also find an excel template for developing run charts… just replace the data with your own!
file:///C:/Users/mayow/Downloads/Donabedian_Evaluating%20the%20Quality%20of%20Medical%20Care.pdf
Histogram
file:///C:/Users/mayow/Downloads/Histogram.pdf
Pareto Diagram
file:///C:/Users/mayow/Downloads/Pareto%20Diagram.pdf
Quality Improvement Tools (Part 1)
This section provides a list of resources that you will want to become familiar with. You do not have to study what is behind each link! It introduces you to common methodologies and tools helpful for facilitating the quality improvement process and comparison data for benchmarking outcomes. Please explore the multiple QI resources provided and integrate their use in the assignment for this unit.
Microsystems
You will recall from readings in Module 3 that microsystems are complex adaptive systems (Roussel, 2017). The video in this unit will provide a basic description of microsystems and the link to quality improvement. The study that follows provides an example of the application of this approach.
Refresher from Module 3: Roussel. L. (2017). The nature of the evidence: Microsystems, macrosystems, and mesosystems. In Hall, & Roussel (Eds.), Evidenced-based practice: An integrative approach to research, administration, and practice (2nd ed., pp.191-212). Burlington, MA: Jones and Bartlett.
Quality Improvement Methods
Resources in this section include various quality improvement (QI) methods such as PDSA, FADE, and Six Sigma. These QI methods serve as guides for the translation of best evidence into practice.
The Plan-Do-Study-Act is one of the most commonly used QI models. This video provides an excellent and easy to understand overview.
Quality Improvement Tools
Failure Modes and Effects Analysis (FMEA) is a systematic, PROACTIVE method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change. An FMEA is performed when The Joint Commission sends out a sentinel event alert. Organizations look at processes to see how likely it is the failure will occur in their organization and take steps to improve processes.
A Root Cause Analysis is performed RESTROSPECTIVELY to determine the factors contributing to a medical error.
file:///C:/Users/mayow/Downloads/IHI%20Root%20Cause%20Analysis.pdf (IHI Root Cause Analysis.pdf)
Quality Improvement Tools (Part 2)
Failure Modes and Effects Analysis (FMEA) is a systematic, PROACTIVE method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change. An FMEA is performed when The Joint Commission sends out a sentinel event alert. Organizations look at processes to see how likely it is the failure will occur in their organization and take steps to improve processes.
A Root Cause Analysis is performed RESTROSPECTIVELY to determine the factors contributing to a medical error.
RCA Questions Framework
Root Cause Analysis framework provided by The Joint Commission. The questions you need to ask
Performance Measures Benchmark
The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare. It is an excellent site to find quality measures.
National Quality Measures Clearinghouse (NQMC) is a public resource for evidence-based quality measures and measure sets. NQMC also hosts the HHS Measures Inventory. You will also find tutorials on quality measures including the difference between structure, process, and outcome measures.
The AHRQ-Health Care Innovations Exchange to speed the implementation of new and better ways of delivering health care. Find quality tools and details of implementation of innovations on this site
CMS
Hospital Compare is a Medicare database open to the public reporting quality performance of hospitals. Transparency is here to stay!
Take a look at the Centers for Medicare and Medicaid recommended clinical quality measures
Institute of Healthcare Improvement
The Institute for Healthcare Improvement (IHI) has a robust website for all aspects of quality improvement. All resources are free …. all you have to do is register.
- Go to www.ihi.org (Links to an external site.)
- Select “Log in/Register” from the top menu bar and create an account. Register as a student.
- Then don’t forget to join our Chapter here at the University of South Alabama, please email your name, role (student or faculty) and university/organization (University of South Alabama) to openschool@ihi.org.
The IHI Open School has 19 online courses that teach the basics of quality improvement, patient safety, leadership, patient- and family-centered care, health care operations, and population health. Each course comprises 3-5 lessons that take between 1 and 2 hours to complete. Each lesson ends with some assessment questions to test the learner and help the education stick. These courses are completely free for students, residents, faculty, and users from the least-developed country. Upon completing the 16 core courses, a learner receives the Certificate of Completion, which is a nice addition to any professional resume. Oh, as a bonus, CEUs are offered for each of the 19 online courses.
The Joint Commission
The Joint Commission and Centers for Medicare and Medicaid work in tandem to develop the core measures required for Joint Commission accredited agencies.
