QI: Nursing’S“Evolving Responsibility” by Mary Wickman, Phd, RN; Diane Drake, Phd, RN; Heather Heilmann, MSN, RN; Rafael Rojas, MBA, MSME; and Corrine Jarvis, MBA, RN

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2.3 CONTACT HOURS QI: Nursing’s“evolving responsibility” By Mary Wickman, PhD, RN; Diane Drake, PhD, RN; Heather Heilmann, MSN, RN; Rafael Rojas, MBA, MSME; and Corrine Jarvis, MBA, RN

istorically, quality improvement (QI) patient care to ensure that changes has been a strategy employed to ensure will lead to improvements in patient consistency in business processes and outcomes (health), system perfor- products, with a primary goal of mance (care), and professional changing performance and improving development (learning).4 Continuous outcomes. Early health services quality improvement (CQI) is a Hresearch proposed the examination of method for improving care that’s the quality of health provision from a characterized by the feedback of sys- QI perspective as aspects of structure, tematically collected data and the process, and outcomes.1 Since the clas- utilization of statistical methods for sic work of Donabedian in 1966, an the purpose of limiting inappropriate emphasis on quality healthcare has process variation.5 The fundamental continued to evolve and is now an principles of CQI include the elimina- integral component of today’s U.S. tion of inappropriate variation and healthcare delivery system. Agencies, continuous improvement through a accreditation processes, and a variety constant effort to reduce waste, repeti- of state and national resources have tion in work, and inefficient processes.6 been created to ensure the delivery of Current evolving forces driving the quality healthcare with a particular improvement of the structure, process, focus on patient safety in response to and outcomes of nursing and the the Institute of Medicine’s (IOM) To Err healthcare delivery system include is Human: Building a Safer Health System regulatory and accreditation require- report.2 The U.S. Agency for Healthcare ments of The Joint Commission and Research and Quality defines “quality” Det Norske Veritas legislation healthcare as “doing the right thing, at (enacted in 2010 with the Patient Pro- the right time, for the right person— tection and Affordable Care Act), the and having the best possible results.”3 enactment of the Patient Protection QI has also been defined as the and Affordable Care Act subpart II combined efforts of all involved in Health Care Quality Improvement

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Programs and its requirements, and Plan, Do, Study, Act success of a process is described by the Magnet® recognition process. The models of PDSA and Focus, a Sigma rating that indicates the The purpose of QI methodologies Analyze, Develop, Execute (FADE) yield of the percentage of defect- is to accomplish measurable organi- are the most commonly used free products. A Six Sigma process zational goals with performance approaches in healthcare settings.9 indicates that products or services improvement.7 The choice of which These methods involve a “trial and are statistically expected to be QI methodology to use within an learning” approach in which a sug- 99.99966% free from defects. The organization depends on the nature gested improvement is tested on a Greek letter Sigma is used in statis- of the improvement project because small scale before changes are made tics to denote standard deviation most methodologies share a com- to the whole system. The PDSA (SD) from the mean. A SD of Six mon trait: repeatedly testing ideas method allows for small tests of Sigma is equivalent to 3.4 defects and redesigning processes or tech- change with quick responses. or 3.4 errors per million opportuni- nology based on previous errors or In the plan phase, an issue is ties. In applying these concepts to lessons learned. Clearly, QI is an identified and a process improve- the patient care process, the provi- evolving responsibility of hospital ment plan is developed. In the do sion of “perfect care” is achieved nurses today, and nurse participation phase, the plan is implemented by reducing variation in care pro- is essential to hospital QI initiatives. and any deviation from the plan is cesses that contribute to errors. For Hospital nurses, from the frontline documented. These deviations are example, when Six Sigma is to management, however, may lack often called defects. The defects achieved in the hospital setting, only 3.4 dose errors occur per million medication administrations, thus approaching “perfection.” The purpose of QI As a QI methodology, Six methodologies is to accomplish Sigma is mainly driven by projects designed to last 3 to 4 months. These measurable organizational projects are led and implemented by executive sponsors, project teams, goals with performance and project owners. A Six Sigma approach follows five phases: define, improvement. measure, analyze, improve, and control. Each one of these steps involves statistical tools to assist with scoping sufficient business background or are then analyzed in the study the improvement opportunity, deter- academic preparation associated phase. In this phase, results from mining measurements of success, with QI specialization for effective the test cycle are studied, and testing the hypothesis, evaluating participation and contributions to questions are asked regarding solutions, and ensuring stability of the process. what went right, what went the process. wrong, and what will be changed The define phase includes tools Industrial and business models in the next test cycle. In the act such as assessing the perspective Industry-based and business models phase, lessons learned from the or “voice” of the customer, stake- for quality management and mea- study phase are incorporated in holder analysis, project charter, surement have been adopted by the the test of change, and a decision definition of the problem healthcare industry over the past is made about continuation of the statement, measurement of success, two decades and include Plan, Do, test cycle. If there’s another test initial return on investment, and Study, Act (PDSA), Six Sigma, and cycle, the steps are repeated.10 benefits to the customer and orga- the Lean process (including the rapid nization. The measurement phase improvement methodology).8 These Six Sigma strictly determines whether the models have shaped and informed Six Sigma is a statistical modeling opportunity for improvement is the way quality is understood, man- process originally used by Motor- related to data validity or process aged, and measured in healthcare ola that’s now used in many hospi- opportunities using gage repeat- settings across the continuum of care. tal settings.11 The maturity and ability and reproducibility. Gage

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. repeatability and reproducibility is In Lean hospitals, the patient is cesses to achieve perfection are a statistical technique that analyzes the primary customer, the one who strategizing continuous improve- reproducibility and repeatability of justifies the existence and value of ments in the delivery of care and a measurement system, which vali- healthcare services. The second ensuring frontline staff involvement dates collected data. The analyze principle of Lean thinking—identi- in identifying patient care systems phase mainly focuses on identify- fying and managing value streams that contribute to error. A Lean ing the biggest opportunities for to ensure the process is analyzed approach fosters interdisciplinary improvement by creating and as a system and maximize oppor- collaboration at the point of patient proving a hypothesis using more tunities to reduce waste—is the care by creating an environment of advanced statistical tools. The most frequently applied Lean tool mutual responsibility and provid- improve and control phases imple- in healthcare.14 The process ing a framework for managing ment and monitor results from any involves visually depicting steps, change inherent in hospital nursing changes put in place. One of the delays, and information flows in care delivery.15 noteworthy advantages of this rig- delivering a product or service. orous process is the identification This is accomplished by mapping Rapid improvement of opportunities that may have every step or individual action Kaizen, or Rapid Improvement been missed without a thorough involved in the process of deliver- Events (RIEs), is a Lean methodol- investigation of process data. ing a specific healthcare service. ogy that provides a mechanism for For example, to streamline the dis- making radical changes to current Lean process charge process, a value stream processes and activities by rapidly The Lean process is evolving as an analysis may be used to identify closing the gap between desired influential QI strategy in healthcare. each step involved from the time and actual states of patient care Lean thinking and the Lean process discharge is planned to the time delivery.13 The distinct benefit of are management strategies that the patient leaves the hospital. RIEs is to reduce the time from originated in the automobile and Flow processes based on cus- problem identification to change manufacturing industries.12 The tomer demand are known as “pull.” implementation. A RIE typically Toyota production system, often This principle relates to producing involves the following stages: known as Lean, has been applied services or goods only when the • planning the event in many environments with impres- customer asks for it, and lets the • defining the current state sive improvements in quality and customer pull value from the com- • defining the target state efficiency. The underpinning values pany versus having the company • identifying waste of Lean are to identify and remove “push” already designed products • designing improvements to nonvalue activities with an over- or services onto the market. An eliminate waste arching goal to improve system example of a push strategy can be • improving process reliability processes by eliminating waste and applied to ordering the same lab and/or improving the patient care maximizing value.13 tests for all patients admitted to the experience Lean has the potential to reduce ED in an effort to save time know- • following up to ensure improve- complexity and enhance the effi- ing that not all patients will need ments are sustained over time. ciency of patient care processes. certain tests (overproducing), versus The cycle is then evaluated and This process is based on the follow- ordering tests only when needed it’s determined if further improve- ing core principles: (pull strategy). ment is needed. • identify value from the custom- The final principle of Lean is A fast and furious approach to er’s perspective excellence, which in healthcare problem solving and identification • identify and manage value stream can be translated to “do no harm.” of solution training occurs in RIE processes used to provide a service Striving for perfection is undoubt- processes. Team members are to customers edly the most important dimension selected from diverse backgrounds • create flow process based on in the provision of hospital services and experiences to include experts customers’ demands because the consequences of not in the current process and “fresh • create an environment of mutual doing the right thing the first and eyes,” or those with no knowledge responsibility every time can result in adverse of the current process. The “fresh • strive for perfection. patient outcomes.2 Essential pro- eyes” are expected to contribute www.nursingmanagement.com Nursing Management • October 2013 33

ideas for change and waste reduc- jected to additional risks or burdens (jhnebp) model. The ARCC tion without the bias of knowing beyond usual clinical practice to model uses an EBP mentor to the current practice. With the use create generalized results. Random- disseminate and implement EBP of a trained facilitator, the team is ized controlled trials, controlled into the environment.20 This expected to stay focused and close studies, pre- and postintervention model first assesses the culture the gaps between current and studies, and time series are com- and cognitive beliefs of clinicians, future states of desired process monly used methods in QI research. which can be a major determinate changes. Outcomes of the RIE pro- A notable advantage of QI research for sustainable change. It then cess are described in two broad (with a robust study design) is that identifies the major barriers and areas: the performance of the the findings from the study are facilitators to successfully navigate healthcare system and leadership/ more likely to be accepted for pub- the implementation phase. EBP educational development of lication, thus contributing to future enculturation is the foundational employees and the work environ- QI research.17 element to the ARCC model and ment. RIE outcomes can provide a requires increased knowledge, structure to evaluate the effective- EBP interactive skill building, and ness of QI projects. Conducting nursing research and strong mentorship. Leadership participation in RIEs using EBP are essential for Magnet The jhnebp model is designed is important so that implementa- recognition. The Magnet Recogni- to guide clinical decision making tion barriers, such as finance or tion Program® promotes the use of by the hospital nurse and provide resource issues, can be immedi- new knowledge, innovations, and processes to answer administra- ately addressed. Frontline or improvements to ensure quality tive, operational, and educational point-of-care staff involvement patient outcomes, with EBP as a questions. This model conceptual- is equally essential in the process, hallmark of nursing excellence in izes the core of nursing into particularly since they’re responsi- Magnet facilities. EBP is the use research and nonresearch evidence ble for implementing the change. of the best evidence to guide and within an open and dynamic orga- The streamlined approach of RIEs direct the delivery of healthcare ser- nizational system providing strate- requires minimal time commit- vices and includes the application gies and guidelines to implement ment while facilitating immediate of research findings, case reports, EBP. The jhnebp process is broken improvement.16 and expert opinion in making down into three step-by-step healthcare decisions.18 phases: Nonbusiness models Although there are significant • develop a practice question Examples of nonbusiness models differences between EBP and QI, • locate and appraise the evidence include QI research, evidence-based the goals of both processes are the • translate the evidence into practice (EBP) projects, and quality same: to improve care processes practice.21 enhancement research initiatives. and ultimately improve patient out- The following nonbusiness QI strat- comes.7 Notably, the Iowa EBP Implementation science egies provide problem-solving model includes monitoring and Implementation science is the study approaches while integrating analyzing structure, process, and of methods to promote the integra- research into the process. outcomes—concepts that are foun- tion of research findings and evi- dational to the QI process. This dence into healthcare policy and Research model begins with the trigger of a practice. An example of implemen- QI can be translated into research, clinical problem or new knowledge tation science is the Quality Enhance- and the PDSA model’s core meth- that can set an EBP project into ment Research Initiative (QUERI), a odology utilizes the scientific motion and ends with the dissemi- new discipline of implementation method for QI research. A QI proj- nation of project findings.19 science and translation research. ect can be considered research if the Other commonly used models The Department of Veterans Affairs tested intervention involves a for EBP include Advancing (VA) developed QUERI to allow change from established practices, Research and Clinical Practice optimal utilization of the VA health individual patients are the subjects, Through Close Collaboration services, research expertise, and randomization or blinding is con- (ARCC) and the Johns Hopkins resources to improve the quality of ducted, and participants are sub- Nursing Evidence-Based Practice care for veterans. The QUERI model

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. is a six-step process to help turn specific language to identify and cient healthcare. These measures research into practice. Specific steps define processes that doesn’t read- provide the healthcare consumer include: ily translate into the common sci- with an assessment of nursing’s • identify high-risk/high-volume entific language used in hospitals. quality contribution to inpatient diseases or problems Nonbusiness models that involve hospital care, as well as identify • identify best practices research should be considered as outcomes and processes of care for • define existing practice patterns a QI methodology when appropri- continuous improvement influ- and outcomes and current variation ate for the problem at hand. It’s enced by nurses. The National from best practices essential that hospitals continue to Database of Nursing Quality • identify and implement interven- evaluate and conduct more Indicators,® a repository of nurse- tions to promote best practices research surrounding the utiliza- sensitive indicators, allows for • document the extent to which tion of business and nonbusiness advances in quality care by provid- best practices improve outcomes models in the hospital setting ing a national comparison of • document the relationship while recognizing the foundational nurse- sensitive indicators grouped between outcomes and improved role that nurses can play in these by patient and unit type. health-related quality of life.22

Considerations Business QI strategies are important Nurses are essential to hospital models to improve hospital QI efforts as direct caregivers response when current systems don’t work well or when improvement is because they can signiﬁ cantly needed in a system “just in time” to improve patient outcomes. Although inﬂ uence the quality of care, there are many advantages associated with using business models in timely treatment, and quality healthcare, a significant disadvan- tage is the lack of research evidence patient outcomes. in the planning phase of many QI projects.16 Often, the objective is to address the need of a localized problem, such as an issue on one unit, processes. (See supplemental con- Nurses as direct care providers, making it fundamentally different tent on the Nursing Management educators, managers, and leaders from the aim of research, which is to iPad app.) share responsibility and account- address problems in a manner that ability to ensure the quality and yields generalized results applicable Hospital nurse practices safety of the healthcare systems throughout an organization. The American Nurses Association where they work. Nurses are essen- Literature reviews, the founda- has developed a research agenda tial to hospital QI efforts as direct tion to all scientific research, aren’t to require the use of research for caregivers because they can signifi- typically incorporated in business EBP to identify gaps in evidence cantly influence the quality of care, models and the quasi-experimental for nursing practice. Priority timely treatment, and quality design of QI projects and small research areas include initiatives patient outcomes. Achieving the sample sizes may not yield accurate that contribute to processes, out- goal of providing quality care and results due the small scale of imple- comes, and measures of safe, reli- ensuring the continuous improve- mentation. QI has inherent risks able, quality, and efficient nursing ment of care is particularly chal- that include making changes too care. Endorsement of 15 nursing- lenging in the complexity of today’s quickly without rigorous testing, sensitive measures by the National healthcare system and requires a and inadequate review and critique Quality Forum was an important structured interprofessional of published resources and studies. advancement to standardize the approach to QI. Another QI limitation is that measurement of nursing care and The IOM and the Robert Wood business methodologies use very its relationship to quality and effi- Johnson Foundation’s visionary www.nursingmanagement.com Nursing Management • October 2013 35

Table 1: IOM recommendations and QI implications IOM recommendation QI implication Nurses should practice to the full extent of their educa- All nurses share QI responsibilities in their daily practice tion and training. when catching errors, preventing harm, using keen assessment and critical thinking skills, and anticipating changes in a patient’s condition. Nurses should achieve higher levels of education and QI content needs to be included in all levels of nursing edu- training through an improved education system that cation and lifelong learning with an expectation for advanced promotes seamless academic progression. practice RNs to lead QI efforts. Nurses should be full partners, with physicians and Quality needs to be viewed as everyone’s responsibility on other healthcare professionals, in redesigning health- the healthcare team to achieve significant and sustained care in the United States. improvement in patient care outcomes. Effective workforce planning and policy making require Publication of QI processes and findings is increasingly better data collection and an improved information important in ensuring an improved information infrastructure infrastructure. for continued QI research.

report on the Future of Nursing pation and training in QI activi- Century. Washington, DC: National Acade- mies Press; 2001. provides insight as to how nursing ties.24 Communication, consistency, 3. Agency for Healthcare Research and Qual- contributions to QI could be consid- and collaboration need to be ity. Your guide to choosing quality health- ered in planning and leading acknowledged and reinforced as care: a quick look at quality. http://archive. change.23 The four key messages in key elements that contribute to ahrq.gov/consumer/qnt/qntqlook.htm. this landmark report provide a quality outcomes. Doing things 4. Batalden PB, Davidoff F. What is “quality improvement” and how can it transform framework for QI recommendations right and doing them well the first healthcare? Qual Saf Health Care. 2007; related to prelicensure education, time reduces waste and rework and 16(1):2-3. lifelong learning, and nurse ultimately frees up valuable time 5. Bobbitt B, Cate R, Beardsley S, Azocar F, involvement in leading QI projects for all healthcare providers. McCulloch J. Quality improvement and and QI research. (See Table 1.) Although QI and evidence-based outcomes in the future of professional psychology: opportunities and challenges. methods are important practice Prof Psychol- Res Pr. 2012;43(6):551-559. Transforming healthcare, strategies for hospital nurses, qual- 6. O’Neill SM, Hempel S, Lim YW, et al. one project at a time ity patient outcomes are equally Identifying continuous quality improve- Important concerns and barriers for important and dependent upon how ment publications: what makes an nursing staff involvement in QI the individual nurse practices. The improvement intervention ‘CQI’? BMJ Qual Saf. 2011;20(12):1011-1019. activities include adequate time and professional dimension of the nurse 7. Radnor ZJ, Holweg M, Waring J. Lean in resources. Notably, all nurses share is an essential contributing factor to healthcare: the unfilled promise? QI responsibilities in their daily excellent patient care, advances in Soc Sci Med. 2012;74(3):364-371. practice when catching errors, pre- nursing science, and hospital suc- 8. Seidl KL, Newhouse RP. The intersection of venting harm, using keen assess- cess. This professional dimension evidence-based practice with 5 quality improvement methodologies. J Nurs Adm. ment and critical thinking skills, and can best be supported by a hospital 2012;42(6):299-304. anticipating changes in a patient’s culture that engages nurse involve- 9. Brennan S, McKenzie J, Whitty P, Buchan condition. Requiring nurses to think ment in QI, EBP, and professional H, Green S. Continuous quality improve- about how they practice, what they development through promoting ment: effects on professional practice and practice, not taking shortcuts, pro- education and lifelong learning health care outcomes. Cochrane Database Syst Rev. [e-pub October 7, 2009.] viding QI tools, and documenting opportunities. NM 10. Varkey P, Reller MK, Resar RK. Basics of processes are foundational to the QI quality improvement in health care. process. (See supplemental content on REFERENCES Mayo Clin Proc. 2007;82(6):735-739. the Nursing Management iPad app.) 1. Donabedian A. Evaluating the quality of 11. Pyzdek T. The Six Sigma Handbook. New Hospitals may benefit from inten- medical care. 1966. Milbank Q. 2005; York, NY: McGraw-Hill Companies; 2009. 12. Nelson-Peterson DL, Leppa CJ. Creating an tionally creating fun activities to 83(4):691-729. environment for caring using lean principles engage staff in QI and offering 2. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st of the Virginia Mason Production System. opportunities for continued partici- J Nurs Adm. 2007;37(6):287-294.

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 13. Korner K, Hartman N, Agee A, et al. Lean A Guide to Best Practice. Philadelphia, Health. Washington, DC: The National tools and concepts reduce waste, improve PA: Lippincott Williams & Wilkins; 2010. Academies Press; 2010. efficiency. American Nurse Today. 2011; 19. Gawlinski A, Rutledge D. Selecting a model 24. Mick J. Promoting clinical inquiry and 6(3):41-44. for evidence-based practice changes: a evidence-based practice: the sacred 14. Poksinska B. The current state of Lean practical approach. AACN Adv Crit Care. cow contest strategy. J Nurs Adm. 2011; implementation in health care: literature 2008;19(3):291-300. 41(6):280-284. review. Qual Manag Health Care. 2010; 20. Melnyk BM. Achieving a high-reliability 19(4):319-329. organization through implementation of the In California, Mary Wickman is a director and 15. O’Neill S, Jones T, Bennett D, Lewis M. ARCC model for systemwide sustainability professor of Nursing at Vanguard University in Nursing works: the application of lean think- of evidence-based practice. Nurs Admin Q. Costa Mesa. Diane Drake is a nurse research ing to nursing processes. J Nurs Adm. 2012;36(2):127-135. scientist at Mission Hospital in Mission Viejo. 2011;41(12):546-552. 21. Newhouse RP, Dearholt SL, Poe SS, Heather Heilmann is a care transitions man- 16. Martin SC, Greenhouse PK, Kowinsky AM, Pugh LC, White KM. John Hopkins Nursing ager at St. Jude Medical Center in Fullerton. McElheny RL, Petras CR, Sharbaugh DT. Evidence-Based Practice Model and Rafael Rojas is a director of Operations and Rapid improvement event: an alternative Guidelines . Indianapolis, In: Sigma Theta Improvement at Mission Hospital. Corrine Jarvis approach to improving care delivery and Tau International Honor Society of Nursing; is a director of Quality and Risk Management the patient experience. J Nurs Care Qual. 2007. at Western Medical Center in Santa Ana. 2009;24(1):17-24. 22. Stetler CB, Mittman BS, Francis J. Overview The authors and planners have disclosed that 17. Atkins D. Connecting research and patient of the VA Quality Enhancement Research they have no financial relationships related to care: lessons from the VA’s Quality Enhance- Initiative (QUERI) and QUERI theme arti- this article. ment Research Initiative. J Gen Intern Med. cles: QUERI Series. Implement Sci. 2010;25(suppl 1):1-2. 2008;3:8. DOI-10.1097/01.NUMA.0000430404.42712.2f 18. Melnyk BM, Fineout-Overholt E. Evidence- 23. Institute of Medicine. The Future of Nurs- Based Practice in Nursing and Healthcare: ing: Leading Change and Advancing ▲ For more than 142 additional continuing education articles related to management topics, go to NursingCenter.com/CE. ▲

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