Learning Objectives
By the end of this section, you will be able to:
- Understand the role of the quality improvement nurse
- Identify benefits of quality improvement in nursing practice
- Recognize different quality organizations for nursing practice
In 2016, an earth-shaking article noted that if medical errors were classified as diseases are, they would be the third-largest cause of death in the United States (Makary & Daniel, 2016). It is estimated that there are over 110 safety events for every 1,000 hospitalizations. Over 11 percent of hospitalized patients will experience such an event, adding thousands of dollars to patient stays and costing too many lives (Finkelman, 2022).
For healthcare providers, the core focus of quality improvement is to decrease errors (Sherwood & Barnsteiner, 2022). An error is a failure to carry out a planned healthcare action or to complete the action correctly, with the result that the patient is harmed or experiences a less favorable outcome. An adverse event is one in which a patient is harmed or killed due to care that is being delivered, not to their underlying health condition. A preventable adverse event is related to human error, such as errors of diagnosis, medication administration, treatment delays, and lack of follow-up (Sherwood & Barnsteiner, 2022). A sentinel event is an adverse event that happens in a healthcare setting, based on an accident (such as fall) or the actions of healthcare workers and results in patient death or permanent disability. Note that deaths related to the progression of a patient’s illness are not sentinel events.
The Institute of Medicine defines quality health care as the provision of health services that improve the chances of preferred outcomes, decrease the chances for error, and are consistent with current evidence and knowledge. Quality improvement (QI) is a framework used to improve patient care and outcomes systematically and continuously. It incorporates the expectation that no matter how good a system’s quality is, it can be improved upon; thus, quality improvement is a continuous, ongoing endeavor.
The American Nurses Association (ANA) considers quality improvement, like evidence-based practice (EBP), to be one of the five core competencies of all healthcare professionals (ANA, 2021). It also expects all nurses to meet the standard of quality of practice. Quality of practice includes several competencies focused on performing safe, effective, efficient, and person-centered care; in addition, several other competencies are directly related to QI in nursing and health care overall (ANA, 2021). They include the following:
- incorporating EBP into practice to improve outcomes
- enhancing nursing through creativity and innovation
- recommending strategies to leadership to improve quality of nursing practice
- engaging in data collection to monitor care quality
- participating in QI initiatives
- collaborating with other disciplines to implement QI
These standards apply to all nurses at all levels of practice. Nurses are responsible for consistently improving their practice and patient care (Finkelman, 2022). In fact, all nurses and healthcare providers must actively engage in ongoing and continuous improvement projects to improve health care for our patients and communities. Hospitals also have standards of practice for nursing staff to encourage QI at the local level.
Link to Learning
Quality improvement is a huge undertaking, continuously occurring across all of medicine. The Institute for Healthcare Improvement (IHI) provides a video on the evolution of QI in health care and a quick snapshot of QI, including many of the concepts covered in this section.
Role of the Quality Improvement Nurse
As with EBP, QI happens both with individual nurses in their practice and at the level of larger systems. Most healthcare systems today have a QI program office that manages ongoing QI systemwide. Often these are staffed with quality improvement (QI) nurses—experienced RNs or advanced practice nurses with a special interest in QI who, by receiving extra education and passing a subject-matter examination, may have undergone the process of certification to become an expert in QI. Quality improvement nurses work with individual nurses, unit leadership, and facility leadership to ensure consistent quality related to current policies and procedures; they engage in the QI process across the agency, department, or facility.
Link to Learning
This video features a QI nurse at Cincinnati Children’s hospital. Her story provides an example of how nurses move into QI through their nursing practice and interest in quality and safety.
Quality Assurance
One component of a quality program is quality assurance (QA), the provision of oversight to ensure that, across a department or agency, the staff is receiving education and support to maintain the current quality standards. Quality assurance nurses review the data on errors and poor patient outcomes at the facility. They look for trends and create opportunities to improve nursing care by identifying where additional education, staffing, or equipment are needed or where new policies and protocols should be implemented. Their work seeks to improve patient outcomes and increase the standard of care by relying on data for problem identification and EBP for interventions.
Quality Assurance and Performance Improvement Programs
Quality Assurance and Performance Improvement (QAPI) is the dual use of QA and performance improvement (PI), specifically in post acute care environments such as rehabilitation centers and nursing homes. The Affordable Care Act (2010) mandated QAPI for all post acute healthcare environments, and the necessary roles are often filled by RNs. The Centers for Medicare and Medicaid Services (CMS) developed the framework to reinforce legal statutes regarding how these facilities perform and how they are accountable for QAPI activities (CMS, 2021). Through the American Association of Post-Acute Care Nursing, nurses seeking to be a QAPI subject-matter expert can earn a QAPI certification.
Quality Improvement Initiatives for Nurses
Nurses are involved in quality improvement through a number of initiatives. For example, the Quality and Safety Education for Nurses (QSEN) competencies provide a bedrock for nursing students, socializing them into a culture of continuous quality improvement. QSEN is discussed further in a later portion of this section. Another QI initiative is Lean, a strategy of quality improvement designed to remove unnecessary steps from healthcare processes, with the expectation that the healthcare staff will be able to provide higher levels of care when unnecessary processes are removed. The Plan-Do-Study-Act (PDSA) is another QI initiative as discussed in Clinical Safety and Procedures (QSEN): QSEN Competency: The Plan-Do-Study-Act Cycle.
Clinical Safety and Procedures (QSEN)
QSEN Competency: The Plan-Do-Study-Act Cycle
Disclaimer: Always follow the policies and procedures of your agency.
The Plan-Do-Study-Act (PDSA) cycle is one of the most used QI initiatives (Agency for Healthcare Research and Quality [AHRQ], 2020). The cycle involves four steps: developing a plan (Plan), running a test (Do), analyzing the results and comparing them to the desired results (Study), and making a plan for the next step (Act). Figure 15.11 shows how the PDSA cycle can be used sequentially—modifying the plan at the end of each cycle based on what was learned, and then running it again until a strategy is successful (AHRQ, 2020; D’Eramo, 2022).
Problem Resolution
When problems arise, QI nurses are frequently involved to determine the cause of the problem and potential ways to prevent it from arising again in the future. For example, after a medication administration error, a QI nurse might be called in to investigate the issue. This investigation may include a root cause analysis, which is a structured process to determine factors that underlie errors and adverse events (AHRQ, 2019). If the root cause is determined to be a systemic issue, the QI nurse may develop a QI intervention to deal with the problem. If it is unique to the nurse who made the error, the QI nurse may instead be involved in retraining that nurse to prevent the error from reoccurring.
Benefits of Quality Improvement in Nursing Practice
Quality improvement should improve patient outcomes. The AHRQ notes that healthcare quality includes these six domains (AHRQ, 2022):
- safe
- effective
- patient centered
- timely
- efficient
- equitable
Quality improvement in nursing practice is always engaged in solving problems or bettering outcomes. As such, QI activities should improve one or more of these domains in an effort to fix broken processes or integrate new practices that are based in local reality combined with the best evidence (Grys, 2022). Further, QI activities should offer measurable outcomes to clearly show their value (or their failure to achieve the expected value) (O’Donnell & Gupta, 2023).
Maximizes Use of Resources
Resources in health care include time, staff, equipment, facilities, and other tangible and intangible resources used to provide patient care. When professional nurses are trusted and included in QI efforts, processes affecting resource allocation and use typically become more effective. Nurses know what they need and do not need in their supply cabinets; when performing procedures, they know how many staff they need on different shifts; and they know how much time they spend performing their daily tasks. Using nursing knowledge to develop QI initiatives can allow for realistic identification of necessary resources versus superfluous ones. Such engagement can ensure that nurses have the resources they need available when they are necessary and discourage the presence of unnecessary ones.
Promotes Innovation of Team Members
The development of new ideas, methods, and procedures, or innovation, is where the future of quality improvement lies. Nurses are perfectly positioned as healthcare innovators thanks to their direct role in patient care and advocacy. They see processes in action daily. Engaging frontline nurses in addressing quality concerns and performing QI activities has the added benefit of encouraging innovation among staff members and during staff development. Quality improvement should encourage nurses to improve their practice and discuss their concerns with leadership and management (Drew & Pandit, 2020). It provides opportunities for nurses on the front lines to clarify their understanding of what causes problems and engages them in developing solutions.
Reduces Unnecessary Tasks
Nurses perform many tasks daily, but these tasks are often redundant or not performed efficiently. The QI method of Lean helps to find and reduce waste: tasks or behaviors that have no value for the system (Kelly, 2022, O’Donnell & Gupta, 2023). For nurses, waste can be found in a variety of locations, such as unnecessary transportation of patients or duplicate tasks; waste also happens when units are laid out inefficiently, necessitating additional time and motion to gather items, or when people are unable to work at the height of their licenses and abilities. Quality improvement strategies can be used by and for nurses to streamline their work, resulting in increased time at the bedside and higher-quality care (Kelly, 2022).
Quality Organizations for Nursing Practice
Nurses can turn to several resources for answers to QI questions or guidance for their practice. As previously mentioned, the ANA provides standards for quality in nursing practice. Additionally, most specialty professional nursing associations, such as the Oncology Nursing Society, have some information relevant to quality or QI on their websites. Nurses can also use several other agencies and programs to advance the quality of their practice, including national and international organizations.
American Nurses Association
The ANA is the primary overarching organization for nurses in the United States. The ANA establishes the Scope and Standards of Practice and Code of Ethics for all RNs and advanced practice nurses, lobbies for nurses with government, seeks to ensure that nurses have safe and ethical workplaces, provides continuing education, and establishes the goals of professional nursing (ANA, 2017). The ANA further provides position statements to help nursing practice and supports nurses to lead change (ANA, 2017). Though affiliated with other specialty nursing organizations, such as the American Association of Critical-Care Nurses, the ANA remains the body that represents all nurses no matter their specialty or job location. The ANA also manages the Nursing Alliance for Quality Care, an organization that seeks to improve healthcare quality among nurses and agencies alike.
Agency for Healthcare Research and Quality
The AHRQ has been discussed several times previously in this text. It is the U.S. Health and Human Services agency tasked with improving the quality, safety, efficiency, and effectiveness of health care for everyone (Finkelman, 2022). The agency provides extensive toolkits and best practice evidence for healthcare professionals at all levels.
For example, in 2005, the AHRQ and the Department of Defense developed the TeamSTEPPS curriculum to improve communication and collaboration within interprofessional healthcare teams in various settings. TeamSTEPPS is now in its third version, TeamSTEPPS 3.0 (AHRQ, 2023b). TeamSTEPPS has been released into the public domain so that all medical agencies can use it to improve their collaboration and team management, regardless of their ability to pay for it (AHRQ, 2019).
Magnet Recognition Program
The American Nurses Credentialing Center has created the Magnet Recognition Program to recognize healthcare organizations that provide high-quality nursing care. Magnet recognition requires several components, including involvement in research, EBP, and QI (Polit & Beck, 2021). There are five components to the Magnet model:
- transformational leadership
- structural empowerment
- exemplary professional practice
- new knowledge, innovation, and improvements
- empirical quality outcomes
The program encourages and rewards hospital systems that place emphasis on QI and actively recognize nurses engaging in QI projects (Finkelman, 2022). Since 2014, one requirement for hospitals seeking Magnet status has been the inclusion of clinical nurses who perform leadership roles on collaborative teams and in shared decision-making (Hughes-Rease, 2015). Today, the ANA also encourages using evidence-based team strategies, such as TeamSTEPPS, to improve patient outcomes and care quality (ANA, 2021).
The Joint Commission
The Joint Commission is an agency that offers accreditation, or official recognition, to membership hospitals that meet their quality and safety standards (Sherwood & Barnsteiner, 2022). It also provides annually updated national patient safety goals for many hospital settings. These goals are set for areas that are considered at risk and include guidance for process and QI initiatives that member agencies can use. Other goals are available for settings such as nursing care centers, behavioral health clinics, ambulatory care centers, and critical access hospitals. Additionally, to promote collaboration between disciplines, The Joint Commission requires its member agencies to have codes of conduct defining appropriate and inappropriate communication and behavior between team members and disciplines (Sherwood & Barnsteiner, 2022).
National Coordinating Council for Medication Error Reporting and Prevention
The focus of the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) is safe medication use and awareness of medication errors (NCCMERP, 2023). The council promotes open communication, error reporting, and QI to prevent medication errors. It uses national reporting systems to evaluate the root causes of medical errors and develop recommendations to prevent such errors. A senior policy adviser for the ANA sits on the council to lend the voice of nurses to policy development.
Quality and Safety Education for Nurses
Quality and Safety Education for Nurses was created in 2005 as a response to the demand from nursing leaders for an increase in nursing safety. The goal of the QSEN project, which was initially funded by the Robert Wood Johnson Foundation, was to discover a way to change nurses’ mental outlook and education. On the topic of nursing education, QSEN identifies four goals (Sherwood & Barnsteiner, 2022). Student nurses should be taught to:
- enter their nursing practice expecting to be involved in inquiry and QI
- use and engage in evidence-based practice and research
- consider outcomes and critical incidents from a system’s perspective
- work effectively in interprofessional care management teams
The QSEN model has also adopted the essential competencies offered by the Institute of Medicine as critical for nursing practice: patient centered, evidence based, teamwork and collaboration, QI, safety, and informatics (Sherwood & Barnsteiner, 2022).
Clinical Judgment Measurement Model
Generate Solutions: Understanding the Differences between Research, Evidence-Based Practice, and Quality Improvement
There are several similarities between research, EBP, and QI. Indeed, they are complementary endeavors that build off each other. However, it is important to recognize the differences between them to use them most effectively in practice. Table 15.3 summarizes these differences.
| Activity | Qualities |
|---|---|
| Research | Purpose: Generate new knowledge or validate existing knowledge Methods: Scientific method Process:
|
| Evidence-based practice | Purpose: Translate evidence into practice and integrate it into clinical decision-making to improve safety, quality, and systems Methods: PICOT, etc. Process:
|
| Quality improvement | Purpose: Improve processes or patient outcomes Methods: Lean, PDSA, etc. Process:
|