Measures of safety and quality can be used to track the progress of quality improvement strategies by using external benchmarks. Bench making in medical care is described as the collaborative and continuous discipline of comparing and evaluating the results of fundamental work processes with those that are the best in the field. There are two kinds of procedures that can be utilized to assess quality performance and patient safety. Internal bench making is employed in the identification of best practices in an organization as well as in the comparison of best practices in an institution (Axley, 2008).
The Continuous Quality Improvement (CQI) efforts at John C. Lincoln North Mountain Medical Center had recorded some success over the last three years particularly in areas to do with patients’ evaluation of nurses’ quality practices. All members of the management team had been trained in techniques of improving quality. However, because of lapses in monitoring these improvements, there was found a need to come up with a three-year monitoring program to ensure effective and permanent results (Fallone, 2010).
Quality Improvement Strategies
About four decades ago, stakeholders in the healthcare sector proposed the effective assessment of healthcare quality through observing its outcomes, structure, and processes. Structure measures evaluate the quality; accessibility, and availability of resources such as the number of nurses, health insurance and a hospital’s bed capacity. Process measures and evaluate, the delivery of medical care services by providers and clinicians, for instance, through using guidelines in the care of diabetic patients. Outcome measures point out the final healthcare results and could be impacted by behavioral and environmental factors. These include improved health, mortality and patient satisfaction (Kohn and Clorrigan, 2009).
In medical care, Continuous Quality Improvement (CQI) is interchangeably utilized with TQM (Total Quality Management) in an attempt to augment clinical practice. It is employed on the basis that there is a platform for improvement in every occasion and process. The objective of this paper is to develop a “Plan-Do-Check-Act (PDCA)” process to address the quality issue of bed sores and falls and the concept of continuous quality improvement (CQI) at John C. Lincoln North Mountain Medical Center (Axley, 2008).
Plan-Do-Check-Act (PDCA)
Quality improvement studies and projects whose aim is to have a positive impact on the processes usually make use of the PDCA model. This is a paradigm that has been broadly employed by hospitals for improving healthcare for rapid improvement cycle. One exclusive feature about this model is its capacity to impact and evaluate change successfully, via small PDCA rather than big ones. The intention of PDCA quality improvement intentions is to create a causal or functional relationship between dynamics in outcomes and processes, particularly capabilities and behaviors. Before using the PDCA, the objective of the project must be illustrated. The method of evaluating whether the project realized its goal should also be ascertained. In addition to that, the researcher should let the reader know if the objective was indeed attained (Fallone, 2010).
The PDCA cycle begins by establishing the scope and nature of the problem, and the changes that can and must be made. Plans for particular changes focus on those that would be involved and what would be done to ascertain specific changes, who should be implicated and what should be evaluated to comprehend the effect of change and where the approach will be targeted. Change is then executed and information is gathered. Outcomes from the study then undergo evaluations and interpretations through reviewing a number of fundamental measurements that designate failure or success. In the end, action is taken on the results through implementation of the change or commencing the process once more (Kohn and Clorrigan, 2009). The process is an ideal cycle that incorporates measures to address issues identified or make certain changes after an evaluation and interpretation of outcomes.
The Project
In redesigning Plan-Do-Check-Act (PDCA)” process to address the quality issue of bed sores and falls and the concept of continuous quality improvement (CQI) at John C. Lincoln North Mountain Medical Center bed hospital, the researcher employed PDCA through a shared decision making model which would in the real sense empower the bed side nurse. This strategy will employ a Councilor Structure where each unit has its own council. Staff nurses will chair the council. Apart from that, councils that are allowed to cross all nursing services include the management councils, research, education, and clinical practice.
With the exemption of management nurses, all councils will be co-chaired and staffed fundamentally by staff nurses. These staff nurses have proper skills and knowledge on how to handle the councils. The PDCA program so designed has the objective of developing a plan that will improve nursing care quality. The PDCA program describes the accountability and process structure for dealing with quality issues with a stress on the role of the bedside nurse. Since the National Data base of nursing quality indicators (NDNQI) is the sole database that has unit level information, the researcher picked it as a standard against which several aspects of the practicing nurses’ quality would be measured.
The NDNQI components that the researcher chose to measure are bedsores and falls, staffing skill mix, pressure ulcers, and total nursing hours provided by each nurse to every patient in a day. Apart from that, the researcher chose to find other nurse sensitive indicators from other sources of data, for instance, the project’s patient satisfaction survey, epidemiologic surveillance, and Midas-a data analysis system. The results data that is gathered by the hospital will be entered into a proportional data base and shared with the nursing units via the researcher’s quality management department in form of a nursing report (Figure 1). As much as the John C. Lincoln North Mountain Medical Center has had a data base for nursing outcomes for quite some time now, the report card data had disparities as far as its usage amongst units was concerned. This included whether it was used by nursing staff or not; hence, the importance of coming up with an independent report.
The fact that a hospital has an outcomes data does not by itself change anything. The real change comes when staffs are made aware of what is required of them in regards to the data. In this regard, the PDCA program will include an accountability structure to show that Unit Based Council (UBC) and nurse managers share report card data with their nursing staff where they address deficits in quality. The challenge is inherent on how the quality improvement plan can be addressed.
Figure 1
Nursing Report Card
| Measures | FY 2013 | January | February | March | April | May | June | July |
| Patient Falls | ||||||||
| Bed Sores | ||||||||
| Voluntary turnover –RNS | ||||||||
| Pressure Ulcers | ||||||||
| Restraint usage | ||||||||
| Total nursing hours per patient in a day | ||||||||
| Patient satisfaction with nursing care |
Planning Timetable for CQI
Initiation Plan 4-7 months starting 6th November, 2013
- November 6: The researcher would develop an initial operational definition for Bed falls.
- November 6: Delineate the objective of the Quality Improvement Council (QIC) and set a rendezvous of 3-5PM every Wednesday and Friday.
- November 6: Incorporate Health Quality Trends (HQT) into the progressive improvement cycle and grasp the initial evaluation.
- November 15: Organize a number of multifunctional teams with their central part from those finishing the leadership workshop with topics chosen by the quality development council using group techniques, surveys, and experience.
- November 15: Heads of departments finish their CEO evaluation to identify patients and their expectations, identify opportunities for each department, and determine training needs. This is to be further discussed with the assistant ward managers on January 5, 2014.
- December 1: Present to the task force the report on research elements to the QIC as well as the recommendations on departmental elements to direct and supervise QIP.
- December 5: Departmental meetings for gaining agreement on divisional plans and set precedence. QIC consolidates and reviews on December 6. Closing assignments to departmental heads on December 7.
- December 7: Draft original copy of statement of objectives for presentation to QIC.
- December 9- December 11: Carry out the initial facilitator’s workshop slated for 16 of January.
- December 11: Task force to report on training needs and extra QIP education for:
- Using HCA networked resources for board of trustees and medical staff.
- Team members hand book and training
- Incorporation of community resources (industry and colleges)
- Head nurses
- December 11: Task force report about a communication program that would be used to support education awareness and feedback from: HCA, employers, universities, vendors, colleges, medical staff and local businessmen.
- December 30: Finish organizing the QIC.
Quality Improvement Execution Plan March 2014
Fall: Pilot and assess the patient comment card system
- March 1: QIC input team to draft rules and policies on quality responsibility, forming teams and the guidelines for multicultural teams. Brainstorming to take place on a March 8 meeting, where revisions will be done on an April 15 meeting and have a draft distributed to employees by April 20.
- March 8: Evaluate proposals for communicating QIP to employees to enhance understanding and awareness, communicate about the awareness of HCA commitments; major guidelines, definitions and policies, QIP and HQT improvements and groups to date; opportunities and improvements for each employee.
- April 16: Make preparations on more considerations of the quality guidelines fir HCA. Discuss with employee orientation, department heads, and hospital staff to point opportunities for QI and barriers to quality improvement (QI). Come up with a particular action plan and discuss it with QIC.
- July 1: Point out and assess Q1 assistance community sources operational, and statistical including the navy, colleges and companies and then come up with recommendations.
- July 4: Carry out a quality 103 course for all new departmental heads and head nurses.
- July 15 2014: Develop and execute a suggested program that is consistent with the HCA Quality rules. This will progress in tandem with making provisions to be involved in making proposals and pointing out circumstances that require improvement through the provision of faster feedback and acknowledgement while interfacing with the QIP opportunities.
- September 1: Survey departmental heads to identify main concerns for more training and education.
- October 14-15: Carry out an administrative workshop to practice and sharpen Q1 methods in order to start Quality team reviews, to include practice methods, to develop process evaluation QIP execution tool, to augment the confidence of staff and management, and develop the process evaluation of the QIP management tool.
- October 16: Come up with a standard team orientation program to cover QI tools and group process rules.
- Fall: Expand the use of HQTs and their integration into the Healthy Quality Improvement Process (HQIP) through improving the incorporation of quality improvement action plans and the communication of results. The psychiatric pavilion will assess and execute the HQT recommendations through the patients comment card system evaluation and piloting.
- November 1: Integrate the implementation of QIP into existing communication/management structures and institute the divisional steering committee functions to direct and smoothen the progress of departmental implementation. Identify QI project for each Assistant administrator and departmental head, while establishing regular quality assessments into departmental management meetings.
- December 1: Assess the effectiveness of the existing practices, policies, and rules for guiding, supporting and sanctioning QI teams. Include standard team presentation format, Cross-functional team sanctioning/Opportunity form, Team progress guiding/monitoring, Team facilitator, and leader responsibilities. Exhibit measurable improvement via Baxter QI team.
- Monthly: Monitoring and improving the suggestion program.
- January 2015: Piloting of the clinical methodology improvement process
- Entire year: In all verbal and written communications, sustain constant messages about the teams commitment to HQIP while reporting suggestions and the successes of each team to ensure the continued education on practices and principles of HQIP strategies.
References
Axley, B. (2008). CQI process in the acute care setting. Presented at the meeting of the American Nephrology Nurses’ Association, Philadelphia, PA, April 29, 2008.
Fallone, S. (2010). Adult inpatient hemodialysis CQI goal. Presented at the meeting of the American Nephrology Nurses’ Association,Philadelphia, PA, April 29, 2008.
Kohn LT, & Clorrigan JM. (2009). To En-Is Human: Buiding a Safer Health System. Washington, DC: The National Academies Press:
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