Putting out fires or preventing them. Safety. Learning. Improvement.
What do we need to create and sustain quality improvement in nursing?
You may be an accomplished problem solver, but to make quality a lasting feature of your healthcare facility, you need the support of a culture of continuous improvement shared by the entire team. Frontline healthcare personnel have perspective and experience that help them discover what we need to improve quality. Nurse rounding is rich in observation and thought-provoking challenges.
Did you know that a nurse invented the crash cart in her basement? And who invented color-coded IV lines? Nurses.
These innovations made an undeniable impact on the efficiency and safety of healthcare. The question is:
How do we foster such observation and creative thinking, incorporate them into the routine, and make them a habit?
First, we need to understand the nature of quality improvement. Long ago, Aristotle said, “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” Quality improvement is an ongoing process that targets both the effectiveness and efficiency of outcomes and products.
What is quality improvement in the context of healthcare?
In healthcare, quality improvement focuses on improved patient outcomes, involving the following four key elements:
- Identifying areas for improvement
- Standardizing and applying best practices
- Engaging all staff in systematic and ongoing observation, reporting, evaluation, and improvement
- Measuring outcomes such as reduced infection rates, fewer readmissions, and improved patient satisfaction
Increasingly, healthcare organizations are applying methods and principles of quality improvement to identify and address systemic weak points, such as:
- Lack of standardized tools or guidelines
- High patient census
- Inefficient appointment systems
- Poor communication systems
Can quality improvement in nursing improve care outcomes?
Yes. For example, scientific studies show that adverse events in healthcare have shown a clear decrease in hospitals where continuous nursing quality improvement procedures and indicators were established regarding management of these adverse events. Examples include:
- Falls
- Medication errors
- Healthcare-associated infections
- Nurse injuries
Solutions to staffing challenges, such as turnover, directly improve the quality of care and patient outcomes.
How to implement quality improvement in nursing?
Several methods are used currently, such as the following:
- Plan-Do-Study-Act (PDSA) Cycle
- Lean and Six Sigma Methodologies
- Donabedian Model
- Toyota Production System (TPS).
But, isn’t Toyota all about cars? In this article, we will learn about these methods and see examples of how they help us establish quality improvement strategies in healthcare.
Toyota Production System (TPS)
According to Toyota, TPS “is based on the premise of making work easier for workers. The objective is to thoroughly eliminate waste and shorten lead times to deliver vehicles to customers quickly, at a low cost, and with high quality.”
As part of the system, all employees practice “kaizen” daily. The Japanese word “kaizen” means continuous improvement.
When applied to the healthcare setting, TPS focuses on improving the way that the healthcare professionals and workers closest to the patient can serve them.
The method helps to develop a system that makes problems readily apparent and then provides the entire organization with the tools to identify and eliminate them, motivating the entire staff to seek improvement.
Examples of TPS in healthcare
Texas Children’s Hospital successfully created a culture of quality improvement using TPS to empower frontline nurses as problem solvers, streamline care processes, and improve the health of the children.
In one year, they reduced central line-associated bloodstream infections (CLABSIs) by 75 percent among the children in the gastroenterology unit.
The Virginia Mason Medical Center adopted TPS and reduced nurse walking distance in the hospital by 750 miles per day, saving $2 million per year in such areas as orthopedic implant standardization. They also improved quality, clearly shown in the lower frequency of patient complications.
TPS is a precursor of the LEAN methodology and Motorola’s Six Sigma. Now, they are practiced together and have effectively merged into what’s called “Lean Six Sigma”.
Lean Six Sigma
Six Sigma was developed by Motorola with a very specific goal: to reduce variation and defect rates in production processes through statistical analysis. The Lean method focuses on eliminating waste.
Lean Six Sigma combines Lean’s continuous improvement focus and Six Sigma’s data-driven quality control, significantly reducing defects and process variability.
Example of Lean Six Sigma in healthcare
The Yale-New Haven Medical Center in Connecticut incorporated Lean Six Sigma into their practice and culture and reduced bloodstream infection rates by 75 percent in the surgical intensive care unit. In addition to quality improvement, they save approximately $1.2 million annually due to the changes.
The Donabedian model
The Donabedian model is foundational to healthcare quality assessment. It provides a conceptual framework for assessing healthcare quality, defining quality in three domains:
- Structure
- Process
- Outcomes
It is not a method, but informs the application of TPS and Lean Six Sigma.
Example of the application of the Donabedian model
The hospital of Soochow University in China found that the application of this three-dimensional quality evaluation led to the following quality improvements:
- Shortened hospital length of stay after surgery
- Decreased hospital anxiety and depression (HAD)
- Decreased subjective measures of pain
- Reduced incidences of postoperative complications
Plan-Do-Study-Act (PDSA)
PDSA is a cyclical quality improvement method. It requires an ongoing cycle of improvement and is often compared to the application of the scientific method.
Lean Six Sigma officially incorporates PDSA into its methodology, and TPS aligns conceptually with the ongoing cyclical nature of PDSA.
Example of the application of PDSA in healthcare
The Mayo Clinic approaches continuous quality improvement in nursing using a blended framework that combines the PDSA cycle with tools like Six Sigma and LEAN.
As a result of their ongoing efforts in quality improvement, nine Mayo Clinic hospitals have received five-star CMS ratings Overall Hospital Quality.
Principles of quality improvement in nursing
All of the methodologies or frameworks mentioned above share certain principles. Seven stand out as widely recognized essentials to grow a culture of ongoing improvement.
- Data-driven decisions for patient-centered care.
- Involvement of all the healthcare workers, from front-line healthcare workers to board members, and interdisciplinary collaboration among the units and departments.
- Focus on measurable improvements and evidence-based practice.
- Patient safety, prioritizing measures to reduce risks and prevent errors.
- Efficiency and timeliness, minimizing wait times and delays, and avoiding waste.
- Equity, providing care that is of equal quality regardless of gender, ethnicity, or socioeconomic status.
- Continuous learning and improvement.
The examples of quality improvement projects in nursing and healthcare mentioned above uphold these principles, which collectively support clinical governance to maintain high standards of care and accountability.
How do we get started?
Choose a method. Engage staff and leadership to benefit from all their perspectives and ensure greater ownership and commitment.
The method will help you establish clear goals and healthcare quality metrics. Once you have defined them, make sure to record your baseline (your starting point).
Start small and roll out projects in phases, perhaps beginning in one unit and then expanding. Quality improvement best practices often recommend starting with your most pressing facility bottleneck. In quality improvement, bottlenecks are any constraints that can cause work to slow down or grind to a halt.
For example, is filling weekend shifts your greatest bottleneck? Try covering sudden increases in patient census using low-cost, flexible, on-demand PRN staffing to fill open shifts with the expertise you need without the incurring added overtime or hiring costs.
Quality improvement is everyone’s responsibility
Schedulers, managers, DONs, and the entire staff share the responsibility. Nursa is here to provide support and strategic staffing solutions.
Browse Nursa’s facility articles, carefully researched and written to help you tackle staffing issues, motivate staff, and establish a culture of improvement and learning.
Sources:
- NIH: Quality Improvement Methods (LEAN, PDSA, SIX SIGMA)
- Toyota Newsroom: Children’s Health Joins Forces with Toyota to Improve Patient Safety and Quality of Care
- Virginia Mason Production System: Fast Facts
- JOMH: Application of a Donabedian quality evaluation model in perioperative nursing of early gastric cancer male patients
- https://www.mayoclinic.org/about-mayo-clinic/quality/rankings
.png)
.png)
