Application of the Clinical Improvement Equation in a Maternal Child Nursing Course Mimi Pomerleau DNP, RNC-OB Post-Doctoral Fellow, VA Quality Scholars Program Kristine Ruggeiro PhD, PNP Brant Oliver, PhD, MS, MPH, APRN-BC Faculty Senior Scholar, VAQS Program

Why care about quality?

Generalizable Scientific Evidence + Particular Context Measured Performance Improvement “Traditional Research” Guidelines Position Statements Microsystem Green Books 5P Assessments Culture Balanced Measures clinical functional satisfaction costs Execution (PDSA, etc.) THE FORMULA FOR IMPROVEMENT (Batalden, 2003) Clinical Improvement Equation EBP Determination Did You Know Poster

“Did You Know” Poster Evidence based practice clinical issue Review literature Summarize Synthesize to poster format Share

Generalizable Scientific Evidence + Particular Context Measured Performance Improvement “Traditional Research” Guidelines Position Statements Microsystem Green Books 5P Assessments Culture Balanced Measures clinical functional satisfaction costs Execution (PDSA, etc.) THE FORMULA FOR IMPROVEMENT (Batalden, 2003) EBP Determination Quality Improvement Group Project Rotation 2

“Clean Room” Context Assessment OR suite Restaurant 5* hotel Motel 6 Teenager’s bedroom

Individual - personal Systems thinking From Dolansky, M. A. & Moore, S. M. (2013). Quality and Safety in Nursing Education: The Key is Systems Thinking.Online Journal of Issues in Nursing. October. PMID:

“A health care clinical microsystem can be defined as the combination of a small group of people who work together in a defined setting on a regular basis—or as needed—to provide care and the individuals who receive that care (who can also be recognized as members of a discrete subpopulation of patients.)” Mesosystem (Department) Macrosystem (Facility, Healthcare System) Market and Geopolitical System (Policy)

A clinical microsystem must… Do the job Meet patient’s needs Meet staff needs for respect, challenge, growth, joy, & earnings Maintain self as an organization mission, values, finances, image Same criteria for any adaptive system

Microsystems Context Assessment: The “5Ps” Purpose - Our aim and mission. Patients - Our reason for doing our work. Professionals - Our staff who work in the trenches to take care of patients. Processes - Our system of inter-related events that constitute the microsystem. Patterns - Our way of doing our work (Measurements, Data, Run Charts) (Nelson, E.C., Batalden, P.B., Godfrey, M.M., Lazar, J.S.( 2011) Value by Design Developing Clinical Microsystems to Achieve Organizational Excellence. Jossey-Bass San Francisico, CA.)

Microsystems Assessment Workbooks Click this link to access workbooks online Free and “downloadable” Customized to different contexts: – Primary care – Inpatient and ED – Specialty care

Purpose Why does the microsystem exist? 5P Assessment of the Microsystem

Patients: Who are the people that the micro-system serves? 5P Assessment of the Microsystem

Professionals: Who are the people that comprise the clinical microsystem? 5P Assessment of the Microsystem

Processes: How does the clinical microsystem function? 5P Assessment of the Microsystem

Bar Chart 16 Why are patient’s not adhering to their treatment plan? Good to compare data during a specified time period

An example of a flow process diagram… 5P Assessment of the Microsystem

Patterns: How does the microsystem behave? Measuring team performance -measurement data -run charts 5P Assessment of the Microsystem

Patterns Run chart Run chart template

Pareto Chart Reasons for poor patient satisfaction “80 /20 Rule” Pareto ranks a data set & displays it graphically in descending order from left to right Second line is added to identify the cumulative percentage Quickly establishes priority list for improvement actions Pareto chart template

5P Data Dashboard 22 Purpose: why does unit exist-understand the current state-link to DYK Patients: Age Average LOS common diagnosis Professionals: Who’s on the team What do they do What are their beliefs? Process: Uncover current state Process flow chart Fish bone diagram Patterns: Run charts Next steps: what would you like to do? Develop Global Aim for a future QI project: Specific aim Change idea-PDSA cycle QI team members: …..

Challenges Clinical units did not know about quality Frustration finding data in EHR Limited time on unit- specialty focused clinical topic Is 5P microsystem assessment appropriate for the context? Is there something better?

Student Comments: “I felt it was very relevant to the new generation of nursing - now more than ever” - “It was simple to conduct our survey of the floor and analyze the process flow” - “The dashboard survey was not too time-consuming and kept things nice and concise” “wanted more space to report on our findings” Understand important but want more OB/Pedi content Limited clinical time could not see how QI project helped to mastery needed clinical skills Communication breakdown between instructors in courses Clinical faculty not on board with assignment

Recommendations: Incorporate the QSEN competencies in all nursing courses and build assignments throughout the curriculum. Revisions to the assignment to focus on clinical practice issue that is seen in the clinical setting. Communication between faculty Collaborate with the next course in the curriculum to reinforce QI skills and Identify change ideas and performance measures. Perhaps include a 1 page reflection of process

Generalizable Scientific Evidence + Particular Context Measured Performance Improvement “Traditional Research” Guidelines Position Statements Microsystem Green Books 5P Assessments Culture Balanced Measures clinical functional satisfaction costs Execution (PDSA, etc.) Clinical Improvement Equation EBP Determination Quality Improvement Group Project Rotation 2 Next steps-