CQI Tools

Nursing Process The nursing process is the foundation of what we do as we provide patient care. We assess the patient and the situation, we diagnose the problem within our scope of practice, and the plan for care is created, implemented and evaluated. This is not a linear process but iterative in that we are constantly evaluating, adapting and implementing care so that our patient achieves optimal outcomes. The plan for quality improvement follows a similar cyclic process.

PDSA Cycle Walter Shewhart is attributed with introducing the Plan, Do, Study (Check), Act cycle which has stood the test of time. The simplicity of this model makes it easy to understand and more recently Langley and associates (2009) have expanded on it to develop what is referred to as “The Model for Improvement”. The Langley model builds on the PDSA model by beginning with three key questions: What are we trying to accomplish? How will know that a change is an improvement? What changes can we make that will result in improvement? The model emphasizes the need to study the issue and the process before making additional changes. The PDSA cycle has been adopted by a large number of health care organizations so it typically serves as the foundation for your CQI effort.

Process Improvement Steps Identify key stakeholders Identify your aim. Outline the process. Brainstorm a list of solutions. Choose a solution or design a new workflow. Gather data and monitor progress Determine if the change that you made really is an improvement. Communicate and support the change. Continue to measure and monitor for improvement. Communicate, celebrate, and learn. There are certain, defined steps to follow when the need to make a change or improvement is identified and it begins with the formulation of a team. The health care industry and particularly its professional practitioners have been slow to realize that health care is no longer provided by a single practitioner who provides a service. The provision of safe, quality health care requires a team of skilled practitioners who have to coordinate their services and communicate effectively with each other and the consumer of their services. A quality improvement team is frequently multidisciplinary and there may be a need to provide some training on team work or help the team set ground rules so that everyone on the team has an equal voice.   The steps in process improvement are shown here. Identify key stakeholders, those who know the issue best. These are usually frontline workers who interface daily with the patient. Once you have created your team, identify what you aim to accomplish. For example, you may want to streamline the process of calling report to another unit. As a team, outline the process, this also includes identifying issues that prevent the process from flowing smoothly. In the example of calling report, an issue may be that the sending nurse and receiving nurse are not always able to speak directly the first time a call is made to give report. Identify (brain storm) a list of solutions. Choose a solution or design a new work flow. Gather data and monitor progress Determine if the change that you made really is an improvement. Communicate the change and support it with education, training and any required policy changes that will help “hardwire” the new process. Continue to measure and monitor for improvement. Communicate and celebrate your successes and learn from your failures.

Flow chart example Process Flow Chart This is one of the most powerful tools to use when analyzing a process. It is a pictorial representation of how the process works. Flow charts can be as simple or as detailed as needed but it is important for the team to agree to how much detail is needed to obtain the required information. The example above is from an analysis of patient flow through the Emergency Department and it took 6 hours to thoroughly evaluate the various steps in the process of a patient presenting to triage, evaluated in the ED and admitted to the hospital. While this may sound daunting, it is very helpful to understand all of the steps in the process to determine where bottlenecks occur and opportunities for improvement lie.

Fishbone Diagram Example materials people Cause-and-Effect Diagram The cause-and-effect diagram is also known as the fish-bone diagram and represents in picture form the causes of variation in a process. These are easy to understand and use and help to identify the main causes of a problem as well as contributing factors. An example of t fish bone would be patient falls as the problem. The categories on the “spines” of the fish are usually broken down into issues with people, equipment, process/polices, plant /environment. In the example of patient falls, an example of a problem with equipment may be the lack of gait belts to use to assist patients. An example of an issue with environment or plant may be the type of flooring, or patients placed in rooms where direct observation is difficult. Once the team identifies the causes of the problem, they can begin to analyze the contributing factors to determine where changes may need to be made. environment policies

Histogram example After a cause-and-effect diagram is created, data will need to be gathered to determine how often the different causes occur. The histogram is a simple bar chart that displays the reasons or types of errors that occur plotted along the x-axis. The number or frequency is plotted against the y-axis. The histogram helps to visually see the data and then determine if there is more investigation needed. Using patient falls as an example, if you look at the day that 8 falls occurred you would have to ask what was happening that day. Were there too few staff? Had the floors just been waxed? Was there influx of intoxicated patients to the ER?

Pareto Chart Example The pareto diagram takes the histogram a step further by arranging the longest on the left and moves toward the shortest as you move to the right of the x-axis. Displaying the data in this format helps the reader easily identify the major causes of an error or issue. The pareto chart helps to quickly identify the main causes of an issue or failure. A Pareto chart helps a team focus on problems that offer the greatest potential for improvement, by showing different problems' relative frequency or size in a descending bar graph, which highlights the problems' cumulative impact. Teams can then focus on problem causes that could have the greatest impact if solved or improved. The Pareto principle: 20% of sources cause 80% of problems.

Run Chart Example Performance data must be monitored over time to determine if improvement has really occurred and if it lasts over time. Run charts are graphs of data over time and are one of the single most important tools in performance improvement. The benefits of run charts are they help you monitor the effectiveness of an improvement over time and provide information regarding the impact of particular changes. In this example of patient falls on 3 nursing units, one can easily see that there were spikes in the number of falls that occurred on the various units. This would draw your attention to the situation and cause you to ask probing questions to better understand what occurred so that the appropriate interventions could be made to decrease future falls on these units.

Control Chart Example Control charts are created in a similar fashion as the run chart but it always has a central line for the average, an upper line for the upper control limit and a lower line for the lower control limit. The control limits are calculated using historical data. The benefit of a control chart is that it allows the user to determine if the variation that exists in a process is normal variation or is due to a special cause impacting the process. The scope of this course is such that I do not expect you to understand how to determine special cause variation but I do want you to be familiar with the term. In this example, the occurrences are considered “in control” since they all fall within the upper and lower control limits. Using the example of patient falls, if this was the pattern, you would notice that the process has a wide range of variation around the mean. This indicates that the process is not very well controlled and as a leader, you would want to work to improve the process so that there was tighter control around the mean.