In this section, we consider how the process of quality improvement works at the unit level, where nursing is often the central focus. For the sake of simplicity, we focus almost exclu- sively on the effect of nursing on client care, although it is generally recommended that quality improvement be interdisciplinary for maximum effectiveness. As a staff member, you will be expected to participate in the qual- ity improvement initiatives for your unit.
Once the policies and procedures for imple- menting quality improvement projects are defined at the organizational level, much of the responsibility for carrying them out may be delegated to staff members of each unit. At the unit level, the first step is to assign respon- sibility to various staff members. All staff members may be brought together to act as a quality circle, or a representative group may be appointed to a committee to implement
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quality improvement activities in consultation with the rest of the nursing staff. It is prefer- able to have as high a level of staff participa- tion as possible, including representation from all three shifts in an inpatient setting.
Once staff members understand the pur- pose of quality improvement, they can begin to identify areas for study. Staff members may use their own judgment about which areas are in greatest need of evaluation, or they may conduct preliminary surveys to determine the most problem-prone areas. Some guidance from the nurse manager may be needed to select a priority area and to prevent avoidance of a difficult problem or one that is hard to define.
Some broad examples of areas for study might include the highest risk clients, the most common client problems, or the source of a high number of incident reports (Elrod, 1991). Other, more selectively focused exam- ples might be physical restraint use, dyspha- gia, ventilator-assisted breathing, respiratory treatments, preoperative teaching, human immunodeficiency virus (HIV)–positive clients, or urinary incontinence. Each of these defines
the scope of the problem to be evaluated (Duquette, 1991).
Once the scope is defined, the problem itself is further analyzed in terms of its important aspects, the generally accepted standards of care for these aspects, indicators (evidence) that these standards have been met, and the criteria (threshold) for determining whether they were met (Table 5–3). For example:
Let’s say that one area chosen for study by an outpatient clinic staff is patient teaching with newly diagnosed hypertensive clients. Three important aspects of this area of care would be teaching the client about the disease process, about lifestyle modifications, and about pharma- cological treatment (Johannsen, 1993). In regard to one of these, lifestyle modification, the stan- dard of care would state, “the client will receive information about exercise, dietary modifica- tions, smoking, alcohol use, and stress reduc- tion.’’ Indicators for the dietary modification portion would be that the client can describe the recommended modifications, modifies the diet as recommended, and maintains weight within 10% of ideal weight. A criterion or threshold for this last indicator would be that
70 ❖ Essentials of Nursing Leadership and Management
ASSIGN RESPONSIBILITIES IDENTIFY VITAL AREAS DEFINE SCOPE OF CARE ANALYZE AREA IN TERMS OF:
ASPECTS STANDARDS INDICATORS CRITERIA
MEASURE ACTUAL PERFORMANCE
&
MEASURE PATIENT OUTCOMES EVALUATE PERFORMANCE AND OUTCOMES
RECOMMEND AND IMPLEMENT ACTIONS EVALUATE DEGREE OF IMPROVEMENT
Figure 5–1• Unit level quality improvement process. (Adapted from Hunt, V.D. (1992).
Quality in America: How to Implement a Competitive Quality Program.Homewood, IL:
Business One Irwin; and Duquette, A.M.
(1991). Approaches to monitoring practice:
Getting started. In Schroeder, P. (Ed.).
Monitoring and Evaluation in Nursing.
Gaithersburg, MD: Aspen.)
at least 50% of clients would achieve this level within 6 months of the original recommendation (see Table 5–3).
A standard of nursing practice describes what nurses do for or with clients and their fami- lies, whereas a nursing standard of care describes the kind of care clients can expect and receive from nurses (JCAHO, 1994).
An indicator is an objective, measurable variable of care. The listed indicators are those variables on which data will be collect- ed in a quality-improvement project. If data are to be collected on a continuing basis, the process is usually referred to as monitoring.
The criteria, or threshold, set a predetermined level of the indicator that will be considered an acceptable level of care (Betta, 1992). For some indicators, such as documenting patient response to a blood infusion, a 100% level of achievement is expected. In other cases, such as weight reduction or smoking cessation, a 75% level of achievement would be consid- ered excellent.
Once these variables are well defined, a plan for data collection is devised. Usually, a worksheet is designed to facilitate data collec- tion. For example:
A form (Fig. 5–2) could be devised to list each newly diagnosed hypertensive client, the client’s weight at diagnosis, ideal weight, and weight at subsequent clinic visits. A final column for not- ing whether clients were within 10% of ideal weight could be added to indicate how many met the criteria after 6 months.
After data are collected, the staff reviews the findings and evaluates the degree to which the criteria were met. For example, if only 25% of the newly diagnosed hypertensive clients were within 10% of their ideal weight in 6 months, the clinic staff might decide to offer weight
reduction classes or a support group. They might also decide to invite the clinic psychol- ogist and nutritionist to participate in the group.
C u r r e n t R e s e a r c h Dingman, S., Williams, M., Fosbinder, D.,
& Warnick, M. (1999). Implementing a caring model to improve patient satisfac- tion. J Nurs Adm, 29(12), pp. 30–37.
Patient satisfaction is an important indicator of quality in healthcare institu- tions. Acknowledging the importance of nurse caring behaviors and the impact of these behaviors on patient satisfaction is beginning to become important. In this study, the following five nursing caring behaviors were identified: (1) introduce yourself to patients and explain your role in their care that day; (2) call the patient by his or her preferred name; (3) sit at the patient’s bedside for at least 5 minutes per shift to plan and review the patient’s care;
(4) use a handshake or a touch on the arm;
(5) use the mission, vision, and values statements in planning your care. Patients were interviewed shortly after discharge, prior to staff receiving a caring-based in- service, and after the in-service. The nurse/
patient satisfaction attributes measured were (1) overall nursing care; (2) staff showed concern; (3) nurses anticipated needs; (4) nurses explained procedures;
(5) nurses demonstrated skill in providing care; (6) nurses helped calm fears; (7) staff communicated effectively; (8) nurses/staff responded to requests. There were signifi- cant differences in the changes in satis- faction during the 6 months after the intervention (caring in-services). This study supported the hypothesis that nurse caring behaviors affect the patient’s perception of caring and patient satisfaction.
What caring behaviors can you identify as indicators to be used in a patient-satisfaction questionnaire? How would you present this idea to the CQI committee?
A d d i t i o n a l R e s e a r c h Ingersoll, G., Spitzer, R., & Cook, J.
(1999). Managed-care research, part 2:
Researching the domain. J Nurs Adm, 29(12), 10–17.
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• Link the process of care and the outcome
• Allow for measuring quality of care
• Increase the predictability of service needs
• Clarify the responsibilities of interdisciplinary team
• Facilitate communication among team members
• Decrease documentation time
• Provide a systematic approach to measurement
TABLE 5–3
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Structured Care MethodologiesSource: Adapted from Mass, S., & Johnson, B. (1998).
Case management and clinical guidelines. Journal of Care Management,p. 19.
A reevaluation of client weights after another 6 months indicating that 50% of the clients were now within 10% of their ideal weights would be evidence that the group was effective in improving the quality of client outcomes. As a result, the clinic staff might decide to continue the group but to work on making it even more effective and perhaps seeking other avenues to help the other 50%
of the clients who had not met their weight reduction goals.
CONCLUSION
Pressure from the JCAHO, consumers of health care, healthcare payers, and healthcare providers has caused the shift in focus in the healthcare system to issues of cost and quali- ty. Experts tell us that quality promotes decreased costs and increased satisfaction.
This should be viewed as an opportunity for nursing to increase professionalism and empower nurses to organize and manage client care so that it is safe, efficient, and of the highest quality.
72 ❖ Essentials of Nursing Leadership and Management Difference
Weight Ideal Weight Weight Weight Weight Weight
Patient at vs. at at at at at
Identification 1st Ideal Actual 2nd 3rd 4th 5th Six
Number Visit Weight Weight Visit Visit Visit Visit Months
01723 135 130 5 136 137 135 133 130
01799 210 145 65 205 204 201 199 197
23045 175 165 10 173 175 176 178 180
Figure 5–2• Personalized patient worksheet.
S T U D Y Q U E S T I O N S
1. As a new graduate, how can you assist the case manager on your floor in plan- ning care for your clients?
2. What problems have you identified during your clinical experiences that could be considered issues to be addressed using CQI?
3. How would you begin discussion of these problems with the nurse manager?
4. What structured care methodologies have you seen implemented in practice?
Which ones might you use to assist you in your planning of care?
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❖ 5. How would you develop your career goals based on the concepts of differenti-
ated practice discussed in this chapter?
6. Considering today’s healthcare climate, discuss the pros and cons of providing nursing care using a primary care model, team model, and client-focused care model.
C R I T I C A L T H I N K I N G E X E R C I S E
The director of quality improvement has called a meeting of all the staff mem- bers on your floor. Based on last quarter’s statistics, the length of stay of clients with uncontrolled diabetes is 2.6 days longer than that of clients for the first half of the year. She has requested that the staff identify members who wish to partic- ipate in looking at this problem. You have volunteered to be a member of the quality improvement team. The team will consist of the diabetes educator, a client-focused care assistant, a pharmacist, and you, the staff nurse.
1. Why were these people selected for the team?
2. What data need to be collected to evaluate this situation?
3. What are potential outcomes for clients with uncontrolled diabetes?
4. Develop a flowchart of a typical hospital stay for a client with uncontrolled diabetes.
R E F E R E N C E S
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Nursing Management, 26(4), 42–45.
American Nurses Association (ANA). (1988). Nursing Case Management.Kansas City, Mo.: ANA.
American Organization of Nurse Executives (AONE).
(1994). Differentiated competencies for nursing prac- tice. Nursing Management, 25(9), 34.
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Brook, R.H., Davis, A.R., & Kamberg, C. (1980).
Selected reflections on quality of medical care evalua- tions in the 1980s. Nurs Res, 29(2), 127.
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Clouten, K., & Weber, R. (1994). Patient-focused care . . . playing to win. Nursing Management, 25(2), 34–36.
Cole, L., & Houston, S. (1999). Structured care method- ologies: Evolution and use in patient care delivery.
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Crummer, M.B., & Carter, V. (1993). Critical pathways:
The pivotal tool. Cardiovasc Nurs, 7(4), 30–37.
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Doenges, M.E., Moorhouse, M.F., & Geissler, A.C. (1997).
Nursing Care Plans: Guidelines for Individualizing Patient Care(ed. 4). Philadelphia: F.A. Davis.
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Donabedian, A. (1977). Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 44(Part 2), 166.
Donabedian, A. (1987). Some basic issues in evaluating the quality of health care. In Rinke, L.T. (Ed.).
Outcome Measures in Home Care. New York:
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Flarey, D.L. (1995). Redesigning Nursing Care Delivery.
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JCAHO: http://www.jcaho.org/accred/genaccr.html accessed 11/16/99
Johanssen, J.M. (1993). Update: Guidelines for treating hypertension. Am Nurs, 93(3), 42–49.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (1994). Framework for Improving Performance: A Guide for Nurses.Chicago:
JCAHO.
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74 ❖ Essentials of Nursing Leadership and Management
75
Time Management
O U T L I N E The Tyranny of Time
How Do Nurses Spend Their Time?
Organizing Your Work Setting Your Own Goals Lists
Tickler Files
Schedules and Blocks of Time Filing Systems
Setting Limits Saying No
Eliminating Unnecessary Work
Streamlining Your Work Keeping a Time Log
Reducing Interruptions Categorizing Activities Finding the Fastest Way Automating Repetitive Tasks Conclusion
O B J E C T I V E S
After reading this chapter, the student should be able to:
• Describe his or her perception of time.
• Set short- and long-term personal career goals.
• Analyze activities at work using a time log.
• Organize work to make more effective use of available time.
• Set limits on the demands made on one’s time.
C H A P T E R 6
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Coming onto the unit, Sofia, the evening charge nurse, already knew that a hectic day was in progress. Scattered throughout the unit were clues from the past 8 hours. Two clients on emergency department stretchers were parked outside observation rooms already occupied by clients who had been admitted the previous day in critical condition. Stationed in the middle of the hall was the code cart, with its drawers opened and electrocardiograph paper cascading down its sides. Approaching the nurses’ station, Sofia found Daniel buried deep in paperwork.
He glanced at her with a face that had exhaus- tion written all over it. His first words were, Three of your RNs called in sick. I called staffing for additional help, but only one is available.
Good luck!’’
Sofia surveyed the unit, looked at the number of staff members available, and reviewed the client acuity level of the unit. She decided not to let the situation upset her. She would take charge of her own time and reallocate the time of her staff. She began to mentally reorganize her staff and alter the responsibilities of each member. Having taken steps to handle the prob- lem, Sofia felt ready to begin the shift.
Business executives, managers, students, and nurses know that time continues to be a valu- able resource. Time cannot be saved and used later, so it must be used wisely. As a new nurse, you may at times find yourself sinking in the “quicksand” of a time trap, knowing what needs to be done but just not having the necessary time to do it (Ferrett, 1996). In today’s fast-paced healthcare environment, time management skills are critical to a nurse’s success. Learning to take charge of your time is the key to time management (Gonzalez, 1996).
Many nurses feel as though they never have enough time to accomplish the tasks that need to be completed. Like the White Rabbit in Alice in Wonderland, they are constantly in a rush against time. Time management is simply organizing and monitoring time so that client- care tasks can be scheduled and implemented in a timely and organized fashion (Bos &
Vaughn, 1998).