Quality Improvement Initiative Evaluation

Running head: QUALITY IMPROVEMENT INITIATIVE EVALUATION 1 Quality Improvement Initiative Evaluation Learner’s Name Capella University Quality Improvement for Interprofessional Care Quality Improvement Initiative Evaluation July, 2017 Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Comment [JS1]: Great job with the submission. This submission is written in a scholarly voice and has a good flow in that it follows the rubric. There is a clear and concise language. Only revision is in the selection of a reference that is out of date per health care research standards of being less than 5 years old. QUALITY IMPROVEMENT INITIATIVE EVALUATION 2 Quality Improvement Initiative Evaluation As primary caregivers and care coordinators, nurses play important roles in ensuring quality and safety in patient care. In fact, health care organizations rely on nurses’ knowledge and insight to design and implement quality improvement (QI) initiatives. However, QI initiatives tend to focus solely on patients’ well-being, creating a stressful work environment for nurses. As a result, nurses suffer from poor nursing outcomes such as burnout and job dissatisfaction that can affect their ability to achieve QI goals. Hence, to ensure a QI initiative’s success, the quality of a nurse’s work environment has to be improved. The importance of nursing quality in a successful QI initiative will be discussed using the example of TrueWill General Hospital (TGH), a multispecialty hospital in the United States. The hospital launched a QI initiative with the goal of improving patient safety, and thereby patient outcomes, in its medical and surgical units. The initiative’s framework was based on the Institute for Healthcare Improvement (IHI) Triple Aim, which is an approach to optimize health system performance by the simultaneous pursuit of three aims (IHI, n.d.). However, early evaluations showed that the initiative led to poor nursing outcomes. As nursing performance declined, patient outcomes deteriorated as well, which contradicted the initiative’s goal. In the QI initiative evaluation, the units’ nursing workforce will be analyzed for quality issues that may have been caused by the Triple-Aim-based initiative. The objective is to examine how nursing quality influences patient outcomes, which patient outcomes are most affected, and what quality benchmarks or measures are relevant to the success of the QI initiative. Based on the findings, the report will recommend more protocols and indicators that will overhaul the QI initiative and improve the initiative’s clinical and organizational outcomes. Analysis of the Quality Improvement Initiative Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Comment [JS2]: Should not leave a heading at the bottom of the page. QUALITY IMPROVEMENT INITIATIVE EVALUATION 3 The QI initiative at TGH started with a series of reforms to promote the three Triple Aim goals to address existing safety issues in the medical and surgical units. The Triple Aim’s three goals—improve the health of the population, improve patient experiences, and reduce per capita cost of health care (IHI, n.d.)—were implemented in primary care or care given by nurses and physicians. Initially, the hospital achieved QI benchmarks in the medical and surgical units— adverse events decreased, patient satisfaction increased, resources and infrastructure utilization optimized, and health care costs reduced. However, the Triple Aim’s patient-centric goals overworked the units’ nurses and put them under a lot of stress. They had trouble balancing their clinical duties with other aspects of their jobs such as mentoring new staff, undertaking selfimprovement plans, auditing the units, and compiling reports for the senior management. High levels of job dissatisfaction among the units’ staff, especially nurses, affected their ability to ensure quality in patient care, which had costly implications on the hospital such as high nursing turnover rates and shortages in the units. As a result, the existing nursing staff were unable to manage their patient panels, forcing them to work longer hours in the units. Delays in the review and follow-up of laboratory results increased the length of inpatient and outpatient stays and burdened the limited facilities and resources such as beds and medical equipment. Burnout reduced the nursing staff’s adherence to treatment plans and made them less empathetic toward patients. The overworked nurses were also unable to notice important changes in their patients’ conditions (Bodenheimer & Sinsky, 2014). The analysis of the QI initiative reveals the fact that an inefficient initiative can adversely affect nursing outcomes, which is detrimental to quality care and patient safety. The quality of the analysis can be improved with more data that bridge knowledge gaps or areas of uncertainty. For example, the data gathered from early evaluations do not provide details about the Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. QUALITY IMPROVEMENT INITIATIVE EVALUATION 4 educational qualifications of the nursing workforce or the kind of training they have received. Hospitals with inadequately trained nurses and unlicensed nurses have more patient safety issues and poorer staff outcomes. Furthermore, early evaluations do not mention the hospital’s investments in improving the quality of nursing staff and other primary care providers (Aiken et al., 2014). Further evaluation can bridge these gaps in knowledge and provide evidence that supports the QI initiative’s improvement. The next step in the evaluation is assessing the success of the QI initiative against recognized measures, outcomes, and benchmarks. The evaluation will also justify why nurses are the most relevant staff group to the QI initiative’s success using certain assumptions about nursing. Concepts such as quality in nursing and indicators of quality will be explored as well. Evaluation of the Quality Improvement Initiative Against Standard Benchmarks and Outcomes A crucial point revealed in the analysis of the QI initiative is that a majority of the nurses in the medical and surgical units felt dissatisfied with their jobs because of overwork. Poor nursing outcomes at TGH are symptomatic of quality issues in the hospital’s nursing workforce. Therefore, prioritizing the quality of nursing is the first step to a successful QI initiative. The statement is supported by certain assumptions about the value of nursing in achieving better patient outcomes: (a) Nurses are the largest workforce in any health care setting and deliver most of the bedside patient care (Stalpers, de Brouwer, Kaljouw, & Schuurmans, 2015); (b) Negative nursing outcomes reduce nursing quality, which can be improved by changing the work environment; (c) Poor nursing outcomes cause similar outcomes in other health care professionals as the latter depend on nurses to a large extent; and (d) Improved nursing quality translates to improved quality of care and patient safety and depends on factors such as strong Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. QUALITY IMPROVEMENT INITIATIVE EVALUATION 5 leadership, adequate staffing and infrastructure, and high standards in nursing education (Huber, 2017). Guided by these assumptions, TGH evaluated the initiative using the IHI’s plan-do-studyact model (PDSA), which is a simple model that focuses on setting aims and selecting or developing benchmarks, outcomes, and measures that indicate if a new process or product resulted in improvement (Agency for Healthcare Research and Quality, 2017). The PDSA’s cycle of systematic steps are as follows: (a) plan—involves developing goals and action plan; (b) do— involves selecting measures to monitor progress; (c) study—involves testing and refining actions on a small scale; and (d) act—involves expanding implementation to achieve sustainable improvement. In accordance with the PDSA model, nursing quality was evaluated across three measures—structure, process, and outcomes—to understand neglected patient outcomes. The hospital focused on nurse-sensitive outcomes in patients—delirium, malnutrition, pain, patient falls, and pressure ulcers—that are the benchmarks of nursing quality (Stalpers et al., 2015). Nurse-sensitive outcomes describe patient outcomes that rely on the quantity and quality of nursing. Additionally, the three measures are made up of nurse-sensitive quality indicators, which are indicators that quantify quality and capture nurse-sensitive outcomes (Heslop & Lu, 2014). These indicators are separate from medical indicators of care quality and are specific to nursing (Montalvo, 2007). The quality indicators were adapted by TGH for internal use in its medical and surgical units from the American Nurse Association’s National Database of Nursing Quality Indicators (NDNQI) and the National Quality Forum’s NQF 15. Examples of some of the nurse-sensitive quality indicators used in the QI evaluation include (a) total number of nursing hours per day; (b) Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. Comment [JS3]: This reference is out of date for accepted medical research. References need to be less than 5 years old to be relevant evidence based practice. QUALITY IMPROVEMENT INITIATIVE EVALUATION 6 details about nurse staffing—skill mix and staff ratios; (c) records of patients’ characteristics; (d) documentation of care plans by nurses; (e) rate of adverse events; (f) patients’ length of stay and level of satisfaction with care; and (g) average waiting time for nursing care (Heslop & Lu, 2014). Using these nurse-sensitive indicators in the evaluation allowed TGH to determine the nursing structures and processes that were underperforming and needed improvement. The evaluation revealed three nurse-sensitive patient outcomes occurring in the units— pain, patient falls, and pressure ulcers—that directly result from a fall in nursing quality and are evidence of an unsuccessful QI initiative. To form a better understanding of quality in nursing and nursing care, certain interprofessional perspectives on initiative functionality and results must be identified. Examining the perspectives will help ascertain the underlying factors in health care that nursing depends on to function well. Interprofessional Perspective on Initiative Functionality and Outcomes Various studies have attempted to understand the different processes and systems driving nursing quality and nursing care. These studies have become more relevant in health care because of the shortage of nurses globally. One perspective that is important in TGH’s context is acknowledging the phantom limb (Spinelli, 2013) of the Triple Aim. In his groundbreaking study, Spinelli observed that the Triple Aim suffers from a phenomenon similar to the condition wherein patients experience twitching, pain, or other sensations in a previously amputated limb. By solely focusing on the quality of patient experience, the Triple Aim isolated and ignored the well-being of the health care professionals who are directly responsible for delivering care. The phantom limb pain often manifests as job dissatisfaction and burnout (Spinelli, 2013) and is an important factor behind the functionality and type of outcomes in a QI initiative. Copyright ©2017 Capella University.

MSNFP6016 Capella University Quality Improvement Initiative Evaluation Copy and distribution of this document are prohibited. QUALITY IMPROVEMENT INITIATIVE EVALUATION 7 Another perspective that is a deciding factor in the success or failure of a QI initiative is organizational leadership. Health care professionals, including nurses, depend on their organizational leaders and management to organize and improve human resources, infrastructure, patient policies, and lines of communication and health technologies that help with the smooth functioning of an initiative (Huber, 2017). Inadequate or inefficient leadership and management can be responsible for stressful working conditions that result in job dissatisfaction and overwork, leading to staff burnout. The third perspective relevant to TGH’s nursing workforce and optimum QI performance is nursing characteristics. These characteristics are factors such as nursing leadership, staffing, nurse–physician collaborations, nurse experience, and nurse education that are inherent to the nursing work environment and influence nursing quality. These characteristics should function properly for attaining good patient outcomes (Stalpers et al., 2015). Quality Improvement Initiative Evaluation

MSNFP6016 Capella University Quality Improvement Initiative Evaluation The staffing characteristic also addresses problems caused by unlicensed nurses. The subject of unlicensed nursing is central to another perspective of functionality: nursing regulations. Often, regulatory barriers prevent nurses from providing quality care for their patients. The lack of regulatory standardization on the ideal ratios of unlicensed nurses to unlicensed nurses causes confusion among health care professionals and increases chances for malpractices such as negligence. Moreover, regulations do not offer any guidance on the definition and scope of nursing practice. The lack of clarity means that nurses are unsure about the boundaries of professional practice (Owsley, 2013) and become vulnerable to committing errors. These problems suggest a need for regulatory reform in nursing. Even though these perspectives are valid in today’s health care context, there are areas of uncertainty. Hospitals are often unable to address the Triple Aim’s phantom limb and improve Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. QUALITY IMPROVEMENT INITIATIVE EVALUATION 8 nursing quality because that would result in an increase in health care costs, which is borne by patients. Training, updating infrastructure, hiring more licensed nurses over unlicensed nurses, and redesigning units and staffing patterns need financial support and time, which can affect per capita health care costs and patient satisfaction. Additionally, the lack of clarity on the scope of practice limits nurses’ opportunities for self-improvement. Nurses may feel discouraged from using their intuitiveness and creativity to go beyond their professional competencies if such actions benefit their patients. The field of nursing and QI will benefit from separate studies that add to the current literature and bridge gaps in knowledge.

MSNFP6016 Capella University Quality Improvement Initiative Evaluation The expanding evidence base provides opportunities for innovation in QI in the form of improved quality indicators, measures, and strategies. Correspondingly, the QI evaluation will use the evidence to recommend additional indicators and protocols to improve and expand the outcomes of the initiative. Additional Indicators and Protocols to Improve Quality Outcomes Nurses need to practice in an environment where providing safe care is a conscious act. As part of the fourth and final step of the PDSA model, the initiative’s indicators and protocols will be expanded to achieve sustainable improvement. TrueWill General Hospital’s QI initiative, which was based on the Triple Aim framework’s goals of quality care and safety, affected nurses’ abilities to achieve patient outcomes. The QI framework can be improved by introducing a fourth dimension to solve the problem of the phantom limb. The resultant Quadruple Aim will address the needs and expectations of those individuals who deliver care for patients (Bodenheimer & Sinsky, 2014). A few strategies can promote the Quadruple Aim: (a) expanding nursing roles to assume preventative care under physician-written standing orders; (b) collocating teams so that Copyright ©2017 Capella University. Copy and distribution of this document are prohibited.

MSNFP6016 Capella University Quality Improvement Initiative Evaluation QUALITY IMPROVEMENT INITIATIVE EVALUATION 9 physicians, nurses, and ancillary staff work in the same space, thereby improving collaborative relationships; (c) implementing team documentation, where staff members involved in a patient’s care enter documentation, assist with order entry, and process prescriptions; and (d) avoiding burnout by training staff and eliminating unnecessary steps in practice (Bodenheimer & Sinsky, 2014). Apart from these strategies, TGH can benefit from evidence-based quality care and patient safety protocols such as those mentioned in the National Patient Safety Goals (NPSG). Examples of the NPSG’s categories include introducing steps to identify patients correctly, improving the effectiveness of communication among caregivers, improving the safety of highalert medications, and reducing the risk of health-care-acquired infections. Orienting medical and surgical units to the NPSG helps improve nursing quality and nurse-sensitive patient outcomes. A well-functioning unit and nursing workforce, in turn, increase job satisfaction among all staff and lower the risk of burnout (The Joint Commission, 2016). The changes to TGH’s QI initiative should be supplemented with appropriate nursesensitive indicators. The additional indicators will ensure that organizational or clinical changes do not eclipse the needs of the health care professionals, especially nurses. The nurse-sensitive indicators can be described as follows: (a) level of nurse education, certification, and years of experience; (b) nursing competency level and support by leadership; (c) level of positive communication between physicians and nurses; (d) extent of organizational support for nurse education; (e) availability of facilities and budget for quality nursing care; (f) level of nurse satisfaction with their jobs; (g) safety of nursing job; and (h) rate of nurse turnover and voluntary vacancy (Heslop & Lu, 2014). Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. QUALITY IMPROVEMENT INITIATIVE EVALUATION 10 While the benefits of implementing the strategies, protocols, and indicators are evident, the drawbacks of including them in TGH’s QI initiative need to be discussed. The main drawback is the fact that these solutions come with a risk of widening the gap between society’s expectations of quality and safety in primary care and primary care’s available resources.

MSNFP6016 Capella University Quality Improvement Initiative EvaluationThe risk is equally great if the emphasis on the well-being of health care professionals comes at the expense of patients’ needs (Bodenheimer & Sinsky, 2014). Health care professionals at TGH have to ensure that any changes in the hospital’s system benefit all stakeholders. Conclusion Quality improvement initiatives carry a large risk of failure if the goals and expectations of different stakeholders do not align. Nursing professionals are crucial to achieving the objectives of quality care and patient safety. Quality Improvement Initiative Evaluation

Devaluing the nursing workforce and implementing policies or programs that cause nurse dissatisfaction are detrimental to QI efforts, which was the case at TrueWill General Hospital.

MSNFP6016 Capella University Quality Improvement Initiative Evaluation Nursing outcomes also affect the productivity of the entire unit and the competencies of other health care professionals who rely on nurses for help in completing the delivery of quality patient care. It is important to remember that quality health care services are a product of a symbiotic relationship between the care providers and patients. Copyright ©2017 Capella University. Copy and distribution of this document are prohibited. QUALITY IMPROVEMENT INITIATIVE EVALUATION 11 References Agency for Healthcare Research and Quality. (2017). Section 4: Ways to approach the quality improvement process. In The CAHPS ambulatory care improvement guide: Practical strategies for improving patient experience. Retrieved from https://ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qiprocess/sect4part2.html#4c Aiken, L. H., Sloane, D. M., Bruyneel, L., Van d …