Data Analysis and Quality Improvement Initiative Proposal
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- Introduction
Health care professionals are constantly striving to improve quality care and safety provided to patients. The culture of care quality and patient safety depends on a strong and supportive work environment that promotes leadership, evidence-based practice, effective communication, and inter-professionalism. Nurse leaders play a crucial role in establishing this culture and directly influence quality outcomes across an organization.
- Problems and Needs
The role of nurse leaders in maintaining the quality in the nursing and clinical departments is discussed using the example of TrueWill General Hospital (TGH), a multispecialty hospital in the US. As part of its annual assessment of organizational quality, the hospital’s quality management office completed its evaluation of dashboard metrics for the surgical units for the year 2015–2016. The office released the data in its Quality and Safety Report 2015–2016. The surgical units’ data comprised of adverse events and near-missed. They used four quality indicators: patient readmission rates, length of stay (LOS) exceeding 7 days, pain level between 7 and 10 for more than 24 hours, and individuals with pressure ulcers.
III. Recommended Solution
The analysis results showed three quality indicators—pain levels, readmission rates, and pressure ulcers—performed below the hospital’s benchmarks. The connection between these indicators and the surgical units’ nurses’ services will be discussed in this proposal for a quality improvement initiative. The proposal will evaluate the relational patterns between the indicators and the data, identify assumptions governing health care quality and nursing characteristics, determine methods to discover the root causes of quality issues, and recommend a framework and strategies to improve the surgical units’ quality outcomes.
Analysis of Dashboard Metrics to Identify Quality Issues
The patients who require full-time perioperative care are admitted to TGH’s surgical units, equipped for general, orthopedic, urology, and ambulatory surgery. The critical nature of patients admitted to these units’ makes quality and safety the units’ highest goals. Quality and safety outcomes are regularly evaluated in these units. The units are staffed by interdisciplinary professionals—physicians, nurses, therapists, dieticians, pharmacists, and auxiliary medical staff.
Table 1
Quality and Safety Report 2015–2016
| Unit –Year | LOS exceeding 7 days | Patient readmission | Pain level between 7 and 10 for more than 24 hours | Patients with pressure ulcers | Total |
| Surgical 2015 | 43 | 29 | 15 | 14 | 101 |
| Surgical 2016 | 31 | 43 | 30 | 25 | 129 |
The data available from the Quality and Safety Report in Table 1 revealed that the annual patient readmission rates increased from 29 in 2015 to 43 in 2016. Similarly, the number of patients who experienced pain for more than 24 hours without relief doubled from 15 in 2015 to 30 in 2016. Pressure ulcers, a common quality and safety issues in surgical patients, also increased to 25 from 14 in 2015. Conversely, the units reported a drop in the number of patients whose LOS exceeded 7 days—from 43 in 2015 to 31 in 2016.
The results may significantly affect the hospital’s stakeholders—the patients, health care professionals, and the organization—in various ways. Patient readmissions are a costly outcome for TGH because the Patient Protection and Affordable Care Act, through its Hospitals Readmissions Reductions Plan, penalizes hospitals with unexpectedly higher readmissions (Bartel, et al., 2014). Hefty penalties are enforced because readmissions are thought to result from poor follow-up care (Abelson, 2013).
Furthermore, studies have found an association between LOS and the risk of readmissions. Bartel et al. (2014) reviewed prior literature on the impact of decreasing patient LOS and increasing readmission rates. They concluded that a patient who stays for an additional day might reach a higher level of stability. At TGH, health care professionals may have faced immense pressure to reduce patient LOS to control per capita health costs. The pressure could have forced the units’ nurses and doctors to rush through patient care plans and hasten the process of educating patients regarding post-discharge behavior. Furthermore, patients who are readmitted may lose trust in their health care providers’ ability to provide complete and quality care.
Just as readmissions are a quality issue that affects all stakeholders, high pain levels and pressure ulcers affect the surgical units’ nurses and patients. This inference is based on the theory of nurse-sensitive patient outcomes, which explains that pain and pressure ulcers are patient outcomes that depend on the quantity and quality of nursing (Stalpers, et al., 2015). Based on this inference, it can be assumed that there could be issues in nursing performance and quality in TGH’s surgical units.
Moreover, there is evidence linking pressure ulcers and postoperative pain to a higher risk of readmissions (Kirkner, 2017). While the hospital’s data do not directly link pressure ulcers and pain to readmission rates, it is possible to theorize that reducing pressure ulcers and pain in patients will also reduce readmissions. Therefore, the surgical units’ nurses can help prevent readmissions by preventing ulcers and managing pain in patients more efficiently.
The degree of nursing quality is a vital predictor of favorable quality outcomes. Based on the reported data analysis, TGH’s nurse leaders met with the unit nurses to evaluate the nursing factors contributing to unfavorable results. The nurse leaders identified the challenge as the transactional leadership style practiced by the perioperative charge nurses. Transactional leadership is defined as a reciprocity relationship that distinctly indicates the leader from the follower and is focused on the conditional reward system with individuals being awarded or penalized based on their executions (Thomas, 2016).
Transactional leadership may have become the supreme leadership style in TGH’s surgical units due to adequacy in training and incompetence among nurses. The nurse leaders decided to change the leadership style of charge nurses with a quality improvement (QI) initiative based on the data analysis. The QI initiative proposal will identify an ideal leadership style and propose strategies to implement the style. Areas of uncertainty that require further evaluation will also be discussed in the proposal.
Outline for the Quality Improvement Initiative Proposal
Charge nurses occupy a vital position in influencing the individuals involved in patient care (Thomas, 2016). They are responsible for coordinating and evaluating nurse staffing plans, balancing unit budgets, and making patient assignments. However, the transactional leadership at TGH was ineffective since the charge nurses were not skilled enough to notice nurse dissatisfaction, prevent conflicts between the nurses, and establish effective communication channels. The surgical units’ nurses were not given any guidance by the charge nurses to accomplish quality improvement tasks or participate in collaborative and inter-professional efforts. Since the transactional leadership tended to reward or punish staff based on performance (Thomas, 2016), the nursing staff paid more attention to accomplishing tasks such as discharging patients quickly than ensuring patient satisfaction.
The QI initiative will provide strategies that support the transition from transactional to transformational leadership. Transformational leaders focus on internalizing ethical and professional values in their team members and aligning them with organizational goals. A transformational leader’s optimism, selfless service, and creativity motivate and encourage teams. It is worth noting that transformational leadership’s motivational and inspirational aspects will significantly change the work environment and the nurses’ commitment to the organization (Thomas, 2016).
The quality improvement model that is best suited to introduce and implement transformational leadership is the plan-do-study-act (PDSA) model. Hence, the model will serve as the framework for the QI initiative. The model’s effectiveness occurs during the need for stimulating change, as in TGH’s case. The four steps of the framework can affect system change that will promote long-term improvement and implementation of the initiative on a larger scale. Various strategies incorporated into the PDSA steps will be discussed briefly.
Plan: This step involves setting up an interdisciplinary team. While the nurse leaders already identified the problem as transactional leadership through discussions and analysis, the inter-professional team will validate the previous results using a Multifactor Leadership Questionnaire survey. The survey will be distributed to the nurses as well as other perioperative health care professionals. After the survey results are analyzed, the team will define achievable goals, such as establishing a transformational leadership style and improving the affected quality indicators (Thomas, 2016).
Do: In this step, the team, with support from the organization, will create a strategic plan to achieve the defined goals. Examples of strategies include introducing training modules for leadership development and quality and safety education. Study: The results from the implementation of strategies devised in the previous steps are analyzed. Observations are based on different inter-professional perspectives and are set against TGH’s surgical units’ performances, not just nursing. Act: In the final step, the goals set in step one are reevaluated to determine whether the strategies were effective. TGH can carry out the step by calculating data on the four quality indicators and noting the quality outcomes trend. Based on that evaluation, the PDSA cycle is deemed complete or renewed with new goals and strategies.
Despite the effectiveness of the PDSA model, knowledge gaps may still affect the QI process. First, just four indicators to measure quality outcomes in the surgical units can fully understand the issues. Further evaluation should be done using indicators such as mortality and patient satisfaction and nurse-sensitive indicators such as nurse perception of job and nursing education level.
Secondly, the data only displays issues regarding the hospital’s surgical units. Basic concepts such as systems theory explain how problems in a single part of the organization affect quality and performance outcomes in other departments. However, there is a lack of data on quality issues from other departments at TGH, possibly connected to the surgical unit’s issues. Therefore, the team spearheading the QI efforts can include data from other units and departments to create a comprehensive QI initiative. Another area of uncertainty is the studies connecting nursing leadership and patient outcomes. Most studies do not test whether nursing leadership directly improves patient outcomes; they evaluate the connection conceptually. Wong (2015) contributed that understanding the relationship between leaders and patient outcomes requires interventions and longitudinal studies with continuous observations.
To achieve better patient outcomes by changing the nursing leadership, the proposed QI initiative will be guided by various inter-professional outlooks. These perspectives will support patient safety, cost-effectiveness, and work-life quality for nurses and other staff. Each perspective will address an aspect relevant to TGH, such as leadership. The discussion will also identify assumptions that highlight the importance of these perspectives.
Integration of Inter-professional Perspectives that Support Quality Improvement
Over the years, efforts to improve health care quality and safety drew inspiration from various inter-professional perspectives. The perspectives important to TGH are systems theory, collaborative relationships, and leadership theory. Identifying these specific outlooks and their integration into the hospital’s QI initiative is based on assumptions made on the factors influencing patient outcomes. One assumption is that health care systems are interconnected, and problems in one unit or department can affect other parts of the system. Huber (2017) argued that problems in surgical units could affect the quality of other hospital departments.
When quality in multiple departments gets compromised, the organization may not function properly and achieve its goals of providing quality care for patients. Poor nursing performance and quality also affect doctors, therapists, and other interdisciplinary professionals working in the surgical unit. These health care professionals work alongside nurses and depend on them to carry out care plans effectively. Another assumption is that nurse leaders can learn and develop leadership attributes that may improve their leadership style (Thomas, 2016). However, leadership development can only take place if the organization is supportive and allocates necessary resources. The third and last assumption guiding the initiative’s conceptual basis is that anyone and not just executives or managers can practice leadership (Smith-Trudeau, 2016).
Leadership is the main theme explored in these assumptions and is a vital system theory factor. Leadership styles influence collaborative relationships. Although the connection between leadership and patient safety needs to be further assessed, professionals concur that some leadership methods produce preferable outcomes than others. Particularly, professionals have contrasted the potency of transformational leadership against transactional leadership in attaining patient well-being. Transactional leadership observed in TGH is ineffective as it focuses on awards rather than results. In contrast, Thomas (2016) claimed that transformational leadership possesses an elevated competence level that aids in motivating and leading team members to pursue a higher level of ethics, thus enhancing patients’ outcomes.
Also, transformational leaders are more competent when introducing cost-reduction plans while maintaining quality in their units. They are more skilled at administrative management, vital expertise for budget planning than transactional leaders. Huber (2017) contributed that transformational leadership is the most recommended leadership plan in executing systems theory proposals. Systems theory is essential in QI as it helps establish the roots of quality issues. By comprehending the origin of quality matters, TGH may pay attention to dynamic quality procedures that mitigate long-term safety and sustainable quality matters
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Transformational leadership on individuals via effectual interpersonal relationships is also important for developing cohesion among teams and ideal work-life quality. The surgical units comprise of inter-professional individuals, who depend on staff having a sense of shared targets. The nurses are the substantial staff body in the surgical units, and issues within their workforce, such as non-alignment of goals, affect other units’ staff. Transformational leaders are capable of guiding nurses in building respectful and positive relationships with their colleagues.
These inter-professional perspectives will act as guides for the QI team when implementing the PDSA steps. The perspectives are useful in facilitating transparent communication. The QI proposal will suggest communication strategies imperative when expanding the proposal into a full-fledged QI program. The proposal will also provide assumptions that will guide those suggestions.
Effective Communication Strategies to Promote Quality Improvement
Communication is a key leadership aspect and facilitates different organizational structures (Huber, 2017). Without effective communication practices, seniors are unable to relay organizational decisions and targets or execute QI amendments. At TGH, the charge nurses could not communicate care plans to their nursing staff or coordinate with other units’ leaders and interdisciplinary professionals to achieve ideal outcomes. Their ineffective communication methods also set a negative example for the nursing staff.
Therefore, the development of effective communication strategies before the implementation of QI strategies is important. Proper communication channels promote inter-professional attempts in quality improvement and patient care. The assumptions guiding the strategies are: (a) Seniors facilitate productive inter-professional alliances in care provision, which is possible only if leaders are proficient in communication skills; (b) Nursing sovereignty in making decisions is necessary for enhancing the effectiveness of nursing personnel.
A few communication strategies will be suggested that the QI team impose to implement the QI initiative and promote inter-professional team-work or team-work based on these assumptions. The strategies include: (a) coaching the QI team in various means of communication, thus improving the relations within the team; (b) Organizing a weekly QI team convention where individuals will receive a copy of the agenda and provide feedback on attaining targets (Thomas, 2016); and (c) filling in units’ staff on decisions made in these meetings.
- Conclusion
Data and outcome-driven organizations must constantly analyze their quality indicators and implement changes that improve all clinical and organizational results. Quality and safety evaluations, such as the one conducted at TGH, often reveal hidden issues that negatively influence patient outcomes, such as ineffective leadership styles. Leadership is important in uncovering the imperceptible problems and implementing changes that improve safety and quality. However, as displayed at TGH, leadership depends on inter-professional care and team-work, communication, and highly-qualified health care professionals. The absence of these factors can significantly affect patient outcomes. Understanding this interdependence between organization, leadership, and staff is necessary for high-quality performance and patient safety.
References
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Kirkner, R. M. (2017, May 7). Postop pain may be a predictor for readmission. ACS Surgery News. Retrieved from http://mdedge.com/acssurgerynews/article/137637/pain/postop-pain-may-be-predictor-readmission
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