The Principles Models and Tools for the Quality Improvement In Healthcare Setting. Numerous quality improvement methods can be applied in the healthcare sector, such as Plan-Do-Study-Act (PDSA), Lean, and Six Sigma. Each method offers a unique, goal-oriented outcome that is used in the healthcare sector to optimize processes.
What are Principles Models and Tools for the Quality Improvement In Healthcare Setting
Quality improvement (QI) in healthcare is based on several key principles, models, and tools to drive positive change and optimize patient care. These include patient-centeredness, fostering strong partnerships, promoting a QI culture, aligning metrics, and leveraging frameworks such as PDSA and Lean Six Sigma.
The Institute of Medicine has identified six dimensions of healthcare quality. These dimensions establish that healthcare should be safe, effective, patient-centered, timely, efficient, and equitable. Harm to patients caused by the treatment intended to help them should be avoided.
Principles of Quality Improvement
Florence Nightingale was concerned about quality 150 years ago. She has been called “the woman who discovered quality” (Meyer & Bishop, 2007, p. 240), and she could also be considered an evangelist for performance improvement. When working in the British Military hospital system, she worked tirelessly to change the conditions for patients. She collected data, developed tables to display the data, and reported statistics to British leaders. Initially, Nightingale’s work was related to mortality rates in hospitals.
However, she soon informed those she reported to that “hospital mortality statistics have hitherto given little information on the efficiency of the hospital, i.e., the extent to which it fulfills the purpose it was established for, because there are elements of existence of which such statistics have hitherto taken no cognizance” (Nightingale, 1859, p. 5). She goes on to discuss the need for better sanitary conditions in hospitals and those surgical operations and their results should be monitored. In essence, what Nightingale was referring to is what we know today as quality improvement.
Quality improvement (QI) as it is used in health care today was first used in industry in the early 1900s. In the 1920s at the Bell Telephone company, a young engineer by the name of Walter Shewhart explored using statistical methods to identify issues and establish strategies to improve them. His main premise was that statistical control would allow identification of causes of variations in a process. Further, by maintaining control over processes, future outputs could be predicted and allows processes to be managed economically (Smith, 2009).
quality methods were used in American industry in the 1930s. He developed various tools such as charts and graphs and principles of statistical control that resulted in the basic principles of quality control still used today. Shewhart is known as the modern father of quality control (Tague, 2005). A student of Shewhart’s, W. Edwards Deming, worked for the United States Census Bureau in the 1940s and also taught quality control methods to engineers and statisticians. He became disillusioned with many engineers and statisticians because they did not understand or value the benefits of the methods he taught.
After World War II, he went to Japan, where he lectured on quality control and statistical and managerial concepts for quality to Japanese engineers and scientists (Tague, 2005). He believed if the Japanese manufacturers applied the principles, they could improve the quality of their products, and those products would be de sired worldwide (Tague, 2005). He is known for 14 key principles for management that are used by managers and leaders to improve business and organizational effectiveness.
Deming was a visionary whose belief in continuous improvement led to many theories and teachings that influence quality, management, and leadership today (W. Edwards Deming Institute, 2016). Joseph Juran was another engineer interested in statistical control and quality. Like Shewhart, he also worked for Bell and was involved in conducting statistical quality control. He is often called the “father of quality.” Juran developed the Pareto principle, which is one of the most useful tools used in management today (Juran Global, 2016).
He described quality from the customer’s perspective and suggested that higher quality means that more features will meet customer needs, and higher quality will also include fewer defects. Juran visited Japan and worked with Deming to further teach and help industrial managers understand their responsibilities for quality production. In the 1970s and 1980s, the American auto industry and electronics industries experienced the influx of high-quality products from Japanese competition in the automotive and electronics industries.
The U.S. companies requested assistance from Deming and Juran to begin quality management and quality control programs or total quality management (TQM) (Tague, 2005). TQM is “any quality management program that addresses all areas of an organization, emphasizes customer satisfaction, and uses continuous improvement methods and tools” (Tague, 2005, p. 14).
Health-care organizations are called to use TQM by implementing QI pro grams aimed at monitoring, assessing, and improving the quality of health care delivered and to continuously seek higher levels of performance to optimize care. QI entails a systematic and continuous series of actions that leads to measurable improvement in health care and the health status of specific patient groups (U.S. Department of Health and Human Services [HHS] Health Resources and Services Administration [HRSA], 2011).
All QI programs incorporate four key principles (HHS and HRSA, 2011):
1. QI works as systems and processes.
2. There is a focus on patients.
3. There is a focus on being part of the team.
4. There is a focus on the use of data.
Successful QI also requires the following elements: “fostering and sustaining a culture of change and safety, developing and clarifying an understanding of the problem, involving key stakeholders, testing change strategies, and continuous monitoring of performance and reporting of findings to sustain the change” (Hughes, 2008, p. 18). In addition, effective QI programs require committed management, an established QI model and processes, and a set of QI tools.
There are many frameworks for QI, and most have steps that assist in asking questions, gathering appropriate data, and taking effective and efficient action to address the issue (Tague, 2005). The QI process is similar to the nursing process in that, once a plan is in place to address an issue or problem, it is re-evaluated. The QI process is cyclical and involves setting standards of care, taking measures according to standards of care, evaluating care, recommending improvements, ensuring that improvements are implemented, and evaluating the improvements.
Nurse leaders and managers are integral in the QI process because they are responsible for ensuring the safety and quality of nursing care. Nurse leaders and managers can improve patient safety by applying the QI principles by using a patient-centered approach (Galt, Paschal, & Gleason, 2011). The QI process begins with monitoring specific measures that are part of a care process to identify variations in care and compare findings with performance levels or benchmarks established. If a measure is outside the expected performance level, a problem is identified, and an investigation ensues to determine the root cause of the problem. The following steps can be used to monitor and improve performance (Donabedian, 2003):
- Determining what to monitor: Some activities are directed by government agencies that provide care, pay for care, and assume responsibility for its quality to be monitored. All activities that fall below an expected level of performance must be monitored.
- Determining priorities in monitoring: All activities that could jeopardize patient safety should be monitored. Four characteristics guide determining the priority of a problem: the problem is believed to occur frequently; error or failure in performance is known or believed to occur frequently; when it occurs, such error or failure in performance is believed or known to have serious consequences to health and is costly; and the error or failure in question can be rather easily corrected (p. 40).
- Selecting approaches for assessing performance: This step requires the nurse leader or manager to determine the type of information needed (structure, process, or outcome) to make an inference about quality. It is important to avoid focusing only on outcome measurements and to recognize that there can be weaknesses in the structure and process that lead to failures or poor performance. A combination of approaches is needed for a more comprehensive assessment of quality. By using a combination of approaches, the cause of poor performance or outcome can be attributed to structure and/or process, and this attribution helps direct the improvement process.
- Formulating criteria and standards: A criterion is “an attribute of structure, process, or outcome that is used to draw an inference about quality” (p. 60), whereas a standard is “a specified quantitative measure of magnitude or frequency that specifies what is good or less so” (p. 60).
- Obtaining the necessary information: Data can be collected from medical records, surveys, financial records, statistical reports, databases, and direct observations
Choosing how to monitor: Monitoring can be prospective (or anticipatory), occurring before the event; concurrent, conducted during the course of patient care; and retrospective, occurring after the event. The most frequent type is retrospective.
- Constructing monitoring systems: Monitoring of activities for improvement should be an organizational endeavor with a specific department or unit responsible to plan, coordinate, direct, and implement the process as a whole. In addition, there should be coordinated efforts at the unit level including all personnel involved in the activity under investigation.
- Bringing about behavior change: Change is implemented with the goal of changing the structure and/or process and, ultimately, improving the outcome or level of performance.
Once a QI activity is identified, nurse leaders and managers form an inter-professional team to implement the QI process. Nurses at all levels may be part of an intra-professional or inter-professional team to explore the problem identified. The team should be made up of members representing those involved with the problem. Nurse leaders and managers may lead the team or designate a nurse or other health-care professional to facilitate the QI team. For the QI process to be effective and successful, nurse leaders and managers must promote teamwork and collaboration in the workplace environment.
As members of the inter-professional team, nurses should be able to understand and use QI principles and processes as well as outcome measures. Nurses at all levels must be concerned about what they are responsible for, what is the most in need of improvement, and what they can improve (Donabedian, 2003). Moreover, nurses at all levels have an obligation to collaborate with others to provide quality health-care services safely (ANA, 2015a).
Nurse leaders and managers must foster staff involvement in safety initiatives and QI processes to begin changing the processes, attitudes, and behaviors of staff (Newhouse & Poe, 2005). They must help staff members understand that patient safety and QI are not interchangeable but should be implemented simultaneously and continuously to make the most impact (McFadden, Stock, and Gowen, 2014).
Models For Quality Improvement
Donabedian Model
One of the most popular frameworks for assessing quality in health care is the Donabedian Model. This model provides a framework for examining and evaluating the quality of health care by looking at three categories of information that can be collected to draw inferences about the quality of health care:
1) structure, the conditions under which care is provided
2) process, the activities that encompass health care
3) outcomes, the desirable or undesirable changes in individuals as a result of health care (Donabedian, 2003).
The model has been used in health care as well as other industries. The Donabedian Model provides a starting point for any QI activity, and other QI models can be used to further define and assess safety and quality problems in health care. Typically, a health-care agency selects a model or a combination of models that will best fit their organization’s mission, vision, and philosophy as well as the goals and objectives of the improvement activity. Everyone in an organization is part of continuous QI, and nurse leaders and managers often oversee QI initiatives.
Lean Model
The Lean Model assumes that all processes contain waste and involves the thought process of doing more with less. The model, originated at Toyota and also known as the Toyota Production System (TPS), is built on four basic principles:
1) all work processes are highly specified;
2) all customer and supplier relationships are clear;
3) pathways between people and process steps are specific and consistent; and
4) improvements are made based on scientific methods and at the lowest level of the organization (Spear & Bowen, 1999).
Factors involved in the successful application of TPS in health care include eliminating non–value-added activities associated with complex processes, work around, and rework; involving frontline nurses throughout the QI process; and tracking issues that arise during the process (Hughes, 2008). A major advantage of the TPS is that frontline workers are empowered to identify problems and make improvements at the point of care. In this model, nurse leaders and managers provide direction and function as coaches.
Six Sigma Model
Originally designed as a business strategy, the Six Sigma Model is a rigorous method that encompasses five steps:
1) define
2) measure
3) analyze
4) improve
5) control (DMAIC)
Sigma is a letter from the Greek alphabet ( ) used in statistics and measures variation or spread. Six Sigma refers to six standard deviations from the mean (Tague, 2005). It is used in QI to define the number of acceptable errors produced by a process. Six Sigma involves improving, designing, and monitoring processes to minimize or reduce waste (Hughes, 2008).
Institute for Healthcare Improvement Model of Improvement
The IHI Model of Improvement has two parts. First, three fundamental questions are asked, in any order:
1) What are we trying to accomplish?
2) How will we know that a change is an improvement?
3) What changes can we make that will result in improvement?
Second, the plan-do-study-act (PDSA) cycle is implemented: Plan involves developing a plan to initiate a small change, do is implementing the plan and collecting data about the process, study includes studying and summarizing the results of the change, and act encompasses three possible actions—adopt the change, adapt the change, or abandon the change. Once the cycle is complete, the process starts over again (IHI, 2014).
Using the PDSA promotes continuous QI. The PDSA cycle is used to identify issues and improve care . PDSA includes implementing small tests of change to improve care; therefore, it can be integrated with any of the QI models to implement and evaluate small tests of change. Nurse leaders and managers may use PDSA when implementing any change in procedures and when planning data col lection and analysis to verify root causes of a problem or error.
Failure Modes and Effects
Analysis Failure modes and effects analysis (FMEA) is useful in determining what aspect of a process needs to change. The goals of FMEA are to prevent patient safety events by identifying all possible ways a process could result in failure, estimate the probability of failure, estimate the consequences of failure, and establish an action plan to prevent potential failures from occurring.
The steps in the FMEA process include failure modes, or what could go wrong; failure causes, or why would the failure happen; and failure effects, or what would be the consequences of each failure (Nolan, Resar, Haraden, & Griffin, 2004, p. 9). FMEA is a systematic approach to evaluate a process. Potential failures are prioritized according to their consequences, with most serious first. Nurse leaders and managers may use FMEA before developing plans to modify a process or analyzing failures in a current process (Tague, 2005).
Root Cause Analysis
Root cause analysis (RCA) is a “formalized investigation and problem-solving approach focused on identifying and understanding the underlying causes of an event as well as potential events that were intercepted . . . used with the understanding that system, rather than individual factors, are likely the root cause of most problems” (Hughes, 2008, pp. 6–7). Should a sentinel event occur, an RCA is required and must be followed by a realistic action plan to address and eliminate risks (TJC, 2012).
An RCA is completed after a patient safety event and includes the sequence of events that led up to the event, possible causal factors and root cause, and an action plan that identifies specific strategies to reduce the risk of a similar incident occur ring in the future. A typical action plan should address the following: responsibility for implementing and overseeing the plan, pilot testing or a small test of change, time lines, and an appropriate approach for measuring the effectiveness of the plan.
Nurse leaders and managers use RCA to investigate any medical error that occurs on their unit. Often, nurse leaders and managers use RCA to find the root cause of an error and use PDSA to implement a change aimed at improving or alleviating the cause.
Quality Improvement Tools
There are many tools available to use in the QI process for different purposes, whether it is to communicate information, determine whether a problem exists, or help in decision making (Boxer & Goldfarb, 2011). QI tools also help to guide data collection, identify trends and possible problems, and provide a way to dis play data collected. All nurses participating in the QI process should be able to use basic QI tools, such as run charts, histograms, fishbone diagrams, flow charts, and Pareto charts, to collect, analyze, and display data.
Selection of an appropriate tool to analyze and display data is based on the goal of the QI project. When determining how to display data, it is important to consider the type of data and the time period during which the data is collected. For example, monthly data are best collected over a 13-month period. This provides trends over an entire year and compares the current month with the same month the previous year (Boxer & Goldfarb, 2011).
Run Chart
A run chart communicates data, shows trends over time, and reflects how a process is operating (Boxer & Goldfarb, 2011). In a run chart, the vertical axis (y) represents the process variable and the horizontal axis (x) represents time. The mean or median of data is displayed as a horizontal line and allows nurses and the QI team to see changes in measurements without having to compute statistics. Data points above the median indicate an improvement in a process, whereas data points below the median reflect deterioration in the process. Run charts are among the most important tools for determining whether a change was effective (IHI, 2016f).
QI teams would use run charts to display trends over time and changes in quality over time. For example, nurse leaders and managers would use a run chart to determine whether there was a change in the number of central line infections after a new dressing change protocol was implemented. Looking at the chart, falls on the unit were above the median line in February and April, thus indicating a problem with the fall precaution protocols during that time. Nurse leaders and managers would use this data to investigate possible causes for the increase in falls during those months.
Bar Chart
A bar chart is the most common method used to display categorical data, and the scale must start at zero. When using a bar chart, categories are listed along the horizontal axis, and frequencies or percentages are listed on the vertical axis (Tague, 2005). Nurse leaders and managers would use a bar chart to illustrate categorical data. For example, in looking at the increase in the number of falls on the unit, the nurse leader and manager may investigate the staff mix (i.e., number of registered nurses, licensed practical nurses, technicians) on the unit during those time periods.
Histogram
A histogram is a type of bar chart used to display frequency distributions and is useful when the time sequence of events is not available. For QI, histograms assist the team in recognizing and analyzing patterns in numerical data that may not be apparent by looking at data in a table or finding the mean or median of data (IHI, 2016d). Nurse leaders and managers could use a histogram to illustrate the average length of stay of surgical patients on the unit.
Fishbone Diagram
The fishbone diagram, also known as an Ishikawa diagram or a cause-and-effect diagram, is used to identify the many possible causes of a problem and any relationships among the causes (Phillips & Simmonds, 2013). It provides a retrospective review of events and can help nurse leaders and managers determine the root causes of a problem. Fishbone diagrams are key tools used to conduct RCAs. They encourage the team to look at all possible causes and contributing factors of an issue, not just the most obvious.
The fishbone provides a graphic display of the relationship between an outcome and possible factors, such as people, processes, equipment, environment, and management. For example, a fishbone diagram would be used by nurse leaders and managers if they wanted to investigate a medication error or an event such as a patient’s suicide. The fishbone allows the QI team to consider all possible causes of the event. Categories of factors that could cause a problem vary depending on the incident.
Flow Chart
A flow chart helps clarify complex processes, shows blocks in activity in the process, and serves as a basis for designing new processes (IHI, 2016c). Flow charts provide a picture of the various steps in a sequential process and allow QI teams to understand an existing process, identify complexity in a process, identify non–value added steps in a process, and develop ideas about how to improve a process. Nurse leaders and managers would use a flow chart to identify problematic areas in the process of admitting a patient
Pareto Chart
The Pareto chart resembles a bar chart in which the height of the bars represents frequency, and the bars are arranged on the horizontal axis in order from highest to lowest. The Pareto chart is designed to look at various causes of a specific problem. Based on the 80/20 principle, the Pareto chart is a tool to help determine the “small portion of causes that account for a large amount of the variance” in a process (Boxer & Goldfarb, 2011, p. 151).
Joseph Juran developed the Pareto chart to help managers determine where to focus improvement activities because it separates the “vital few” from the “useful many.” The Pareto chart visually shows areas that are most significant and provides information to help identify where to focus improvement for the greatest impact. Nurse leaders and managers would use a Pareto chart when there are many causes of an issue, such as breaks in isolation procedures, but the QI team wants to focus on the most significant cause. Pareto chart for identifying possible causes of medication errors on a unit during a specific period of time.
Based on this chart, the “vital few” categories are being short staffed, high number of admissions, high number of float nurses, and staff mix. These are the areas where QI should be focused. The QI tools presented can assist nurses at all levels with measuring processes and outcomes of care. Additional information about QI tools can be found on the Society for Quality (ASQ) website at www.asq.org/learn-about-quality/quality-tools. html and the Institute for Healthcare Improvement (IHI) website at www.ihi.org/ resources/Pages/Tools/default.aspx.
Conclusion
Safety is a basic component of health-care quality. Because nurses are at the front line of care, have the most contact with patients, and are the last line of defense against medical errors, they have an integral role in discovering and correcting processes that can result in an adverse event. In addition, nurses can significantly influence the quality of care provided and are essential members of the QI team.
Nurse leaders and managers must promote a culture that focuses on patient and staff safety by encouraging error reporting, error reduction, and patient safety (ANA, 2016). Nurse leaders and managers are responsible for evaluating the quality and appropriateness of nursing care (ANA, 2016), and to do so, they must engage nurses in the QI process.
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