continuous daily improvement by front-line nurses drives quality outcomes

Continuous Daily Improvement

in healthcare with

Transparency and Accountability

Abstract

Continuous Daily Quality Improvement (CDI) is the cornerstone for delivering high quality and cost

effective care by frontline providers in the healthcare setting. The challenge is to implement a quality

improvement program within a learning organization framework.1 This white paper advocates an

alternative quality approach that permits a typical healthcare worker to convert 10 to 15 minutes blocks

of unstructured work time to structured improvement work that can be allocated to CDI. The results of

CDI quality initiatives by the front-line, can be measured through objective clinical outcomes, professional

growth, and total cost of care while keeping hospital operating budgets cost neutral.

2 | P a g e

© Copyright iCareQuality Inc. 2013 www.iCareQuality.org

Close Care Gap is a component organization of iCareQuality, Inc.

Close Care Gap is federally designated Patient Safety Organization

Copyright© 2013 iCareQuality, Inc.

All rights reserved.

CloseCareGap, CCG is a trademark of iCareQuality,Inc. All other brand, company,

and product names are used for identification purposes only and may be

trademarks that are the sole property of their respective owners.

"Continuous Daily Improvement Program with Transparency and

Accountability"

Document No. 2013-02-011

Published by iCareQuality Inc.

Any comments relating to the material contained in this document may be

submitted to:

Email: [email protected]

761 West Sproul Road,

Suite #301 Springfield,

PA 19064 USA

3 | P a g e


Background and Context of the Problem

Dr. Atul Gawande, in his recent TED talk, "How do we Heal Medicine",

described how the science of medicine, has made great discoveries in the

last 60 years.3 The future challenge for the healthcare industry is this - how

do we deliver "new advances in medicine" to the general public, with the

right technology, price, quality, and simplicity that we can all afford? 4-5

"Better care" means - engaged patients, providers and organizations that

support the quality mission in a learning organization. Overcoming this

challenge will require new skills, new technology, and new ways of care

delivery that incorporates real-time information from routine patient care,

disseminates this critical patient data using electronic methods and e-tools

to help analyze and trend key metrics to improve care at the micro and

macro levels. 1,5,6,7

The continuous pursuit of quality improvement (QI), in many industries,

has proven to lower costs, customizable product offerings, better

customer service and improved satisfaction. Successful companies have

achieved improved outcomes and lowered costs by engaging their staff,

leading by example, being transparent in actions, with a priority focus on

quality and safety. 6,8,9

In healthcare, employees are primarily "knowledge workers" with a

"human touch" factor that is essential for the delivery of patient-centric

care. How then, can we leverage our best asset, our employees, to deliver

high quality care that that is cost effective, timely and efficient? How can

we engage all stakeholders - including populations, patients, providers, and

family members, to govern the CDI program in a transparent, accountable

and patient-centric way?

-----------------------------------------------------------------------------

Considerations for Implementing CDI

In this paper, we examine the process of implementing a CDI program

within a hospital or long term care setting to promote the 2013 National

Definition of

Standardized

Work is:

"The current one

BEST way to

safely complete

an activity with

the proper

outcome, and the

highest quality,

using the fewest

possible

resources".2

4 | P a g e


Quality Strategy 4 triple aim. Listed below are some important questions

to consider with key stakeholders and leadership:

1. What are the main obstacles to implementing a CDI program?

2. What should be the key characteristics of this quality solution?

3. What would a model CDI program look like?

4. What results can we expect from deploying this program to front-

line staff?

5. How do we (patients, providers and organizations) pay for it?

If such a program can be defined, implemented and leveraged, then policy

makers and leaders can begin to address the specific challenges of Dr.

Gawande's dilemma in medicine - how can we afford the "future state" of

healthcare to improve the population and deliver better, cost-effective

services?

---------------------------------------------------------------------------------

Obstacles in Quality Improvement Performance

Patient safety, rising costs, healthcare outcomes, targeted measures, and

improvement efforts, are much talked about concepts in government,

academia, and senior leadership circles. Healthcare workers, at all levels,

agree to the need for Continuous Daily Improvement, however, many

challenges exist to implementation and sustainability on the unit. Research

frequently lists leadership, unit culture and staff engagement as reasons

why CDI programs fall short in the work place setting. Common beliefs

and views from staff and management are listed below:

CDI can be done by staff in their spare time

QI isn’t my job, it’s someone else’s

Staff don’t make the connection between their work and QI

Don’t want to get peers in trouble for not doing a good job

Too many unit projects and nothing gets done

We’re busy with direct patient care

Staff as unit brown-noser for being engaged

Too many metrics to track and confusing

If we always DO

what we’ve

always DONE,

We will GET,

what we’ve

always GOT.

~ Adam Urbanski

5 | P a g e


---------------------------------------------------------------------------------

CloseCareGap, PSO Safety Solution

For CDI programs to be successful, all of the obstacles noted above need

to be defined and addressed with key stakeholders. The organization's

solution cannot be a compromise between these requirements. But rather-

a new strategy, a new paradigm needs to evolve into a satisfactory solution

to meet the needs of Gawande's goal.

Thus, we advocate an innovative Continuous Daily Improvement (CDI)

program, that embodies the principles of the Patient Safety Act (2005) 10

that can be managed at the individual hospital and unit level by

collaborating with our Patient Safety Organization (PSO). 11

The main advantages of our patient safety solution are:

1. Meaningful Engagement of Frontline: Front-line staff spends most of

their shift in direct patient care activities, and to a lesser extent in

meetings, research and process improvement. Using industrial

engineering techniques, a brief time study conducted in 2013 revealed

that work productivity by front-line staff is approximately 70%

occupied. The challenge with the remaining 30% of "unoccupied" time

is that it is not contiguous. It is often unpredictable and materializes in

short spurts (roughly 5, 10 or 15 minutes intervals) scattered

throughout the day. CloseCareGap, PSO, has a user friendly online

safety program that provides simple tools, techniques, and support to

frontline staff to convert these brief time blocks into meaningful quality

improvement activities.

2. Transparency and Accountability: The cornerstone of any CDI program

is explicit transparency and accountability. Both are required to get the

program off the ground and to ensure its long term sustainability.

CloseCareGap, PSO provides real-time dashboards that allow staff and

unit managers to measure capability performance and tangible

outcomes. These two performance measures are essential and

necessary to achieve lasting behaviour change at all levels of the

enterprise.

3. Life Long Learning and Professional Reward: Physicians, Nurses and

other healthcare professionals are required to earn continuous

education credits to maintain their medical and nursing licensure. Close

Care Gap, PSO enables healthcare providers to earn CNE and CME

credits when participating in quality improvement activities.

Work SMARTER,

not HARDER is

the key to

building CDI with

peer review audit

observations for

frontline staff.

~ Carl Banks

6 | P a g e


---------------------------------------------------------------------------------

How the Safety Improvement Program Works

This safety improvement program is specifically designed for Healthcare

Professionals in the acute and long term care settings in collaboration with

Close Care Gap (CCG) PSO. Specific features of our unique program

include:

1. Engage with CCG to begin your new safety program

2. Select from a catalogue of care delivery process (CAUTI, CLABSI, Falls,

Pressure Ulcers, VAP and more)

3. Use our online tool to perform real-time clinical audits of common

care practices

4. Investigate important patient safety events using our secure portal

5. Use our electronic tool to conduct professional peer reviews

6. With our tool, you can evaluate your quality improvement plan that

aligns with specific best practice interventions

7. Obtain continuing education credits by submitting quality

improvement activities

8. Our tool allows for Real-Time Performance Reporting

9. CCG will assign a Mentor to assist your quality safety team.

10. The Mentor will collaborate with all levels of your organization to

support quality improvement and safety targets

-----------------------------------------------------------------------------

Results and Impact Areas for CDI

Taking a balanced scorecard approach to defining results, we defined

results in three broad categories as outlined below along with their specific

performance measures.

1. Clinical Outcomes for Key Process Measures such as CAUTI, VAP,

VLABSI, etc. Examples of key metrics for CAUTI include:

– Number of CAUTI per 1000 catheter-days

– Number of BSI secondary to CAUTI per 1000 catheter-days

Quality is

EVERYONE'S

responsibility.

~ W. Deming

http://www.brainyquote.com/quotes/quotes/w/wedwardsd380787.html




7 | P a g e


– Catheter utilization ratio (urinary catheter-days/pt-days) x 100

2. Cost of Care and Continuing Nursing Education

Nursing units generally allocate 24 hours per staff/per year for

Continuing Nursing Education (CNE) activities that is traditionally

delivered in a class room setting. During this time, the RN is away from

direct patient care and frequently is covered by another staff member.

The cost of this education model is estimated below. See Figure 1.

3. Transfer of Unstructured Time into Structured Time for CDI:

Typically staff nurses work 8 hour shifts. During that shift, approximately

70% of the day is occupied with patient care activities, including handoff,

report and charting. Thus, a significant amount of work-time 30% is

downtime (12% for lunch/breaks + 18% unstructured).

We advocate using this 18% or 1.4 hours = 84 min per staff/ shift to engage

in direct unit quality improvement activities that is "patient centric". See

example below calculating CDI for a typical general medical/surgical unit.

Assume you average 10 RN staff per unit per day = 840 min of quality

time available per day for CDI.

840 X 365 days = 306, 000 minutes/year = 5, 110 hours

Thus, almost 5000 hours of quality work can be done on each unit

per year for CDI.

Thus, our solution is an alternative quality approach that permits a typical

healthcare worker to convert 10 to 15 minutes blocks of unstructured work

time to structured improvement work that can be allocated to CDI. This

approach is consistent with PDSA 12 and rapid cycle improvement to

improve care delivery with a quick test of change.13 Staff nurses can

THPPD X BUDGETED PT HOURS/UNIT

Includes 24 CNE hours/RN/year

Med/Surg Unit with 60 Nursing FTE's X 24 hours/year = 1440 CNE hours

shourshrs/yr

1440 CNE hours/year X $40.00/hr = $56, 000 needed/year for unit

On Average

each staff nurse

on general

ward has 84

min of

unoccupied

time per day to

do Quality

Improvement

Activities

8 | P a g e


participate in quality improvement activities on their respective units

(without leaving the floor) to expedite change and demonstrate positive

results, while keeping unit operating costs budget neutral.

4. Nursing Education Credit for Quality Activities

Since the average nurse manager spends $56,000 per year on outside

education activities where staff are off the unit, our solution advocates

translating those 24 hours of education into "unit specific quality

activities". Using the CCG, PSO platform, staff can complete quality audits

(CAUTI, VAP, CLABSI, etc), conduct peer reviews and submit their projects

for continuing nursing education credits that are required by most states to

maintain nursing licensure. Quality Improvement activities submitted for

education credit is a common practice in CME and is now becoming a focus

area by ANCC, Nursing Accreditation Committee. As per the new 2012

guidelines, "a clearly defined method is used to evaluate the effectiveness

of an educational activity - such as, "observation of performance".14

"Observation of performance" is also know "Peer Review" and "Clinical

Process Audits" , are of which are built into the CCG platform for CDI.

5 . Staff Reward and Unit Recognition

The unit manager can re-allocate the $56K dollars saved on nursing

education and distribute these monies to fund a staff reward and

recognition program for quality. Such a reward system can offer positive

financial benefits for having: highest number of audits submitted per

month, best percentage on process compliance for CAUTI, most positive

peer reviews, etc.

6. Professional Accountability and Transparency

Professional accountability is a fundamental principle in the ANA

nursing code ethics. Central to the transformation process is self-

regulation and accountability for clinical practice (Code of Ethics,

ANA) 15 Peer Review and nursing observation, as part of the CDI

program, affirms the nurse's duty to being accountable for professional

practice, competence in skills and knowledge in evidence-based care

delivery. The NSQ Principles 16 also support ways to improve provider

performance where healthcare professionals evaluate their own

practice and their colleagues performance. Here they can quickly

learn how interventions work in the "real-world and see the benefits of

innovation, change and best practice. With this framework the NQS

supports a culture of learning and builds team work, trust and

collaboration at the unit level.

9 | P a g e


7. Team Work and Staff Engagement

As part of the CDI program, nursing staff can participate in various quality

improvement projects that are meaningful to their patient and specific to

their own needs. Together, staff can work towards common unit goals and

collaborate as professionals assuming complementary roles and

cooperatively working together as a team, to share responsibility for

problem-solving and making decisions to formulate and carry out plans of

care for their patients. Engagement and quality go hand in hand. Both have

a positive effect on patient care and patient satisfaction. Using the CCG

quality tools, staff can use the audit tools and submit peer reviews with

real-time feedback and track daily dashboards.

------------------------------------------------------------------------------------------------

Conclusion

The culture of patient safety, quality, and transparency is central to promoting

learning at every level in the healthcare industry. Creating short, individualized

learning opportunities that focus on quality will require new leadership

thinking, applications of system engineering minds, and operational models

that reward quality improvements and better patient outcomes. Our safety

program supports a culture of transparency and may reduce healthcare

education costs, while improving patient outcomes. To that end, achieving the

discipline of CDI will depend on these critical factors: deliberate actions of

front-line individuals (patient and providers); strategic planning of high

reliability organizations to lead the way; industry partners that support open

exchange of electronic health information; and policy makers with a population

health focus. Together we can make incremental kaizen changes for the good

at the unit , hospital, and systems level. These small changes can positively

impact our patients of today that have a big impact for healthcare of

tomorrow.

10 | P a g e


About CloseCareGap

CloseCareGap (CCG) is a federally approved Patient Safety Organization. Our mission and vision is to

"close gaps in care" delivery by: developing a sustainable quality engagement framework; and

collaborating with key organizational stakeholders, physicians, nurse, and clinical leaders to ensure high

quality, cost effective, patient centric care in the US, Canada and abroad.

How can CCG, PSO help?

Using our online portal, Providers can use smart tools to measure best practice, standardize processes,

reduce variations, and improve care quality through real-time audits and continuous learning. CCG, PSO

has adopted the HRET - Partnership for Patients campaign and the IHI Triple Aim strategies to help

improve quality of care through real-time audits and continuous learning.

Our Focus Area:

At CCG, PSO we focus on targeted opportunities for improvement, such as: high risk events, high volume

events, patient outcomes, problem prone events, and hospital acquired conditions (HAC's) - CAUTI,

Pressure Ulcers, CLABSI, VAP, Surgical Site Infections, and Falls.

Benefits of Working with CCG, PSO:

Engage frontline staff in quality and patient safety initiatives

Develop a safety culture by building transparency and accountability

Perform real-time peer reviews from approved list of clinical processes

Analyze process variance for CAUTI, CLABSI, Pressure Ulcer, Falls, VAP, SSI

Benchmark process performance against organization and industry standards

Obtain Professional Continuing Education Credits for quality projects

For More Information Contact:

Kate Oneill, MSN, RN VP of Quality and Safety CloseCareGap, PSO 761 Sproul Road, Suite 301 Springfield, PA 19064 [email protected] Phone: 610.505.0996

mailto:[email protected]

11 | P a g e


References 1. IOM , Institute of Medicine (2013). Best Care at Lower Cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press. SBN 978-0-309-26073-2 http://www.iom.edu/~/media/Files/Report%20Files/2012/Best-Care/BestCareReportBrief.pdf 2. Graban M (2012). Lean Hospitals. Improving Quality, Patient Safety, and Employee Engagement. CCR Press, Boca Raton FL. ISBN: 978 1 4398 7043 3. Gawande A. (2012) Ted Talk: How Do We Heal Medicine? http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine.html 4. Agency for Healthcare Quality and Research (2013). Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care. Retrieved 8-10-13. http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm 5. Anderson KM, Marsh CA, Flemming AC, Isenstein H, Reynolds J. Quality Measurement Enabled by Health IT: Overview, Possibilities, and Challenges (Prepared by Booz Allen Hamilton, under Contract No. HHSA290200900024I.) AHRQ Publication No. 12-0061-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2012. http://healthit.ahrq.gov/sites/default/files/docs/page/final-hit-enabled-quality-measurement-snapshot.pdf 6. Lighter D (2013). Basics of Healthcare Performance Improvement: A Lean Six Sigma Approach. Jones and Bartlet Learning, Burlington, MA. ISBN13: 978 0 7637 7214 7 7. Nash D (2006). The Quality Solution: A Stakeholder Guide to Improving Healthcare. Jones and Bartlett. ISBN13: 987 0 7637 2748 2 8. Langley G (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossy-Bass, San Francisco, CA. ISBN: 978 470 19241 2. 9. Inozu B (2012). Performance Improvement for Healthcare: Leading Change with Lean, Six Sigma, and Constraints Management. Mcgrall-Hill, ISBN13: 978-0071761628 10. Patient Safety and Quality Improvement Act , Public Law 109-41, United States Government (2005). Retrieved 8-15-13. http://www.gpo.gov/fdsys/pkg/PLAW-109publ41/pdf/PLAW-109publ41.pdf 11. Agency for Healthcare Quality and Research (2009). Your Partner in Improving Healthcare Quality. http://www.pso.ahrq.gov/psos/psopartners.pdf 12. Walton M (1988). The Deming Management Method. Pedigree Books. ISBN13: 978-0399550003 13. PDSA: Plan-Do-Study-Act – Quality Improvement at MDH. Office of Performance Improvement www.health.state.mn.us/qualityimprovement. Retrieved 8-10-13 14. ANCC: Primary Accreditation Manual (2012). American Nurses Credentialing Center, Silver Springs, MD 15. Nursing World. ANA, Code of Ethics with Interpretive Statements (2010). http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf 16. Agency for Healthcare Quality and Research (2013). Principles for National Quality Strategy 2013. Working for Quality. http://www.ahrq.gov/workingforquality/nqs/principles.htm Retrieved 8-10-13.

http://www.iom.edu/~/media/Files/Report%20Files/2012/Best-Care/BestCareReportBrief.pdf

http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine.html

http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm

http://healthit.ahrq.gov/sites/default/files/docs/page/final-hit-enabled-quality-measurement-snapshot.pdf

http://www.gpo.gov/fdsys/pkg/PLAW-109publ41/pdf/PLAW-109publ41.pdf

http://www.pso.ahrq.gov/psos/psopartners.pdf

http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf

http://www.ahrq.gov/workingforquality/nqs/principles.htm

continuous daily improvement by front-line nurses drives quality outcomes

Health & Medicine