NURS 8302 Quality Improvement Models
NURS 8302 Quality Improvement Models
Quality Improvement: Model and Implementation
Health care delivery is complex and faces numerous challenges. An adequate response to these challenges and ensuring that health care remains optimal requires continuous improvement of processes and outcomes. As a result, quality improvement initiatives to address a performance gap should be part of everyday practice. Quality improvement (QI) models should be applied to ensure that the process is systematic and procedural.
The Root Cause Analysis (RCA) Model
The RCA model is among the commonly applied models when the cause of an adverse problem needs to be explicit. RCA is founded on the premise that issues causing errors must be identified, and health care providers should avoid focusing on individual mistakes (Martin-Delgado et al., 2020). In this case, there is more to errors and other adverse events than what is generally seen. Karkhanis and Thompson (2020) explained that RCA has three main components: data, a multidisciplinary team, and error prevention. When a problem occurs, health care providers should collect relevant data through records’ analysis and participants’ interviews, among other strategies. The multidisciplinary team helps to analyze the problem in-depth from a team approach. Eventually, the identified error is eliminated, and appropriate measures to prevent future harm are implemented (Agency for Healthcare Research and Quality, 2019). The method identifies errors, responds effectively, and guides interventions to prevent future harm.
RCA Implementation in Response to an Adverse Event
The RCA model can be highly effective when responding to a medication error problem. A suitable example would be when a patient receives the wrong prescription. Implementing RCA in this situation would commence with data collection from the health care providers involved in the process. Next, a multidisciplinary team would analyze the problem to examine whether it was individual or administrative. The problem would then be fixed through technology adoption or training health care professionals to prevent recurrence.
Health care organizations should be committed to continuous quality improvement. For better outcomes, they should apply QI models to ensure that QI is systematic and procedural. The RCA model is highly effective in problem identification, analysis, and solution. It can be used in health care organizations and the broader nursing practice to guide quality improvement.
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Agency for Healthcare Research and Quality. (2019). Root cause analysis. https://psnet.ahrq.gov/primer/root-cause-analysis
Karkhanis, A. J., & Thompson, J. M. (2020). Improving the effectiveness of Root Cause Analysis in hospitals. Hospital Topics, 99(1), 1-14. https://doi.org/10.1080/00185868.2020.1824137
Martin-Delgado, J., Martínez-García, A., Aranaz, J. M., Valencia-Martín, J. L., & Mira, J. J. (2020). How much of Root Cause Analysis translates into improved patient safety: A systematic review. Medical Principles and Practice, 29(6), 524-531. https://doi.org/10.1159/000508677
One quality improvement model (QIM) that is specific towards adverse events is Root Cause Analysis (RCA). The
RCA model uses a team approach with significance on the system versus the individual, to accumulate pragmatic data on what happened and why (Balakrishan et al., 2019). The RCA model supports a Just Culture. More specifically, the RCA method focuses on determining what transpired, why it occurred and what can be done to keep it from happening again; it looks beyond human inaccuracy to detect system issues that contributed to an event (Charles et al., 2017). The University of North Carolina Medical Center (UNCMC) outlines an effective process for RCA in Table 1. I favor this QIM related to adverse events because it takes out the human factor and assesses process. Humans are prone to error (Kohn et al., 2000); therefore, the next best action is to focus on what can be controlled and changed, and that is processes.
The RCA QIM is presently being used in my healthcare organization. The RCA QIM is something that has significance to me because I have been the one to make an error and have navigated the RCA process. In the most succinct explanation possible, I was a link the in the chain of events that contributed to an already critically ill patient receiving tranexamic acid (TXA) instead of tissue plasminogen activator (TPA) in a newly opened free standing emergency department. As soon as I realized what had happened, I notified the doctor and followed reporting processes after assuring care of the patient. Using a brief RCA, the human factor (3 nurses and a physician) is removed. The process examination revealed lack of education regarding TXA and TPA, poor Pyxis labeling and placement, and poor Pharmacy resources for staff. Because I was a staff nurse and not on management at the time of the incident, I was not acutely aware of the RCA process. As noted with the UNCMC Program Guide, information synthesis and action plan formation are key components of the process. As a nurse leader, my focus would focus on action plan formation that addressed the process deficiencies found to have contributed to the adverse event. By utilizing the RCA QIM, nurse leaders can fortify staff nurse trust by fostering a Just Culture in practice that also contributes to increased patient safety and outcomes through process improvement.
Balakrishnan, K., Brenner, M. J., Gosbee, J. W., & Schmalbach, C. E. (2019). Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA 2 ). Otolaryngology–Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery, 161(6), 911–921. https://doi-org.ezp.waldenulibrary.org/10.1177/0194599819878683
Charles, R., Hood, B., DeRosier, J. M., Gosbee, J. W., Bagian, J. P., Li, Y., Caird, M. S., Biermann, J. S., & Hake, M. E. (2017). Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education. Orthopedics, 40(4), e628–e635.
Kohn, L. T., Corrigan, J., & Donaldson, M. S. (2000). To err is human. [electronic resource] : building a safer health system. National Academy Press.
University of North Carolina Medical Center. (2020, July). UNC Medical Center Root Cause Analysis (RCA) Program Guide. UNC Medical Center Root Cause Anaylsis (RCA) Program Guide. Retrieved from https://www.med.unc.edu/ihqi/wp-content/uploads/sites/463/2021/01/UNCMC-RCA-Team-Packet.Final7_.1.2020.pdf.
The Plan-Do-Study-Act Cycle is the Quality Improvement Model that I have chosen for this discussion. It has been utilized for continuous improvement as described by Edwards Deming (Nash et al., 2019). This improvement model assumes that 15 percent of poor quality is due to people and 85 percent of poor quality is due to improper management, systems and processes (Nash et al., 2019).
Under this phase of the quality improvement model, we seek to understand the problem and where a gap in practice exists as well as establish an objective laying out what we are trying to accomplish. In my clinical arena, we would be collecting and analyzing data to identify where a gap exists based on the data. It is possible that we find what we least expected or that the gap exists in a different place than expected. From here we can plan how to carry out the cycle.
Under this phase of the cycle, we use the gap that we’ve identified and the plan that we’ve made to educate and train staff to carry out the plan. We can start to make small scale changes and evaluate its effectiveness, challenges, and problems on a small scale to prepare for implementing in a much bigger scale.
In this phase of the quality improvement model, we evaluate the effects of the change and decide if it was successful or not. We evaluate whether and to what degree success was obtained or did the gap get larger. Here we can determine what changes need to be made and what steps should be taken next to achieve the objective that was set during the initial plan phase of the cycle.
This is action phase of the cycle where we make changes based on what we have learned whether that is repeating what was done, making small modifications, or creating an entirely new plan and cycle. It is the ending as well as the beginning. In this phase, new gaps can be identified, or current gaps can be modified until the goal or objective is met (Nash et al., 2019).
Shaw et al. (2019) utilized rapid cycle PDSA quality improvement model to improve hypothermia in term and near-term infants delivered vaginally. After 4 PDSA cycles, the incidence of hypothermia dropped from 50% to zero at 1 hour of life (Shaw et al., 2019). A similar project utilizing the PDSA would be beneficial in my healthcare organization in the population mentioned above but could be expounded on to include premature infants who are also risk complications secondary to hypothermia. Shaw et al. (2019) found that regular feedback regarding success and correction of the previous PDSA cycles was important to continue to move forward with the quality improvement project. This model is ideal because the cycles required to achieve the necessary change will vary from hospital to hospital and can be affected by many variables but if continued the result will eventually be achieved. The expectation is not that the objective will be achieve after the first cycle, but that continuous improvement will be achieved. Healthcare is a dynamic field where change is the only constant and therefore, we must aim to be improving continuously an not stop the cycle once a goal is achieved.
Nash, D. B., Joshi, M. S., Ransom, E. R., & Ransom, S. B. (Eds.). (2019). The healthcare quality book: Vision, strategy, and tools (4th ed.). Health Administration Press
Shaw, S. C., Devgan, A., Anila, S., Anushree, N., & Debnath, H. (2018). Use of Plan-Do-Study-Act cycles to decrease incidence of neonatal hypothermia in the labor room. Medical Journal Armed Forces India, 74(2), 126–132. https://doi-org.ezp.waldenulibrary.org/10.1016/j.mjafi.2017.05.005