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Quality Improvement Process Emily Vance & Lisa Dust Ferris State University


This paper contains an analysis that demonstrates what steps to take to improve a clinical activity through quality improvement initiatives. These initiatives are backed by evidence-based practice that enables nursing managers to implement them in their departments. An oncology nurse manager, Carol Baker, has implemented bedside reporting to her oncology department to increase patient satisfaction and safety. Bedside reporting creates accountability between shift changes that can otherwise be overlooked when just completing a regular end-of-shift report. By reporting in the patients room, an introduction can be made, safety checks can be created, the ending nurse can talk about the day and the oncoming nurse can then ask questions to clarify. Bedside reporting can assist in pushing forward the patient care that the healthcare system is continually raising.

QUALITY IMPROVEMENT Quality Improvement Process Nursing practice is always changing. For nurses, this requires them to stay up-to-date

with nursing research. Quality improvement (QI) initiatives are ways for nursing staff to keep on top of research and to have their nursing practice be evidence-based. According to Yoder-Wise (2014); quality improvement refers to an ongoing process of innovation, prevention of error, and staff development that is used by institutions that adopt the quality management philosophy (p. 390). The purpose of this assignment is to analyze a clinical activity from a Quality Improvement perspective (Dood, 2014, p. 11). Clinical Need for Change After interviewing Carol Baker, an oncology nurse manager at Munson Medical Center (MMC), it was deduced that the nursing end-of-shift reports needed improvement. An end-ofshift report is a designated time when nurses at the end of their shift communicate to oncoming nurses updated information about their patients condition, status, symptoms, treatment, tests, test results, medications, and responses to nursing and medical interventions (Nelson & Massey, 2010, p 162). A typical end-of-shift report at MMC occurs at a nursing pod or outside the patients room. This can be a very loud disruptive experience as there are other nurses in the vicinity also receiving report. Some barriers for this type of reporting were identified by Evans, Grunawalt, McClish, Wood, & Friese, interruptions, lack of standardized reporting processes, and underdeveloped information and communication technology (2012, p. 282). Yoder-Wise states, QI efforts should be concentrated on changes to patient care that will have the greatest effect (2014, p. 395). By changing the end-of-shift report to a bed side report it will help reduce the amount of time spent giving report, the number of call lights at shift change,

QUALITY IMPROVEMENT and the amount of errors made. It will also promote patient safety by requiring the nurses to perform safety checks while in a patients room. Interdisciplinary Team

To begin this process of change a team needs to be assembled. QI team members should represent a cross section of workers who are involved with the problem (Yoder-Wise, 2014, p. 395). Nurse supervisors, managers, nurse leaders, and floor nurses will be vital members of this team because they are amidst the problem every day. As a nurse leader, the nurse will advocate to implement the change in policy. They are also in charge of educating the entire staff on the project. Floor nurses will be the individuals performing the actual tasks and providing the data to evaluate that task. Nurse supervisors and managers will encourage, empower, give advice, and guide the floor nurses during the bedside reports. The administrators will also gather, interpret data, and report it back to the staff. Data Collection To measure the current status of bed side reportings effectiveness, data needs to be collected. According to Ferris, Staff surveys can yield information on what nurses think about report: Are they getting and giving enough information? Are they doing reports on time? (2013, p. 49). However, surveys may not yield very accurate results of how the change is working. That is why measuring conditions such as the amount of overtime resulting from reports being too lengthy, call-light use at shift change, and amount of complaints reported by patients (Ferris, 2013, p. 49). Outcomes The next step for quality improvement is to develop a goal or outcome. This goal should be patient-centered and sensitive to nursing. In order to make these goals nurses must follow


standards. One place a nurse can find these standards are from the American Nurses Association (ANA). A standard that the interdisciplinary team could use is Standard 10 Quality of Practice. The nurses must be able to monitor quality, safety, and effectiveness of nursing practice; analyze quality data to identify opportunities for improving nursing practice; and implement activities to enhance the quality of nursing practice (ANA, 2010, p. 52). This standard fits with the goal of increasing patient safety, decreasing the amount of time giving report while also increasing the amount of pertinent patient information. Implementation Once this plan is selected it is time to start implementing it to the unit. To begin this process the interdisciplinary team needs to change the policies and procedures. According to Yoder-Wise communication about the change or improvement is essential (2014, p. 401). Communication will reduce the amount of resistance among nurses on the unit and reduce confusion over which procedure to perform. One change that needs to be added to the policies and procedures handbook is a bedside shift report script (see Appendix A). This script will ensure that nurses will give report in a timely manner and wont get off topic or forget vital patient information. Evaluation Data will need to be collected to make certain that the new policy is having the desired outcome. Surveys, both by nurses and patients, can be conducted to determine if attitudes have changed since the trial period. But more effective measurements would be the amount of overtime resulting from reports being too lengthy, call-light use at shift change, and amount of complaints reported by patients (Ferris, 2013, p. 49). Even if a change in policy did well during the trial period it could end up failing after implementation. If an outcome is not met, revisions

QUALITY IMPROVEMENT in the implementation plan are needed (Yoder-Wise, 2014, p. 401). So the interdisciplinary

team will need to analysis the data and see where improvements can be made and then reevaluate it again. Scholarship A theory that can be applied to this change in end-of-shift nurse reporting is Sister Callista Roys Adaptation Model. During the policy changing experience nurses must change their whole practice. This means they have to adapt to a new way to relay information. Patients will also have to adapt to the new procedure. The Adaptation Model states, The goal of nursing is to promote adaptive responses in relation to 4 adaptive modes, using information about persons adaptation level, and various stimuli (Roy, 2012). Research findings are consistent with positive use of bedside reporting. Evans et al. found that with decreased report times, nurses spend less time socializing among themselves, resulting in decreased times to obtain report from an offgoing nurse. (2012, p. 284). Ferris found similar findings stating bedside report had helped avert problems (2013, p. 48). However, Evans et al. also found that staff members showed concern about the report style. Concern exits regarding the sustainability of bedside report; many nurses believe the process violates patient confidentiality and they are not comfortable talking in front of the patient (Evans et al., 2012, p. 284). Even with these concerns the evidence suggests that bedside reporting is an excellent evidence-based practice to adopt.

QUALITY IMPROVEMENT References Dood, F. (2014). NURS 440 Leadership in nursing [spring 2014 course syllabus] . Retrieved

February 5, 2014 from https://fsulearn.ferris.edu/bbcswebdav/pid-482889-dt-content-rid3008985_1/courses/10261.201401/NURS%20440%20Syllabus%20SP%2014Accelvs3.p df Evans, D., Grunawalt, J., McClish, D., Wood, W., & Friese, C. R. (2012). Bedside shift-to-shift nursing report: implementation and outcomes. MedSurg Nursing, 21(5), 281-293. Ferris, C. (2013). Implementing bedside shift report: implementing bedside shift report improved communication with patients and families. American Nurse Today, 8(3), 47-49. Nelson, B., & Massey, R. (2010). Implementing an electronic change-of-shift report using transforming care at the bedside processes and methods. Journal of Nursing Administration, 40(4), 162-168. doi:10.1097/NNA.0b013e3181d40dfc Nursing: scope and standards of practice. (2nd ed.). (2010). Silver Spring, Md.: American Nurses Association. Roys Adaptation Model. (n.d.). Roys Adaptation Model. Retrieved February 8, 2014, from http://currentnursing.com/nursing_theory/Roy_adaptation_model.html Yoder-Wise, P. S. (2014). Leading and managing in nursing (5th ed.). St. Louis, Mo.: Elsevier Mosby.

QUALITY IMPROVEMENT Appendix A Bedside Shift-to-Shift Nursing Report Script Patient Introduction Preferred name, age, diagnosis, and code status if known

Pain Management/Vital Signs Patient pain rating, pain management interventions, physiological effects of interventions Fluid Intake/Output Fluid restrictions, intravenous infusion solutions and rates, surgical drains Skin and Wound Assessment and Care Current status of patient skin, risk for acquisition of pressure ulcers, interventions to prevent pressure ulcers, wound assessment and location, prescribed treatments and schedules Glucose Monitoring and Management Serum glucose values, frequency of monitoring, management and evaluation of interventions Cognitive/Perceptual Mental status, pain description, and therapies (if not mentioned previously) Activity/Exercise Assessment of circulation, muscle strength, tolerance of activities, staff assistance required to ambulate Elimination Bowel sounds, nausea/vomiting, stool color/consistency, urine color/consistency Nutrition Diet status, plan for advancing diets Fall Risk Patient risk for falls, related interventions Other Discharge plan, scheduled tests and procedures, documentation needs, education needs, and equipment needs (Evans et al., 2012, p. 283)