714 CONTINUOUS QUALITY IMPROVEMENT MARY C. ZONSIUS AND KERRY A. MILNER ■ THE HISTORY OF QUALITY IMPROVEMENT IN HEALTHCARE In the late 1980s, with the beginning transition from fee for service to a prospective payment plan, healthcare organizations were first challenged to evaluate their inefficiencies. With further changes in the financing of healthcare to rein in costs (e.g., capitation and contracting by large insurers and managed care organizations), hospitals began to recognize the competitive nature of healthcare and that inefficiency cut into profits. Healthcare organizations began to shift from quality assurance, a retrospective review of individual’s compliance with policies and procedures, to proactive analysis of system’s processes and outcomes called quality improvement (QI; Colton, 2000). In addition to financial factors, several sentinel events accelerated the evolution of QI in healthcare organizations. The National Demonstration Project in QI in Health Care examined whether or not the industrial QI paradigm was transferable to healthcare organizations (Colton, 2000). The industrial QI paradigm was based on the founding work of Walter Shewhart, W. Edwards Deming, and Joseph Juran and results supported the use of this paradigm to drive patient safety and quality care in healthcare organizations (Burda, 1988). Bolstered by these results, co-author and physician Donald Berwick, made the case, in the New England Journal of Medicine, for using industrial-based QI methods to improve American healthcare (Berwick, 1989). Another sentinel event was The Joint Commission’s Agenda for Change that included the use of QI in hospitals and included input from key stakeholders (e.g., patients, healthcare workers, and hospital administrators) to achieve its goal of rewriting its accreditation standards (Colton, 2000). The new standards focused on the QI process and included the use of run charts, Pareto charts and statistical process control to evaluate and improve systems to achieve better outcomes. The Institute for Healthcare Improvement (IHI) emerged from the National Demonstration Project on QI in Health Care in 1991 in Cambridge, Massachusetts (IHI, n.d.). The creators of the IHI envisioned clinicians in healthcare systems using QI methods to fix unreliable common care practices (Berwick et al., 1990). The IHI recognized the need to build capacity for change in the U.S. healthcare system by creating an organization that would engage in knowledge sharing and training on performance improvement. From 2005 to the present, the IHI has been establishing patient safety initiatives in the United States and abroad (IHI, n.d.). As part of this work, the IHI launched the Triple Aim in 2006 with a call to enhance the patient experience, improve population health, and reduce costs to optimize health system performance (Berwick et al., 2008). Clinicians in primary care practices across the United States have adopted the Triple Aim framework; however, stressful work life has interfered 72with their ability to achieve the three aims. In response to this, Bodenheimer and Sinsky (2014) proposed the Quadruple Aim that includes the tenets of the Triple Aim plus the aim of improving the work life of the healthcare workforce. The Quadruple Aim recognizes that a healthy workforce is needed to optimize health system performance. ■ DEFINING CHARACTERISTICS OF QUALITY IMPROVEMENT IN HEALTHCARE The IHI, whose mission is to improve healthcare quality and safety for all, defines QI in terms of using a team of managers and staff that have the relevant expertise to analyze the current process (Scoville & Little, 2014). This team is supported by QI specialists who work behind the scenes to improve the overall quality of care of that health facility. The team identifies the symptoms and causes of poor quality and devises a theory of what is needed to improve the process. The team uses a variety of improvement methods and tools to develop, test, and implement changes and redesigns the process if needed. The redesigned process is then monitored to ensure it performs at a new level (with new upper and lower control limits), with new work specifications, improved results, and reduced variation. The National Quality Forum (NQF) was established in 1999 to improve the quality of U.S. healthcare. The forum works to define national goals and priorities for healthcare QI and develops standard metrics for measuring performance in healthcare nationally (Marjoua & Bozic, 2012). They have metrics for processes (appropriate use), structures, outcomes, cost/resource use, and efficiency. The NQF stakeholders include hospitals, healthcare providers, consumer groups, purchasers, accrediting bodies, and research. Having national measures to assess healthcare performance is a critical component of ensuring appropriate and high-quality patient care. The Health Resources and Services Administration (HRSA) is a federal agency whose mission is to improve access to healthcare and health outcomes of vulnerable populations. The HRSA defines QI as systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient groups (Department of Health and Human Services and HRSA, 2011). HRSA collaborates with other federal and state entities to improve care. For example, HRSA partners with the Centers for Medicare & Medicaid Services (CMS) to improve care for vulnerable populations. The CMS defines QI as standardized behavior that is made systematic so that the same inputs result in the same outputs (CMS, n.d.). In this definition, behavior is aligned with best evidence. Donabedian’s structure, process, and outcome (Donabedian, 2005) are used to increased desired health outcomes and Deming’s PDSA (plan-do-study-act) cycle (Moen & Norman, 2010) is used to standardize behavior. The Quality and Safety Education for Nurses (QSEN) initiative began in 2005 with the mission of preparing competent nurses to improve the quality and safety of the healthcare system. The founding faculty members adapted the Institute of Medicine (IOM) competencies from the Health Professionals Education: A Bridge to Quality (Greiner & Knebel, 2003) report and defined essential knowledge, skills, and attitudes (e.g., competency) in the areas of patient-centered care, evidence-based practice (EBP), teamwork and collaboration, safety, QI, and informatics for undergraduate (Cronenwett et al., 2007) and graduate nursing levels (American Association of Colleges of Nursing QSEN Education Consortium, 2012). The QSEN faculty defined QI in terms of “use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems” (Cronenwett et al., 2007, p. 127). QSEN has helped to bridge the gap between what is and what should be in delivering healthcare. 73■ ADVANCED PRACTICE REGISTERED NURSE ENGAGEMENT IN QUALITY IMPROVEMENT The 2019 American Association of Nurse Practitioners (AANP) standards for practice include APRN engagement in QI. Standard VII: Quality Assurance and Continued Competence calls for “participation in quality assurance review, including the systematic, periodic review of records and plans of care that may result in quality improvement plan.” Standard IX: Research as Basis for Practice calls for APRNs to “support research and dissemination of evidence-based practice by developing clinical research questions, conducting or participating in studies, implementing quality improvement, and incorporating system changes into practice” (AANP, n.d.). Reimbursement is another key reason for APRNs to be engaged in QI activities. APRNs are eligible clinicians under the CMS value-based initiative called Merit-Based Incentive Payment System (MIPS; Curtin, 2019). In this new payment system, performance is measured using data that APRNs report in three areas: quality (50% of score), promoting interoperability requirements (25% of score) and improvement activities (15% of score) and cost makes up the last 10%. For quality, APRNs pick performance measures that best fit their practice from a provided list (e.g., appropriate use, patient safety, efficiency, patient experience or care coordination; AANP, n.d.). Promoting interoperability is fulfilled by hospitals and APRNs demonstrating compliance with information sharing. Improvement activities include how clinicians improve care processes, enhance patient engagement and access to care. It is assumed that these activities will promote ongoing improvement and innovation in healthcare. Additionally, reimbursement under MIPS relies on performance measures. These performance measures should be based on metrics that assess the outcomes of APRN care on patient care and quality of care measures (Kapu & Kleinpell, 2013). APRN outcomes must also be included in the benchmarks for hospital performance. Thus, APRNs must engage in the development of APRN-associated metrics in order to generate relevant data to accurately assess their performance and contributions to patient safety and quality care nationally. ■ QUALITY IMPROVEMENT COMPETENCIES FOR ADVANCED PRACTICE REGISTERED NURSES The National Organization for Nurse Practitioner Faculty (NONPF) developed core competencies for nurse practitioners that include a quality competency. NONPF defines quality as the degree to which health services increase the desired health outcomes consistent with professional knowledge and standards, the understanding of how to access and use information databases, and how to critically evaluate research findings. Other QI competencies for nurse practitioners include: ■Uses best available evidence to continuously improve quality of clinical practice. ■Evaluates the relationships among access, cost, quality, and safety and their influence on healthcare. ■Evaluates how organizational structure, care processes, financing, marketing, and policy decisions impact the quality of healthcare. ■Applies skills in peer review to promote a culture of excellence. ■Anticipates variations in practice and is proactive in implementing interventions to ensure quality. ■ DIFFERENCES AMONG RESEARCH, EVIDENCE-BASED PRACTICE, AND QUALITY IMPROVEMENT APRNs need to be knowledgeable about the differences among research, EBP, and QI, and how they form the basis for practice inquiry. Table 4.1 outlines the specific characteristics of each method of inquiry. Research is pursued when there is a lack of knowledge upon which to base practice. EBP is a problem-solving approach to practice and EBP projects are undertaken when new evidence from research needs to be translated into practice. QI inquiry is followed when the current practice is the best thing to do (e.g., based on best available evidence), however there is breakdown in the process or structures, or the outcomes are not meeting expectations. ■ QUALITY IMPROVEMENT AS THE CENTRAL COMPONENT OF THE NURSING INQUIRY PROCESS Figure 4.1 displays the Clinical Inquiry Process from Virginia Commonwealth University where performance improvement, also known as QI, is a central component of clinical inquiry. The EBP steps of problem identification, question development using the PICOT format, search for evidence, and appraisal of evidence appear across the top of Figure 4.1. If the Appraise Evidence step reveals adequate evidence but the current practice is not fully implemented, then the performance improvement (Process Enhancement/Improvement) inquiry should be followed. If the practice setting is not following the evidence-based recommendation for practice, then the EBP (Change in Practice) inquiry should be followed. If the current practice is fully implemented, then the APRN can stop or pursue new questions. If the Appraise Evidence step reveals a lack of evidence upon which to base practice, then the research inquiry (Creation of New Knowledge) should be followed. 75FIGURE 4.1Nursing inquiry process diagram. EBP, evidence-based practice; IRB, institutional review board; NHSRD, Not Human Subjects Research Determination; PICOT, P=Patient population, I=Intervention, C=Comparison intervention, O=Outcome, T=Time. Source: Used with permission from Roy, R. E. (2020). The Clinical Inquiry Process diagram. https://scholarscompass.vcu.edu/libraries_pubs 76■ THE QUALITY IMPROVEMENT PROCESS APRNs are well-suited to engage in the QI process because they have been prepared as critical thinkers and problem solvers in both their graduate education and in their foundational education (guided by the nursing process that is based on the scientific method). The QI process is considered an extension or rework of the scientific method (Cleghorn & Headrick, 1996). APRNs are integral to the QI process and armed with the knowledge and skills to navigate improvement at the micro, meso, and macro system levels. As a QI team leader, the APRN selects the QI model and tools that will improve the existing process. In practice there is not one “right” model to use and the choice may come down to the model with which the APRN and the QI team has the most experience (Silver et al., 2016). The APRN ensures the QI process is successful from start to finish and recognizes the importance of instilling a continuous improvement culture among the key stakeholders (Chandrasekaran & Toussaint, 2019). ■ QUALITY IMPROVEMENT MODELS This section provides an overview of five common QI models used by APRNs in the healthcare setting. Exemplars of how APRNS have used the QI models to improve practice are shared. Table 4.2 depicts how the steps of the nursing process closely align with the steps of each of the QI models. Moreover, the table shows that the models have more similarities than differences and have become more comprehensive across time. Donabedian Model of Care Donabedian was one of the early fathers of the quality movement who developed a model to evaluate the overall quality of medical care. The focus of the Donabedian Model of Care that was first 77presented in the 1960s is an evaluation of quality that includes the triad of structure, process, and outcome (Donabedian, 2005). The thought was that to fully evaluate quality one had to have the proper structures in place that would influence the given process and ultimately the outcomes of care. Structure refers to the inputs; characteristically the setting where the process occurs, the staff involved in the process, and the material and organizational resources. Process is as stated, the process to be implemented and/or evaluated: What are the technical and interpersonal activities involved in delivering care? The outcome is the output, the effect of whether care of patients or population groups was improved (Donabedian, 1988). The Donabedian model can be used to implement a QI change as well as to evaluate an existing process. APRNs Compton and Carrico (2018) used Donabedian’s model to develop and implement a chronic obstructive pulmonary disease (COPD) tool to improve the patient and provider communication process and thereby improve patient outcomes by decreasing emergency department visits, hospitalizations, and healthcare costs. The Plan-Do-Study-Act (PDSA) Cycle The PDSA cycle that is commonly used in healthcare settings today stems from the original work of Walter Shewhart that began in the 1920s at Bell Telephone Laboratories that was later modified by W. Edwards Deming (Re & Krousel-Wood, 1990). Together Shewhart and Deming are viewed as the founders of the industrial quality movement and fathers of the modern-day QI movement. This four-step iterative model (PDSA) is best used to test interventions in a pilot setting using multiple cycles to refine the process prior to expanding system-wide. This model allows for rapid-cycle change (Taylor et al., 2014). The PDSA cycle is one of the most common QI models used by APRNs to improve the patient safety and quality care related to delirium (Fraire & Whitehead, 2019), falls (Cangany et al., 2018; Grillo et al., 2019; Kohari, 2018), 30-day readmission rates (House et al., 2016), heparin infusion protocols (Johnson et al., 2018), pediatric asthma care (Kennedy & Jolles, 2019), colon screening rates (Florea et al., 2016), sleep disturbances (Lopez et al., 2018), and medical management for older adults (Vejar et al., 2015). ■ FOCUS-PDCA MODEL In 1993, the Hospital Corporation of America created the Find, Organize, Clarify, Understand, Select (FOCUS) model from Deming’s PDSA model (Taylor et al., 2014) to guide the QI efforts of their healthcare workers. The five steps in this model are: The five step FOCUS is followed by the Plan-Do-Check-Act (PDCA) cycle. However, small tests of change using PDCA are used in steps 3 and 4 to inform the improvement implemented in the PDCA cycle that begins following step 5 (Batalden & Stoltz, 1993). Note that in the PDCA cycle “C” is used for “Check” rather than the “S” for “Study.” Many organizations use the “S” and “C” interchangeably although Deming stressed that semantically “check” was not appropriate because it means “to hold back” (Moen & Norman, 2010). The FOCUS-PDCA model provides additional structure and guidance to the planning of the QI process. An example of APRNs’ use of this model in practice is the work by Watts and Nemes (2018) who used the FOCUS-PDCA model to guide the implementation of a hypoglycemic protocol to increase rechecks within 30 minutes of treatment. Institute for Healthcare Improvement Model for Improvement The IHI Model for improvement (MFI), an outgrowth of the more common PDSA cycle from Deming, was designed by Langley and colleagues concurrent to the FOCUS-PDCA model (Langley et al., 2009). The MFI, a comprehensive QI model, begins with three questions that inform the subsequent PDSA cycle. Note that the IHI MFI uses study for the third step of the cycle. The three questions are (a) What are we trying to accomplish? — purpose or aim; (b) How do we know that a change is an improvement? — feedback/data are needed; and (c) What change can we make that will result in an improvement? — what specific change can be made that will address the purpose or aim? Next, rather than randomly implementing a change and hoping to get the expected result, the MFI supports a pilot test of the change using the PDSA model. The overall goal is to spread and sustain the change (Langley et al., 2009). The IHI MFI provides additional structure and direction to guide the QI process. APRNs have used the model to improve suicide screening practices in an outpatient mental health clinic (Spear, 2018); implement a mobility plan in a long-term care facility (Kazana & Murphy, 2018); and implement scripted post-discharge phone calls to heart failure patients to improve outcomes (Ruggiri et al., 2019). Six Sigma (DMAIC) The development of Six Sigma quality methodology, in the late 1980s, is attributed to the Motorola Corporation with the goal of decreasing process variability but also improving financial performance and customer satisfaction. The use of data to establish pre-change baseline performance, and statistical analysis tools distinguish this data-driven methodology from previous QI models that have been discussed (Glasgow et al., 2010; Takao, 2017). Sigma uses the 5-step DMAIC model (define, measure, analyze, improve, and control):
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