Nurses Benefits On Quality Improvement Teams Nursing Essay

fosters Benefits On Quality Improvement Teams nursing EssayAs part of a randomized control trial to meliorate the auction pitch of preventative function, the authors studied the effect on clinic nurses in the purposes of team leaders or facilitators of multidisciplinary, continuous quality improvement (CQI) teams. Our remainder was to learn how these nurses felt near their experience with this project, circumstantial bothy their satis situationion with butt on improvement, acquired intimacy and skills, and the impact on their nursing lineament. Overall, the nurses multiform in this poll report signifi move gains in all three areas. This study suggests that CQI can be a valuable vehicle for improving and expanding the nursing image for clinic nurses.QUALITY improvement (QI), also referred to as round-the-clock QI (CQI), Total Quality focal point (TQM), and other terms, has undergone an explosive growth in health conduct oer the last 10 years.1,2 This growth has bee n tended to(p) by the publication of a steadily increasing number of articles. However, examine of these articles would lead one to believe that nearly all of this QI activity has occurred in hospitals and large medical organizations and, until recently, or so has involved administrative processes rather than clinical ones.3-6 Very few articles have addressed smaller ambulant dish out settings and almost nonee have chance upond the QI role of clinic nurses or the impact of these activities on nurses. Is sake on QI teams helpful to nurses and do the changes in care processes produced by these teams improve the ability of nurses to provide better patient care? What is the potential for QI to affect the often-restricted role of nurses in ambulatory care?Our involvement in a large scientific trial of QI as a vogue to create more than systematic delivery of preventive services in private medical clinics has provided us with an opportunity to begin answering these questions. T his involvement brought us into frequent contact with all types of clinic personnel, but particularly with the nurses who often served in leadership roles on the clinics QI teams. As we provided schooling or consulting with these nurses, we noned that many of them seemed to enjoy the opportunity and report anecdotes ab proscribed how it had expanded their abilities.We conducted a systematic series of interviews and a survey with the clinic nurses who were involved in the trial as leaders or facilitators of the QI teams established in these clinics for preventive services. This studys goal was to learn how these nurses felt about their experience in three areas1. satisfaction with the process and its results for them2. acquisition of specific association and skills3. impact on the nursing role cover version to TopBACKGROUNDThe trial was called IMPROVE (IMproving PRevention through Organization, Vision, and Empowerment) and it was funded by the Agency for wellness Care Policy and interrogation as a randomized controlled trial.7,8 Sponsored by two normally competing managed care plans (Blue Plus and HealthPartners), it was designed to test the hypothesis that such plans could improve the delivery of specific adult preventive services in contracted clinics by using CQI methods to develop prevention systems.Forty-four individual primary care medical clinics in the Twin Cities sphere of Minnesota were recruited for the trial from 33 of the 71 medical groups eligible to participate by reason of a contract with one or both plans and fixture within 50 miles. No financial incentives were provided to the clinics to participate other than reimbursement for the research evaluation efforts (eg, pulling charts for audits, providing patient appointment lists for sampling, etc.). The clinics ranged in size from 2 to 15 primary care clinicians (except for one residency-training clinic with 28), with an average of 8. At the time of recruitment, save an average of 19 perc ent of their patients were members of the two sponsoring plans. Thus, they were fairly regular of this regions clinics except possibly in having a particularly strong interest in working on improvement of their preventive services and in learning how to use CQI.At the start of the trial in September 1994 from each one of the 22 clinics randomized to the intervention arm was asked to form a multidisciplinary QI team with a way sponsor and a leader and facilitator for the team. We suggested that they name a physician as leader and a nurse as facilitator but in this, as in all aspects of the trial, all decisions were up to the clinic. The IMPROVE team provided just-in-time group training to the leaders and facilitators in six seances over seven months for a total of 26 hours. The training was focused on the specific knowledge and skills needed to use a seven-step CQI process to improve preventive services. During and by and by the training, IMPROVE project nurses provided half-h ourly telephone and on-site consultation. After an 11-month training period, additional periodic opportunities were provided to network with other clinic leaders and facilitators and to obtain additional group consultations about areas of particular concern.Back to TopMETHODSIn June of 1996 (22 months after starting the intervention), two of the authors obtained written surveys and conducted individual interviews with each of the nurses who had served as leader or facilitator for one of the clinic teams. One nurse practician and two nurses who became facilitators after the completion of the training were excluded in devote to provide a more homogeneous group and experience. This left 13 nurses to participate in the study, 9 of whom had served as facilitators and 4 as leaders for their teams. All agreed and signed consents, although one nurse could non find time for the interview and only completed the questionnaire. Other nurses participated as members of some teams, but we felt t hat the views of those with more project training and experience were especially valuable.The questionnaire was designed to assess the respondents attitudes and beliefs in each of the areas of focus for this study as well up as to obtain relevant demographic information. It contained 55 close-ended questions that were developed from learning objectives for the training and a literature review of previous research on the nursing role in ambulatory care settings.9-12 Questions about skills and activities asked for a six-point Likert-scale reaction from none to very much choices and those petition about satisfaction and nursing roles asked for a five-point scale response from strongly agree to strongly disagree. After pretesting and revision, the questionnaire was mailed to the nurses to complete before the interview. The questionnaire is included in the Appendix.The interviews were structured to obtain qualitative data to expand on the questions in the survey. Eleven interviews were conducted in person at the clinical site and one was conducted over the telephone. Each was tape-recorded and transcribed later.Survey responses were simply summarized and reported directly for the small numbers involved. Questions that were stated negatively in order to improve response validity have been reworded for ease of comparing the answers. The interviews were analyzed for themes and for examples to illustrate questionnaire responses.Back to TopRESULTSMost of the nurses studied had already been involved in some item of management in their clinics prior to the study. Only four were clinic nurses while two each were clinic manager, patient care manager, and nursing coordinator. The other three nurses were vice chairperson of information services, medical services director, and health educator. Eight held positions that involved supervision of others, and an overlapping eight worked in direct patient care at least(prenominal) part time.As might be expected from such a grou p, 12 had been nurses more than 10 years and 10 had worked at their present clinics for at least 5 years. Educationally, seven nurses were registered nurses (RNs) (2 with bachelors of science in nursing, two with diplomas, and three with associate degrees) and six were licensed practical nurses (LPNs). All were female.Only four nurses reported that they had received previous formal training in CQI, although another four reported informal on-the-job training as part of a process improvement team. However, only the latter four and one additional other reported previous participation in QI. Three of these had been team leaders, one had been a facilitator, and one was a member of a team.Back to TopSatisfaction with the IMPROVE process improvement experience put off 1 suggests that, even after working on this process for 22 months, most nurses reported full(prenominal) levels of satisfaction associated with this experience of process improvement. That is particularly true for questions about obtaining personal set and improving patient care. Positive recognition from their clinics and greater job security are much less strongly supported. elude 1From the interviews, several comments fortify the written survey results concerning the opportunity to learn and growI was flavour for the experience of a CQI project. I had done some reading on Dr. Deming on my own. I k crude he was very successful and I didnt know how. This was just very fascinating to me.Learning something new was probably one of the greatest things that attracted me to this. My school principal is just constantly going all the time and I strongly like getting involved in new things.The nurses also reported high scores in task significance. Questions included, The time spent on this process improvement has been worth it, I receive like what I am doing with my team is worthwhile, and I believe that our process improvement activities have resulted in our patients receiving better care. Comments arou nd task significance centered largely on the perceived acquire to their clinics patients. One nurse responded to the question, What are the three most positive benefits of your involvement in process improvement? by answeringNumber one is that we in reality focused on those eight preventive services and that when you take a look at them they are actually going to improve somebodys life. And thats going to spread over here even after were formally finished.Another repeated theme focused on participation-the opportunity provided to interact in a positive way, not only within each clinic site, but with other clinics involved in the projectYoure not in this alone, youre working with a lot of good people, and not just health jobals. We have good people like _____ who is not a health professional. She works in the business part, but I cant imagine doing this without her because they have the skills of getting the word out when youre busy with patients. So we need each other.It has bee n fun to be involved with other people. This has given me an sentience of not only my own clinic site, but awareness of the broader picture of health care within the Twin Cities.Back to TopAcquisition of specific knowledge and skillsOverall, these nurses reported increasing a wide variety of knowledge and skills relevant to process improvement and working with people as a result of this experience. Table 2 summarizes these reported changes between self-perceived skills before and after the 22-month project. The largest improvements involved learning how to make use of data, managing change, and managing meetings. Even the eight respondents with previous training in QI reported gains, even though they had rated their previous overall QI knowledge and skills as average (3 nurses) to above average (5 nurses).Table 2From the interviews, several themes emerged as to what the nurses perceived as skills gained from participating in process improvement. The most frequently mentioned skill was the ability to apply a model for problem solving (the seven-step model)I think really learning how to problem solve was very beneficial because we had tried to solve some situational process problems in our clinic before and it gets to a certain(a) point where everyone complains about something and they decide to do something about it and we would set up some basic rules or policies and three or four months later no one was doing it anymore because it didnt work. There never was a lot of follow through, so I think this really gave us a good role model on how to go about problem solving in the clinic.Another frequently cited skill was the ability to effectively conduct meetingsOne of the major things I learned was how to run a meeting. It is so effective and we use it so much in other meetings now. People come out of those meetings and say, This is a great way to do a meeting we get out of here on time and we get something done.Other themes cited were around skills gained in s ocial relationships, specifically the ability to directly deal with coworkers or others on solving problemsI now am being more direct and am looking at things more from a process point of view rather than a personal point of view.Another nurse reportedOverall, now if individual is not following the standard, I go up them now by going over what the protocol is or what the process is, rather than honing in on the fact that the person may not be a good nurse.Back to TopImpact on the nursing roleAs illustrated in Table 3, these nurses reported that they believe QI is important for nurses and that nurses have a crucial contribution to make to QI. With a few exceptions, they believe that QI bequeath improve the ability of nurses to control their work and many of them feel that their work on process improvement has helped them to be better nurses. However, when asked about each of nine specific areas of nursing activities (room preparation, technical activities, nursing process, telepho ne communications, patient advocacy, patient education, care coordination, expert arrange, and quality improvement), only in QI did more than 3 of the 13 nurses report that they had experienced a significant change in the frequency with which they performed that type of activity after working on this project.Table 3During the interviews, the nurses were asked whether they power saw a role for process improvement in the nursing profession. The majority of the responses revolved around the value they perceived in being able to approach problems in a systematic wayI dont think nurses training ever gave us the skills to deliberately study something and improve it. Yet we get out and we become head nurses.It has helped the role of the nursing supervisors in dealing with their staff. It has helped them work through problems and problem solve rather than just coming to me for an answer.Many of the nurses reported that their environment was changing and that their role had changed. Becaus e of this changing environment, they reported needing new skills and a new way of thinkingEverything is changing. We need to improve for our patients.I think the grasp of nursing has changed and that the nurses need to look at the whole system, you know what goes on with the patient besides just with the hands-on things. I think it (process improvement) is a give way of how you clinically take care of somebody, but I think it kind of helps you to vituperatively look at other things. Youre dealing with so many systems with the patient and how they move through these systems.We were never trained to deal with the system, we were only trained to deal with each patient.In the clinic setting, we need to be aware of what we are doing and wherefore we are doing it. There is a lot of time and wasted effort.Back to TopDISCUSSIONAlthough the sample is small, this study helps to document the generally positive feelings of ambulatory practice nurses involved in leading or facilitating their local clinic QI effort to improve the process of providing preventive services. Both their questionnaire responses and their interview comments and anecdotes suggest that they feel they benefited from their involvement with this project, despite the fact that it required a great deal of time and energy from them. Overall, they report that they were very satisfied with the experience and that it provided them with increased knowledge and skills as well as enhancements for their nursing role.In light of the reported knowledge, skill, and role enhancements, it is not surprising that these nurses would feel satisfied with their experience. Even though most of these nurses were already working at higher-level positions, nursing in ambulatory practice has traditionally been viewed as less prestigious and challenging than hospital nursing, both by nurses and by the public generally. Hackbarths study showed that ambulatory nurses reported more frequent performance of lower-level work dimen sions and less frequent performance of dimensions requiring disciplinary knowledge and critical thinking, despite the growing complexity of care in ambulatory settings.12 Capell and Leggats comment that the traditional view of the nurse as one only involved in the accomplishment of tasks prescribed by others is no longer fitting in todays health care environment, does not mean that traditional role is disappearing.13(p39) Thus, anything that promises improvement in the nursing role is likely to find appeal.Counte has shown that in the hospital setting, personal participation in a TQM program was associated with higher job satisfaction.14 McLaughlin and Kaluzny feel that the new set of decision-making skills required by TQM includes not only technical skills like data management and statistical analysis, but also the ability to work well in multidisciplinary teams.15 Despite previous QI training and/or experience, all of the nurses in this project reported gains in skills, and most o f these skills were gained in the areas noted above, along with change management.Another aspect of the current health care environment that lends both importance and urgency to acquiring new skills is the extreme degree of commotion in health care, especially in the Twin Cities. As Magnan has documented for these clinics involved in the IMPROVE trial, enormous change is going on.16 Within a one-year time period during the process improvement efforts described here, 64 percent of the clinics were purchased, merged, or underwent a major shift in affiliations 77 percent of the clinics changed at least one major internal system and 45 percent of the clinics changed their medical director and/or their clinic manager. This turmoil may explain why so few respondents reported that the experience provided them with more job security in their current clinic (question 12 in Table 1), even though it gave them more job opportunities for the future (question 9).Clearly QI is very important to h ealth care improvement and reform. Phoon et al.17 believe that the success of health care delivery depends on the successful integration and coexistence of QI and managed care. Moreover, they believe that nurses play a key role in this integration, although they tend to emphasize primarily nurse managers and practitioners. Spoon et al., on the other hand, use their experience with 45 CQI process improvement teams in a community hospital to highlight the potential for this experience to empower typical hospital nurses.18 They also point out the many ways nurses are essential to most of the steps in the improvement process. Corbett and Pennypacker go on to describe a process improvement effort that took place entirely within a hospital nursing department,19 although that is not particularly consistent with the interdisciplinary demand for most QI efforts.It is worth highlighting that the training in this project was very action oriented. It focused not on theory, but on the act of p rocess improvement and team skills. For example, the trainees learned to flow chart their own clinics prevention process and to collect and analyze their own data in order to learn the root causes for the problems with that process. Role plays of meeting management skills and audits of dummy charts prepared them for applying those skills with their own clinic teams.A basic assumption governing the intervention with these trainees and their teams was that they could act their way into a new way of thinking by applying specific skills in a structured way. These new ways of thinking derive from a real understanding of work as process and include recognizing that problems are generally due to systems deficiencies rather than to individual workers. In other words, we were teaching systems thinking-what Peter Senge describes in The Fifth Discipline as the discipline for seeing wholes.20(p68)We believe that we saw this type of fundamental change in thinking in these nurses and others invol ved in this improvement process. Over time, the language of the group began to change and to include terms and statements that reflected systems thinking. For example, one rather taciturn physician remarked after the third training session that I never realized how many people were involved in getting the patient ready to be seen by meAside from the knowledge and skills acquired from the training and the task, it was clear that most of these participants highly valued the opportunity to talk with others in similar environments. They liked to share frustrations as well as to learn from the efforts of peers in other situations. Most clinic personnel are surprisingly isolated, with few opportunities to attend broadening learning experiences, much less to learn first-hand how their way of doing things compares with that of others.We believe that this study and our experience with providing training and consulting for 60 clinics show that there is a great deal about the concepts and tech niques of QI that appeals to nurses and other health care professionals. It appeals to both their scientific orientation and their desire to help improve things, in particular their customers-each patient. The acquisition and the application of these concepts and techniques appear to be both satisfying and broadens their views of how they can contribute to health care.Finally, it is worth noting that besides enhancing the skills and satisfaction of nurses, the QI projects in which they work are often likely to lead to role enhancements for nurses, especially those in ambulatory care settings. QI teams interested in improving prevention or other clinical areas of focus, like those we had the privilege to work with, will find that they cannot do this without expanding the role of nurses. McCarthy et al.,21 among others, have demonstrated the power of empowering clinic nurses to offer and arrange for mammography as patients are seen. The Oxford Project in England has carried this even further by creating a new profession for facilitators to help primary care practices improve their prevention activities by training practice nurses to fill an expanded role in performing health checks and facilitating practice system changes.22 Most of these external facilitators are also nurses and it is recommended that all of them have that background.23 Astrops description of the facilitators activities within a practice sound very similar to those of the nurses involved in this project and paper.Both this project and the literature suggest that QI concepts and techniques can be important vehicles for improvements in both patient care and in the skills, roles, and job satisfaction of nurses. This can be stimulated and assisted by managed care plans and others external to individual practice settings, but ultimately its success will depend on individual nurses, like those in this study, using their creativity and energy to make it happen.Back to TopREFERENCES1. Berwick, D.M. Con tinuous Improvement as an angel in Health Care. New England Journal of Medicine 320, no. 1 (1989) 53-56. UvaLinker bibliographical Links Context Link2. Laffel, G., and Blumenthal, D. The Case for Using Industrial Quality Management lore in Health Care Organizations. Journal of the American Medical Association 262, no. 20 (1989) 2869-2873. Context Link3. Barsness, Z.I., Shortell, S.M., and Gillies, R.R. National Survey of Hospital Quality Improvement Activities. Hospitals and Health Networks 67, no. 23 (1993) 52-55. UvaLinker Context Link4. Shortell, S.M., OBrien, J.L., Carman, J.M., et al. Assessing the Impact of Continuous Quality Improvement/Total Quality Management Concept versus Implementation. Health serve Research 30, no. 2 (1995) 377-401. Context Link5. Shortell, S.M., Levin, D.Z., OBrien, J.L., and Hughes, E.F. Assessing the Evidence on CQI Is the Glass Half Empty or Half Full? Hospital and Health Services Administration 40, no. 1 (1995) 4-24. Context Link6. Carman, J.M. , Shortell, S.M., Foster, R.W., Hughes, E.F., et al. Keys for favored Implementation of Total Quality Management in Hospitals. Health Care Management Review 21, no. 1 (1996) 48-60. Ovid Full text edition UvaLinker Request Permissions bibliographical Links Context Link7. Solberg, L.I., Isham G., Kottke, T.E., et al. Competing HMOs Collaborate to Improve Preventive Services. The Joint Commission Journal on Quality Improvement 21, no. 11(1995) 600-610. Context Link8. Solberg, L.I., Kottke, T.E., Brekke, M.L., et al. Using CQI to Increase Preventive Services in Clinical work-Going Beyond Guidelines. Preventive Medicine 25, no. 3 (1996) 259-267. Context Link9. Solberg, L.I., and Johnson, J.M. The Office guard A Neglected but Valuable Ally. Family Practice Research Journal 2, no. 2 (1982) 132-141. UvaLinker Context Link10. Flarcy, D.L. Redesigning Management Roles, The Executive Challenge. Journal of Nursing Administration 21, no. 2 (1991) 40-45. UvaLinker Request Permissions Bibliog raphic Links Context Link11. Haas, S.A., Hackbarth, D.P., Kavanagh, J.A., and Vlasses, F. Dimensions of the Staff Nurse Role in Ambulatory Care Part II-Comparison of Role Dimensions in Four Ambulatory Settings. Nursing Economics 13, no. 3 (1995) 152-165. Context Link12. Hackbarth, D.P., Haas, S.A., Kavanagh, J.A., and Vlasses, F. Dimensions of the Staff Nurse Role in Ambulatory Care Part I-Methodology and Analysis of Data on Current Staff Nurse Practice. Nursing Economics 13, no. 2 (1995) 89-97. Context Link13. Capell, E., and Leggat, S. The Implementation of Theory-Based Nursing Practice Laying the Groundwork for Total Quality Management Within A Nursing Department. Canadian Journal of Nursing Administration 7, no. 1 (1994) 31-41. UvaLinker Bibliographic Links Context Link14. Counte, M.A., Glandon, G.L., Oleske, D.M., and Hill, J.P. Total Quality Management in a Health Care Organization How are Employees touch? Hospital and Health Services Administration 37, No. 4 (1992) 503-518. UvaLinker Context Link15. McLaughlin, C.P., and Kaluzny, A.D. Total Quality Management in Health Making it Work. Health Care Management Review 15, no. 3 (1990) 7-14. Context Link16. Magnan, S., Solberg, L.I., Giles, K., et al. Primary Care, Process Improvement, and Turmoil. Journal of Ambulatory Care Management 20, no. 4 (1997) 32-38. Ovid Full Text UvaLinker Request Permissions Bibliographic Links Context Link17. Phoon, J., Corder, K., and Barte, M. Managed Care and Total Quality Management A Necessary Integration. Journal of Nursing Care Quality 10, no. 2 (1998) 25-32. Ovid Full Text UvaLinker Request Permissions Bibliographic Links Context Link18. Spoon, B.D., Reimels, E., Johnson, C.C., and Sale, W. The CQI Paradigm A Pathway to Nurse Empowerment in a Community Hospital. Health Care Supervisor 14, no. 2 (1995) 11-18. Ovid Full Text UvaLinker Request Permissions Bibliographic Links Context Link19. Corbett, C., and Pennypacker, B. Using a Quality Improvement Team to Reduce Patient Falls. Journal of healthcare Quality 14, no. 5 (1992) 38-54. Context Link20. Senge, P.M. The Fifth Discipline The Art and Practice of the Learning Organization, New York Doubleday, 1990. Context Link21. McCarthy, B.D., Yood, M.U., Bolton, M.B., et al. Redesigning Primary Care Processes to Improve the Offering of Mammography. The Use of Clinic Protocols by Nonphysicians. Journal of General Internal Medicine 12, no. 6 (1997) 357-363. Context Link22. Fullard, E., Fowler, G., and Gray, M. Promoting Prevention in Primary Care Controlled Trial of Low Technology, Low Cost Approach. British Medical Journal 294, no. 6579 (1987) 1080-2. UvaLinker Bibliographic Links Context Link23. Astrop, P. Facilitator-The Birth of a New Profession. Health Visitor 61, no. 10 (1988) 311-312. Context LinkThe authors would like to thank the 46 clinics that participated in the IMPROVE project. These included the two demonstration clinic sites Kasson Mayo Family Practice Clinic and HealthPartners St. capital o f Minnesota Clinic.Intervention ClinicsApple Valley Medical CenterAspen Medical Group, W. St. PaulAspen Medical Group, W. SuburbanChanhassen Medical CenterChisago Medical CenterCreekside Family PracticeDouglas Drive Family PhysiciansEagle MedicalFridley Medical CenterHastings Family PracticeHopkins Family PracticeInterstate Medical CenterMetropolitan InternistsMork Clinic, AnokaNorth St. Paul Medical CenterRamsey Clinic, AmeryRamsey Clinic, BaldwinRiver Valley Clinic, FarmingtonRiver Valley Clinic, NorthfieldSouthdale Family PracticeStillwater ClinicUnited Family Medical Centercomparative degree ClinicsAspen Medical Group, BloomingtonEast Main Physicians