essays on quality improvement in nursing

What is Quality Improvement in Nursing?

What is quality improvement in nursing.

• 4 Components
• Continuous Quality Improvement
• Why It Matters

Continuous quality improvement (CQI) in healthcare is a systematic approach to improving patient safety and care. This process is essential to nursing practice, as it helps ensure patients receive the best possible care.

Quality improvement in nursing involves identifying and addressing problems in healthcare delivery to improve outcomes. CQI uses data to identify improvement areas, develop and implement interventions, and evaluate the results.

This article will define nursing quality improvement, its importance, various models, and real-world examples that illustrate its impact.

At its core, quality improvement in nursing is the systematic approach to evaluating and enhancing healthcare practices. It involves identifying areas for improvement, creating strategies to address them, and measuring outcomes.

CQI is rooted in evidence-based practices and empowers nurses to actively contribute to improving healthcare services. 

What Are the Four Components of Quality Improvement?

The four components of quality improvement are:

1. Identify a Problem

The first step in CQI is to identify a healthcare delivery problem. You can do this by reviewing patient data, conducting surveys, or observing the care process.

2. Gather Data

Once you've identified a problem, the next step is to gather data about it. You can use this data to understand the scope of the dilemma and identify potential solutions.

3. Develop and Implement an Intervention

With sufficient data, you can develop and implement an intervention to address the issue. You should base your intervention on the best available evidence and tailor it to your problem.

4. Evaluate the Results

The final step in CQI is to evaluate the results of the intervention. This step involves collecting data to determine whether the intervention has effectively improved the problem.

Continuous Quality Improvement Definition for Nursing

Experts often use quality improvement and continuous quality improvement interchangeably. These terms emphasize the evaluation and enhancement of practices to ensure excellence in patient care. Different regulatory agencies use other models of CQI and have different definitions for what it means.

Centers for Medicare & Medicaid Quality Improvement Definition

Centers for Medicare & Medicaid Services ( CMS ) defines CQI as “…the framework used to improve care systematically. Quality improvement seeks to standardize processes and structure to reduce variation, achieve predictable results, and improve outcomes for patients, healthcare systems, and organizations.”

Joint Commission Quality Improvement Definition

The Joint Commission defines CQI as standards that “…are the basis of an objective evaluation process that can help health care organizations measure, assess, and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high-quality care.”

What Are the Different Quality Improvement Models?

You can use several models to implement CQI in your nursing practice. Some of the most prevalent models include the following:

Plan-Do-Study-Act (PDSA)

PDSA involves planning a change, implementing it on a small scale, studying its effects, and acting based on the results. This cyclic process facilitates gradual improvements while minimizing risks.

Borrowed from the Motorola manufacturing industry, Six Sigma seeks to minimize defects and process variations. It emphasizes data-driven decision-making and aims for near-perfect results.

Lean Methodology

Also originating from manufacturing, Lean Methodology focuses on reducing waste and streamlining processes. In nursing, this translates to optimizing workflows and resource utilization.

The Model for Improvement

This model focuses on improving the quality of care by setting goals, measuring progress, and making data-informed changes. The model for improvement is the most popular CQI model in the healthcare industry. 

The model for improvement combines three fundamental questions with the PDSA model to better guide the improvement process.

Model For Improvement Three Fundamental Questions

You can address the three fundamental questions of the model for improvement in any order. However, answering them thoroughly will ensure your team understands the purpose behind the intervention.

These fundamental questions are as follows:

1. What are you trying to accomplish? Setting a goal can help you answer this question. You should create your objective using the  SMART format, which means your goal should be:

M easurable

A chievable

R elevant, and

T ime-bound

2. How will you know whether a change is an improvement? Creating metrics by which you can measure your intervention's success will help you answer this question. Your metrics will help you determine your intervention's efficacy by measuring its structure, process, outcome, and balance.

3. What changes can you make that will result in improvement? Perform a root cause analysis (RCA) to identify the cause of your problem. Understanding the root causes of your issue will help you create tailored, practical changes.

Using the PDSA Model

After answering the fundamental questions, you can complete the PDSA cycle. Remember, needing multiple PDSA cycles to achieve your desired results is okay.

P lan: Create a plan for your intervention

D o: Set your plan in motion

S tudy: Study the results of your plan

A ct: Review your results, whether they worked or didn’t 

You can adapt the intervention into your framework if the results are helpful. If not, you can make improvements based on the pitfalls and try again.

6 Quality Improvement in Nursing Examples

Healthcare quality improvement projects implemented by nurses improve patient safety and healthcare delivery. Nurses must follow specific quality measures every day to ensure they're optimizing and advancing patient care.

Common quality improvement in nursing examples include the following:

• Reducing the incidence of hospital-acquired infections
• Improving patient satisfaction
• Increasing the use of evidence-based practices
• Decreasing falls in high-risk fall patients
• Reducing medication errors
• Improving communication between healthcare providers

Do you recognize how you implement some of these in your daily work? For example, you can implement “Decreasing falls in high-risk fall patients” by applying non-slip socks on a patient and turning on the bed alarm.

Additionally, you may implement “reducing medication errors” by scanning the patient’s wristband and the medication while verifying the correct dose, medication, time, and patient.

Why Does Quality Improvement in Nursing Matter?

Quality improvement in nursing is essential because it helps patients receive the best possible care. By identifying and addressing healthcare delivery problems, CQI improves patient outcomes, reduces costs, and increases satisfaction.

Quality improvement in nursing is an ongoing process that allows healthcare professionals to optimize their practices. Healthcare is a continuously evolving landscape, and CQI enhances its expansion.

Breann Kakacek BSN RN has been a registered nurse for more than 8 years and a CNA for 2 years while going through the nursing program. Most of her nursing years include working in the medical ICU and Cardiovascular ICU and moonlighting in the OR as a circulating nurse. She has always had a passion for writing and enjoys using her nursing knowledge to create amazing online content.

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Quality improvement into practice

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• Related content
• Peer review
• Adam Backhouse , quality improvement programme lead 1 ,
• Fatai Ogunlayi , public health specialty registrar 2
• 1 North London Partners in Health and Care, Islington CCG, London N1 1TH, UK
• 2 Institute of Applied Health Research, Public Health, University of Birmingham, B15 2TT, UK
• Correspondence to: A Backhouse adam.backhouse{at}nhs.net

What you need to know

Thinking of quality improvement (QI) as a principle-based approach to change provides greater clarity about ( a ) the contribution QI offers to staff and patients, ( b ) how to differentiate it from other approaches, ( c ) the benefits of using QI together with other change approaches

QI is not a silver bullet for all changes required in healthcare: it has great potential to be used together with other change approaches, either concurrently (using audit to inform iterative tests of change) or consecutively (using QI to adapt published research to local context)

As QI becomes established, opportunities for these collaborations will grow, to the benefit of patients.

The benefits to front line clinicians of participating in quality improvement (QI) activity are promoted in many health systems. QI can represent a valuable opportunity for individuals to be involved in leading and delivering change, from improving individual patient care to transforming services across complex health and care systems. 1

However, it is not clear that this promotion of QI has created greater understanding of QI or widespread adoption. QI largely remains an activity undertaken by experts and early adopters, often in isolation from their peers. 2 There is a danger of a widening gap between this group and the majority of healthcare professionals.

This article will make it easier for those new to QI to understand what it is, where it fits with other approaches to improving care (such as audit or research), when best to use a QI approach, making it easier to understand the relevance and usefulness of QI in delivering better outcomes for patients.

How this article was made

AB and FO are both specialist quality improvement practitioners and have developed their expertise working in QI roles for a variety of UK healthcare organisations. The analysis presented here arose from AB and FO’s observations of the challenges faced when introducing QI, with healthcare providers often unable to distinguish between QI and other change approaches, making it difficult to understand what QI can do for them.

How is quality improvement defined?

There are many definitions of QI ( box 1 ). The BMJ ’s Quality Improvement series uses the Academy of Medical Royal Colleges definition. 6 Rather than viewing QI as a single method or set of tools, it can be more helpful to think of QI as based on a set of principles common to many of these definitions: a systematic continuous approach that aims to solve problems in healthcare, improve service provision, and ultimately provide better outcomes for patients.

Definitions of quality improvement

Improvement in patient outcomes, system performance, and professional development that results from a combined, multidisciplinary approach in how change is delivered. 3

The delivery of healthcare with improved outcomes and lower cost through continuous redesigning of work processes and systems. 4

Using a systematic change method and strategies to improve patient experience and outcome. 5

To make a difference to patients by improving safety, effectiveness, and experience of care by using understanding of our complex healthcare environment, applying a systematic approach, and designing, testing, and implementing changes using real time measurement for improvement. 6

In this article we discuss QI as an approach to improving healthcare that follows the principles outlined in box 2 ; this may be a useful reference to consider how particular methods or tools could be used as part of a QI approach.

Principles of QI

Primary intent— To bring about measurable improvement to a specific aspect of healthcare delivery, often with evidence or theory of what might work but requiring local iterative testing to find the best solution. 7

Employing an iterative process of testing change ideas— Adopting a theory of change which emphasises a continuous process of planning and testing changes, studying and learning from comparing the results to a predicted outcome, and adapting hypotheses in response to results of previous tests. 8 9

Consistent use of an agreed methodology— Many different QI methodologies are available; commonly cited methodologies include the Model for Improvement, Lean, Six Sigma, and Experience-based Co-design. 4 Systematic review shows that the choice of tools or methodologies has little impact on the success of QI provided that the chosen methodology is followed consistently. 10 Though there is no formal agreement on what constitutes a QI tool, it would include activities such as process mapping that can be used within a range of QI methodological approaches. NHS Scotland’s Quality Improvement Hub has a glossary of commonly used tools in QI. 11

Empowerment of front line staff and service users— QI work should engage staff and patients by providing them with the opportunity and skills to contribute to improvement work. Recognition of this need often manifests in drives from senior leadership or management to build QI capability in healthcare organisations, but it also requires that frontline staff and service users feel able to make use of these skills and take ownership of improvement work. 12

Using data to drive improvement— To drive decision making by measuring the impact of tests of change over time and understanding variation in processes and outcomes. Measurement for improvement typically prioritises this narrative approach over concerns around exactness and completeness of data. 13 14

Scale-up and spread, with adaptation to context— As interventions tested using a QI approach are scaled up and the degree of belief in their efficacy increases, it is desirable that they spread outward and be adopted by others. Key to successful diffusion of improvement is the adaption of interventions to new environments, patient and staff groups, available resources, and even personal preferences of healthcare providers in surrounding areas, again using an iterative testing approach. 15 16

What other approaches to improving healthcare are there?

Taking considered action to change healthcare for the better is not new, but QI as a distinct approach to improving healthcare is a relatively recent development. There are many well established approaches to evaluating and making changes to healthcare services in use, and QI will only be adopted more widely if it offers a new perspective or an advantage over other approaches in certain situations.

A non-systematic literature scan identified the following other approaches for making change in healthcare: research, clinical audit, service evaluation, and clinical transformation. We also identified innovation as an important catalyst for change, but we did not consider it an approach to evaluating and changing healthcare services so much as a catch-all term for describing the development and introduction of new ideas into the system. A summary of the different approaches and their definition is shown in box 3 . Many have elements in common with QI, but there are important difference in both intent and application. To be useful to clinicians and managers, QI must find a role within healthcare that complements research, audit, service evaluation, and clinical transformation while retaining the core principles that differentiate it from these approaches.

Alternatives to QI

Research— The attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods. 17

Clinical audit— A way to find out if healthcare is being provided in line with standards and to let care providers and patients know where their service is doing well, and where there could be improvements. 18

Service evaluation— A process of investigating the effectiveness or efficiency of a service with the purpose of generating information for local decision making about the service. 19

Clinical transformation— An umbrella term for more radical approaches to change; a deliberate, planned process to make dramatic and irreversible changes to how care is delivered. 20

Innovation— To develop and deliver new or improved health policies, systems, products and technologies, and services and delivery methods that improve people’s health. Health innovation responds to unmet needs by employing new ways of thinking and working. 21

Why do we need to make this distinction for QI to succeed?

Improvement in healthcare is 20% technical and 80% human. 22 Essential to that 80% is clear communication, clarity of approach, and a common language. Without this shared understanding of QI as a distinct approach to change, QI work risks straying from the core principles outlined above, making it less likely to succeed. If practitioners cannot communicate clearly with their colleagues about the key principles and differences of a QI approach, there will be mismatched expectations about what QI is and how it is used, lowering the chance that QI work will be effective in improving outcomes for patients. 23

There is also a risk that the language of QI is adopted to describe change efforts regardless of their fidelity to a QI approach, either due to a lack of understanding of QI or a lack of intention to carry it out consistently. 9 Poor fidelity to the core principles of QI reduces its effectiveness and makes its desired outcome less likely, leading to wasted effort by participants and decreasing its credibility. 2 8 24 This in turn further widens the gap between advocates of QI and those inclined to scepticism, and may lead to missed opportunities to use QI more widely, consequently leading to variation in the quality of patient care.

Without articulating the differences between QI and other approaches, there is a risk of not being able to identify where a QI approach can best add value. Conversely, we might be tempted to see QI as a “silver bullet” for every healthcare challenge when a different approach may be more effective. In reality it is not clear that QI will be fit for purpose in tackling all of the wicked problems of healthcare delivery and we must be able to identify the right tool for the job in each situation. 25 Finally, while different approaches will be better suited to different types of challenge, not having a clear understanding of how approaches differ and complement each other may mean missed opportunities for multi-pronged approaches to improving care.

What is the relationship between QI and other approaches such as audit?

Academic journals, healthcare providers, and “arms-length bodies” have made various attempts to distinguish between the different approaches to improving healthcare. 19 26 27 28 However, most comparisons do not include QI or compare QI to only one or two of the other approaches. 7 29 30 31 To make it easier for people to use QI approaches effectively and appropriately, we summarise the similarities, differences, and crossover between QI and other approaches to tackling healthcare challenges ( fig 1 ).

How quality improvement interacts with other approaches to improving healthcare

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QI and research

Research aims to generate new generalisable knowledge, while QI typically involves a combination of generating new knowledge or implementing existing knowledge within a specific setting. 32 Unlike research, including pragmatic research designed to test effectiveness of interventions in real life, QI does not aim to provide generalisable knowledge. In common with QI, research requires a consistent methodology. This method is typically used, however, to prove or disprove a fixed hypothesis rather than the adaptive hypotheses developed through the iterative testing of ideas typical of QI. Both research and QI are interested in the environment where work is conducted, though with different intentions: research aims to eliminate or at least reduce the impact of many variables to create generalisable knowledge, whereas QI seeks to understand what works best in a given context. The rigour of data collection and analysis required for research is much higher; in QI a criterion of “good enough” is often applied.

Relationship with QI

Though the goal of clinical research is to develop new knowledge that will lead to changes in practice, much has been written on the lag time between publication of research evidence and system-wide adoption, leading to delays in patients benefitting from new treatments or interventions. 33 QI offers a way to iteratively test the conditions required to adapt published research findings to the local context of individual healthcare providers, generating new knowledge in the process. Areas with little existing knowledge requiring further research may be identified during improvement activities, which in turn can form research questions for further study. QI and research also intersect in the field of improvement science, the academic study of QI methods which seeks to ensure QI is carried out as effectively as possible. 34

Scenario: QI for translational research

Newly published research shows that a particular physiotherapy intervention is more clinically effective when delivered in short, twice-daily bursts rather than longer, less frequent sessions. A team of hospital physiotherapists wish to implement the change but are unclear how they will manage the shift in workload and how they should introduce this potentially disruptive change to staff and to patients.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this article?

Adopting a QI approach, the team realise that, although the change they want to make is already determined, the way in which it is introduced and adapted to their wards is for them to decide. They take time to explain the benefits of the change to colleagues and their current patients, and ask patients how they would best like to receive their extra physiotherapy sessions.

The change is planned and tested for two weeks with one physiotherapist working with a small number of patients. Data are collected each day, including reasons why sessions were missed or refused. The team review the data each day and make iterative changes to the physiotherapist’s schedule, and to the times of day the sessions are offered to patients. Once an improvement is seen, this new way of working is scaled up to all of the patients on the ward.

The findings of the work are fed into a service evaluation of physiotherapy provision across the hospital, which uses the findings of the QI work to make recommendations about how physiotherapy provision should be structured in the future. People feel more positive about the change because they know colleagues who have already made it work in practice.

QI and clinical audit

Clinical audit is closely related to QI: it is often used with the intention of iteratively improving the standard of healthcare, albeit in relation to a pre-determined standard of best practice. 35 When used iteratively, interspersed with improvement action, the clinical audit cycle adheres to many of the principles of QI. However, in practice clinical audit is often used by healthcare organisations as an assurance function, making it less likely to be carried out with a focus on empowering staff and service users to make changes to practice. 36 Furthermore, academic reviews of audit programmes have shown audit to be an ineffective approach to improving quality due to a focus on data collection and analysis without a well developed approach to the action section of the audit cycle. 37 Clinical audits, such as the National Clinical Audit Programme in the UK (NCAPOP), often focus on the management of specific clinical conditions. QI can focus on any part of service delivery and can take a more cross-cutting view which may identify issues and solutions that benefit multiple patient groups and pathways. 30

Audit is often the first step in a QI process and is used to identify improvement opportunities, particularly where compliance with known standards for high quality patient care needs to be improved. Audit can be used to establish a baseline and to analyse the impact of tests of change against the baseline. Also, once an improvement project is under way, audit may form part of rapid cycle evaluation, during the iterative testing phase, to understand the impact of the idea being tested. Regular clinical audit may be a useful assurance tool to help track whether improvements have been sustained over time.

Scenario: Audit and QI

A foundation year 2 (FY2) doctor is asked to complete an audit of a pre-surgical pathway by looking retrospectively through patient documentation. She concludes that adherence to best practice is mixed and recommends: “Remind the team of the importance of being thorough in this respect and re-audit in 6 months.” The results are presented at an audit meeting, but a re-audit a year later by a new FY2 doctor shows similar results.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this paper?

Contrast the above with a team-led, rapid cycle audit in which everyone contributes to collecting and reviewing data from the previous week, discussed at a regular team meeting. Though surgical patients are often transient, their experience of care and ideas for improvement are captured during discharge conversations. The team identify and test several iterative changes to care processes. They document and test these changes between audits, leading to sustainable change. Some of the surgeons involved work across multiple hospitals, and spread some of the improvements, with the audit tool, as they go.

QI and service evaluation

In practice, service evaluation is not subject to the same rigorous definition or governance as research or clinical audit, meaning that there are inconsistencies in the methodology for carrying it out. While the primary intent for QI is to make change that will drive improvement, the primary intent for evaluation is to assess the performance of current patient care. 38 Service evaluation may be carried out proactively to assess a service against its stated aims or to review the quality of patient care, or may be commissioned in response to serious patient harm or red flags about service performance. The purpose of service evaluation is to help local decision makers determine whether a service is fit for purpose and, if necessary, identify areas for improvement.

Service evaluation may be used to initiate QI activity by identifying opportunities for change that would benefit from a QI approach. It may also evaluate the impact of changes made using QI, either during the work or after completion to assess sustainability of improvements made. Though likely planned as separate activities, service evaluation and QI may overlap and inform each other as they both develop. Service evaluation may also make a judgment about a service’s readiness for change and identify any barriers to, or prerequisites for, carrying out QI.

QI and clinical transformation

Clinical transformation involves radical, dramatic, and irreversible change—the sort of change that cannot be achieved through continuous improvement alone. As with service evaluation, there is no consensus on what clinical transformation entails, and it may be best thought of as an umbrella term for the large scale reform or redesign of clinical services and the non-clinical services that support them. 20 39 While it is possible to carry out transformation activity that uses elements of QI approach, such as effective engagement of the staff and patients involved, QI which rests on iterative test of change cannot have a transformational approach—that is, one-off, irreversible change.

There is opportunity to use QI to identify and test ideas before full scale clinical transformation is implemented. This has the benefit of engaging staff and patients in the clinical transformation process and increasing the degree of belief that clinical transformation will be effective or beneficial. Transformation activity, once completed, could be followed up with QI activity to drive continuous improvement of the new process or allow adaption of new ways of working. As interventions made using QI are scaled up and spread, the line between QI and transformation may seem to blur. The shift from QI to transformation occurs when the intention of the work shifts away from continuous testing and adaptation into the wholesale implementation of an agreed solution.

Scenario: QI and clinical transformation

An NHS trust’s human resources (HR) team is struggling to manage its junior doctor placements, rotas, and on-call duties, which is causing tension and has led to concern about medical cover and patient safety out of hours. A neighbouring trust has launched a smartphone app that supports clinicians and HR colleagues to manage these processes with the great success.

This problem feels ripe for a transformation approach—to launch the app across the trust, confident that it will solve the trust’s problems.

Before continuing reading think about your own organisation— What do you think will happen, and how would you use the QI principles described in this article for this situation?

Outcome without QI

Unfortunately, the HR team haven’t taken the time to understand the underlying problems with their current system, which revolve around poor communication and clarity from the HR team, based on not knowing who to contact and being unable to answer questions. HR assume that because the app has been a success elsewhere, it will work here as well.

People get excited about the new app and the benefits it will bring, but no consideration is given to the processes and relationships that need to be in place to make it work. The app is launched with a high profile campaign and adoption is high, but the same issues continue. The HR team are confused as to why things didn’t work.

Outcome with QI

Although the app has worked elsewhere, rolling it out without adapting it to local context is a risk – one which application of QI principles can mitigate.

HR pilot the app in a volunteer specialty after spending time speaking to clinicians to better understand their needs. They carry out several tests of change, ironing out issues with the process as they go, using issues logged and clinician feedback as a source of data. When they are confident the app works for them, they expand out to a directorate, a division, and finally the transformational step of an organisation-wide rollout can be taken.

Education into practice

Next time when faced with what looks like a quality improvement (QI) opportunity, consider asking:

How do you know that QI is the best approach to this situation? What else might be appropriate?

Have you considered how to ensure you implement QI according to the principles described above?

Is there opportunity to use other approaches in tandem with QI for a more effective result?

How patients were involved in the creation of this article

This article was conceived and developed in response to conversations with clinicians and patients working together on co-produced quality improvement and research projects in a large UK hospital. The first iteration of the article was reviewed by an expert patient, and, in response to their feedback, we have sought to make clearer the link between understanding the issues raised and better patient care.

Contributors: This work was initially conceived by AB. AB and FO were responsible for the research and drafting of the article. AB is the guarantor of the article.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: This article is part of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ , including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ ’s quality improvement editor post are funded by the Health Foundation.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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Quality Improvement in Professional Nursing

Introduction, roles of professional nurses in quality improvement, improving nursing quality in the healthcare setting.

Quality in nursing and health care is one of the most fundamental concepts. Though it is frequently compared with safety and positive outcomes, it is wrong to search for similarities or contradictions of all these issues in order to grasp their essence. Quality is a complex and multidimensional aspect that has to be characterized by a number of organizational improvements and assessments (Coleman, 2015). Nurses are usually aware of the importance of high-quality services. They are involved in numerous activities the aim of which is to improve quality, recognize strong and weak aspects, and offer the best level of care. Professional nursing and quality improvement are two interrelated concepts that will be discussed in this paper.

The role of professional nurses in quality improvement cannot be ignored. Coleman (2015) states that modern nurses are well prepared and educated to understand their responsibilities and affect organizational changes. Their roles in quality improvement may vary depending on their background knowledge, practical experience, duties, and even personal desire to participate in certain activities. In the investigation developed by Coleman (2015), the necessity to understand what may define quality care is mentioned, proving that it should be discussed “within a local and national context as they [nurses] formulate action plans for improvement” (p. 262). Therefore, one of the main roles of professional nurses in quality improvement is to introduce action plan and make sure that every medical worker within a facility follow it.

Active participation and leadership are also important issues for performance excellence. It is not enough for a nurse to know how to improve the quality of care. This person has to be prepared to promote care with all its characteristics like team-orientation, patient-centeredness, and comprehensiveness, explain other members of a team how to achieve success, and support those who face challenges or need additional assessments (Coleman, 2015). Therefore, it is suggested not only to gain some skills and use them all the time, but pay more attention to lifelong learning and the possibility to discover new aspects of health and nursing care.

Nursing quality in healthcare settings has to be regularly evaluated and improved. For example, many organizations demonstrate regular failures in their intentions to promote organizational change projects because of poorly developed implementation attempts (Coleman, 2015). In fact, success in improving the quality of health care depends on how well nurses and other stakeholders develop their plans and explain their steps (Hood, 2014). When people know what they have to do and why, they have more chances to achieve success.

Other approaches to improve quality include self-assessment and information categorization. In some organizations, much time is required to promote change and improvement. Some facilities are able to cope quickly and prove their experience and knowledge. Communication, evaluation, and hard work are the keys to positive changes in health care.

In general, quality improvement in healthcare settings is an important aspect that cannot be ignored either by nurses or other medical workers. The level of knowledge and practice make nurses responsible for numerous organizational changes in their settings that lead to quality improvement. Though nurses can lead and motivate people, presenting new ideas and taking new steps, they may also need additional help and support. The improvement of nursing quality depends on how well they develop action plans and communicate all changes.

Coleman, C. (2015). Stimulating a culture of improvement: Introducing an integrated quality tool for organizational self-assessment. Clinical Journal of Oncology Nursing, 19 (3), 261-264.

Hood, L. (2014). Leddy & Pepper’s conceptual bases of professional nursing (8th ed.). Philadelphia, PA: Lippincott-Raven Publishers.

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StudyCorgi. (2020, October 14). Quality Improvement in Professional Nursing. https://studycorgi.com/quality-improvement-in-professional-nursing/

"Quality Improvement in Professional Nursing." StudyCorgi , 14 Oct. 2020, studycorgi.com/quality-improvement-in-professional-nursing/.

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Quality Improvement & Safety in Health Care Essay

Studying in a nursing school may often be challenging as students receive vast amounts of new information without being able to practice it properly. Thus, when finally obtaining this opportunity, many novice nurses become confused as they do not have basic experience in communicating with patients (Manoochehri et al., 2015). When I was in nursing school, I remember not receiving some essential knowledge like how to deal with complex patients and address their needs carefully and correctly. Nevertheless, knowing core patient-centered care competencies is vital for all medical workers to improve the quality of services provided. When becoming a novice nurse myself, the primary focus of my work was to ensure that patients received their medicine on time. Therefore, I believe that healthcare students were not educated enough throughout the curriculum and did not learn to deliver patient-centered care at a higher quality. The following example proves my opinion.

There was a situation when a novice nurse reported to me that she could not teach a patient how to administer insulin, which made the inexperienced nurse stressed out. Since one of the core competencies of patient-centered care is to find ways to help clients communicate their issues (“QSEN competencies,” n.d.), I talked to the client, and the further assessment revealed that she was not able to see and did not have her eyeglasses. In addition, the patient’s sister appeared to have a learning disability and could not become responsible for learning insulin administration. However, I was pressured by management to discharge the patient. Finally, I managed to get an endocrinologist to follow her closely and change their insulin to PO, and I believe this was the best I could do in such a case.

In my opinion, this situation represents the possible and rather common challenges a nurse may face when communicating with clients and making a decision about their treatment or discharge. What is more, this is a great example proving the necessity of possessing core competencies in order to make sure that the quality of provided medical services is high. For instance, a nurse should identify, care about, and respect a patient’s expressed needs and differences, as well as relieve their pain (Manoochehri et al., 2015). Nurses also have to educate patients and have clear communication with them (“QSEN competencies,” n.d.). Unfortunately, the novice nurse in the story I told did not possess these competencies, even though they are vital for quality improvement as they allow establishing a strong connection and collaboration with clients.

Overall, I regret not paying more attention to the new nurse or helping her with her inexperience. I could give her some advice on the example of this situation we both were involved in. For instance, I should have told her about additional core competencies, including the necessity to speak and listen to our patients correctly, ask the right questions, support them, advocate for them, and eliminate possible issues (Edgman-Levitan & Schoenbaum, 2021). I hope that all novice nurses learn to do that in the future.

Edgman-Levitan, S., & Schoenbaum, S. C. (2021). Patient-centered care: Achieving higher quality by designing care through the patient’s eyes. Israel Journal of Health Policy Research, 10 (21). Web.

Manoochehri, H., Imani, E., Atashzadeh-Shoorideh, F., & Alavi-Majd, A. (2015). Competence of novice nurses: Role of clinical work during studying. Journal of Medicine and Life, 8 (4), 32–38.

QSEN competencies . (n.d.). QSEN Institute. Web.

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Critical Thinking Tools for Quality Improvement Projects

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Kimberly Whiteman , Jason Yaglowski , Kimberly Stephens; Critical Thinking Tools for Quality Improvement Projects. Crit Care Nurse 1 April 2021; 41 (2): e1–e9. doi: https://doi.org/10.4037/ccn2021914

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This article explores the use of 4 quality improvement tools and 2 evidence-based practice tools that, when used within the nursing process, encourage critical thinking about quality issues.

Patients and families expect to receive patient-centered, high-quality, and cost-effective care. Caring for critically ill patients is challenging and requires nurses to engage in quality improvement efforts to ensure that they provide evidence-based care.

To explore the use of critical thinking tools and evidence-based practice tools in assessing and diagnosing quality issues in the clinical setting.

The nursing process serves as the framework for problem solving. Some commonly used critical thinking tools for assessing and diagnosing quality issues are described, including the Spaghetti Diagram, the 5 Whys, the Cause and Effect Diagram, and the Pareto chart.

This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives:

Describe how the nursing process can be used to improve the quality of nursing care.

Identify the Institute for Healthcare Improvement’s Model for Improvement as a free resource for improving patient care.

Explore a clinical practice issue using one of the described critical thinking tools: the Spaghetti Diagram, the 5 Whys, or the Cause and Effect Diagram.

To complete evaluation for CE contact hour(s) for activity C2121, visit www.ccnonline.org and click the “CE Articles” button. No CE fee for AACN members. This activity expires on April 1, 2023.

The American Association of Critical-Care Nurses is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation, ANCC Provider Number 0012. AACN has been approved as a provider of continuing education in nursing by the California Board of Registered Nursing (CA BRN), CA Provider Number CEP1036, for 1 contact hour.

Nursing practice has become increasingly driven by data since the late 1990s . In 1998, the American Nurses Association established the National Database of Nursing Quality Indicators to collect data on nursing-sensitive patient care outcomes, which enabled the Association to benchmark quality data. 1   National initiatives such as the core measures from The Joint Commission and Centers for Medicare and Medicaid Services require documentation of patient outcomes that have been improved through the application of evidence-based processes. 2   Many states and specialty organizations participate in registries that permit the quality of care to be benchmarked. 3   In addition, the use of electronic medical records has made it possible for nurses to gather information from patient records that can be tailored to investigations of specific quality questions or the care that patients with a given diagnosis or treatment receive while in the hospital. 4  

As technology and levels of information advance, nurses must decipher and synthesize numerous reports, charts, and spreadsheets, and then implement that knowledge to improve the quality of patient care. In fact, both the American Nurses Association 5   and the American Association of Critical-Care Nurses 6   identify participation in quality improvement (QI) efforts as part of a nurse’s role. Some hospitals, especially those that have received or are seeking Magnet designation, have hired nurses with advanced degrees to guide bedside caregivers in research, evidence-based practice, and QI initiatives. 7   For nurses who work in hospitals but do not have advanced education related to QI, navigating the many critical thinking and evidence-based practice tools to improve patient care can be daunting.

Participation in quality improvement efforts is part of every nurse’s role .

This article explains 4 critical thinking tools and 2 evidence-based practice tools that nurses can use as adjuncts to the nursing process (assess, diagnose, plan, implement, and evaluate) to facilitate QI. In clinical practice, registered nurses use observations, communications, and a stethoscope to assess patients and formulate diagnoses. In quality initiatives, nurses replace their stethoscopes with critical thinking, QI, and evidence-based practice tools. Nurses can use these tools in conjunction with the familiar nursing process to identify areas for improvement and, when appropriate, to plan practices changes.

As in the nursing process, the first step in any quality initiative is to assess the process or problem that needs to be improved. An early initial step is to form an interprofessional team of caregivers. The team should include stakeholders whose practice could be involved in or changed by the initiative. Consider forming an interprofessional team including bedside nurses; physicians; respiratory, physical, and speech therapists; nursing assistants; and unit-based secretaries as well as patients and their families. Improving clinical practice and sustaining those improvements require leadership support from all levels within the organization. 3  

Once the team has been assembled, it should thoroughly assess the problem or quality issue. When problems occur in the workplace—either as a clinical issue, such as an increase in the number of medication errors, or as a need for improvement, such as a change in workflow—health care workers often want to identify the cause and remedy the situation quickly. Solving complex problems, however, requires in-depth exploration of both the issue and the factors contributing to it. Investing the time necessary to complete a thorough assessment is an essential step in improvement. Include as many means of examining the problem as possible, such as unit or hospital data, observations of current practices, conversations with caregivers and stakeholders, and information specific to the local problem. Clinical nurses who provide direct care to patients are in a unique position to identify quality issues. 8  

In addition to clinical nurses identifying quality issues, hospital data—such as quality or risk reports that reveal, for example, an increase in the number of infections or falls—often alert nursing leaders to clinical triggers for improvement, but triggers can also arise from interactions with patients and families or from new knowledge. 9   Examples of improvement opportunities arising from interactions with patients are a request for a family to be present during resuscitation 10   and frequent requests from patients or family members for educational materials. 11   The release of new or updated practice guidelines, such as the 2016 update to the sepsis guideline 12   and subsequent changes in the 2018 update, 13   are examples of new knowledge that might prompt the need for practice changes.

Despite the type of trigger for a quality initiative, once the team has identified a problem, the next nursing actions are the same: Complete an inquiry to determine whether the event was a 1-time occurrence or a continuing problem. Explore current practices to determine the scope of the problem. Also, determine whether this issue is a priority for the organization. In general, selecting continual problems that are a high priority for the organization will result in increased administrator and staff buy-in. 14  

After the scope of the problem has been evaluated and the problem determined to be a priority, clinicians should review the current literature related to the problem. This step is still early in the QI process. During the literature review, look for background information to determine the characteristics of the problem, its prevalence at other centers, and factors that contribute to it. 15   After completing the review of the literature, the team can use a variety of critical thinking tools to assess the problem. Many hospitals have adopted formal programs such as Lean methodology or Six Sigma to assess and manage improvement efforts. For nurses working in hospitals without a formal QI model, the Institute for Healthcare Improvement (IHI) has extensive free resources such as critical thinking templates, videos, and toolkits 16   ; these assets are available to educate nurses about the IHI’s improvement model, the Model for Improvement. The items in the toolkits can be combined to best suit the improvement need. Scoville and Little 17   suggest that no 1 method is superior to another and that a combination of tools that are specific to the problem, rather than to the QI method, might best serve patients.

Observations and Conversations

A foundation for any assessment is built from targeted, direct observations that qualified clinicians make at the point of care. Clinicians can gather important information by going into clinical units, watching care being delivered, and asking questions of the direct caregivers. The purpose of these observations and questions to staff is not to assign blame but to understand fully the factors that have led to the clinical problem. Observation of units that do not have the same problem can often yield important information that helps determine what factors contribute to those units’ relative success.

When observing a unit, team members may find that more than 1 factor contributes to the quality issue. For example, a nurse manager in a medical intensive care unit noted a high rate of central catheter–associated bloodstream infection. The nurse manager convened a team that included a nurse leader, a critical care medicine physician, staff nurses, an infection control nurse, and nursing assistants. After being assembled, the team decided to observe the process of a nurse caring for central venous catheters on the unit. One team member observed the nurse searching for equipment both in the patient’s room and on the supply cart while changing a dressing. The team decided to investigate the workflow further to determine whether the multiple interruptions to care resulting from the nurse obtaining supplies was routine on the unit or an anomaly. Conversations with staff confirmed that supply carts were inconsistently stocked, and the bedside carts did not always have the supplies necessary for dressing changes. The process in place for replenishing supplies seemed to be broken. In this case, improving workflow to increase efficiency was not the only intervention necessary to solve the unit’s multidimensional problem with central catheter–associated bloodstream infections, but it was the first step in improving it.

Improving the workflow to increase efficiency may be a first step in solving your unit’s problem .

Spaghetti Diagram

The team decided to complete a Spaghetti Diagram, a visual tool that allowed them to examine the flow of people within the unit to determine whether the layout or organization of supplies could be improved. The team’s goal was to use the Spaghetti Diagram to redesign the work and processes—in this case, the supply and bedside carts—on the basis of how staff completed the work. 18   To create a Spaghetti Diagram, the team started with a blank schematic of the area. They selected a nurse and recorded on the unit schematic that nurse’s movement from 1 area to another ( Figure 1 ). In addition, they recorded the nurse’s step count.

After counting the lines on the diagram and the steps the nurse took to gather supplies, the team noted an excessive number of trips to the supply area; this finding indicated that the restocking process needed to be improved. The observations also illuminated other workflow problems, such as the need to call frequently for more supplies on busy days or to leave the unit to obtain equipment. The team collaborated with the hospital’s central supply department to change the par stock and the location of items. A second Spaghetti Diagram created after the reorganization depicts improvements in workflow ( Figure 2 ).

After assessment, the next step in the nursing process, diagnosis, requires nurses to synthesize what they found during the assessment into information that is meaningful for patient care. For quality issues, after gathering the initial information, nurses attempt to determine all possible causes of the issue. Many nurses are familiar with root cause analysis (RCA), which The Joint Commission requires in response to a sentinel event. 19   The purpose of an RCA is to identify any system-related problems that may have contributed to the adverse event in question and to allow changes to be made that will prevent a similar event in the future. An RCA involves identifying what happened, what should have happened, and the causes of the adverse event. Through efforts of the National Patient Safety Foundation, standard RCA has been modified to include an additional A for “action plan,” changing the acronym to “RCA2.” 20   This change emphasizes the need to both identify the root cause and create sustainable improvements in care delivery to prevent future harm.

The components of the RCA2 include factors related to communication, the environment, equipment, processes, staff performance, the team, management, and the organization. The RCA2 leads teams to think critically about the event, to uncover the contributing factor(s) that precipitated it, and ultimately to make plans to mitigate the current problem and prevent similar events in the future. 21   Teams planning improvements related to sentinel events should collaborate with risk management to identify root causes and implement plans for mitigation. Fortunately, not all quality issues result in sentinel events, but in a learning culture, it is helpful for teams to consider less serious events and near-miss or “good catch” events as opportunities for improvement. 22   In addition to the RCA2, QI teams can use other tools to enhance critical thinking in relation to nonsentinel events, near misses, and good catches. Three critical thinking tools commonly used to diagnose quality issues are the 5 Whys, cause and effect diagrams, and Pareto charts.

The 5 Whys tool requires the team to examine the cause of a clinical problem in an attempt to discover the underlying cause; to do so, the team asks the question “Why?” 5 times. 23   Users must thoughtfully consider all aspects of the problem before deciding on a root cause. Often, what might initially seem to be the cause of a problem is actually only a symptom. Figure 3 shows an example of a 5 Whys process that was completed for a mucosal injury caused by an endotracheal tube holder. As seen in the figure, the initial cause of the injury was determined to be use of the wrong tube holder. The 5 Whys tool forced the team to search further for the root cause. At first, the use of the wrong tube holder seemed to be simply an error in nursing judgment; after completing the 5 Whys, however, the team determined the root cause of this problem to be poor communication about a newly stocked item.

The 5 Whys tool is useful for relatively simple problems. Not all problems require 5 steps, but users should attempt to fully explore causes in depth before ending the process. Alternatively, the exercise might require more than 5 steps. The strength of the 5 Whys tool is its ease of use; however, it may lead teams to oversimplify complex issues by suggesting that a problem arises from a single cause or that a search for a root cause will end after 5 steps. 24 , 25  

Cause and Effect Diagram

For complex problems, the 5 Whys tool might be inadequate or cumbersome. A Cause and Effect Diagram, also called a fishbone or Ishikawa diagram, helps clinicians examine complex clinical problems by considering that multiple causes may exist. This diagram has its roots in the manufacturing sector, and so the typical categories are materials, methods, equipment, environment, and people. 26   The categories, however, can be tailored to the specific problem. When completing a cause and effect diagram, enter the problem or adverse event in the “mouth” of the fish and work backward to identify causes within each main category. The 5 Whys method can then be used to determine a root cause within individual branches. The example in Figure 4 details the work of a team exploring the reasons for an increased number of catheter-associated urinary tract infections in the intensive care unit at their hospital.

Pareto Chart

A Pareto chart is based on the Pareto principle, which suggests that 80% of a problem stems from 20% of the causes, called the “vital few.” Identifying these vital few causes is intended to begin the improvement process by mitigating the causes of most of the events. The remaining causes—the “useful many”—can be fixed later. 27  

After examining the multiple causes of a quality issue, the team may need to determine which to tackle first. For example, the nurse manager in a surgical intensive care unit noted an increased number of pressure injuries and formed a team to investigate. While reviewing the types of pressure injury that occurred throughout the previous year, the team discovered numerous sites of injury, including heels, coccyx, hips, elbows, back of the head, ankles, face, and ears. The team created a Pareto chart to display visually the frequency and cumulative percentage of pressure injuries at each location. Figure 5 shows the Pareto chart the team created; 80% of the pressure ulcers were located on the heels and coccyx. On the basis of this information, the team decided to explore the literature about how to prevent pressure injuries on the heel and coccyx.

When planning what causes to mitigate first, a team should consider other elements of the Pareto chart, such as events in the “useful many” category that can be easily fixed. An early win for the team not only encourages them to continue but can help gain buy-in from leadership and staff. 3 , 14   In our pressure injury example, the team noted that all stage 3 pressure injuries were injuries to the ears and had been caused by respiratory equipment. 28   Although ear injuries were not represented in the “vital few,” their severity was a concern. The team decided to include prevention of pressure injuries from respiratory equipment as a priority, along with prevention of those on the heel and coccyx.

As with the use of any tool for patient care, nurses bring their own unique insights to solving problems. Although a Pareto chart can aid nurses in critically thinking about an issue, their knowledge of patient care should still inform practice decisions.

After the quality issue has been assessed and diagnosed, return to the nursing literature to find evidence-based best practices and potential solutions. Organizations such as The Joint Commission, Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and many professional specialty organizations have published evidence-based practice guidelines and toolkits that are ready to be implemented in clinical practice. Such high-quality assets provide 1 way to ensure that interventions are based on evidence and are useful in practice, without requiring the team to reinvent the wheel and resynthesize the literature. 3  

To determine the quality of a clinical practice guideline, use the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. 29   This 23-item instrument is reliable and valid, and it is available online at no cost. It leads users through the evaluation of 6 quality domains: Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence. If the team determines that the guideline is of sufficient quality to use, a literature review should focus on identifying strategies to implement the guideline into practice. If no guideline exists, complete a standard review of the literature to find potential solutions.

Evidence Table

Teams should use evidence-based practice skills to critically appraise and synthesize the literature. An evidence table is an evidence-based practice tool that summarizes the relevant literature in just a few pages. 30   Common column headings in the table include the citation, purpose of the study, sample and setting, methods, results, and a rating of the level and quality of evidence. Create a separate entry for each study within the rows of the table. Once the table has been completed, use the information it provides to identify recommendations for practice that are based on the literature. Use the level of evidence and quality ratings of individual studies to determine the overall strength of the evidence. For example, practice recommendations from numerous experimental studies are considered stronger than recommendations from an equal number of nonexperimental studies, on the basis of the rigor of the study design. Similarly, if most of the articles are of high quality, the overall quality of the evidence can be rated as high. 31   When trying to obtain necessary support for a quality initiative from staff and leadership, the creator of the evidence table can easily share it with other team members, stakeholders, and administrators to provide a summary of the current evidence. 30  

Gap Analysis

Once the team has determined evidence-based practice recommendations, they should use a gap analysis, another evidence-based practice tool, to compare best practices with their organization’s current practice. A template with instructions is available online from the Agency for Healthcare Research and Quality 32   ; this template can help teams summarize the practice gap. Column headings in the gap analysis table include best practice, best practice strategies, how your practice differs from the best practice, barriers to implementing the best practice, and whether the best practice will be implemented. For problems that are guided by hospital policy, a 2-step gap analysis may be required: the team first compares the evidence-based best practices with the policy and then compares the policy with care delivered on the unit. If the policy is not congruent with best practices, it should be revised to reflect current evidence as an initial step in the quality initiative.

Completing a gap analysis requires that users not only assess how a practice differs from evidence-based best practice, but also identify organizational characteristics that might affect the implementation of change. Factors such as readiness for change within the environment or the ability to engage staff can be either drivers of or barriers to change, and they should be considered in a gap analysis. When deciding whether to implement best practices, consider how the organization’s strengths and weaknesses influence the team’s ability to embark on a QI initiative. Alternatively, consider possible threats to the organization if the initiative is not begun. When the gap analysis has been completed and the team has determined what actions will be part of the QI initiative, it is helpful to clarify the vision for the initiative by formalizing its purpose and goals.

Project Purpose and Goals

A project’s purpose is directly related to the outcome that the team wants to achieve. For example, the purpose may be to improve patient safety by decreasing alarm fatigue among nurses. The project goals should flow directly from the gap analysis and target the best practices that are described in the literature but are missing from practice. For example, if the gap analysis for alarm fatigue noted that the unit lacked a standardized process for determining alarm limits, writing and implementing a policy for setting alarm limits would be a goal for the initiative.

Unfortunately, it is not always possible to implement immediately all the best practices noted in a gap analysis. In the alarm fatigue example, the team may have identified supply issues related to the quality of electrocardiogram electrodes, but implementation of the solution may need to be delayed as the team collaborates with members of the supply chain to evaluate options and select a new product. Other reasons for delaying full implementation might include financial limitations, inadequate staffing, or accessibility of equipment; however, making some progress toward improvement is usually better than waiting for perfect conditions before starting. 3  

Quality improvement requires an interprofessional team effort. Many models exist to guide the process of quality initiatives, including Lean methodology, Six Sigma, and the IHI’s Model for Improvement; however, QI remains the work of every nurse, and nurses can use the familiar nursing process in such initiatives. In this article we have provided an overview of 4 frequently used QI tools and 2 evidence-based practice tools teams can use in quality initiatives. When nurses use these tools in conjunction with their knowledge and expertise, they can help improve care delivery and patient outcomes.

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected] .

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To learn more about quality improvement reports, read “Blending Quality Improvement and Research Methods for Implementation Science, Part I: Design and Data Collection” by Granger and Shah in AACN Advanced Critical Care , 2015;26(3):268-274. Available at www.aacnacconline.org .

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Data & Figures

Spaghetti Diagram for obtaining supplies used in changing the dressing for a central venous catheter. The observer captured the route the nurse took to gather supplies before the supplies had been reorganized. The diagram includes 8 lines. The nurse took 71 steps to gather the necessary items.

Spaghetti Diagram based on repeated observations after the supplies for changing central catheter dressings were reorganized so they were all available in supply room 1. This diagram includes 2 lines, and the nurse had to take just 33 steps to gather the necessary items.

The 5 Whys for an oral mucosal injury related to an endotracheal tube (ETT) holder.

Cause and Effect Diagram.

Pareto diagram showing pressure injuries by site. Values above each bar represent the number of pressure injuries.

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Quality Improvement

Why healthcare leadership should embrace quality improvement.

Making quality improvement a core tenet of how healthcare organisations are run is essential to ensuring safe, high quality, and responsive services for patients, write John R Drew and Meghana Pandit

Healthcare staff often have a positive experience of quality improvement (QI) compared with the daily experience of how their organisations are led and managed. 1 This indicates that some of the conditions and assumptions required for QI are at odds with prevailing management practices. For QI to become pervasive in healthcare, we need to change leadership and management.

At a QI event, we listened to an experienced nurse explaining a QI project to improve patient flow. The most striking thing was not her description of the project or what she had learnt or the benefits for patients, but instead how it had made her feel “valued and respected.”

A manager’s job is to achieve organisational goals. In the NHS, this includes meeting emergency and elective targets, such as the referral to treatment target, cancer and diagnostic standards, and the emergency department standard. Clinicians often perceive managerial interactions as authoritarian and lacking patient centredness and see QI as inclusive, bottom-up engagement. 2 Staff appreciate non-hierarchical approaches.

QI can be defined as “a systematic approach that uses specific techniques to improve quality.” 2 It requires infrastructure—systematic and disciplined ways to eliminate waste from processes, improve outcomes and experiences for patients, and eradicate mistakes. It requires organisational patience and a culture that empowers staff to achieve positive change. Organisations that foster continuous improvement might say that all staff have two jobs: first, to do their job; second, to improve it.

The nurse we spoke to said that the main difference when working on the QI project was having the time and the “permission” to make improvements in her own work. Staff engagement scores indicate that many NHS clinicians increasingly feel trapped in a flawed system with little prospect of changing it. 3

Understanding why there is a gap between the predominant management practices and culture of the NHS and the “microclimate” associated with local QI activities, and how to close that gap, is vital. Staff often report two contributors to this gap: a lack of “headspace” and feeling like a cog in a machine. 4

Rising demand for healthcare and an estimated 8% vacancy rate 5 in the clinical workforce make it difficult to find time for QI. Some leaders have committed to protecting time for QI because it generates a return in improved quality and productivity. 6 But this is still rare. Without long term strategic commitment, expecting people to find time for their second job is unrealistic. There is growing recognition that this needs to change. 7 8

Increased demand has been compounded by a rise in transparency and regulation, especially in publicly funded health systems, placing managers and leaders under greater pressure. Regulators often require improvement plans to be developed quickly, making meaningful staff engagement difficult. Recent changes in contracts, such as job planning, and pension tax rules in the UK have led many doctors to think that their employment has become more transactional. This, combined with top-down target setting and a narrative of “grip and control,” might explain why staff increasingly feel insignificant.

QI as the basis of management

QI depends on engaging and empowering the teams delivering care and equipping them with the tools and skills they need to improve care pathways. Ultimately, it means trusting professionals’ knowledge and judgment of what patients need and allowing them to make decisions, including the allocation of resources, with appropriate accountability. This requires a shift in managerial and leadership thinking ( box 1 ).

Cycles of c ontinuous i mprovement

All QI activities need to start small and then scale up. The transition to full implementation requires constant plan-do-study-act cycles with user involvement and feedback. One QI activity that changed organisational culture received the HSJ National Patient Safety Team Award in 2018.

The process began with the team members asking themselves, if they were a patient, what would they like to happen after a clinical harm incident in a hospital. The team then defined the current state and future vision. Eight frontline staff participated in a five day workshop to define the key steps that would help achieve the desired outputs. They tested the approach over the next few weeks and agreed metrics that were reported to executives at 30, 60, and 90 days. The workshop included patient representatives. Several changes resulted in increased incident reporting and user feedback, introduction of safety huddles, and the creation of an innovative patient safety response team.

Making such changes stick requires constant and consistent messaging and leading by example. Appreciating the efforts of frontline workers, and saying “thank you,” is vital.

QI needs to become the basis of how organisations are led and managed, replacing traditional, hierarchical structures and incentives. Regulators already recognise this; the Care Quality Commission’s report on quality improvement in hospital trusts, for example, says that when leaders and frontline staff work together it creates a powerful sense of shared purpose. 6 This is often present in the NHS trusts that it rates “outstanding,” it says. Dido Harding, chair of NHS Improvement, has said, “If all of the boards in the NHS chose to take culture and people management more seriously and put it on a level footing with financial and operational performance, we’d see a huge improvement in culture and outcomes for patients as well.” 9

The profound shifts in leadership and management needed for QI to thrive sometimes run contrary to traditional approaches for optimising short term performance. The recent average tenure of an NHS chief executive is 2-3 years, undermining the sustainable culture change needed for QI. 10 Burgess and colleagues describe a different type of governance that fosters learning, citing the partnership of NHS Improvement and five trusts with the Virginia Mason Institute in the United States. 11 Creating a compact with regulators enables a change in attitudes and allows organisations to grow and learn, they say. This promotes board longevity, which is a requirement for continuous improvement. 6

When do QI and good management coalesce?

The most senior leaders might have the greatest challenge; their roles would shift from being responsible for all performance to a devolved model of collective, inclusive, and compassionate leadership. Embedding QI can challenge senior leaders’ fundamental beliefs and management practices. Safe healthcare depends on defining and following standards, but an emphasis on engaging frontline staff to develop, apply, and improve those standards is often lacking. Instead, standards are implemented rapidly in a top-down, non-negotiable fashion. 12

The language of QI often reflects nature, describing organisations as ecosystems to cultivate or living systems to keep healthy rather than machines to optimise. Human factors (such as relationships, trust, and healthy multidisciplinary teams), talent management, succession planning, and assurance are central to this way of working.

Senior leaders must be role models. Their behaviour is amplified throughout the organisations they lead, whether they recognise it or not. Staff will judge what is important by where and how leaders spend their time rather than by what they say.

The Virginia Mason Institute partnership was enabled in 2015 by the secretary of state for health and social care to adopt “lean thinking” (a method developed by Toyota to deliver more benefits to society while eliminating waste) in the NHS. The trusts’ progress is being evaluated, but some trusts already report having developed a “golden thread” of QI that is visible to all, leading to improvements in CQC ratings and staff engagement.

Translating QI endeavours into operational and financial success takes time, and caregivers, providers, and regulators need to hold their nerve to see lasting performance improvement. Other healthcare providers have embraced QI methods without formal partnerships with international organisations and have delivered strong long term results. A key feature in most of these cases has been coaching for the most senior leaders and managers (for example, with a “lean” coach, usually people with experience from other industries who have moved into healthcare or consultants) so that they understand the changes they need to make in their own behaviours and practices. This has been described in the motor industry. 13

So is QI just good management?

Management, leadership, and QI are distinct but overlapping. Some leaders are not managers, and vice versa. Some, but not all, leaders and managers will undertake QI, which can be performed in isolation from leadership and management. But integrating all three is likely to optimise outcomes. Broadly, management is controlling a group or team to accomplish a goal. Leadership is influencing others to contribute towards success. Management requires “grip” (staying on top of details, intervening quickly, and giving orders or instructions if performance is below expectations), and QI often requires a deliberate loosening of that grip. This could create conflict unless management has QI as a fundamental principle.

One could argue that QI requires more people to behave like leaders and fewer to behave like managers. In the most radical forms of QI (such as those described in Reinventing Organisations 14 ), many of the roles and responsibilities of management become shared among well functioning, trusted frontline teams. The sense of “them and us” between frontline workforce and management vanishes.

The chairman of the Japanese electronics company Matsushita famously issued a challenge: “The essence of management is getting ideas out of the heads of the bosses and into the heads of labour . . . Business, we know, is now so complex and difficult, the survival of firms so hazardous in an environment increasingly unpredictable, competitive, and fraught with danger, that their continued existence depends on the day-to-day mobilisation of every ounce of intelligence.” 15

How can we help leaders get on this path?

Embedding QI in any organisation requires a new narrative from regulators and boards, strategic intent, investment in training leaders and staff, a more distributed leadership model that empowers frontline teams, and a meaningful role for patients so that improvement activity is aligned to what they most need and value. 6 16

It also requires courage and patience from the most senior leaders as they commit to new management practices. Their incentives must depend not only on delivery of top-down targets but also on building a culture conducive to long term quality improvement, which could be personally uncomfortable for them. 17

Quality management systems have an important role. 18 Taichi Ohno, architect of the Toyota Production System (popularised as “lean”), would instruct managers to spend hours “watching” from within a chalk circle on the factory floor. He wanted managers to learn to see waste and opportunities to improve quality and flow.

Learning good management in healthcare includes not only learning to see opportunities to improve healthcare processes but also noticing the experience of frontline staff, and consequently leading in ways that engage and empower them to “mobilise every ounce of intelligence.”

This article is one of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ , including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ ’s quality improvement editor post are funded by the Health Foundation.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

Implementation of Quality Improvement Initiatives

To prepare:

• Review the Learning Resources regarding the implementation of quality improvement initiatives.
• Consider what stakeholders must be presen t to implement these initiatives, and reflect on the leadership strategies needed for success in promoting quality improvement initiatives in healthcare organizations and nursing practice.
• Select a healthcare organization or nursing practice (with which you are familiar) to complete the Organizational Culture Assessment Tool.

Complete the Organizational Culture Assessment Tool for the healthcare organization or nursing practice you selected. Then, address the following 2-3 pages:

• What is the state of cultural/organizational readiness for quality improvement?
• Is the organizational culture present for quality improvement?
• What leadership strategies are present in the organization to support quality improvement, positive patient experiences, and healthcare quality?

Reminder : The College of Nursing requires that all p a p e r submitted include a title page, introduction, summary, and references. APA format

Organizational Culture Assessment

Please evaluate each statement below writing number on Scale 1 – 5, thinking about your organization.  Answer with 1 = Strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree.

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Nursing Home Basics: Who Qualifies, Who Pays, and Other Helpful Facts

Why it matters.

Understanding how nursing homes work can be confusing because standards for eligibility, insurance coverage, etc. vary from state to state in the US.

In this second article in our series on nursing homes ( read Part I here ), we answer some commonly asked questions about nursing home structures and functions.

Who Is Eligible to Enter a Nursing Home?

People qualify for nursing home/facility level of care (NFLOC) if they are unable to live alone safely in the community. There is no federal definition of NFLOC and the exact rules governing level of care vary from state to state. Despite this lack of consistency, the following four areas are commonly considered when a state determines a person’s level of care need: physical functional ability; health issues/medical needs; cognitive impairment; and behavioral issues. In many states, there has been significant rebalancing toward home and community-based services and away from nursing home care. Check state websites for updated information on specific eligibility requirements.

Who Pays for Nursing Home Care?

Medicare is the federal health insurance program for people in the US who are 65 or older, some younger people with disabilities, people with End-Stage Renal Disease. A common misconception is that Medicare will pay for all nursing home costs. This is not true.

Post-acute care (PAC) or skilled nursing facility (SNF) care is usually covered by Medicare or private insurance up to 100 days (100 percent for 20 days and then 80 percent for 80 days based on certain criteria). Long-term care (meals, room and board, and basic health services) is often paid for privately until funds are spent down. A “ spend down ” is how someone with Medicare may qualify for Medicaid — a joint federal and state program that provides health coverage to some people with limited income and resources — even if their income is higher than a state's Medicaid limit. Under a spend down, a state lets the person subtract their non-covered medical expenses and cost sharing (like Medicare premiums and deductibles) from their available income. Each state’s Medicaid program covers approximately 70 percent of nursing home care.  Long-term care insurance can also pay for nursing home care, but relatively few people have it.

The average cost of a nursing home is over $90,000 per year but this varies state to state. Multiple organizations provide information about nursing home costs and Medicaid daily rates online, including the  American Council on Aging .

Who Oversees and Regulates Nursing Home Quality and Safety?

The Centers for Medicare and Medicaid Services (CMS) oversees nursing home quality and safety at the federal level. Several divisions have regulations that pertain to nursing homes. 

The CMS Division of Nursing Homes develops and oversees most nursing home regulations. CMS delegates nursing home surveys and inspections to a designated organization in each state, usually the State Survey Agency (SSA). SSAs conduct annual, recertification, and complaint surveys and assess compliance with regulations. There is also a Special Focus Facility program for a small number of low-performing nursing homes that receive more intensive oversight and guidance on quality improvement in each state.

How Do We Measure Nursing Home Quality?

Because definitions of quality may vary, there are different methods used by federal, state, or private organizations to collect and analyze quality data. Here are a few examples:

• Minimum Data Set (MDS) is a standardized assessment tool required by CMS that measures health status in nursing home residents. All nursing homes that accept Medicare or Medicaid must submit the MDS regularly for each resident to receive payment.
• National Healthcare Safety Network is an electronic system for infection reporting, including COVID and other data that goes to CDC.
• CMS Five Star Quality Rating System gathers information from inspections (surveys), quality measures, and staffing from each nursing home and makes this information publicly available on the CMS website.
• Medicare’s Care Compare   allows users to locate and compare data from nursing homes.

What are Quality Innovation Networks-Quality Improvement Organizations (QIN-QIOs)?

QIN-QIOs focus on working with nursing homes, states, and regions to improve quality of life and quality of care across settings, including nursing homes. QIN-QIOs have their own separate line item in the US federal budget to support the national program which covers  all 50 states and US territories . QIN-QIOs are not part of state survey agencies or the survey process. Their focus is on quality improvement, support, education, and training, which are often provided free or at very low cost.

Who Works in Nursing Homes?

Women make up most of the nursing home workforce, particularly direct care workers such as certified nursing assistants (CNAs). ( Almost 90 percent of nursing assistants are female). Many are single parents.  People of color comprise most of the US nursing assistant workforce.

Most nursing assistants are low-income wage earners. Many live at or near the federal poverty level and almost half receive some type of public assistance. Nursing homes typically pay CNAs the minimum wage, but this is not necessarily a livable wage depending on where they live. For this reason, CNAs often work in multiple settings and have multiple jobs. For many CNAs, English is not their first language, and they may have limited English proficiency. Many are immigrants.

What Are Some Challenges Faced by the Nursing Home Workforce?

There are many issues facing nursing home CNAs today and some new opportunities. The National Association of Health Care Assistants (NAHCA) conducted a survey of 1,420 CNAs in July 2023. When asked about their jobs, many CNAs reported that low wages and benefits would be the primary reasons they intend to seek another type of employment. They also cited unstable or inadequate hours, lack of supervisor’s/manager’s support, lack of career advancement or professional development, and feeling under-valued.

High rates of turnover (in some cases over 100 percent in a year) and the need for stronger, stable leadership are important reasons to better support CNAs and other direct care workers. Creating and testing standardized career ladders or lattices and providing more training and education on topics of interest to CNAs represent opportunities to promote better retention and reduce turnover. Another way to respond to CNA concerns is by becoming an  Age-Friendly Health Systems Nursing Home .

Alice Bonner, PhD, RN, is IHI’s Senior Advisor for Aging. Amanda Meier, BSW, MA, is IHI’s Project Manager, Age-Friendly Health Systems. If you have any questions or ideas about nursing homes or related policy issues, please feel free to reach out to Alice Bonner ( [email protected] ) or Amanda Meier ( [email protected] ).

You may also be interested in:

The Basics We (and Policymakers) Should Know about Nursing Homes

Centering What Matters: The Core of Age-Friendly Care

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