this competency, nurses use data to monitor the outcomes of care processes. They also use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. As part of the nursing process, direct care nurses evaluate the care they deliver to each patient. In addition, direct care nurses work together to improve the outcomes of care for the populations served in the care setting. Clinical nurses and nurse leaders identify gaps between local outcomes and best practice outcomes. Nurse leaders lead and provide resources for quality improvement efforts, including access to quality data, quality improvement tools, and quality experts.
An HRO has a strong commitment to health care process improvement. Becoming an HRO requires that the organization systematically review the complexity of health care processes, identify the root causes of failures, implement solutions, measure and monitor outcomes, and sustain the improvement. In some cases, an entirely new process may be required to enhance safety. Increasingly, patients and their families are being engaged to assist in health care process improvements. Quality improvement is described in greater detail in Chapter 18.
Case Study 4.4
Nurses who work on an Orthopedic Unit notice that their patients have a longer length of stay after hip replacement surgery than the national average. They use QI tools to understand this variation and determine that an underlying cause is inconsistent patient preparation prior to surgery. Some patients anticipate a speedy recovery and have not identified the help they will need after discharge. Other patients expect to be admitted to a rehabilitation unit to recover after surgery, which may not be indicated for the procedure. These situations result in discharge delays while the unit's nurse case manager arranges for family help, home care services, or rehabilitation services. The nurses work with other members of the interprofessional team, including physicians, physical therapists, and occupational therapists, to design a test of change. They create a patient education video that clearly outlines recovery expectations and guides patients in establishing a post‐discharge plan of care.
After implementing the intervention, they note that length of stay has decreased and there are still opportunities for improvement. The team designs another test of change. In addition to the video, each patient also receives a call from the nurse case manager to answer questions and discuss and document the plan of care. Again, the team sees a decrease in length of stay and continued opportunities. The team designs a third test of change. The day before the surgery, a nurse from the Preadmission Testing Unit (PAT) calls the patient and verifies the plan of care that the patient developed with the nurse case manager. If the plan is still in place and appropriate, the surgery is performed as scheduled. If the plan needs to be changed, the PAT nurse notifies the surgeon and nurse case manager and they work together to resolve the issues. After implementing this test of change, length of stay for patients having total hip replacement surgery is lower on the orthopedic Unit than the benchmark, and the team also sees a decrease in 30‐day readmission rates.
1 What was the original opportunity that the nurses wanted to improve?
2 Why was it important for the nurses to work with the interprofessional team to address this opportunity?
3 Why did the team elect to conduct three tests of change rather than implementing everything at once?
4 Why was the use of a patient video partially effective in reducing length of stay for patients after total hip replacement surgery?
5 Why did the conversation with the nurse case manager improve the length of stay for patients after total hip replacement surgery?
6 Why did the call from the PAT nurse further improve length of stay?
7 What factors may have resulted in the decrease in the 30‐day readmission rate?
Real World Interview with Karen Zaehler – Edward Quality Council
The purpose of the Nursing Quality Council is to review house‐wide quality data and share unit‐based quality improvement projects. As chair of the council, my role was to support staff nurses working on quality improvement projects by helping to provide data, research evidence, and other resources needed. Working with patients directly at the bedside gives staff nurses a unique insight on what positively affects quality of care. Having staff nurses involved in quality and safety improvement is vital, as it not only broadens the staff nurse's knowledge related to performance data, but also empowers them to offer their perspective on improvement projects that will directly affect patient care.
Karen Zaehler, BSN, RN, CMSRN
Staff Nurse, Surgical Care Unit, Edward Hospital
Naperville, IL
Safety
In this competency, nurses minimize risk of harm to patients and providers through both system effectiveness and individual performance. Direct care nurses incorporate human factors and other safety design principles into their care. They use effective strategies to decrease reliance on memory to reduce risk of harm to self and others. Direct care nurses identify and report concerns about safety and participate in analyzing errors and designing system improvements. They participate in root cause analyzes and use national patient safety resources in their professional development. Nurse leaders strategically plan to improve practice and reduce risk of harm to patients, staff, and others. They create HROs based on human factors research and foster a safe and reliable culture where safe design principles are developed and implemented. Nurse leaders anticipate and mitigate system failures and hazards and design and implement changes in response to identified hazards and errors.
Incorporate Human Factors
Incorporate Human Factors. Humans function primarily in three performance modes: skill‐based, rule‐based, and knowledge‐based. Errors occur in each performance mode. By understanding the way humans function, nurses can decrease the number of errors that occur in each performance mode.
Skill‐Based Performance
Individuals use skill‐based performance for routine, familiar tasks that can be done without thinking about them. The drive home, for example, may be so familiar that drivers arrive without knowing how they got there. Nurses often function in this mode because of the repetitive nature of some nursing tasks. Consider, for example, Jerry who is completing his documentation in the EHR. Jerry logs onto the EHR many times each day and he doesn't need to think about his user identification or his password. He's on auto‐pilot. He pulls up his assigned patients in the EHR and begins to document.
Generally, skill‐based performance is accurate, but there is still risk for error. Slips occur when, without intending to, the individual does the wrong thing. Jerry could open a patient's record and document care that was delivered to a different patient. Lapses occur when, without intending to, the individual fails to do what he meant to do. Jerry could document on the correct patient but forget to save or file his work before closing the record. Fumbles occur when, without intending to, an individual mishandles a word or action. Jerry might notice that his patient was visited by a “dear friend” and accidently document that the patient was visited by a “dead friend.”
Several strategies help nurses to stop and think before acting to prevent skill‐based errors. Nurses may use PAR (Pause‐Act‐Review). With this technique, nurses pause for
