to broad systems of care. They encouraged examination of how workflow happens, consideration of the various staffing roles and skill mix, and the question we ask every time: “Can it be done better?”
“PSI RNs”: A Significant Structural Change to Support Performance and Safety Improvement Initiatives and Gain More Operational Insight
In our organization, a significant change brought about by these deep dives was the development of a “staff RN quality charge nurse” position. The charge of these nurses was to focus solely on performance and safety improvement (PSI). The PSI RNs are staff nurses who monitor care on a particular unit or division and identify the factors that impact practice. As experienced RN staff members, they can identify gaps in workflow and resources, redundancy in workload, and the competency levels of both new and experienced staff members. The PSI RNs noted where and when staff members created workarounds for care delivery because operational pauses prevented people from getting their work done. It made sense to look at workflow and workload at the unit level, since as first‐line workers, these PSI RNs were using their insight and experience to assess what was occurring operationally in patient care. The action plans that came from the data they provided could then focus directly on solving real‐life problems in the care delivery system. The thorough data collection the PSI RNs made possible meant we would get more and better insights into our day‐to‐day operations.
Once the data analyst and PSI RNs were in place, the organization made sure resources were available for them to do deep dives as a team. As each unit has its own culture and specific service line, the PSI RNs and the staff members of individual units came together to review the data reports from the analyst and discuss the “whys” and “hows.” They came up with responsive interventions that were specifically designed for their patient population, since what works in a pediatric unit, for example, may not work in an intensive care unit. This grassroots approach made sense to the team and led to greater staff buy‐in. It is largely staff‐to‐staff discussions, not manager‐to‐staff mandates, that create effective planning to meet the unit‐specific goals of excellence and positive patient outcomes.
It is largely staff‐to‐staff discussions, not manager‐to‐staff mandates, that create effective planning to meet the unit‐specific goals of excellence and positive patient outcomes.
The PSI RNs provided context and clarity, helping managers and staff members see how policies, standards, regulations, and best practice come together to define quality care. This support for the nurse manager helped facilitate the change to a high‐quality/high‐reliability culture on the units, ensuring that each unit was delivering high‐quality, evidenced‐based care around the clock. This work can be overwhelming in organizations where there is a clinical staff of 150 nurses in large units, such as in the emergency department. The addition of the PSI RNs provided a unique mediating and educating role which served to support both staff members and managers in establishing standards of quality that were consistent with policy.
The work of these teams also provided a great example of “measuring care delivery” when it came time to write our Magnet® document. The Magnet methodology sets the outline an organization must use to describe how data is used to improve care delivery as well as organizational and professional growth, within the context of the unit culture. Our new quality structure and process proved to be a benefit when it came time to write the Magnet application, because the data management process and the PSI RN role were based on an understanding of the drivers of the data, innovative action plans that answered “why” and “how,” and most importantly, they demonstrated sustained positive outcomes.
The Importance of Interdisciplinary Collaboration in Data Analysis
Nurses have always been a driving force in quality. Whether at the chief nurse officer's level or leading the organization's quality improvement department, nursing is charged with providing and ensuring excellent patient care. However, application of the quality data is interdisciplinary by nature, as each discipline's care delivery impacts the others. In our organization, after the addition of a data analyst and the PSI RNs, people in other disciplines observed that nursing had made significant sustainable improvements in care and outcomes. They started to ask for consultation from nursing in the proper use of predictive analytics and its application for operational refinement and outcomes improvement. Leaders in radiology asked nursing to teach their staff members how to examine the data and how to use the same brainstorming techniques the nursing staff had used to develop action plans.
A memorable example of interdisciplinary impact on outcomes was the presumably “cost‐effective” decision to change the color of caps used for central lines. Although to the products and purchasing team it was just a color, and the yellow ones were less expensive than the green ones, they had no idea the impact the change in cap color would make on our infection control practices. After the cap change, the catheter‐associated infections in the ICU began to rise, and it was not until the interdisciplinary team dove deeply into the discussion of line maintenance, and then finally down to cap use (an element rarely thought of), that we discovered what had gone wrong. It was becoming clearer to people throughout the organization that everybody's input matters.
Although to the products and purchasing team it was just a color, and the yellow caps were less expensive than the green caps, they had no idea the impact the change in cap color would make on our infection control practices.
Key Success Factors
There are two key success factors that I would recommend to organizations pursuing the sort of quality improvement work outlined in this chapter. They are (a) hiring nurses with MSN and BSN degrees to work as PSI RNs, and (b) using recognition as an incentive for the good work done on quality improvement projects.
Education Levels of PSI RNs
Advanced practice nurses and clinical staff members with baccalaureate or master's‐level education have been taught to be consistent in asking the “why” and “how” questions that need to be asked in the data analysis process. When the question arises: “Did we look at this specific factor?” these highly prepared clinicians tap into their knowledge of the subject and ask the necessary questions to get at meaningful, actionable data that can be used to improve care outcomes. Leaders need to advocate for nurses who are hired as PSI RNs and into other performance improvement positions, to be MSN and BSN level nurses, and they must support nurses at all levels of preparation in seeking continuing education in areas such as statistics, research, ethics, and practice standards. (Fun fact: Our PhD prepared data analyst was once an associate nurse.) This emphasis will promote sustainability and encourage a culture of innovation.
Recognition of Excellence
Staff recognition is also crucial to sustaining the changes that bring about improved outcomes. When a staff council makes a change that improves practice, giving thank‐you notes, awards, and parties lets staff members know they are appreciated for the great work they have done. Be as specific as possible in your expressions of appreciation, focusing on specific improvements in practice and changes people have made that are meaningful to professional care. When staff members are recognized, they are motivated to keep working to improve things. They are proud of the outcomes they have achieved, and they love to know that leaders are also proud of them.
Summary
Healthcare is now very competitive, and the public often chooses healthcare based on online consumer advocacy resources. Improved outcomes help the organization score well with online resources such as Leapfrog and Hospital Compare, negotiate with payor sources, and even successfully achieve Magnet recognition. All
