4.12 Quality Improvement Measures
Kathy Andresen DNP, MPH, RN, CNE
Measuring Outcomes
An important aspect of quality improvement is the use of measures, also referred to as metrics, to identify the level of change on specific elements of the project. The Institute for Healthcare Improvement(IHI) provides a white paper on Whole System Measures (Martin et al., 2007). The IHI white paper identifies a system of existing metrics that impact quality in a health system. These metrics are unique to each health system and should be considered as the leader selects measures for their specific project. Depending upon the scope of the project, multiple measures are utilized.
IHI identifies three types of measures that are used in for improvement efforts. They include outcomes measures, process, measures and balancing measures (IHI, n.d.).
For this textbook, we are focusing on Outcome and Process measures examples from the IHI. Process measures can be considered indicators that are measured at specific intervals of the project. Process measures are vital for success of a project as they can inform leaders of the need to change the direction throughout the project, as opposed to waiting until the end of a change project.
Process Measures (IHI, 2019)
Are the parts/steps in the system performing as planned? Are we on track in our efforts to improve the system?
- For diabetes: Percentage of patients whose hemoglobin A1c level was measured twice in the past year
- For access: Average daily clinician hours available for appointments
- For critical care: Percentage of patients with intentional rounding completed on schedule
Outcome measures are those that indicate change at the end of a specified period of time.
Outcome Measures (IHI, 2019)
How does the system impact the values of patients, their health and wellbeing? What are impacts on other stakeholders such as payers, employees, or the community?
- For diabetes: Average hemoglobin A1c level for population of patients with diabetes
- For access: Number of days to 3rd next available appointment
- For critical care: Intensive Care Unit (ICU) percent unadjusted mortality
- For medication systems: Adverse drug events per 1,000 doses
Use of existing measures is ideal so change can be tracked over a period of time. This box shares some examples of existing measures. Additional measures are described in further detail in the pages below.
Examples of Existing Measures (IHI, 2019)
- Patient/client satisfaction surveys
- Length of stay
- Adverse events
- Staff turnover rates
- Staff-to-patient ratio
- Infection rates
- Employee satisfaction surveys
Utilization Review
Health care agencies are reimbursed from Medicare, Medicaid, and private insurance based on their quality performance measures. A utilization review is an investigation of health care services performed by doctors, nurses, and other health care team members to ensure money is not wasted covering unnecessary or inefficient expenditures for proper treatment. Utilization review also allows organizations to objectively measure how their health care services and resources are being used to best meet their patients’ needs. Information from patients’ medical records is analyzed, along with patient demographics, to evaluate resource allocation, efficiency, and quality of health promotion initiatives (Institute of Medicine, 1989).
Using Informatics to Promote Quality
Utilization review relies on the collection of meaningful data from health records to determine if quality metrics are being met. Informatics refers to using information and technology to communicate, manage knowledge, mitigate error, and support decision-making (QSEN, n.d.). Informatics allows members of the health care team to share, store, and analyze health-related information. Nurses have an important role in informatics. Nursing informatics is the science and practice of integrating nursing knowledge with information and communication technologies to promote the health of people, families, and communities worldwide (AMIA, n.d.). It is a nursing specialty with certification available from the ANCC.
These are several benefits of using informatics in health care (Otokiti, 2019):
- Improvement of Patient Safety: Informatics allows for up-to-date information sharing by both the patient and members of the health care team. Using informatics can help to reduce the occurrence of medication errors, as well as monitor patient side effects and overall health status. For example, barcode scanning has reduced medication errors by ensuring the correct dose is administered to the correct patient at the correct time.
- Reduction of Delays in Care: Some health care informatics systems allow for direct communication between health care team members and patients. The ability to ask and answer questions without needing to schedule an office appointment promotes the ability for care to be delivered efficiently in a cost-effective manner.
- Reduction of Waste: The use of informatics to share information between care team members reduces waste associated with duplication of tests or exams when more than one provider is on the care team. Additionally, patients can request their records be shared with health providers from other health organizations, which reduces duplication and unnecessary spending across the nation.
- Promotion of Patient-Centered Care: Many informatics systems have “patient portal” options where the patient and/or designated personnel are able to be active participants in the care planning and health promotion processes. Informatics offers an inclusive environment for patients to communicate and share directly with their care team regardless of physical location and timing.
- Support of Quality Improvement: The continuous process of quality improvement requires the ability to collect and analyze data in a systematic and reliable manner. Using informatics provides members of the health care team a secure place to store data, as well as the ability to review in a timely manner.
Quality Indicators
The National Database of Nursing Quality Indicators (NDNQI) was developed as a national nursing database used to evaluate quality in nursing care. This database was purchased by Press Ganey in 2014. In collaboration with the American Nursing Association (ANA), the original NDNQI database established nurse-sensitive quality indicators such as these (Montalvo, 2007):
- Nursing Care Hours Per Patient Day
- Hospital-Acquired Pressure Injuries
- RN Job Satisfaction
Nurses use quality indicators to support practice changes with evidence directly related to improved patient outcomes.
Learn More
Read about current quality measures promoting clinical excellence at the Press Ganey website.
Next: 4.13 Spotlight Application
Followership
Followership is described as the upward influence of individuals on their leaders and their teams. The actions of followers have an important influence on staff performance and patient outcomes. Being an effective follower requires individuals to contribute to the team not only by doing as they are told, but also by being aware and raising relevant concerns. Effective followers realize that they can initiate change and disagree or challenge their leaders if they feel their organization or unit is failing to promote wellness and deliver safe, value-driven, and compassionate care. Leaders who gain the trust and dedication of followers are more effective in their leadership role. Everybody has a voice and a responsibility to take ownership of the workplace culture, and good followership contributes to the establishment of high-functioning and safety-conscious teams (Dreier et al., 2019)
Team members impact patient safety by following teamwork guidelines for good followership. For example, strategies such as closed-loop communication are important tools to promote patient safety.
Leadership and Management Characteristics
Leadership and management are terms often used interchangeably, but they are two different concepts with many overlapping characteristics. Leadership is the art of establishing direction and influencing and motivating others to achieve their maximum potential to accomplish tasks, objectives, or projects (Northhouse, 2004; Specchia et al., 2021). There is no universally accepted definition or theory of nursing leadership, but there is increasing clarity about how it differs from management (Scully, 2015). Management refers to roles that focus on tasks such as planning, organizing, prioritizing, budgeting, staffing, coordinating, and reporting (Hannaway, 1989). The overriding function of management has been described as providing order and consistency to organizations, whereas the primary function of leadership is to produce change and movement (Cherry & Jacob, 2017). View a comparison of the characteristics of management and leadership in Table 1.1a.
Table 1.1a Management and Leadership Characteristics (Northhouse, 2004)
| MANAGEMENT | LEADERSHIP |
|---|---|
Planning, Organizing, and Prioritizing
|
Establishing Direction
|
Budgeting and Staffing
|
Influencing Others
|
Coordinating and Problem-Solving
|
Motivating
|
Not all nurses are managers, but all nurses are leaders because they encourage individuals to achieve their goals. The American Nurses Association (ANA) established Leadership as a Standard of Professional Performance for all registered nurses. Standards of Professional Performance are “authoritative statements of action and behaviors that all registered nurses, regardless of role, population, specialty, and setting, are expected to perform competently” (ANA, 2021). See the competencies of the ANA Leadership standard in the following box and additional content in other chapters of this book.
Competencies of ANA's Leadership Standard of Professional Performance
- Promotes effective relationships to achieve quality outcomes and a culture of safety
- Leads decision-making groups
- Engages in creating an interprofessional environment that promotes respect, trust, and integrity
- Embraces practice innovations and role performance to achieve lifelong personal and professional goals
- Communicates to lead change, influence others, and resolve conflict
- Implements evidence-based practices for safe, quality health care and health care consumer satisfaction
- Demonstrates authority, ownership, accountability, and responsibility for appropriate delegation of nursing care
- Mentors colleagues and others to embrace their knowledge, skills, and abilities
- Participates in professional activities and organizations for professional growth and influence
- Advocates for all aspects of human and environmental health in practice and policy
Leadership Theories and Styles
In the 1930s Kurt Lewin, the father of social psychology, originally identified three leadership styles: authoritarian, democratic, and laissez-faire (Carlin, 2019; Lewin et al., 1939).
Authoritarian leadership means the leader has full power. Authoritarian leaders tell team members what to do and expect team members to execute their plans. When fast decisions must be made in emergency situations, such as when a patient “codes,” the authoritarian leader makes quick decisions and provides the group with direct instructions. However, there are disadvantages to authoritarian leadership. Authoritarian leaders are more likely to disregard creative ideas of other team members, causing resentment and stress (Carlin, 2019).
Democratic leadership balances decision-making responsibility between team members and the leader. Democratic leaders actively participate in discussions, but also make sure to listen to the views of others. For example, a nurse supervisor may hold a meeting regarding an increased incidence of patient falls on the unit and ask team members to share their observations regarding causes and potential solutions. The democratic leadership style often leads to positive, inclusive, and collaborative work environments that encourage team members’ creativity. Under this style, the leader still retains responsibility for the final decision (Carlin, 2019).
Laissez-faire is a French word that translates to English as, “leave alone.” Laissez-faire leadership gives team members total freedom to perform as they please. Laissez-faire leaders do not participate in decision-making processes and rarely offer opinions. The laissez-faire leadership style can work well if team members are highly skilled and highly motivated to perform quality work. However, without the leader’s input, conflict and a culture of blame may occur as team members disagree on roles, responsibilities, and policies. By not contributing to the decision-making process, the leader forfeits control of team performance (Carlin, 2019).
Over the decades, Lewin’s original leadership styles have evolved into many styles of leadership in health care, such as passive-avoidant, transactional, transformational, servant, resonant, and authentic (Northhouse, 2004; Specchia et al., 2021). Many of these leadership styles have overlapping characteristics.
Passive-avoidant leadership is similar to laissez-faire leadership and is characterized by a leader who avoids taking responsibility and confronting others. Employees perceive the lack of control over the environment resulting from the absence of clear directives. Organizations with this type of leader have high staff turnover and low retention of employees. These types of leaders tend to react and take corrective action only after problems have become serious and often avoid making any decisions at all (Specchia et al., 2021).
Transactional leadership involves both the leader and the follower receiving something for their efforts; the leader gets the job done and the follower receives pay, recognition, rewards, or punishment based on how well they perform the tasks assigned to them (Northhouse, 2004). Staff generally work independently with no focus on cooperation among employees or commitment to the organization (Specchia et al., 2021).
Transformational leadership involves leaders motivating followers to perform beyond expectations by creating a sense of ownership in reaching a shared vision (Northhouse, 2004). It is characterized by a leader’s charismatic influence over team members and includes effective communication, valued relationships, and consideration of team member input. Transformational leaders know how to convey a sense of loyalty through shared goals, resulting in increased productivity, improved morale, and increased employees’ job satisfaction (Specchia et al., 2021). They often motivate others to do more than originally intended by inspiring them to look past individual self-interest and perform to promote team and organizational interests (Specchia et al., 2021).
Servant leadership focuses on the professional growth of employees while simultaneously promoting improved quality care through a combination of interprofessional teamwork and shared decision-making. Servant leaders assist team members to achieve their personal goals by listening with empathy and committing to individual growth and community-building. They share power, put the needs of others first, and help individuals optimize performance while forsaking their own personal advancement and rewards (Specchia et al., 2021).
Learn More
Visit the Greenleaf Center site to learn more about "What is Servant Leadership?"
Resonant leaders are in tune with the emotions of those around them, use empathy, and manage their own emotions effectively. Resonant leaders build strong, trusting relationships and create a climate of optimism that inspires commitment even in the face of adversity. They create an environment where employees are highly engaged, making them willing and able to contribute with their full potential (Specchia et al., 2021).
Authentic leaders have an honest and direct approach with employees, demonstrating self-awareness, internalized moral perspective, and relationship transparency. They strive for trusting, symmetrical, and close leader–follower relationships; promote the open sharing of information; and consider others’ viewpoints (Specchia et al., 2021).
Table 1.1b Characteristics of Leadership Styles
| Authoritarian | Democratic | Laissez-Faire or Passive-Avoidant |
|---|---|---|
|
|
|
| Transactional | Transformational | Servant |
|---|---|---|
|
|
|
| Resonant Leaders | Authentic Leaders |
|---|---|
|
|
Outcomes of Various Leadership Styles
Leadership styles affect team members, patient outcomes, and the organization. A systematic review of the literature published in 2021 showed significant correlations between leadership styles and nurses’ job satisfaction. Transformational leadership style had the greatest positive correlation with nurses’ job satisfaction, followed by authentic, resonant, and servant leadership styles. Passive-avoidant and laissez-faire leadership styles showed a negative correlation with nurses’ job satisfaction (Specchia et al., 2021). In this challenging health care environment, managers and nurse leaders must promote technical and professional competencies of their staff, but they must also act to improve staff satisfaction and morale by using appropriate leadership styles with their team (Specchia et al., 2021).
Systems Theory
Systems theory is based on the concept that systems do not function in isolation but rather there is an interdependence that exists between their parts. Systems theory assumes that most individuals strive to do good work, but are affected by diverse influences within the system. Efficient and functional systems account for these diverse influences and improve outcomes by studying patterns and behaviors across the system (Anderson, 2016).
Many health care agencies have adopted a culture of safety based on systems theory. A culture of safety is an organizational culture that embraces error reporting by employees with the goal of identifying systemic causes of problems that can be addressed to improve patient safety. According to The Joint Commission, a culture of safety includes the following components (The Joint Commission, 2017):
- Just Culture: A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn by managers between human error, at-risk, and reckless employee behaviors. See Figure 1.2 (Palarski, 2020) for an illustration of Just Culture.
- Reporting Culture: People realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses. For example, nurses complete an “incident report” according to agency policy when a medication error occurs or a client falls. Error reporting helps the agency manage risk and reduce potential liability.
- Learning Culture: People regularly collect information and learn from errors and successes while openly sharing data and information and applying best evidence to improve work processes and patient outcomes.
The Just Culture model categorizes human behavior into three categories of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior (ANA, 2010):
- Simple human error: A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a patient. In this example, a root cause analysis reveals a system issue that must be modified to prevent future patient errors (e.g., change the labelling and storage of look alike-sound alike medications) (ANA, 2010).
- At-risk behavior: An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the patient. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time (ANA, 2010).
- Reckless behavior: Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk. For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk (ANA, 2010).
These categories of errors result in different consequences to the employee based on the Just Culture model:
- If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes (ANA, 2010). In the “simple human error” example above, system-wide changes would be made to change the label and location of the medications to prevent future errors from occurring with the same medications.
- Individuals committing at-risk behavior are held accountable for their behavioral choices and often require coaching with incentives for less risky behaviors and situational awareness (ANA, 2010). In the “at-risk behavior” example above, when the nurse chose to ignore an error message on the barcode scanner, mandatory training on using barcode scanners and responding to errors would likely be implemented, and the manager would track the employee’s correct usage of the barcode scanner for several months following training.
- If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken (ANA, 2010). In the “reckless behavior” example above, the manager would report the nurse’s behavior to the State Board of Nursing for disciplinary action. The SBON would likely mandate substance abuse counseling for the nurse to maintain their nursing license. However, employment may be terminated and/or the nursing license revoked if continued patterns of reckless behavior occur.
See Table 1.1c describing classifications of errors using the Just Culture model.
Table 1.1c Classification of Errors Using the Just Culture Model
| Human Error | At-Risk Behavior | Reckless Behavior |
|---|---|---|
| The caregiver made an error while working appropriately and focusing on the patient’s best interests. | The caregiver made a potentially unsafe choice resulting from faulty or self-serving decision-making. | The caregiver knowingly violated a rule and/or made a dangerous or unsafe choice. |
| Investigation reveals system factors contributing to similar errors by others with similar knowledge and skills. | Investigation reveals the system supports risky action and the caregiver requires coaching. | Investigation reveals the caregiver is accountable and needs retraining. |
| Manage by fixing system errors in processes, procedures, training, design, or environment. | Manage by coaching the caregiver and fixing any system issues:
|
Manage by disciplining the caregiver. If the system supports reckless behavior, it requires fixing. |
| CONSOLE | COACH | PUNISH |
Systems leadership refers to a set of skills used to catalyze, enable, and support the process of systems-level change that is encouraged by the Just Culture Model. Systems leadership is comprised of three interconnected elements (Dreier, 2019):
- The Individual: The skills of collaborative leadership to enable learning, trust-building, and empowered action among stakeholders who share a common goal
- The Community: The tactics of coalition building and advocacy to develop alignment and mobilize action among stakeholders in the system, both within and between organizations
- The System: An understanding of the complex systems shaping the challenge to be addressed
Applied Learning Experience 1.2 Leadership Self Assessment
- Complete the quiz "What is your Leadership Style?"
- Review your leadership style
- Reflect on your findings
Next: 1.12 Emotional Intelligence
Overview
The position of either leader or follower does not hold power. Rather, it is how we respond when we are in these roles, based on our emotional intelligence, that gives power to each role. Emotional intelligence has been described as the “ability to monitor and discriminate among emotions and to the use the data to guide thought and action” (Goleman, 2020).
Goleman (2020), a researcher who has completed work spanning decades in the area of work performance, studied the importance of emotional intelligence in achieving personal excellence. He defines emotional intelligence in greater depth, stating that it is composed of abilities such as being able to motivate oneself and persist in the face of frustrations; to control impulse and delay gratification; to regulate one’s moods and keep distress from swamping the ability to think; to empathize and to hope (Goleman, 2020). Goleman’s model of emotional intelligence contains five skills that comprise personal and social competencies (see Table 1.2 below). The three skills of self-awareness, self-regulation, and motivation relate to the individual’s personal competence. The remaining skills of empathy and social skills are classified as social competencies (Liu & Boyatzis, 2021).
|
Competency |
Skill Area |
Description |
|---|---|---|
|
Personal |
Self-awareness |
Knowing one’s self |
|
Self-regulation |
Managing one’s self |
|
|
Motivation |
Sentiments and passions that facilitate the attainment of goals | |
|
Social |
Empathy |
Understanding of others and compassion toward them |
|
Social skills |
Expertise in inspiring others to be in agreement |
Developing Emotional and Social Intelligence
As a nurse, gaining emotional and social intelligence is critical to expanding leadership capacity. Emotional Intelligence contributes to achievement of effective management in healthcare (Prezerakos, 2018). You encounter many different types of people, both colleagues and patients. It is extremely important to be self-aware, reflect on your feelings, and think about how emotions can influence both actions and relationships (or social interactions). That is, you must learn to reflect on your clinical experiences and think of how you could have changed a situation by using self-awareness or mindsight. It is essential for nurses to improve social and emotional skills (Prezerakos, 2018). See Applied Learning Activity 1.2 to complete an assessment of your Emotional Intelligence.
Applied Learning Activity 1.2 Emotional Intelligence
- Take this Emotional Intelligence self-assessment test.
- Complete this online survey: the online system calculates the results for you.
- Review your EI score.
- Reflect on your findings.
