a nurse's viewpoint
focus on improvement
by roberta b. abrams, for healthleaders online, oct. 21, 2002
the nursing shortage promises to create a major public health crisis unless it is fixed in the near future. so says steven a. schroeder, m.d., president and ceo of the robert wood johnson foundation. his thoughts are echoed by many sources, including the joint commission on accreditation of health care organizations, and by philip authier, president of the american organization of nurse executives.
research documents the connection between nurse staffing shortages and the recovery of hospitalized patients. several recent studies have linked improved staffing with decreased incidences of urinary tract infections and respiratory infections - including pneumonia. indeed, a strong correlation exists between decreased availability of professional nurse staffing and increased patient mortality.
the current nursing crisis, its causes and attempts at amelioration, have been the subject of many articles in a nurse's viewpoint and elsewhere, and will continue to be for some time to come. the current situation must remain a focal point for nurses, for other health care providers, and for healthcare administrators.
to help solve the crisis, major pieces of legislation must be supported by healthcare executives and passed by our elected representatives to facilitate the necessary recovery? this is certainly an appropriate time to remind those who would choose to represent us to attend to funding the nurse reinvestment act, the fy2003 nursing appropriations bill, and the patient bill of rights. having said that, however, while we expend all necessary efforts to recruit, prepare, and retain professional nurses, we must also pay attention to other aspects of the healthcare delivery system. as nurses, we can never allow ourselves to become complacent about the quality of the care we deliver.
the processes of continued vigilance are known by many names: process improvement, continuous quality improvement, quality assurance, and risk management, among others. however titled, the essence remains the same: the healthcare system needs a constant assessment of our patient care delivery systems with a focus on seeking opportunities to improve.
many say that given the current staffing problems, there is no time for anything other than the essentials of patient care. the logical rejoinder for that thought process is that errors or inefficiencies cost time and that "quality is cost-effective." if, by examining both what we do and the way in which we do it, we can find more efficient or effective ways of delivering care, we save time. if we can eliminate problems in completing care and facilitating discharge, we can eliminate rework. if we can include or improve the use of labor-saving devices such as robots and computerized charting systems, we can improve the work life of the nurse and other caregivers.
the process of improvement begins on the patient care unit. it starts best with a staff meeting with as many participants as possible. staff should be encouraged to brainstorm about factors or processes that are problematic for staff and/or patients. in most cases, the list will appear rather daunting.
the next step is to triage the list, deciding on priorities. some prefer to begin by attacking "low-hanging fruit" -those things that can be easily fixed. the gains may be small - but it's a good way to "debug" the process. even small gains build momentum and interest in going further.
in other cases, the staff may wish to begin by attacking high-volume issues. for example, if medication errors are a frequent problem, it may be prudent to begin by examining the factors involved and modes of preventing these patient incidents.
still, other staff may wish to begin with infrequent issues whose importance is dictated by what caused them. problems such as unplanned extubations or problems with peripherally inserted central catheters would be appropriate examples.
in some care arenas, external forces may dictate where reparations must begin. insurance carriers, third-party payors, or jcaho surveys may remove choice from the staff.
whatever the issue, the process remains essentially the same. the process begins by listing all steps involved. for example, if the problem is medication errors, the list would begin with the prescription (or order) for the medication, include obtaining the medication, administering it to the patient, and end with documentation.
at the same time, it is appropriate to identify all the people who participate in the issue:
* the physicians who write the prescriptions
* the nurses (or clerks) who transcribe the orders
* the pharmacists who fill it
* the nurses who assess the patients and administer the medications
* the patients who receive them
in some process improvement systems, these folks are called "stakeholders." it doesn't matter what they are called, all who participate in the problem need to be involved in fixing it.
the next phase involves examining the source of the errors. in medication errors, errors may result from more than one source: illegible prescriptions, wrong dosage, incompatible medications, undetected allergies, improper patient identification, errors in timing, or failure to document - or any combination thereof. this is not a case of finding fault - or assessing blame. it involves a multifaceted, multi-disciplinary diagnosis of where and how things can and do go wrong.
planning for process improvement is a detailed - and sometimes lengthy - event. continuing with the medication error example, if the problem is in correctly transcribing the order, what experiences have team members had with similar problems? what possible solutions are described in the literature? many healthcare facilities have dealt with errors in transcription by installing computerized order entry systems. a good order entry system can eliminate transcription problems, problems with incompatible medications, and allergy identification. it will not eliminate problems in administration.
once the potential solution has been identified, the stakeholders should establish a plan for its implementation. the plan should include potential risks, benefits, and measurement criteria to evaluate the success of the proposed solution. in our medication error analogy, what was the incidence of errors before the new system was installed, and what is the incidence after installation of the order entry system?
evaluation of the practice change is an incremental process. the decrease in errors must be studied over time. is the new system successful in reducing errors? are the costs associated with it worth the benefit achieved? what are the effects of the change on the stakeholders? and, finally, are there other parts of the system that still need to be improved? for example, how long after prescriptions are written do medications arrive at the point of administration? is that time interval acceptable? what modes exist for improvement?
and so it goes. a series of processes designed to ensure that, at any given point in time, we are giving our patients the best possible care that we are capable of giving. it's a lengthy, and sometimes arduous, process. so is everything else in nursing. the goal, at the end of the day, is to be able to say: "i helped. i cared. and the care was good."
roberta b. abrams, rnc, ma, lcce is principal of rba consults, in farmington hills, mich., and is on the adjunct nursing faculty at madonna university. she may be contacted at firstname.lastname@example.org