Health care organizations increasingly rely on quality improvement, or QI, to deliver more value for less money. Quality improvement involves more than making updates to processes and procedures. It is a codified and structured approach to improvement organizations can use to set goals related to health care quality, patient satisfaction, process enhancement, and more. Hallmarks of quality improvement include systemic enhancement, data analysis, quantifiable interventions, and performance measurement. Whether QI adoption is driven by internal demand or external forces, the professionals who provide or oversee patient care services are often the most qualified to identify what is and is not working in health care environments.
Nurses play a pivotal role in QI implementation for several reasons. They make up the largest segment of U.S. health care providers, representing 30% of hospital employees and a sizable segment of the workforce in other areas of health care. Nurses also spend significantly more time with patients compared to other providers. RNs and nurse managers have a thorough understanding of the resources necessary to care for patients effectively and efficiently. And their frontline nursing care experience makes them uniquely suited to lead initiatives focused on clinical transformation, patient safety, and patient satisfaction.
Continuous quality improvement initiatives may be more successful when nurse leaders who possess advanced education in quality science, decision science, performance analytics, and resource allocation step up to drive change. The University of Michigan School of Nursing’s Online MSN in Leadership, Analytics, and Innovation program can help you become one of them. It teaches experienced clinical nurses with BSNs to use data to facilitate continuous quality improvement in their organizations and change nursing for the better.
Defining Quality Improvement in Health Care
This systematic, data-driven approach to enhancing patient care and patient safety in health care environments addresses six primary areas of patient care outlined by the National Academy of Medicine: efficiency, effectiveness, equity, respect, safety, and timeliness.
Efficiency focuses on quality improvements to reduce unnecessary waste and provider burnout as much as possible without compromising the patient experience or patient satisfaction.
Effectiveness refers to the fact that all change must result in measurable improvements to patient safety and outcomes, process efficiency, resource allocation, or provider wellbeing.
Equity involves improving access to care and quality of care for all. Biases should not exist in health care based on gender, socioeconomic status, ethnicity, or other factors. Inclusivity among staff is vital as hospitals and health facilities need nurses with diverse cultural, ethnic, and religious backgrounds to effectively care for diverse populations.
Respect is crucial because person-centered care is a critical component of QI. Clinical decisions in primary care and other settings must align with patient needs.
Safety is emphasized in the framework because all improvements must enhance providers’ ability to give patients the best possible care. Upgrading care processes and systems cannot lead to mistakes.
Timeliness is important because process delays invite risk in medical settings. QI initiatives should reduce roadblocks and make it easier for providers to deliver value.
The six core pillars help nurse leaders and other clinicians identify broad and granular areas of improvement in nursing practice, create actionable solutions for driving change, develop measurable goals, identify metrics for measurement, and analyze initiative impact. They act as a flexible guide to QI, which is dynamic. Nurses must approach quality improvement programs with the understanding that there is always room for incremental change.
Why Continuous Quality Improvement Is Important
Quality improvement is an ongoing process that challenges the status quo, not a one-and-done initiative. QI-focused health systems integrate sustained transformation into daily operations by setting goals, establishing a culture of quality improvement, building QI infrastructure, putting methods into practice, measuring improvements, and adjusting strategy as necessary to meet evolving benchmarks. Applying the QI framework is incremental, progressive, and iterative because as initial goals are met, new goals emerge.
Fundamentally, QI is as simple as making, measuring, and adjusting improvements, and then repeating the process. Most organizations find, however, that a deeper dive is necessary to reap the benefits of quality improvement initiatives. Continuous QI looks at organizational and patient outcomes and addresses managerial and clinical processes required to improve those outcomes. It works particularly well in health care environments because the cyclical nature of the work presents never-ending opportunities to optimize, evaluate, and improve.
The perpetual nature of continuous QI can be a stumbling block. Maintaining the necessary focus on performance improvements can be challenging in the long term — particularly in chaotic and stressful medical settings. When everyone works at their capacity, handling the day’s duties takes precedence over maintaining quality measures in the long term. The continuous quality improvement framework focuses on processes instead of the work of individuals so people are less likely to become overwhelmed.
Nurse leaders need to lead the charge in QI implementation. They are equipped to show RNs that while viewing one’s nursing practice through a QI lens can be overwhelming at first, the benefits of continuous quality improvement make the necessary time and resource investment worthwhile. Implementing the framework can reduce redundancy, waste, costs, and risk and improve operational efficiency and clinical outcomes. Additionally, a demonstrable commitment to nursing quality shines a positive light on an organization, leading to increases in strategic partnerships and funding opportunities.
Examples of Quality Improvement Initiatives in Health Care
Showing quality improvement in nursing examples or examples of QI in other areas of health care can be difficult because improvements should be specific to an organization. For instance, a hospital might design a plan to reduce postoperative readmissions by changing the discharge process. A medical practice might explore measurable ways to improve the accuracy of medication lists as part of QI initiatives focused on reducing medical errors. A nurse manager who is aware that Electronic Health Records (EHR) systems can increase mental demand on nurses might focus on process enhancements specific to that system.
Health care leaders across departments must look to their organizations first for guidance when developing quality assurance and improvement initiatives. Only then can they address specific issues that need attention. Many organizations find significant room for improvement in processes related to care coordination, electronic medical record documentation, medication administration, patient engagement, patient safety, readmission rates, staff engagement, and infection control.
Nurses, doctors, administrators, and leaders in health care organizations can do several things to identify potential areas of improvement. First, they can research case studies to learn more about how thriving health care systems implement and maintain QI in different clinical and administrative departments. Next, they can look for pain points — areas where processes break down or with quantifiable room for improvement. Finally, they can establish preliminary goals, formulate a theory of change, define quality indicators, and put a plan into action.
Some health care organizations take QI a step further and assemble dedicated improvement teams made up of clinicians and administrators responsible for developing goals, promoting quality assurance initiatives, and monitoring signs of progress.
The Role of Nurses in Quality Improvement
Even before quality improvement became codified as a framework, it was a part of nursing. Nurses at all levels — from bedside nurses to Chief Nursing Officers — have long recognized how challenging it is to provide high-quality patient care in an imperfect system. A study by the Center for Studying Health System Change (HSC) found that nurses are integral to official and unofficial QI efforts because “they spend the most time at the patient’s bedside and are in the best position to affect the care patients receive during a hospital stay” and are “the eyes and ears of the hospital.”
Bedside nurses are particularly well-placed to positively influence the patient experience as well as patient outcomes. Their buy-in is increasingly essential as facilities and networks face increasing demands to launch QI programs as part of Value-Based Care (VBC). According to the American Nurses Association, the staff nurse at the heart of the system “is the best person to assess the status of health care services and to work toward improving the processes by which these services are provided.”
However, staff nurses are not the only nurses critical to QI success. Nurse managers change health care environments for the better by inspiring and empowering staff in their quest to improve processes. Nurse executives help drive organizations’ QI strategies and help secure the resources necessary to ensure continuous quality improvement efforts are successful.
It is essential to have nurses at all levels participate in QI projects even when other stakeholders lead because frontline nurse participation expedites transformation. Quality improvement is built into nursing — not as an extra duty busy nurses have to take on in addition to their primary responsibilities but as part of existing processes. As one hospital CEO who participated in the HSC study put it: “when nurses champion a project, they are able to achieve ‘real, sustained improvement.’”
Nurses Face QI Challenges
Involving nurses and nurse leaders in collaborative quality improvement projects is crucial to success, yet nurses tackling improvement work run into significant roadblocks. For example, capacity issues can get in the way of QI success. RNs who are overworked or work in understaffed departments may have to choose between acting as caregivers and fully engaging with process improvement initiatives. They may feel pushed into either/or situations instead of taking a “yes, but” approach to both when they are overworked.
Additionally, bedside nurses may not feel they have a voice in QI projects. In contrast, nurse managers may feel obligated to participate in as many quality improvement initiatives as possible — to the detriment of other activities. Nurses at all levels may disengage when they do not understand their role in QI. And asking nurses to handle additional data collection, analysis, and reporting tasks can be a burden in settings with technology that is out of date or hard to use.
Finally, traditional clinical nursing education models do not adequately prepare nurses to participate in systematic quality improvement. Considering the emphasis of QI in today’s health care system, however, quality improvement should be a part of nursing education at the bachelor’s degree and master’s degree levels. One participant in the HSC study linked above indicated that nurses in academic programs should learn about change models and be taught the basics of the QI framework. They added that, “data are all around nurses, and they are using data for clinical decisions. We need them to understand how to use data to change practice.”
The widespread adoption of continuous QI may represent an opportunity for qualified nurses to take the lead in redesigning the quality of care for the betterment of patients — and the nursing profession — provided they have the requisite skills. U-M School of Nursing’s Online MSN program covers the applications of analytics in decision analysis, program and process evaluation, quality science, and the foundations of change management in health care because understanding QI is good for nurses.
One study that tracked clinical nurses put in charge of QI teams discovered that participating nurses reported feeling highly satisfied with not only the improvements they’d brought about but also the new skills they acquired in the process and the overall impact of their work. Feeling impactful at work is a win-win situation for clinicians, the health organization, and of course, the patient. Ultimately, research suggests that involving nurses in quality improvement can expand nurses’ influence at all levels and make health care better.
To learn more about who pursues the MSN and why, the wide range of career pathways for MSN holders, the online student experience at U-M, or financial aid options, register for an upcoming online event. Or take the next step in your nursing career and apply online today.