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Quality improvement tools for nursing practice

Harkness, Turna L. MSN, RN, LGBC; Pullen, Richard L. Jr. EdD, MSN, RN, CMSRN

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Nursing Made Incredibly Easy!: May/June 2019 - Volume 17 - Issue 3 - p 47-51
doi: 10.1097/01.NME.0000554602.68360.ed
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The healthcare environment is now more complex than ever. Patient satisfaction data in the form of Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores play a significant role in driving change; for example, clinical staff training, menu changes, patient relations, housekeeping/support services, and hourly rounding. Pay for performance has facilitated the implementation of evidence into practice by using the rates of infections, readmissions, falls, hospital-acquired wounds, wrong-site surgery, and medication adverse events as part of an effective patient safety and quality improvement (QI) program. Additionally, it's been demonstrated that patient harm is most frequently attributable to system failures. That's why it's essential for nurses to understand how to respond to small errors or problems in their daily practice environment before a sentinel event can occur. When we're knowledgeable about QI tools and processes, we can promote system consistencies, effectively manage change, and ensure harm-free care.

Process scope

Implementation of QI has been an ongoing process in healthcare organizations. Amidst HCAHPS surveys and pay-for-performance initiatives, organizations are tasked with collecting and evaluating data on patient outcomes and satisfaction. Patient-centered care and QI teams are central to improvements in these areas.

Every QI initiative requires having key stakeholders involved in the process. Teams should consist of four to six people and be interprofessional. Members of the risk management and/or QI department are helpful to have on the team because they can often provide unbiased views and serve as facilitators. Consideration should be given to subject matter experts, clinicians, and staff members who know the workflow. And garnering clinical and administrative support from hospital leaders is important to the success of QI initiatives because some projects require a significant amount of time and expense.

One of the most important activities of the QI leader is to ensure that the team has the correct data—sufficient in detail, scope, and depth—to analyze. The QI leader collaborates with the team to determine which tool(s) is most appropriate to use in the problem-solving process. The team must compare the findings of their analysis to local, regional, and national benchmarks in nursing practice. They then develop core measures in structure, process, and outcomes as they plan, develop, and implement improvement strategies. Lastly, the team will conduct periodic audits to ensure that the benchmarks have been achieved.

Tools of the trade

Examples of QI tools include the model for improvement/plan–do–study–act (PDSA), Lean process improvement, Six Sigma, root cause analysis (RCA), the frontline dyad approach, and failure modes and effects analysis (FMEA). Let's take a closer look.

Model for improvement

The model for improvement is a systematic approach that enables teams to reevaluate processes and improve outcomes for patients, families, and staff. It's made up of three questions that drive the basis for the improvement:

  • What are we trying to accomplish? (Aim: Answering this question establishes the vision for the improvement.)
  • How will we know that a change is an improvement? (Measures: Answering this question outlines the steps to achieve the desired outcome.)
  • What changes can we make that will result in improvement? (Change ideas: Answering this question generates ideas for testing.)

Answering the three questions sets the framework for the improvement plan. The third question gives the QI team a basis for testing their changes using PDSA cycles. Plan the test or observation, which can include a plan for collecting data. Do the test of change on a small scale (pilot). Study the results and analyze the data. Act on what's learned from the test and refine the change. PDSA cycles should be repeated until the desired outcome is reached, with each test building on information learned from the previous cycle. As the desired outcomes are met, testing is spread from the pilot group to larger groups until there's full implementation of the change.

Lean process improvement

Lean is generally defined as a systematic method of identifying and eradicating waste by implementing value-added processes driven by customers' perceptions of satisfaction. Lean approaches center around key definitions:

  • value—what the customer is willing to pay for
  • nonvalue added—a process that has no added value from the customer's perspective but must be done under the present condition
  • waste—what the customer is unwilling to pay for.

Lean concepts are incorporated into the model for improvement by answering the fundamental question: “What changes can we make that will result in improvement?” Effective organizations benefit from including Lean concepts in improvement initiatives to continuously enhance the value proposition for customers.

Six Sigma

Six Sigma focuses on reducing variation using a five-step process—define, measure, analyze, improve, and control:

  • Define refers to process improvement goals that are consistent with customer demands and the organization's strategy (defining the customers, process owners, and stakeholders).
  • Measure examines the current process (defect focus) and develops a baseline for future comparison. The statistical tools (descriptive statistics, run charts, and Pareto charts) used in the measure stage help team members understand the data and guide the QI plan.
  • Analyze focuses on verifying relationships and cause and effect. Simply put, it identifies ways to eliminate the gaps between the current state and the desired state.
  • Improve optimizes the process based on the analysis. In this phase, the plan is implemented, evaluated, and transitioned into standard processes.
  • Control ensures that variances are corrected before they result in defects. This can be achieved by identifying and articulating formal plans and processes through ongoing data collection and evaluation, resulting in new policies and procedures if needed.


An RCA is a retrospective, systematic approach used to understand the causes of an adverse event and identify system flaws that can be corrected to prevent the error from happening again. The term root cause analysis can be misleading because it implies that there's a single root cause; however, there are usually multiple events leading up to an error. Importantly, when conducting an RCA, the focus should be on system causes, going beyond the individuals involved in the occurrence. An effective RCA leads to an action plan that identifies strategies to reduce the risk of future adverse events, outlining implementation, oversight, pilot testing, a time frame, and outcome measurement.

A framework used for conducting an RCA should focus on:

  • identifying what happened
  • reviewing what could have or should have happened
  • determining the causes
  • developing causal statements
  • generating a list of recommended actions to prevent recurrence of the event
  • writing a summary and sharing it with leadership, staff, and others involved in the event.

Frontline dyad approach

The frontline dyad approach is a methodology to maximize frontline staff engagement in improvement and minimize resource use. The term dyad stems from the concept that the defects identified using this method are relatively simple, regularly occurring, and can be solved by a small team of two frontline staff members. The model represents a bottom-up approach to improvement, structured by deliberate conversations that look for both clinical and nonclinical defects in daily work. The approach suggests that the greatest number of defects are only visible to frontline staff members.

This framework depicts the timeline, design benefits, specific actions, and design/test strategies. Defects surface from the frontline and must show significant improvement in 30 days or less. The dyad is held accountable for the work.


Teams use FMEA to proactively evaluate possible failures and prevent them, rather than reacting to adverse events after failures have occurred. Reducing risk and harm to patients and staff is a high priority for organizations when a new process is implemented, or a change is proposed for an existing process.

The FMEA tool prompts teams to review, evaluate, and record steps in the process:

  • failure mode—What could go wrong?
  • failure causes—Why would the failure happen?
  • failure effects—What would be the consequences of each failure?

Practice applications

The QI process is used by nurses in the practice setting who influence others in a collegial, communicative, and collaborative manner to problem-solve and effect changes. In fact, leadership roles in QI aren't solely for nurses in management positions, but also for nurses who practice at the bedside in hospitals and community health agencies, clinics, physician offices, and academic settings. QI requires us to analyze the scope of the problem, identify improvement strategies, and establish measurable benchmarks to indicate that improvement has been achieved.

QI teams may be assembled to address problems such as an increase in infections or falls, a decrease in patient satisfaction, a nursing program that isn't meeting outcome benchmarks, a lack of patient knowledge about portal use, or a steadily increasing nurse-to-patient ratio on a unit that at the same time is experiencing an increase in medication errors. The QI team needs members who can stay energized from the initial meeting and brainstorming process to the final recommendations for improvement to the administration.

Prelicensure nursing programs should prepare students for leadership roles in QI using unfolding case studies and clinical simulation experiences that require critical thinking using appropriate QI tools. Students and new graduate nurses need to understand how the team communicates and collaborates to incrementally improve structures and processes.

Problem solvers

Patient-centered care is complex, requiring nurses to use a variety of QI tools during the problem-solving process to enhance institutional efficiency and ensure safe, quality care. Healthcare institutions—from hospitals and clinics to academic settings—can use these tools to achieve the desired outcomes. For an animated video summarizing the concepts in this article, visit

cheat sheet

Getting involved with QI


Getting involved in the QI process is part of our professional role. Nurses at every level of practice should be aware of key factors in the QI process, promote a culture of QI, and communicate to their supervisor a desire to serve on QI teams. Here are some important points you need to know about QI as an administrator, supervisor, clinical nurse, advanced practice nurse, or educator.

  • Establish a mindset dedicated to continuously improving systems and processes, with policies in place that outline the QI process and include clear goals and organizational outcomes.
  • Have individuals who are certified in QI oversee the process in collaboration with everyone in the organization.
  • Promote QI by creating a collaborative and trusting culture that focuses on the needs of internal and external customers.
  • Encourage all employees to be involved in QI by cultivating a learning culture and embracing change.
  • Focus on systems and processes, not individuals, as problems arise.
  • Ensure that individuals who have the most expertise or experience in a problem area are involved in the QI process.
  • Use quantitative and qualitative data as the impetus for improvement.
  • Select appropriate QI problem-solving tools in team meetings.
  • Develop statistical measures that indicate improvement, with a focus on key stakeholders.
  • Identify, implement, and evaluate improvement strategies.
  • Celebrate the achievement of improvement benchmarks.
  • Utilize the Institute for Healthcare Improvement ( as a staff development resource.

consider this


To fully understand the implementation of the frontline dyad approach, let's take a look at how a small, 25-bed unit dealt with reducing alarm fatigue to minimize and prevent patient harm.

The first step in the dyad approach was to engage staff members in conversations to identify the safety defects on the unit. The QI director scheduled an hour-long meeting with two RNs, the charge nurse, and the health unit coordinator. In this meeting, the purpose and goal were discussed to identify barriers or broken processes on the unit that were creating safety issues.

Three anchoring questions were used to elicit the conversation:

  • What causes you to have a bad day?
  • What's one process that causes delays?
  • What patient safety concerns do you have?

By the end of the hour, there were several safety defects that surfaced for consideration, including the admission process, the discharge process, telemetry pager/alarm fatigue, and inpatient hospice services.

Next, a scoping tool was implemented to determine the appropriateness of each identified defect. Within the scoping tool, questions were asked to determine if this was a system or unit problem, if the problem affected other parts of the organization, whether outside resources were needed, whether this was a project that a dyad could handle and be completed in less than 30 days, if the project aligned with organizational goals, if there was willing frontline participation, and if a coach for just-in-time training was available. It was then determined that telemetry pager/alarm fatigue was a defect that could be addressed, resulting in positive changes at the unit level within the desired time frame.

Over the next 2 weeks, PDSA was used to perform a rapid-cycle test to collect data from telemetry logs, documenting the room number, issue or problem, time of page, staff notified, and/or rapid response team required, as well as the time that the issue was resolved. After 7 days, when reviewing the data, the average number of pages per day and the peak time of day for most calls were documented. Staff members' perceptions were supported in that either the phone or the pager interrupted unit workflow and could potentially lead to patient safety issues.

Attention was then directed to problems related to telemetry monitoring, such as leads being off or battery failure. Another 7 days of data were reviewed, looking specifically at pages for leads being off or battery failure. A literature review was done to establish the standard of practice and recommendations for lead and battery changes. Rapid-cycle PDSA was used to determine strategies and implementation of guidelines.

Documentation of the processes was effective when charge nurses on the unit engaged in staff education. Dashboards were made visible to unit staff, recording the data results and substantiating a decrease in alarms and pages per shift after the interventions. Implementation decisions were then made that focused on unit policy revisions and potentially extending the policies to other units within the organization.


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