Quality Improvement



Leadership Strategy Analysis

Abigail Fish, Jacqueline Mulder, Jordan Mullauer, Katie Coon,

Roxanne Rickert & Stephanie Ford

Ferris State University

Leadership Strategy Analysis

The purpose of the leadership strategy analysis is to identify an area of patient care that can be improved. Quality patient care and safety are two aspects of health care that can always be improved. As defined by the American Nurses Association [ANA] (2010), quality is “the degree to which health services for patients, families, groups, communities, or populations increase the likelihood of desired outcomes and are consistent with current professional knowledge” (p. 67). The ultimate goal of quality improvement is to provide better patient outcomes. Quality improvement removes the blame from individual mistakes within the health care facility, and instead focuses on improving patient outcomes. In this paper, the incidence of catheter-associated urinary tract infections (CAUTIs) and incident reduction strategies will be discussed. An interdisciplinary team and data collection method will be included. Desired patient outcomes and strategies to achieve these outcomes will be discussed. A nursing theory and evidence-based practice (EBP) will be integrated throughout the analysis.

Clinical Need

CAUTIs are “the most frequent health care-associated infection in the United States” (Saint, Meddings, Calfee, Kowalski, & Krein, 2009, p. 877). A urinary tract infection (UTI) affects about 600,000 patients each year. UTIs are most common in women; about 11.3 million women annually receive the diagnosis of a UTI in the United States (Smeltzer, Bare, Hinkle, Cheever, 2010). Not all UTIs are symptomatic, but the typical clinical manifestations include: dysuria (pain and burning with urination), frequent urination, incontinence, and pelvic pain (Smeltzer et al., 2010). Dangerous and potentially life-threatening complications can occur as a result of a UTI, including: sepsis (infection spreading to the blood), kidney damage, and kidney infections. All of these can lead to even further complications and death if left untreated (Smeltzer et al., 2010).

The transurethral route is the most common way for bacteria to enter the bladder, causing a UTI; catheter insertion increases the risk for bacteria entering through this route (Smeltzer et al., 2010). One in five patients receives an indwelling catheter at some point during hospitalization and his or her risk of getting a CAUTI increases by 5% each day the catheter is in place (Saint et al., 2009). A catheter in place is a serious contributing factor to all hospital acquired urinary tract infections. According to Janzen and Geerlings (2011), 71-80% of patients with urinary tract infections acquired in the hospital had an indwelling catheter in place. As the most common nosocomial infection, quality improvement interventions must be implemented to reduce the incidence of CAUTIs.

Interdisciplinary Team

According to Yoder-Wise (2014), an interdisciplinary team is, “essential to quality patient care” (p. 362). The members that make up an interdisciplinary team, work together to provide high quality, safe care to patients. To reduce the incidence of catheter usage and prevent CAUTIs, members from several different areas of the hospital can be utilized. Members of this particular interdisciplinary group include nurses, nurse aids, physical therapists, physicians, and nutritional services.

Nurses are a very important part of this interdisciplinary team because they have direct contact with the patient and are responsible for a large portion of his or her care. Nurses make sure that catheters are inserted properly and set up according to policy. After catheters are in place, the nurse is responsible for performing catheter care such as cleaning the area around the catheter and emptying the reservoir bag regularly. The nurse is able to see first hand how the patient is handling an indwelling urinary catheter, and can monitor for the first signs of infection, or hazards that may lead to infection.

Nurse aids and physical therapists also have direct contact with patients and play a part in preventing CAUTIs. Nurse aids are often the first to respond to patient call lights when they need to use the restroom. They can encourage the patient to get up and try to urinate on his or her own more frequently to prevent the need for catheters in the first place. Physical therapists work similarly because they help the patient to ambulate and gain his or her strength back, which can encourage healthy bladder function and patient motivation to empty the bladder.

Another important member of this interdisciplinary team is the physician. Physicians ultimately give the order for a patient to be catheterized. Often, physicians are quick to suggest catheterization if a patient has not been able to void on his or her own quickly enough. After becoming a member of the interdisciplinary team, physicians can become part of the conversation on how to prevent CAUTIs, a serious issue in the hospital setting, and may be more willing to try other interventions before ordering catheterization for a patient.

Finally, a member from nutritional services is important to have as a part of this interdisciplinary team. A consult one on one with a patient provides an assessment of the patient’s nutritional status and ensures that they are getting what they need to achieve optimum health and remain healthy. A nutritionally healthy patient has a stronger immune system and is therefore better equipped at fighting off infections such as CAUTIs.

Data Collection Method

All together, the members of a unique interdisciplinary team can help prevent the need for catheterization and decrease the incidence of CAUTIs by using their individual knowledge and skills. In order to prevent and decrease the incidences, the rates of infection need to be collected and evaluated effectively to help assess the problem and need for attention. Collecting the data efficiently allows for a better chance at improving quality and safety of patient care. The data can be collected at a hospital, state or national level as well as through previous research studies.

For this quality improvement measure, the data will be collected from the Michigan Health and Hospital Association’s (MHA) Keystones Center for Patient Safety and Quality, which is located in Lansing, Michigan (Michigan Health and Hospital Association, 2014). In this organization, the registered hospitals throughout the state report the incidences of CAUTIs in order to be assessed for quality improvement measures at three different phases in an 18-month cohort. The data collected regarding the incidences of CAUTIs from the organization will be assessed at the end of each phase. The data will then become part of a study for improvement measures to be implemented regarding the use of Foley catheters.

This quality improvement measure will also collect data through a specific unit database. The database will record all Foley catheters placed with the length of time the Foley stayed in and if a reminder/stop order was utilized (Appendix A). Those numbers will be correlated to the reported CAUTIs, showing if they were factors in the infection. The new data collected, along with the use of previous research studies, accompanies the definition of transformational leader (Yoder-Wise, 2014). The use of data from a new research study in conjunction with the research in past studies allows for higher levels of morality and motivation for better quality patient care. The more data collected, the more credible the research.

Outcomes

CAUTIs are a preventable infection, avoidable through proper care and uses of Foley catheters. According to Meddings, Rogers, Macy and Saint (2010), "urinary catheters often are placed unnecessarily, remain in use without physician awareness, and are not removed promptly when no longer needed" (p.550). The goal for health care providers should be to assess and remove catheters from patients when they are no longer needed. This simple action will help to decrease the incidence of CAUTIs hospital wide.

Meddings et al. (2010), performed a study to determine if implementing a reminder or a stop order for nurses and physicians would help in the removal of unnecessary catheters, therefore decreasing the incidence of CAUTIs. When this standard was implemented into practice, the outcomes were quite substantial. The study proved that "the rate of CAUTIs (episodes per 1000 catheter-days) was reduced by 52 percent with the use of a reminder or stop order" (Meddings et al., 2010, p. 550). Implementing the reminder or stop order for catheters into patient care standards has been proven to decrease the incidence of CAUTIs. This standard of care aids in the removal of unnecessary catheters and therefore provides better patient outcomes.

With knowledge about unnecessary and extended placement of Foley catheters lead to CAUTI incidence, the unit implementing this quality improvement measure will focus on reducing both of those occurrences. Consequently, CAUTI incidence should decrease on the unit. When considering Meddings et al.’s (2010) study, reducing incidence by 52 percent, an attainable outcome for first time implementation on the unit would be to reduce the incidence of CAUTIs by 40% in the next 12 months.

Strategies

For this change to take place, an effective strategy must be put into place. The change theory that will be used to initiate appropriate Foley discontinuation was developed by Kurt Lewin. According to Doolin, Quinn, Bryant, Lyons, and Kleinpell (2010), Lewin’s theory is very useful when implementing change and is widely used in the field of nursing. The three stages of change include: the unfreezing stage, the moving stage, and the refreezing stage. Lewin’s theory is characterized by driving forces, which are forces that push in a direction that causes change to occur (Kritsonis, 2005).

The unfreezing stage of this process involves increasing the driving forces that steer away from how things used to be done, which are proven to be less efficient (Kritsonis, 2005). This stage is necessary to overcome the resistance of individuals or groups. In the case of CAUTI prevention, unfreezing would involve moving toward less days of indwelling catheter placement, giving the physician reminders about orders for discontinuing them, and initiating stop orders. The moving stage takes place during the transition from old ways to new ones. During this stage, a change in thoughts, feelings, and behaviors takes place about the new practice (Kritsonis, 2005). This is where nurses get used to the Foley protocol and determine how effective they think the new method is. Finally, the refreezing stage, takes place when the change is established as a habit. Unless this stage takes place, it is possible to fall back into the old ways (Kritsonis, 2005). The recommended reminders and stop orders will now become the standard protocol for each patient with an indwelling catheter.

Lewin’s change theory was used in a number of Emergency Departments (ED) in the United Kingdom to decide whether family members should be present during cardiopulmonary resuscitation (CPR) of their loved ones (Doolin et al., 2010). The theory proved to be effective with helping healthcare providers accept this transition that they were resistant to allow. Providers were concerned about the distress family members might experience if they are present during such a traumatic event. However, research has proved by allowing family members to be present, positive outcomes can take place (Doolin et al., 2010). A trusting relationship between family members and healthcare providers can be established, family member anxiety is decreased, family presence helps to facilitate the grieving process, health care providers maintain professional attitudes, families understand the patient’s condition, and they also get to witness that everything possible was done for their loved one (Doolin et al., 2010). These findings were established by initiating Lewin’s change theory, which used driving forces to make this change occur.

Evaluation

The last element that needs to be planned in the quality improvement process assesses the improvement made in the clinical need. Did all elements of the plan outlined above lead to positive change? Understanding the desired outcome and utilizing the resources implemented to collect data will measure the gains made.

For this quality improvement process, the outcome aimed to decrease incidence of CAUTIs by 40% in 12 months. Therefore, evaluation should be done at the three, six, nine, and 12-month mark. Evaluation throughout the study period will ensure the interventions and strategies for improvements are being carried out actively.

The data retrieved from the data collection methods mentioned above will be analyzed in order to evaluate if there was an improvement in practice. The effectiveness of the new order protocol will be determined by analyzing the correlation of a reminder/stop order in place and the number of days the Foley catheter was in place. If an order reduces the number of days the catheter is in, and therefore decreases CAUTIs, then continuing the protocol into routine practice will be suggested. However, if no correlations can be made, then new strategies must be analyzed, and the quality improvement measures plan, re evaluated.

Conclusion

The purpose of the leadership strategy analysis is to identify an area of patient care that can be improved. The area of need identified through this analysis was the rate of CAUTIs in acute care settings. Data was collected from various Michigan settings, and desired outcomes were identified. Strategies to achieve these outcomes were discussed, and the overall quality improvement process was evaluated. The incidence of CAUTIs is an alarming statistic for health care providers, and strategies must be implemented to reduce overall hospital infection rates.

References

American Nurses Association (2010). Nursing scope and standards of practice (2nd edition). Silver Spring, MD.

Doolin, C., Quinn, L., Lyons, A., Kleinpell, R., & Bryant, L. (2010, November 5). Family presence during cardiopulmonary resuscitation: Using evidence-based knowledge to guide the advanced practice nurse in developing formal policy and practice guidelines. Journal of the American Academy of Nurse Practitioners, 23(1), 8-14. doi:10.1111/j.1745-7599.2010.00569.x.

Janzen, J., & Geerlings, S. (2011). Appropriate and inappropriate use of indwelling urinary catheters. Nederlands tijdschrift voor geneeskunde, 156(37), A5052-A5052.

Kritsonis A. Comparison of Change Theories. International Journal of Scholarly Academic Intellectual Diversity; 8:1, 2004-2005.

Meddings, J., Rogers, M., Macy, M., & Saint, S. (2010). Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Oxford Journals: Clinical Infectious Diseases, 51(5), 550-560.

Michigan Health and Hospital Association. (2014). Improving Quality and Saving Lives. MHA Keystone Center. Retrieved on August 22, 2014 from

Saint, S., Meddings, J. A., Calfee, D., Kowalski, C. P., & Krein, S. L. (2009). Catheter-associated urinary tract infection and the Medicare rule changes. Annals of internal medicine, 150(12), 877-884.

Smeltzer, S.C., Bare, B.G., Hinkle, J.L., & Cheever, K.H. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (12th ed.). Philadelphia: Lippincott Williams & Wilkins.

Yoder-Wise, P. (2014). Leading and managing in nursing. St. Louis, Mo: Elsevier Mosby.

Appendix A

Foley Catheter Database Outline

The Foley catheter database will keep track of how many Foleys are placed along with the characteristics of each. It will help to correlate CAUTI incidence in relation to number of days the Foley catheter is in place, if there was a reminder/stop order utilized, and how often they are occurring in patients who have a Foley as a whole.

|Number of Days in Place |Reminder/Stop Order Initiated? |Resulting CAUTI? |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download