Leadership Strategy Analysis-Quality Improvement Process



Leadership Strategy Analysis-Quality Improvement Process

Tammy A. Garcia

Ferris State University

Abstract

Nursing leadership is critical to the quality improvement (QI) process. The QI process consists of six steps that resemble the nursing process. The steps of the QI process, identifying a need, assembling a team, collecting data, establishing outcomes, making a plan, and evaluating the plan, are applied to urinary tract infection (UTI) prevention in the skilled nursing facility (SNF) and long-term care facility (LTCF) environment. By applying the process to an area of need, a greater understanding of the process and the interdisciplinary team’s (IDT) role in it are achieved.

Leadership Strategy Analysis

The quality improvement process (QI) is an ongoing process for achieving and improving customer satisfaction. The QI process involves several steps, resembling the nursing process. Research has indicated that organizations that have leaders “who facilitate open communication, set goals, value and seek input from staff, and support team work among staff members” perform better (Vogelsmeier & Scott-Cawiezell, 2011).

There are six steps involved in the QI process. Those steps include: identifying a need, assembling a team, collecting data, establishing outcomes, making a plan to achieve the outcomes, evaluating the plan and making revisions as needed. Nursing leadership is critical to the QI process in the skilled nursing facility (SNF) and long-term care facility (LTCF) environment. To demonstrate the QI process in action I have applied it to the clinical need of urinary tract infection prevention in the SNF/LTCF environment.

Clinical Need

Urinary tract infections (UTI’s) are the second most frequently diagnosed infection in the elderly population. It is the most common infection diagnosed in patients residing in long-term care facilities (LTCFs) and cost over one billion dollars annually (Matthews & Lancaster, 2011). The elderly have several functional and anatomic predispositions that increase their risk of developing a UTI. Decreased mobility, dementia and other neurologic disorders are factors for both male and females. Changes in prostatic function, urinary incontinence, and increased risk of obstructive uropathy are three predispositions for men. For women childbearing, reproductive surgeries, mucosal and smooth muscle changes from menopause, changes in vaginal flora, urinary incontinence, and cystocele are some factors that increase the risk of UTI (Shortliffe & McCue, 2002).

The increase risk based on the functional and anatomical changes in the elderly, combined with the increased prevalence of drug resistant bacteria, make UTI prevention more of a challenge. Reducing the risk has multiple advantages including: improved resident and family satisfaction, improved resident health and comfort, improved regulatory compliance, improved reputation of facility care, improved health outcomes (as evidenced by no bacteremia or septicemia), improved survey results, better resident outcomes, decreased cost (as evidenced by decreased antibiotic usage and repeated lab work), and improved resident and staff morale (, n.d.). All those factors make UTI prevention a topic for the QI process.

Interdisciplinary Team

The members of the QI interdisciplinary team (IDT) in a SNF/LTCF are: the administrator, the director of nursing (DON), director of social work, dietary manager, dietician, clinical resource manager (MDS coordinator), infection control manager/staff development nurse, clinical coordinators (unit managers), activities director, medical director, director of human resources, and director of environmental services. The problem for the QI process determines the amount of involvement of the members and what input is needed from each discipline.

For the clinical problem of UTI prevention the director of nursing (DON), medical director, the clinical coordinators or unit managers (LPN or RN), infection control /staff development nurse, and clinical resource manager are the primary members of the IDT.

Yoder-Wise (2011) states “QI team members should represent a cross section of workers who are involved with the problem. To maximize success, the team members may need to be educated about their roles before starting the QI process” (p.395).

Data Collection Method

UTI’s are one of the issues reported daily to the whole team in their morning meeting. The DON submits monthly reports to corporate office with the infection control data. The clinical coordinators report on patients on their units. Information reported includes who has new infections, who has cultures/UA’s pending, who has been started on antibiotics, and who has new symptoms: fevers, mental status changes, dysuria, frequency, urgency, suprapubic pain, lethargy, and increased weakness (Matthews & Lancaster, 2011). The clinical resource manager audits charts and previous MDS’s to ensure proper documentation and coding. The infection control nurse starts tracking all the information and makes sure the supporting documentation is there for the action taken. If the doctor has ordered an antibiotic and there is not enough supporting evidence to meet the McGreers criteria, the doctor is contacted to either discontinue the antibiotic or justify in writing why one is needed.

McGreers criteria are a standard for surveillance, infection control and outcome measurement in LTCF’s. McGreers criteria for symptomatic urinary tract infections state that one of the following criteria must be met:

1. The resident does not have an indwelling urinary catheter and has at least three of the following signs and symptoms: (a) fever (≥38 ̊ C) or chills, (b) new or increased burning pain on urination, frequency or urgency, (c) new flank or suprapubic pain, or tenderness, (d) change in character of urine, (e) worsening of mental or functional status (may be new or increased incontinence).

2. The resident has an indwelling catheter and has at least two of the following signs or symptoms: (a) fever (≥38 ̊ C) or chills, (b) new flank or suprapubic pain or tenderness, (c) change in character of urine, (d) worsening of mental or functional status. (McGreer et.al, 1991)

Establishes Outcomes

There are national and corporate benchmarks that the facilities are expected to meet. The corporate benchmark is that each month 3% or less of the population in the SNF/LTCF will have a UTI. Facility performance is measured against the center for Medicare and Medicaid services (CMS) quality standards (quality indicators/quality measures or QI/QM) as well. Monthly reports are generated for state comparison and targets. The rationale for the quality measure NQMC-2218, title: Nursing facility chronic care: percent of residents with a urinary tract infection is:

Most urinary tract infections (UTI) can be prevented by keeping the area clean, emptying the bladder regularly, and drinking enough fluid. Nursing home staff should make sure the resident has good hygiene. Finding the cause and getting early treatment of a UTI can prevent the infection from spreading and becoming more serious or causing complications like delirium. It is important to find out whether the UTI is caused by a physical problem, like an enlarged prostate, so proper medical treatment can be given (National Quality Measures Clearinghouse (NQMC), n.d.).

Implementation Strategies

The process for data collection and implementation is as follows. The infection control nurse reports in a QI meeting that the rate for UTI’s the previous month was 30% (an example) over the acceptable benchmark. The QI team decides this needs to be investigated. A task force or subcommittee is appointed to investigate and report. This team may include just QI team members or may also include some frontline staff like certified nurses assistants (CNA). The committee meets and determines what data needs to be gathered. In this case it may be looking at the risk and precipitating factors: incontinence, medical conditions, declines in functional or mental status, past history of UTI, new medications, and oral fluid intake. What is the location in the building of the infections, are they on one unit? Did the patients have the same caregivers? The process to implement methods for improvement is based on the findings and guided by current evidence based practices that “have been validated and are based on the best research currently available” (NQMC).

If the findings indicate it may be a caregiver issue, decisions might include observing care giving staff and then providing inservices and education on deficits. If the issue is related to incontinence, obstacles to toileting may be considered: toileting plans, peri care, brief changes. There maybe a different reason for each resident. Action plans may be specific to each resident and accurate documentation to the plan will need to be provided.

Once a plan is selected, it is implemented. If education is needed, it is given. If policies and procedures need to be changed, they are changed. Communication among the team is critical at all times but especially during the implementation stage. Additional adjustments may need to be made to the plan. Research shows that in the highest performing SNF/LTCF’s, QI occurred with team member input and feedback (Vogelsmeier & Scott-Cawiezell, 2011).

Evaluation

Measuring improvement is done by audits. Has there been a decline in the number of UTI’s each month? Are the clinical thresholds for corporate and state QI/QM being met? If the thresholds are not being met consistently (two months or more in a row) that is a good indication that the process isn’t working and needs to be altered. If that is the case then QI team needs to regroup and start from a point in the process where different outcomes may be achieved. If the clinical thresholds are met, monitoring continues until 3-4 months of data is collected that meets and/or exceeds the clinical thresholds, which at that time the action plan is considered a success. Normal monitoring continues from that point on.

Scholarship

The IDT uses accepted standards of care to achieve the desired outcomes. These clinical practice guidelines are based on the most up to date evidence based practice standards. As demonstrated throughout the outlined process and scenario, the guidelines are utilized.

Conclusion

Urinary tract infections are a common problem in the elderly patient, especially the elderly patient residing in a SNF/LTCF. With solid evidence based practice interventions the rate of UTI’s in the elderly can be decreased. The QI process is an important piece in the reduction and prevention of infection. Strong nursing leadership is a driving force of the QI process.

References

Bergman, J., Schjott, J., Blix, H. S. (2011). Prevention of urinary tract infections in nursing

homes: lack of evidence-based prescription? BMC Geriatrics 11(69).

doi: 10.1186/1471-2318-11-69

Matthews, S. J., & Lancaster, J. W. (2011). Urinary tract infections in the elderly population.

The American Journal of Geriatric Pharmacotherapy, 9(5), 286-309. doi:

10.1016/j.amjopharm.2011.07.002

McGreer, A., Campbell, B., Emori, T. G., Hierholzer, W. J., Jackson, M. M., Nicolle, L. E.,

Peppler, C., ….Wang, E.L. (1991). Definitions of infections for surveillance in long-term

Care facilities. American Journal of Infection Control, 19(1), 1-7.

National Quality Measures Clearinghouse (NQMC). (n.d.). Nursing facility chronic care:

percent of residents with a urinary tract infection. Measure Summary NQMC-2218.

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Shortliffe, L. M., & McCue, J. D. (2002). Urinary tract infection at the age extremes:

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Nursing Care Quality. 26(3), 236-242. doi: 10.1097/NCQ.0bo13e31820e15c0

Yoder-Wise, P. S. (2011). Leading and managing in nursing (5th ed.). St. Louis, MO:

Elsevier Mosby

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