NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

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Few people have had more influence on the science and practical application of process management than Dr. W. Edwards Deming. His impact on the automotive industry is legendary, and many other industries have tried with varying degrees of success to implement his principles as well.

 

For years I have followed and admired those that have tried to bring his quality improvement processes to healthcare. I strongly believe that healthcare has much to gain by successfully implementing key Deming principles. Let me share five principles that I believe can make the biggest difference in healthcare process improvement.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

1. Quality improvement is the science of process management.

When Deming and others developed their approach to modern quality improvement in the 1940s, they were basically developing a way for modern organizations to deal with the complex challenges that were confronting them. The approach they developed to improvement was remarkably simple, yet extraordinarily powerful. It’s centered on the fact that quality improvement is really about process management. These quality improvement concepts and techniques have been used to transform almost every major industry in the world with dramatic results. The last holdouts, the last passions of resistance, are primarily healthcare, higher education, and government. Now, it’s happening to healthcare. I believe higher education is imminent; it’s anyone’s guess whether government will ever succumb to these forces.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Now, we all know healthcare is very complex, but it’s not fundamentally different from other industries. Healthcare simply consists of thousands of interlinked processes that result in a very complex system. If we focus on the processes of care one at a time, we can fundamentally change the game and deal with the challenges facing healthcare. Now, this may seem like a tall order, but the Pareto principle tells us that there are probably 20 percent of those processes that will get us 80 percent of the impact. So, the challenge of every organization is to identify that 20 percent, roll up their sleeves, and begin the important work of addressing those challenges.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

2. For quality control in healthcare, if you cannot measure it—you cannot improve it.

Deming clearly understood the importance of data. Meaningful quality improvement must be data-driven. This is particularly true for quality control in healthcare. You’re basically dead in the water if you try to work with healthcare providers and you don’t have good data. I think everybody recognizes that.

Deming said, “In God we trust…and all others must bring data.” I love this quote because it reflects that reality. I’ve had physicians during my career tell me pretty much the same thing, only they’re not quite so polite. They basically say, “Dr. Haughom, John, get lost! Bring the data. And then we’ll decide if we believe it.” So, data is critical if we’re going to have a meaningful impact in healthcare.

3. Managed care means managing the processes of care, not managing physicians and nurses.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

An important application or clarification of a Deming principle was put forward by my good friend, Dr. Brent James. Managing care means managing the processes of care. It does not mean managing physicians and nurses. What James said is very true. One of the big mistakes made in the 90s with the managed care movement was naively thinking that managing care meant telling physicians and nurses what to do. The reality is that you need to engage clinicians in the process because they understand the care delivery process and they are best equipped to figure out how to improve the process of care over time. And for this reason, I strongly believe that these changes will, in fact, ultimately be very empowering for all clinicians who try to get involved.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

4. The right data in the right format, at the right time, in the right hands.

If clinicians are going to manage care, they need data. They need the right data delivered in the right format, at the right time, and in the right place. And the data must be delivered into the right hands—the clinicians involved in operating and improving any given process of care.

5. Engaging the “smart cogs” of healthcare.

If quality improvement is going to work in healthcare—if we are going to realize value—it means we must engage clinicians. To use Deming’s term, clinicians are healthcare so-called “smart cogs.” They are the front line workers who understand and own the processes of care. And as I said in an earlier slide, we’re very fortunate in healthcare because we have a workforce dominated by clinicians who are extraordinarily committed, very intelligent, and highly educated.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

But we live in a pristine time. I once received from an email from a fellow physician leader at a leading national delivery system. I’m going to withhold the name of the delivery system, but I can tell you that if you ask knowledgeable people to list of top 10 delivery systems in the country, almost everyone would put this organization on their list. Despite that, this physician wrote to me lamenting how difficult it was for him to get his peer physicians to see a new future. And in his email, he succinctly described the problem by saying that his physicians were “historically encumbered and demoralized.” And I love the succinctness of his description because what he is basically saying is they’re clinging to the past and are demoralized because they don’t see a new future. And in that short phrase, this very excellent physician leader pretty much encapsulated the problem and points us towards the solution.

Basics of Quality Improvement
Quality improvement (QI) is a systematic, formal approach to the analysis of practice performance and efforts to improve performance.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

A variety of approaches—or QI models—exist to help you collect and analyze data and test change. While it’s important to choose a reputable QI model to guide your efforts, it’s more important that you fully commit to using the QI process and good QI practices.

Benefits of QI

Understanding and properly implementing QI is essential to a well-functioning practice, and is necessary for any practice interested in improving efficiency, patient safety, or clinical outcomes.

In addition, good QI practices and improved patient outcomes position your practice for success by:

Helping you prepare for the transition to value-based payment models.
Allowing you to participate in the public reporting of physician-quality data.
Giving you the opportunity to participate in the federal Quality Payment Program (QPP) following one of two tracks: the Merit-based Incentive Payment System (MIPS) or the Alternative Payment Model (APM).
Equipping you with the skills necessary to apply for and complete national recognition programs, such as National Committee for Quality Assurance’s (NCQA) Diabetes, Heart/Stroke, and patient-centered medical home (PCMH)-recognition programs.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
Helping you earn Family Medicine Certification-Performance Improvement activity credit (formerly Maintenance of Certification) requirements.
The AAFP’s Office Champions Project are an example of QI demonstration projects in which participating family physician practices select staff and physician office champions to lead the implementation of an intervention. Read the results:

Child and Adult Immunization(794 KB PDF)
Treating Tobacco Dependence Practice Manual
Tobacco Cessation 2013(15 page PDF)

Quality Improvement Basics
The QI process is grounded in the following basic concepts:

Establish a culture of quality in your practice. Your practice’s organization, processes, and procedures should support and be integrated with your QI efforts. The culture of a practice—attitudes, behaviors, and actions—reflect how passionately the practice team embraces quality. The QI culture looks different for every practice, but may include establishing dedicated QI teams, holding regular QI meetings, or creating policies around your QI goals.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
Determine and prioritize potential areas for improvement. You will need to identify and understand the ways in which your practice could improve. Examine your patient population (e.g., to identify barriers to care, frequently diagnosed chronic conditions, or groups of high-risk patients) and your practice operations (e.g., to identify management issues such as low morale, long patient wait times, or poor communication). Use established quality measures, such as those from the National Quality Forum(www.quality forum.org), Agency for Healthcare Research and Quality(www.quality measures.ahrq.gov), and the Quality Payment Program(qpp.cms.gov) to guide your efforts.
Collect and analyze data. Data collection and analysis lie at the heart of quality improvement. Your data will help you understand how well your systems work, identify potential areas for improvement, set measurable goals, and monitor the effectiveness of change. It’s important to collect baseline data before you begin a QI project, commit to regular data collection, carefully analyze your results throughout the project, and make decisions based on your analysis.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
Communicate your results. Quality improvement efforts should be transparent to your staff, physicians, and patients. Include the entire practice team and patients when planning and implementing QI projects, and communicate your project needs, priorities, actions, and results to everyone (patients included). When a project is successful, celebrate and acknowledge that success.
Commit to ongoing evaluation. Quality improvement is an ongoing process. A high-functioning practice will strive to continually improve performance, revisit the effectiveness of interventions, and regularly solicit patient and staff feedback.
Spread your successes. Share lessons learned with others to support wide-scale, rapid  improvement that benefits all patients and the health care industry as a whole.
Quality Improvement Models and Tools
Quality improvement models present a systematic, formal framework for establishing QI processes in your practice. Examples of common QI models include the following:

Model for Improvement (Plan-Do-Study-Act [PDSA] cycles)(www.ihi.org): The Institute for Healthcare Improvement’s Model for Improvement combines two popular QI models: Total Quality Management (TQM) and Rapid-Cycle Improvement (RCI). The result is a framework that uses PDSA cycles to test interventions on a small scale.
Six Sigma(asq.org): Six Sigma is a method of improvement that strives to decrease variation and defects.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
Lean(www.ihi.org) is an approach that drives out waste and improves efficiency in work processes so that all work adds value.
Five top challenges affecting healthcare leaders in the future
Healthcare is a big topic which presents even bigger challenges for healthcare leaders.

For centuries there has been much debate about how best to implement affordable healthcare coverage for millions of uninsured Americans has taken center stage in the political arena (Wood, 2011). Today’s leaders are hard pressed to find solutions to multiple complex issues which impacts the ability to successfully implement cost-effective programs, maintain efficient operations and services, staff and trained employees, and support other healthcare initiatives.

The future of organizational entertainment in healthcare requires skilled leaders to plan for any potential problems. Over the next five to ten years, healthcare leaders should expect to encounter a plethora of challenges including regulatory and policy changes; medicinal and technological advancements; funding; education; and ethical issues. Leaders must realize a combination of these challenges could quickly consume time and money for medical research, facility upkeep, equipment overhaul, and operational training. Research suggests technological advancements will present additional challenges with programming, control, and support issues. Indoctrination of new systems requires leaders to educate themselves, their staff and the vulnerable public on the use of new systems, processes, and programs. This article provides foresight information about the future challenges healthcare leaders will face and suggestions to help them overcome.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Healthcare rising costs

As more people strive to live longer, healthier and more active lifestyles, healthcare concerns increase and so does the costs. Research reveal healthcare costs and spending often rise at rates exceeding inflation, and is expected to increase in the future. The Society for Human Resource Management present that the Office of “1 the Actuary at the Centers for Medicare and Medicaid Services estimates that aggregate health care spending in the United States will grow at an average annual rate of 5.8 percent from 2015 through 2025, or 1.3 percentage points higher than the expected annual increase in the gross domestic product.” This causes a huge concern for leaders as they seek to provide coverage for their employees.

Leaders must find alternative methods to combat the rising costs of care. They must do the research to find funding, grants and contributors to help them conduct research, set up programs and implement processes at the pace of change. The Health Services Research Information Central (HSRIC) provides a list of “grants, funding and fellowships” leaders might consider helping them train staff members, open up public information sites or labs for processing paperwork and other initiatives.2NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Healthcare regulatory challenges

Healthcare has taken center stage in the political arena under the Trump administration. As tension and uncertainties mound regarding Trump’s threats to repeal and replace Obamacare, insurance and medical executives scramble to determine “what business is going to look like in the years ahead” (Gomes, 2016). Larry Levitt, a senior executive with the Kaiser Family Foundation emphasized any transition from one program to the next will require time for insurers to adjust to the “reverse disruption” and “overhaul to how individuals buy policies” (Gomes, 2016). Healthcare leaders must inform themselves, and staff on how to handle the changes in coverage. Currently, there is a “noticeable gap between the belief that change is necessary and actual support for specific reform plans designed to achieve that change” (Wood, 2011). Leaders will be challenged to counter frustration and confusion from Americans, once deemed otherwise uninstallable, who have formed a sense of security their current coverage, argues Wood (2011).NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Regulatory challenges drive up the cost of providing services and care. As the Trump administration strive to regulate Medicare and Medicaid eligible healthcare providers are overwhelmed by regulated “changes and new reporting requirements” (Brown, n.d.). Research provide that healthcare leaders are further burdened to comply with a variety of newly revised standards including the Health Insurance Portability and Accountability Act (HIPAA), Centers for Medicare and Medicaid Services (CMS), and Joint Commission on Accreditation of Healthcare Organizations (JCAHO). To combat these challenges, the healthcare provider needs actively engage in awareness and information sharing regularly. Studies suggest leaders must implement document control programs, compliance training, routine audits and address non-conformance incidents immediately utilizing integrated healthcare platforms.3NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Medicinal and technological advancement challenges

The practice of medicine and technology has created opportunity and challenges in the way providers practice medicine today and in the future. Today’s health organizations are facing physician shortages and need “low-cost alternatives to office visits” and in-patient care (Austin, Beethoven, & Chait, 2016). Five to ten years from now, leaders can expect more of a shift from the traditional office visits and prescribing in favor of virtual and cyber doctor patient interactions. Sanicola (2016) argue “medicine” – the use of “electronic communication” such as “two-way video, phone, email, wireless tools, and other forms of telecommunications technology.” Telemedicine “works well for treating common conditions such as colds, flu, pink eye and sprains” and “more easily manages patient care for chronic illnesses that require daily interventions” adds Sanicola (2016). The rapid change requires leaders to acquire and develop methods for maintaining and accessing private sessions and data of patients.

Saslow (2016) argue the pressure and “growing influx of patient data, legal requirements for strict privacy and security, rapidly advancing clinical technology increases costs, and other factors. At a minimum, leaders should explore innovative ways to manage and store the information adequately adds Saslow (2016). Heathfield, Pitty and Hanka (1998) posit leaders must “understand and predict the behavior of systems and provide important knowledge to inform further developments.” Once the leader understands the system, they can prepare training strategies for the staff and the patient. The leader’s training efforts must be a continuous initiative to keep up with the continual change of technology and medicine in the future.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Training and education challenges

Professional development is the key. Healthcare leaders must take steps to assess, develop and fine tune key personal and professional skills to remain proficient (Northouse, 2013). Most training initiatives, per Dunn (1995) remain centered around “traditional clinical interview with its focus on acute illness,” but healthcare providers will be challenged to change that dynamic. The future will require healthcare leaders to take more of a hands-off approach; involve patients more in personal care; offer alternatives to current practice and make themselves and staff available to forms of communicating with the patient without a trip into the office (Gomes, 2016).

Ethical challenges

Ethical challenges in healthcare is a big deal. Recent news stories support this claim with headlines about ethical violations of healthcare providers. In 2016 the British Broadcast Center (BBC) reports Dr. Paolo Macchiarini, was accused of providing misleading medical research which led to the deaths of seven patients (Kremer, 2016). More recently an Olympics Physical Therapy doctor, Larry Nassar was found guilty and sentenced for sexual misconduct. These incidents hurt the character and trust of the medical leaders. In addition, it creates legal costs and rise in malpractice insurance coverage for the agency.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Giving the very serious ramifications, healthcare leaders must ensure their behavior and their employees are above reproach. Bruning and Baghurst (2013) suggest “reform requires ethical decision-making from leaders” because these leaders influence “various relationships” and “creates fundamental successful changes in healthcare.” Sound “ethical principles to transformational leadership improves healthcare relationships and alleviates stress and tension produced by change” (Bruning & Baghurst, 2013). Leaders must understand the success of the organization; heavily rely on their ethical behavior. Building trust earns money and funding and reduces unnecessary liability costs for the agency.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Conclusion

Healthcare managers must be able to provide direction and guidance to organizations about roles, responsibilities, and functions (Gomes, 2016). The leader must devise and revise strategies everyone can understand and follow. Thompson et al. (2011) argue “decisions made by healthcare managers not only focus on ensuring that the patient receives the most appropriate, timely, and effective services possible, but also address achievement of desired performance targets.” Ultimately, decisions made by an individual manager affect the organization’s overall performance (Northouse, 2013).

Leaders should not take on the many challenges “posed by complex health care systems” therefore, it takes “a shared, distributed, or collective approach to address complex problems with diverse perspectives, talents, and skills” (MacPhee et al., 2013). Leaders must build a collaborative environment whereby everyone is involved in the process of developing strategies to help overcome the challenges as they arise. Staying abreast of the changes and implementing a plan of action will create successes for healthcare leaders and their organization for years to follow.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Why Quality Improvement in Healthcare is Important?
Healthcare, safety, efficiency and equability are few of the concerned facts which every human must remain aware about. With the improvement of technology and science, improving quality in healthcare has become important.

The institutions dedicated to medical practices need to give high effort for healthcare services. Implying specialized methods for healthcare settings, the doctor office need to stream measurable improvement in the quality of healthcare services.

As said, quality improvement is meant for enhancing safety, effectiveness, and efficiency which is achieved by deploying various methods. Both qualitative and quantitative healthcare improvement has become imperative.

Healthcare features are becoming complex with time and the requirement of new and enhanced methods is becoming inevitable. This would reduce costs as well offer access to new technology.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Changes in Healthcare System Would Improve the Level of Performance

The main reason behind the quality improvement of healthcare is that, if the healthcare practice institutions are stuck with the traditional concepts with no further enhancements, it will fail in generating better results. Streamlining the changes into the system, a new level of performance can be achieved.

Replacing the inefficient parts of the structures with new inventions can prove to be worthy. For the proven efficiencies, improved methodologies are implemented in healthcare on a global scale.

Digital version of patient’s health record or simply the EHR- Electronic Health Records software renders real-time records that are patient-centered. The EHR contains medical and treatment histories of a patient. EHR system is prepared at the doctor office that goes beyond standard clinical data and features a broader view of the health standard of a patient.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

What Are The Aims Of Healthcare Improvement?

Safety- It renders a protective shield that avoids the patients from injuries for the care.
Effectiveness- Basing on the knowledge of science, the healthcare services are rendered as would be beneficial for the patient and avoid the services that are not profitable.
Patient-Focused- The provided health-care is as per preferences of any individual patient. The requirements and values of healthcare ensure the patients with precise clinical decisions.
Real-time- Quality improvement in healthcare reduces the time of lingering which may sometimes are harmful when delayed.
Efficiency- It avoids certain wastes that include effort, idea, supply as well as equipment.
Equability- Basing on personal characteristics, the rendered healthcare quality mustn’t differ.
Benefits of Continuous Quality Improvement (CQI)
Continuous Quality Improvement (CQI) is a systematic approach to achieving ongoing improvements in a product or service. CQI users define the problem, map the process, identify improvement opportunities, implement the improvements and continually monitor the results for improvement opportunities. There are several benefits of using CQI.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Use of data
CQI uses quantitative information (e.g., output, defects) instead of subjective information to improve the process. Monitoring the data identifies ongoing opportunities for improvement.

Improved morale
The use of CQI helps improve employee morale by not blaming the employee for the problems in the system. Instead, it focuses on the problems in the process, not the people performing the process.

Better customer service
Because CQI focuses on continuously improving the organization’s performance and removing problems from the system, customer satisfaction increases.

Increased productivity
Removing errors from the process results in fewer errors and less repeat work on the part of the employees. Less repeat work means increased productivity.

Increased revenue
By removing errors and increasing customer service, the organization has the opportunity for increased sales.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Principles Of Quality Improvement In Healthcare
Principle 1: Promote hands-on improvement projects.
High-level strategy discussions and ideas aren’t enough to promote quality improvement in healthcare. Hands-on work aids the adoption of quality improvement projects because staff and physicians can see the direct impact in real-life situations. It also incentivizes internal teams when the organization identifies an area that needs improvement, and encourages staff and physicians to play an active part in the strategy.

Principle 2: Get buy-in on what “quality” means.
Part of the difficulty in defining quality improvement stems from the word “quality” itself. It’s subjective, and organizations sometimes suffer from internal clashes on how to characterize those seven letters. It’s important to get buy-in across the organization on exactly what quality means so you can objectively determine if it’s improving. However you decide to define quality, it should be measurable and revolve around patients. Healthcare organizations are guided by a mission to improve the lives of patients, so your definition of quality should overlap with how you care for them.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Principle 3: Focus measures on improvement vs. accountability.
Since quality improvement in healthcare revolves around the patient, performance measures should focus on improvement rather than accountability. When accountability is overemphasized, the needs of the patient are superseded and quality improvement can’t be applied. For example, a typical accountability measure might collect data on the percentage of ER patients who waited more than 30 minutes, and hold management accountable for keeping wait times under 30 minutes. A better tactic would focus on the system and collect actual wait time data in minutes to measure performance, instead of just focusing on the person who’s held accountable for those wait times. By taking this approach, a process can be improved.

The concept of quality has been contemplated throughout history and continues to be a topic of intense interest today. Quality presently is addressed in numerous academic and trade publications, by the media, and in training seminars; it is perhaps the most frequently repeated word among managers and executives in contemporary organizations. In a recent survey, executives ranked the improvement of service and product quality as the most critical challenge facing businesses [1]. Quality has been described as “the single most important force leading to the economic growth of companies in international markets” [2]. Quality in healthcare is also a determinant issue as healthcare accomplishes a work of life perpetuation and quality in healthcare sector is getting thorough attention. So far, different approaches have been introduced to improve healthcare service quality. Therefore, this research aims at reviewing the methods and approaches with their improvement models used for service quality improvement in a healthcare and gives alternatives insights for further research in the area.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

The need for service quality improvement
Both public and private organizations exist to serve their customers. The service quality particularly in the public sector has become ever more important in improving customer satisfaction. Organizations, especially in the public sector agree that customer satisfaction is one of the most vital factors that contribute establishment of reputation and credibility among the public. The public complaint of long queues, poor service delivery and insufficient physical facilities affect the image and level of service quality in the public sector. Service quality that customers receive must be reliable, responsive and emphatic involving service product, service delivery and service environment. Service quality has been documented as one of the key driving forces for business sustainability and is crucial for firms’ accomplishment. Hence, research on service quality has been carried out worldwide.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Earlier studies have focused on service quality construct by Paranormal et al. [3-5]. The development of the original 22-item SEMIQUAVER instrument signifies one of the most extensively used operation of service quality. It has provided researchers with the possibility of measuring the performance-expectations gaps composed of five determinants namely, reliability, responsiveness, empathy, assurance and tangibility. Existing studies focus on measuring the service quality level by these five dimensions in a holistic manner without considering the independent focus that should be given for each dimension through prioritization and their integrated impact to other improvement activities.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

The apparent reluctance of service organizations to utilize quality improvement based strategies and practices are difficult to understand, especially in light of the increased significance of the service industries and the demand of customers. The trend signifying the increasing importance of the service sector is expected to strengthen in the foreseen future. This trend, coupled with an increasing emphasis on the customer-focus strategic orientation makes the reluctance of some service organizations to implement quality improvement initiatives difficult to fathom. Some attribute this apparent reluctance of service organizations to implement quality improvement initiatives to the difficulties associated with defining service quality. Despite apparent difficulty, some practical research has attempted to practically address issues related to service quality in different service operational settings such as rapid assessment methodology to improve service quality in healthcare operational setting by attempting to integrate service quality improvement initiatives into a form of a system-wide quality improvement philosophy.

Based on a stream of research comparing operational practices and related quality improvement initiatives in manufacturing and service organizations, the need for service organizations to benchmark their manufacturing counterparts was underscored and the studies concluded that despite the multi-faceted nature of service quality, the implementation of quality improvement initiatives in service operational settings is not only feasible, but rather it leads to effective operational and strategic gains. In recent years, some service organizations in different service industries, such as healthcare, insurance and tourism among others, have shown increasing interest in developing quality improvement initiatives. This interest may be attributed to the positive operational and strategic benefits of these initiatives.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

In general, however, the effective implementation of quality improvement initiatives in service operational environments is still lagging behind compared with that of manufacturing. This may be attributed to the common misconception that quality improvement initiatives are, either inapplicable or at best, very difficult to implement in service operational settings. The research presented in this study analyzes and discusses on the existing moves concerned with quality improvement activities in healthcare operational environments and comes up with concluding remarks on what has been done till now , and indicates future direction for further study.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Quality in Healthcare
Healthcare industry is an integral and inseparable part of every society and every country. It consists of organizations, people and actions whose primary intent is to promote, restore or maintain health. According to government industry classifications mostly based on the United Nations system (World Health Organization and United Nations Children’s Fund, 1978) and the International Standard Industrial Classification (United Nations Statistic Division, 2001), health- care generally consists of hospital activities, medical and dental practice activities, and other human health activities. Those activities are conducted within the healthcare organizations which could be, depending on the type of services they deliver, facilities of primary, secondary or tertiary level of care they provide (WHO, 2007). Quality in health is defined as doing the right thing, the first time, in the right way, and at the right time.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

The Framework for Managing the Quality of Health Services in University of New South Wales (NSW) provides the structure for Area Health Services and clinicians to effectively govern the quality of care and to ensure that the clinical care and services provided are safe, effective, appropriate, consumer focused, accessible and efficient. The framework challenges healthcare organizations, clinicians and managers to undertake rigorous evaluation of processes and outcomes of services in a manner that is transparent and leads to sustained improvement.

Historically, quality departments have been important parts of hospitals since the 1950s, but only recently; quality management theory transformed the role of these departments, renewed their original quality mandate, and empowered them to logically restructure fundamental hospital processes to produce better quality. Hospitals have historically modeled quality according to systems paradigm, but only recently have been able to benefit from bench marking important new management theory from other industries. As a result, the rate of adoption of quality management within healthcare has been almost uniform in different areas and even in the smallest hospitals. The process in healthcare mainly focuses on “identifying problem in customers’’ health and does a work to eliminate or treat it.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper During the last decade, the healthcare sector has changed rapidly due to increased competition and the growing influence of patient association and a necessity to deliver health services in a more efficient and effective way. Different quality improvement approaches have been studied. The approaches include quality improvement initiatives such as; total quality management (TQM), just in time (JIT), job re engineering (JR), process re engineering (PR), organizational restructuring (OR), bench marking (BM) among others aiming at continuous improvement.

These approaches, with especial focus on the continuous quality improvement approach should be further studied to help in seeing the strengths and drawbacks of what is worked on and to identify a gap that gives a room as well as unique direction for further improvement.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Continuous quality improvement is a concept which includes: Quality assurance–the provision of services that meet an appropriate standard. Problem resolution–including all departments involved in the issue at hand. Quality improvement–a continuous process involving all levels of the organization working together across departmental lines to produce better services for health care clients. Deming (1982b) and others have espoused total system reform to achieve quality improvement–not merely altering the current system, but radically changing it. It must be assumed that those who provide services at the staff level are acting in good faith and are not willfully failing to do what is correct (Ber wick, 1991). Those who perform direct services are in an excellent position to identify the need for change in service delivery processes. Based on this premise, the staff nurse–who is 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 to clients in the health care setting. The nurse manager must structure the work setting to facilitate the staff nurse’s ability to undertake constructive action for improving care. The use of quality circles, quality councils, or quality improvement forums to facilitate the coordination of quality improvement efforts is an effective way to achieve success. The QA coordinator assists departments in documenting that the quality improvement efforts are effective across all departments of the organization, and aggregates data to demonstrate that they meet the requirements of external regulatory agencies, insurers, and professional standards.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper The nurse executive provides the vision and secures the necessary resources to ensure that the organization’s quality improvement efforts are successful. By inspiring and empowering the staff in their efforts to improve the process by which health care is provided, nurse managers participate in reshaping the health care environment. The professional nurse plays a vital role in the quality improvement of health care services. However, nurses cannot make these improvements in a vacuum; they must include other professionals and ancillary personnel in their efforts. Total quality commitment must include all levels of an organization’s structure. Quality patient care services will be achieved as the result of positive interactions among departments working together to build a dynamic mechanism that continuously improves the processes and outcomes of health care services.

Strategies to Engage Nurses in Quality Improvement Activities
There was little increase in nurses’ participation in quality improvement activities from 2004 to 2008, according to a study published in the Journal of Nursing Care Quality and reported by the Robert Wood Johnson Foundation. NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Researchers studied participation levels in QI activities of registered nurses who were first licensed between 2004 and 2005 compared with the levels of nurses who were first licensed between 2007 and 2008. QI activities included measuring performance, working to improve processes or systems of care, monitoring sustainability of improved practices and working to improve performance.A survey of 539 registered nurses employed in hospitals in 15 states revealed that participation in these QI activities did not differ significantly over the time period studied, despite the increase in the number of hospitals who participated in programs to engage nurses in quality and safety initiatives. However, the “use of appropriate strategies to improve hand washing compliance to reduce nonsocial infection rates” did improve over time, according to the RWJF news release.

The authors suggested several ways hospital leaders can engage nurses in QI activities:
•    Subscribe to programs in which nurses complete self-directed online modules to learn about QI, such as the Institute for Healthcare Improvement Open School for Health Professions and the RWY-funded Quality and Safety Education for Nurses initiative.
•    Have more experienced colleagues help early-career nurses translate newly acquired QI knowledge into action.
•    Ensure adequate staffing levels and that nurses have sufficient release time to participate in QI activities.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
•    Ensure nurses have access to an information technology infrastructure that provides meaningful, timely and actionable QI data.

Hospitals face growing tensions and trade-offs when allocating nurses between the competing priorities of direct patient care and quality improvement efforts, according to a study released today by the Center for Studying Health System Change (HSC).

Commissioned by the Robert Wood Johnson Foundation (RWJF), the study included interviews with hospital leaders in Detroit, Memphis, Minneapolis-St. Paul and Seattle to examine the role of nurses in hospital quality improvement activities.

“Nursing has the biggest impact on a patient’s experience in the hospital, so involving nurses in quality improvement is critical,” said John Lump kin, M.D., M.P.H., senior vice president and director of the Health Care Group at RWJF. “We commissioned this study to gain a better understanding of the role that nurses play in quality improvement and the challenges nurses face when balancing the competing priorities of direct patient care and quality improvement efforts.”

RWJF has been on the forefront of efforts to involve nurses and other front-line staff in quality improvement. Transforming Care at the Bedside, a joint initiative with the Institute for Healthcare Improvement, has significantly improved the quality and safety of patient care on medical and surgical units, increased retention of nurses in hospital-based jobs and helped to improve the effectiveness of the entire health care team.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

According to the HSC study, hospital organizational cultures set the stage for quality improvement, including nurses’ involvement. Hospitals with supportive leadership; a philosophy of quality as everyone’s responsibility; individual accountability; physician and nurse champions; and effective feedback reportedly offer greater promise for successfully involving nurses in quality improvement activities.

Even when hospitals are committed to including nurses in quality improvement, they often face various problems, including a shortage of nurses; growing demands to participate in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving role in today’s contemporary hospital setting, the study found.

“The stakes for hospitals to demonstrate high quality are increasing at the same time that resources—especially nurses—are in short supply,” said Debra A. Draper, Ph.D., HSC associate director and co-author of the study with Laurie Felland, M.S., an HSC health researcher; Allison Liebhaber, an HSC health research assistant; and RWJF director Lori Melichar, Ph.D.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

“While quality improvement isn’t solely the domain of nurses, they are critical because of their day-to-day patient responsibilities, and hospitals will need to guard against diminishing nurses’ involvement in quality improvement activities,” Draper said

The study’s findings are detailed in a new HSC research brief, The Role of Nurse in Hospital Quality Improvement, available online at www.hschange.org.

Other key study findings include:

Hospitals face ever-growing demands to participate in more quality improvement activities, many of which are viewed as duplicative. The lack of standardization in quality measurement and reporting intensifies the challenge, according to hospital respondents.
Respondents reported that nurses are well positioned to serve on the front lines of quality improvement since they directly affect the care patients receive during a hospital stay. As one hospital chief nursing officer noted, “Nurses are the safety net. They are the folks that are right there, real time, catching medication errors, catching patient falls, recognizing when a patient needs something, avoiding failure to rescue.”NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
The scarcity of nurses is a major challenge for hospitals. Hospital respondents in two communities—Memphis and Seattle—reported being significantly affected by a nursing shortage, which some believed would only worsen, particularly as more nurses age out of the workforce and demand continues to exceed supply.
Another dilemma hospitals face is that they want their best nurses at the bedside caring for patients and these same nurses leading their quality improvement activities. This poses an even greater quandary when nurses are in scarce supply. Some respondents said that trying to balance nurses’ work at the bedside with their involvement in quality improvement activities has sometimes resulted in nurses receiving mixed messages about the importance of their role in quality improvement.
Respondents discussed that to optimize the role of nurses in quality improvement, it is important for nursing education programs to strengthen curricula to emphasize the concepts and skills needed to participate in quality improvement activities. Respondents also emphasized the need for effective continuing education programs to help nurses be more adept at translating their observations of problems at the beside into an effective improvement effort.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded in part by the Robert Wood Johnson Foundation and affiliated with Mathematical

How the Four Principles of Health Care Ethics Improve Patient Care
Whether your role is that of a doctor or a health care administrator, working in the field of health care is both highly rewarding and challenging. Many medical procedures and treatments have both merits and downsides, and patients have their own input and circumstances to consider. The four principles of health care ethics developed by Tom Beau champ and James Childless in the 1985 Principles of Biomedical Ethics provide medical practitioners with guidelines to make decisions when they inevitably face complicated situations involving patients. The four principles of health care ethics are autonomy, beneficence, non-maleficence, and justice.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

The Four Principles of Health Care Ethics
The basic definitions of each of the four principles of health care ethics are commonly known and used often in the English language, but they take on special meaning when being utilized in a medical setting. All of these principles play a key role in ensuring optimal patient safety and care.

1. Autonomy: In medicine, autonomy refers to the right of the patient to retain control over his or her body. A health care professional can suggest or advise, but any actions that attempt to persuade or coerce the patient into making a choice are violations of this principle. In the end, the patient must be allowed to make his or her own decisions – whether or not the medical provider believes these choices are in that patient’s best interests – independently and according to his or her personal values and beliefs.

2. Beneficence: This principle states that health care providers must do all they can to benefit the patient in each situation. All procedures and treatments recommended must be with the intention to do the most good for the patient. To ensure beneficence, medical practitioners must develop and maintain a high level of skill and knowledge, make sure that they are trained in the most current and best medical practices, and must consider their patients’ individual circumstances; what is good for one patient will not necessary benefit another.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

3. Non-Maleficence: Non-maleficence is probably the best known of the four principles. In short, it means, “to do no harm.” This principle is intended to be the end goal for all of a practitioner’s decisions, and means that medical providers must consider whether other people or society could be harmed by a decision made, even if it is made for the benefit of an individual patient.

4. Justice: The principle of justice states that there should be an element of fairness in all medical decisions: fairness in decisions that burden and benefit, as well as equal distribution of scarce resources and new treatments, and for medical practitioners to uphold applicable laws and legislation when making choices.

Care Management of Patients with Complex Health Care Needs
They represent an opportunity to control the growth of health care costs by better managing their conditions, reducing hospitalizations and avoiding emergency department visits.

What is care management?

Care management is a set of activities intended to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminate duplication, and helping patients and caregivers more effectively manage health conditions. These efforts have demonstrated potential to improve quality and control costs for patients with complex conditions.

Care management is relatively costly. Offering care management to patients who are not expected to be high utilize rs of hospital, specialty and emergency department care would not reduce costs. Similarly, care management for patients too sick to benefit is ineffective.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
Does care management improve quality and reduce costs?

Patients who are experiencing poor quality outcomes often require more hospitalizations and emergency department visits. For this reason, utilization of high-cost services can be viewed as one marker of inadequate quality of care.

There is strong research evidence that care management improves quality, but the effect on cost reduction is less consistent. Hospital-to-home care management programs have had the most success in reducing costs. Care management in primary care improves quality, but research indicates it may take time to see results.

Commercial disease management vendors have provided data demonstrating success, but methodological issues call into question these findings. The evidence demonstrating quality improvement is stronger than the evidence on cost reduction.

Care management within integrated multi specialty groups improves quality, but does not consistently reduce costs. The most effective care management programs are those targeting patients discharged from hospitals. Studies have found that care management programs targeting the hospital-to-home transition have reduced hospital readmission’s and lowered costs.

What are the keys to successful care management?

In-person encounters: Person-to-person encounters, including home visits, are necessary features of effective care management. Care management relying solely on telephone encounters has not shown success.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper
Training and personnel: Programs with specially trained care managers who have a relatively low workload are most successful. Most care managers are registered nurses (RNs) who work as part of a multidisciplinary team.
Physician involvement: Placing care managers with physicians in primary care practices may help facilitate physician involvement.
Informal caregivers: Patients with complex health care needs, particularly those with physical or cognitive functional decline, often need the assistance of informal caregivers to actively participate in care management.
Coaching: Coaching involves teaching patients and their caregivers how to recognize early warning signs of worsening disease.
Background: The Clinical Nurse Leader (CNL) is the first new role in nursing since the nurse practitioner was introduced over many years ago. The CNL evolved after the American Association of Colleges of Nursing (AACN) convened a task force to identify ways to improve quality of patient care and determine how to prepare nurses with the skills and competencies needed to thrive in the current and future healthcare system. The original task force on education developed models for nursing education and regulation. A second task force was established, and from that work, a new role emerged-the Clinical Nurse Leader (CNL). Aim: The aim of the present study was review the literature about the role of Clinical Nurse Leader. Method and Material: Method was used is to search in databases (PUBMED, SCOPUS) to identify articles related to the role of clinical nurse leader. The search took place in February 2011 for scientific papers until February 2011. The keywords used in combination were: clinical, nurse, leader, leadership. Results: The Clinical Nurse Leader role was developed in response to concerns about the quality and safety of nursing care in the complex, technologically advanced, ever-changing healthcare system. The CNL could be a clinician, an advanced generalist, an outcomes manager, an interdisciplinary care team manager, a patient advocate, an educator, an information manager, a member of the profession and a lifelong learner. Conclusions: NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper The Clinical Nurse Leader role emerged following several years of research and discussion with stakeholders as a way to engage highly skilled clinicians in outcomes-based practice and quality improvement strategies. The CNL is an advanced generalist clinician with education at the master’s degree level. The Clinical Nurse Leader is an emerging nursing role developed by the American Association of Colleges of Nursing (AACN) in collaboration with an array of leaders from the practice environment. Two AACN task forces were convened to identify a) how to improve the quality of patient care and b) how to best prepare nurses with the competencies needed to thrive in the current and future health care system.

Introduction
Twenty-first century realities affecting healthcare are dramatically and radically changing the landscape for nursing practice [1]. Much of the intensive and comprehensive professional and role development for the entire field of nursing grew out of the focused action of nursing leaders during the 20th century [2]. A clinical nurse is certainly one involved in clinical practice with knowledge, experience and understanding of providing nursing care. Leadership implies authority in the broadest sense of the word, is non hierarchical and not confined to a specific set of skills, attributes or traits. One can deduce, then, that clinical nursing leadership reflects all of the complexity of the culture, the organization, the practice setting and situational variables of each clinical nurse leader [3].NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Clinical leadership requires dedication. Clinicians are being asked to respond to a range of challenges: investment is slowing down, and demands for quality, safety, and efficiency are rising. Strategic plans from health authorities and trusts are identifying key areas for service redesign and improvement. Clinical leaders are standing in the gap between management and their clinical colleagues-enthusing, negotiating, pacifying, and challenging are all part of a day’s work [4].

The Clinical Nurse Leader (CNL) is the first new role in nursing since the nurse practitioner was introduced over many years ago. The CNL evolved after the American Association of Colleges of Nursing (AACN) convened a task force to identify ways to improve quality of patient care and determine how to prepare nurses with the skills and competencies needed to thrive in the current and future healthcare system. The original task force on education developed models for nursing education and regulation. A second task force was established, and from that work, a new role emerged – the CNL. The role is prepared in a new master of nursing curriculum that educates nurses to understand how to provide care and improve quality in today’s complex healthcare system.

The coursework provides theoretical and clinical experiences that result in competencies that prepare the CNL to be a strong leader and clinician in today’s healthcare setting. CNLs are putting a new face on nursing as a true partner in care with colleagues across the healthcare system by acting as an integrator of the threads of care provided by many to weave a new fabric of comprehensive, coordinated care. Nurses have always been patient advocates and did what needed to be done for patients, no matter what the circumstances or environment in which they practiced. Today, nursing is called upon to rise above the staccato pace of fragmented and complex healthcare delivery, as well as partner with, others to ensure that patient care is safe and effective. The CNL is a fresh new role that is helping to answer this call and holds great promise for the future in a time when it is desperately needed [5].NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Healthcare is as complex an industry as any, and is becoming even more so. Highly fragmented, and largely thought of a type of service you don’t want to need, the industry has long suffered from a lack of coordination, high variability and failure to ties costs to quality. In our efforts to “fix” this, leading a healthcare organization has become even more complicated. There’s little doubt that integration and population health will lead to lower costs, better outcomes and better health, but getting there isn’t easy. Leaders who were once tasked with overseeing a single acute-care hospital, or group of hospitals, now oversee a portfolio of hospitals, employed physician groups, outpatient centers and contracts with retail health providers, community hospital affiliates, professional services groups and more. The list seems to grow monthly.

One impact of this complexity seems to be less effective leadership and organizational performance. One study recently found the number healthcare leaders rated as “struggling” has grown considerably over the last five years, and their expanding responsibilities may explain why this is the case.

There’s no sign of this complexity letting up, so how will organizations adapt? What do those that are successful at managing complexity do differently?

Boston Consulting Group has an idea. In a new article, the authors, all BCG consultants, propose the following:

“Many organizations thrive amid this complexity. They sort signals from noise and focus on the opportunities that matter most.  NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

Others stumble and struggle. They create an overabundance of committees, layers, key performance indicators, processes, and other internal mechanisms. This organizational mishmash fails to address the complexity they face in the outside world.”

We see this in healthcare. To deal with the expanding role of the organization amid financial pressures, health systems form numerous committees to set and monitor various KPIs, examine where to cut costs, develop protocols around care, EMRs, technology decisions, etc., etc., etc.

It’s worth noting that while a fair amount of the expansion of structures and processes is self-imposed, many result from increasing governmental regulations. This creates a whole separate discussion that is outside the scope of this piece. Instead of arguing over how to stem the tide of complications, I’ll focus on accepting it for what it is and how to best deal with it.

Regardless, we’ve reached a point in healthcare, that for many organizations, their internal workings have become more complicated in response to the outside world becoming more complex.

Should it be the other way around?

Based on discussions with leaders of successful organizations across a variety of industries, the authors of the BCG report suggest the answer is yes.

“Just because the world is becoming more complex, organization structures and processes do not need to follow suit…many organizations unnecessarily create internal complicates — procedures, vertical layers, interface structures, coordination bodies, and decision approvals — in response to external complexity.

The end result is that managers spend most of their time shuffling papers and attending meetings and very little time working with their teams. Rather than creating formal guidelines and processes, [organizations should embrace]…an environment in which employees can work with one another to develop creative solutions to complex challenges.”How do organizations cultivate an environment that embraces complexity without creating complication? Here are five of BCG’s recommendations.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

•    Impart directional vision rather than set detailed, inflexible strategic plans.
•    Favor fluid decision-making over non-flexible guidelines for organizational decisions. Don’t be afraid to improve and experiment.

•    Simplify organizational structure and processes. Remove structural and procedural complicated so employees can exercise personal judgment.

•    Institutionalize leadership throughout the organization. Avoid relying only on top-down management.

•    Embrace collaboration among employees, units and entities outside the organization.

The science and theory of complex adaptive systems, also known as complexity science, has emerged as an alternative to existing paradigms. Complex adaptive systems demonstrate identifiable characteristics: embedded, self-organization, non-linearity, unpredictability, and others. These systems exhibit emergent behavior that arises from simple rules and interconnections among diverse elements with porous boundaries, as they interact with and respond to the environment. The health system and the profession of nursing can be viewed as complex adaptive systems, and when done so, new insight can be gained. While several authors have stated they believe nursing is indeed a complex adaptive system, a visual model has not yet been advanced. This article offers a model of nursing viewed as a complex adaptive system, a discussion of key properties of a complex adaptive system, and potential implications of the use of complexity science in nursing and health care.NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

The science and theory of complex adaptive systems, also known as complexity science, has emerged as an alternative to existing paradigms. Complex adaptive systems demonstrate identifiable characteristics: embedded, self-organization, non-linearity, unpredictability, and others. These systems exhibit emergent behavior that arises from simple rules and interconnections among diverse elements with porous boundaries, as they interact with and respond to the environment. The health system and the profession of nursing can be viewed as complex adaptive systems, and when done so, new insight can be gained. While several authors have stated they believe nursing is indeed a complex adaptive system, a visual model has not yet been advanced. This article offers a model of nursing viewed as a complex adaptive system, a discussion of key properties of a complex adaptive system, and potential implications of the use of complexity science in nursing and health care. NURS 6230 – Case Study: Quality Nursing in a Complex Healthcare Organization Research Paper

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