1
Running head: Leadership Analysis
Leadership Strategy Analysis – Quality Improvement Process
Darla Stutzman
Ferris State University
Leadership Analysis
2
Abstract
Decreasing errors and increasing patient safety are nursing management’s main responsibilities.
Ensuring that the best methods of practice are performed by each individual nurse and patient
satisfaction is high is part of the nurse leader’s roles. In home care, when it comes to the activity
of changing a tracheotomy tube, flow sheets were developed by individual nurses and compared.
As part of the quality improvement process it is important to gain input from all staff members.
After evaluating each flow sheet against current evidence based practice, interventions were
developed to implement into practice and increase patient safety and decrease the possibility of
infections. After implementation of the quality improvement process, evaluation strategies were
discussed to ensure staff members understood the importance of the changes.
Keywords: Tracheotomy, quality improvement, safety, evidence based practice
Leadership Analysis
3
Leadership Strategy Analysis – Quality Improvement Process
Keeping patients safe is key for customer satisfaction and paramount for direct patient
care in the healthcare setting. Maintaining safety prevents adverse events and includes the
prevention of the spread of infection. Quality improvement (QI) is used to identify errors and
maximize safety and quality outcomes for each healthcare team. “Nurses maintain a unique role
in quality management and quality improvement because of the amount of direct patient care
provided at the bedside and because they have an understanding of the day-to-day issues and
“real world” nursing involved in delivery of care” (Yoder-Wise, 2011, p. 390). Including nurses
in the quality improvement process allows for increased job satisfaction and a closer and
increased quality involvement of patient care. To run this quality improvement process the nurse
manager needs to work as a leader in communication and education to research an activity that
can be improved for all parties in the healthcare team, including the patient.
Each individual in the healthcare system needs to be involved in quality improvement.
When choosing one clinical activity to improve upon, there needs to be a dedicated leader. When
it comes to patient care in the home, the nurse takes the role of the leader to achieve accurate
results.
When looking at the roles of a senior leader, Yoder-Wise (2011) includes:

Leads culture transformation

Sets priorities for house-wide activities, staffing effectiveness, and patient health
outcomes

Builds infrastructure, provides resources, and removes barriers for improvement
Leadership Analysis

4
Defines procedures for immediate response to errors involving care, treatment, or
services and contains risk

Assesses management and staff knowledge of quality management process regularly, and
provides education as needed

Implements and monitors systems for internal and external reporting of information

Defines and provides support system for staff who have been involved in a sentinel event.
(p. 393)
A true leader can empower nurses to work efficiently to properly execute the quality
improvement plan. Leaders that understand their own role can educate each individual involved,
and open the lines of communication.
Clinical Need
Tracheotomies are becoming more common today in the health care setting. Being able to
efficiently change a tracheotomy tube plays a key role in keeping a patient’s airway patent.
El-Sayed, Ryan, Schell, Rappazinni, & Wang (2010) states, “After tracheotomy, the rate of
serious complication is reported at 2.7% for tube intubation and 1.5% for tube displacement”
(para. 15). Having inconsistencies among nurses when changing a tracheotomy tube can present
a threat to patient safety in the form of infections, prolonged hospitalizations, scarring or other
airway complications, and even death. Respiratory therapist have found in about 5% of patient’s
that the tracheotomy tube was malpositioned and resulted in further complications. “The
presentation of tube malposition included failure to wean, inability to pass a suction catheter
down the tracheotomy tube, and intermittent high peak airway pressures recorded during
mechanical ventilation” (White, Kher, & O’Connor, 2010, p. 1072). This can result in respiratory
distress and possible death of a patient due to a decannulation.
Leadership Analysis
5
Although safety during a tracheotomy tube change can depend on each client, there are
still guidelines that need to be placed by each institution to prevent possible complications.
When it comes to changing the tube in a home environment, there are added risks due to not
having endoscopy equipment available, carbon dioxide monitor, another caregiver to help at the
bedside, or caregivers without adequate education on tracheotomy tube changes. Standards for
home care tracheotomy tube changes need to be researched, compared, and contrasted so that all
patients are kept as safe as possible.
Design of an Interdisciplinary Team and Data Collection Method
When establishing a team for quality improvement research, Yoder-Wise (2011) states,
“QI team members should represent a cross section of workers who are involved with the
problem. To maximize success, team members may need to be educated about their roles before
starting the QI process” (p. 395). Working in a home care environment the task of tracheostomy
care and tube change falls in the hands of the licensed nurse. In pediatric home care this can be
either a licensed practical nurse or a registered nurse. Since the tube changes do not take place in
a professional facility, such as a hospital, the only other caregiver available for the patient are the
parents, who are not involved in the quality improvement process. Therefore, the
interdisciplinary team for this QI process was formulated with other pediatric home care nurses,
including one who worked for another home care agency. This allowed similarities and
differences to be discovered that contribute to both patient safety and infection.
When researching any activity for quality improvement, there are several types of
methods that can be used to collect data. Although changing a tracheostomy tube is complex, the
use of a statistical expert was not used in this QI process. With the explanations of data types
Leadership Analysis
6
given in Yoder-Wise (2011) the decision to use flowcharts was made by the author. “The
flowchart is a data tool that uses boxes and directional arrows to diagram all the steps of a
process or procedure in the proper sequence” (Yoder-Wise, 2011, p. 396). With the help of
another pediatric home care nurse, the actions of tracheotomy care were compared through the
use of separate flowcharts (Appendices A and B). This allows for the author, in the leadership
position, to see the differences in each nurses procedure where changes may need to be
implemented to increase patient safety. “Loss of the airway can rapidly result in the patient
demise and there is not always time for a knowledgeable airway specialist” (El-Sayed, et al.,
2010, para. 18).
Establishes Outcomes
When comparing the flow sheets against current evidence based practice it is agreed that
having an open airway is priority for each patient. However, safety was not a priority in either
nurses’ flow sheet in the fact that there was not a second caregiver available in case there was a
type of decannulation, or an episode of respiratory distress. The failure to be able to replace the
tube within a timely manner may result in an emergency and then a possible loss of an airway. In
a study done by Alexander White, et. al (2010), the authors state, “There is a risk of tracheotomy
dislodgement during the tie placement, and it is important that one person maintain the airway by
securing the tracheostomy tube in place, while the other person secures the tie” (p. 1075). Not
only is it important to increase patient safety with another caregiver present while working in
home care, it is also important to have a tracheotomy available at the bedside which in one size
smaller than what the patient wears on a daily basis. This also provides safety for the patient in
case there is any sign of tracheal stenosis or inflammation, the smaller tracheotomy will still
provide an open airway. This is especially important if the patient has a newer tracheostomy; the
Leadership Analysis
7
patient has a smaller neck circumference, or unusual airway anatomy (White, et. al, 2010). It is
important that having a spare tracheotomy available and an extra set of hands become part of the
tracheotomy tube change process in home care nursing. This will decrease episodes of
respiratory distress along with possibilities of tracheotomy infections, and even death due to loss
of the patient’s airway.
Implementation Strategies
To ensure that the outcomes of the quality improvement process were achieved, input
from pediatric home care nurses would be gathered. Nurses are the main workers involved in the
process of improving tracheotomy tube changes. When discussing quality management (QM),
Yoder-Wise (2011) states, “ Because QM stresses improving the system rather than assigning
blame to employees, change strategies emphasize open communication and education of workers
affected by the new standard and outcome” (p. 400). To educate these nurses so that a positive
change may be implemented it’s important to use the self-efficacy and social cognitive theory as
a leader to understand how each nurse will adapt to the change. In Health Promotion in Nursing
Practice (2011), the author Nola Pender informs the reader that, “…individuals must believe
they have control to change the behavior in order to take actions. Health behaviors are also
influenced by outcome expectancies and goals set by the individual, as they serve as incentives
for change” (p. 42).
Home care nurses need to be educated on the proper safety checks for tracheotomy tube
changes more frequently. Educating each nurse will provide them with positive influence and
provide enough knowledge so they will have enough self-confidence to adapt to the changes.
Through the use of frequent competencies each nurse will be aware of health risks and the
Leadership Analysis
8
benefits of reducing risk by increasing patient safety. The higher level of self-efficacy an
employee holds the more adaptable behavior to change. Increasing educational competencies
would be an opportunity to watch each nurse’s hands-on skills and provide open lines of
communication, and therefore increase patient safety.
Evaluation
After implementing the quality improvement process it is important for the leader to
gather feedback on how the activity change impacted the healthcare environment. Each outcome,
both tracheal infections and decannulations, would be reported to the nursing supervisor for
every client and recorded for at least an 8 month period. Also to ensure that only proper
technique is performed in the home, other than emergency situations, each nurse would have to
pass their tracheotomy competency with at least a grade of 80%, until that point they would not
be permitted to work with children who have tracheotomies. To benefit nurses who join the
agency shall also be educated with the correct procedure during orientation periods.
Yoder-Wise (2011) suggests nurses use the six steps of the QI process to assess their own
skills on performing the activity improvement. These steps include:
1. “Identify needs most important to the consumer of healthcare services
2. Assemble a multidisciplinary team to review the identified consumer needs and services
3. Collect data to measure the current status of these services
4. Establish measurable outcomes and quality indicators
5. Select and implement a plan to meet the outcomes
Leadership Analysis
9
6. Collect data to evaluate the implementation of the plan and the achievement of
outcomes” (p. 395).
Patient safety is expected to be the highest priority for all healthcare providers. Working as a
team with fellow caregivers, nursing supervisors and parents, existing nursing procedures can
be combined with current evidence based practice to develop new policies and procedures to
decrease variance. Although the adaption process may take a long length of time to get each
employee acclimated, the best interest of the patient is worth the wait.
Leadership Analysis
10
References
Bissell, Cynthia (2011). Aaron’s tracheostomy page: Tracheostomy complications. Retrieved
April 1, 2012, from http://www.tracheostomy.com/care/complications/index.htm
El-Sayed, I.H., Ryan, S., Schell, H., Rappazini, R., & Wang, S.J. (2010, May). Identifying and
Improving Knowledge Deficits of Emergency Airway Management of Tracheotomy and
Laryngectomy Patients: A Pilot Patient Safety Initiative. International Journal of
Otolaryngology, 2010, 1-7.
White, A.C., Kher, S., & O’Connor, H.H. (2010). When to change a tracheostomy tube.
Respiratory Care, 55(8), 1069-1075.
Yoder-Wise, P.S. (2011). Leadership and Managing in Nursing (5th ed.). St. Louis, MO:
Elsevier, Mosby.
Leadership Analysis
11
Appendix A
Flow sheet for Tracheotomy tube change
Assess patient airway and
need for tracheostomy
change
Remove old split sponge and
prepare patient for trach
change. Hyperextend
patient's neck and overoxygenate before removal
Make sure new tracheostomy is
fully lubricated, untie old trach
ties and remove current
tracheostomy
Wash Hands and Set up
supplies
(Including: Gloves, trach ties,
surgical lubricant, appropriate sized
tracheostomy)
If tracheostomy site is
dirty perform
tracheostomy care
Insert new tracheostomy
with curve facing down,
and remove obturator. Tie
new trach ties with one
finger width between neck
and ties.
Ensure airway patency.
Document findings and care
in MAR/TAR and nurse's
notes.
Inflate balloon if
appropriate. Make sure
ties are secure and insert
new split sponge. Place
patient back on oxygen if
ordered.
Assess stoma site for signs of
infection
(Example: Redness, drainage, and
swelling)
Prepare new
tracheostomy by testing
balloon if a cuffed trach,
secure trach ties to face
plate and keep obturator
in place
Leadership Analysis
12
Appendix B
Procedure for Tracheotomy Change
Identify need to
change
tracheotomy
Gather
supplies:
tracheotomy,
vial of normal
saline, clean
neck tie
Prepare trach
and patient for
insertion
Place trach near
patient with inserted
end up
Use normal saline
to lubricate end
and tube
Lift patient
shoulders
Wait for
patient to
exhale
Secure neck
tie
Remove old trach and
insert new trach
Provide suctioning
and/or oxygen
support as needed
Document
results
Leadership Analysis
13
Author: Eppie LaBiche
Date: February 20, 2012 12:59 PM
Darla:
Overall, excellent content; you have addressed all grading rubric requirements. Points deducted
was due to APA formatting. Take a moment to review your work and follow the points listed
below:
1. page 3 ... legal/ethical issues, last sentence in the paragraph had incomplete citation...direct
quotes require page or paragraph number in the citation.
2. page 4... power/influence...incorrect block quote citation (should not have quotation marks
and the section should begin with an opening statement prior to the block). Refer to APA on how
to cite it. I do not have my APA with me to provide further direction but refer to the manual as
well the tutorial. If you are unable to find it, let me know and I will look when I return home.
3. refer back to the reference page...titles should be formatted upper/lower case.
Please let me know if you have any questions.
Eppie