Running Head: QUALITY IMPROVEMENT PROCESS
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QUALITY IMPROVEMENT PROCESS
Kimberly K. Proux
Ferris State University
QUALITY IMPROVEMENT PROCESS
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Abstract
This paper reflects a leadership strategy analysis indicating a quality improvement process. The
quality improvement process concentrates on patient advocacy and patient safety regarding
pediatric tracheostomy suctioning. Pediatric tracheostomy patients are even more vulnerable
than their adult counterparts because of their inability to communicate effectively. Nurses,
family, and other care givers must be trained to be aware of the patient’s needs as well as the
actual evidence-based techniques used to suction pediatric tracheostomy patients. The quality
improvement process integrates action theory and education to address the needs of pediatric
tracheostomy patients.
Keywords: quality improvement process, patient advocacy, patient safety, pediatric
tracheostomy suctioning, evidence-based practice, action theory, education
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Quality Improvement Process
In the healthcare field when quality improvement is addressed it can be delivered in a
couple of different ways; there is more than one focus regarding quality improvement. There are
quality improvement indicators for patients. Evidence-based management is used in achieving
patient safety; “the National Database of Nursing Quality Indicators (NDNQI) are good
resources for the nurse manager. The NDNQI measures are specifically concerned with patient
safety and aspects of quality of care that may be affected by changes in the delivery of care”
(Yoder-Wise, 2011, p.63). There are quality improvement indicators of staffing effectiveness
such as average daily census (ADC), percentage of occupancy, and average length of stay
(ALOS), these are measures used to help the nurse manager calculate the number of patients
coming and going on a particular unit so that the nurse can “match the needs of the patients with
the appropriate number of staff members” (Yoder-Wise, 2011, p.288). The last quality indicator
this paper will focus on is what Yoder-Wise (2011) refers to as “the basic building block of
quality, patient safety” (p. 26), which healthcare workers provide by advocating for their
patients. The examples of quality improvement provided are not only used in facilities, but by
nurses who work in patient homes. In the home nurses provide quality improvement by being
concerned with patient safety, there is usually only one nurse in the home at a time, but that
nurse has a team to work with to help ensure the patient needs are met, and patient advocacy is a
home care nurse’s way of giving the patient a voice. Home care nurses also provide education to
patients as well as families so that they can be assured that the patient will be properly cared for
when they are not in the home. This paper will address leadership strategies by focusing on
advocacy and education to safeguard patient safety.
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Identified Clinical Need
The particular home care service I am employed with has approximately 114 clients, of
the 114 clients 4 are clients who have tracheostomies; of the 4 clients who have tracheostomies 3
are children. Some of these children have diseases that will improve to the point where they will
no longer need the assistance of a tracheostomy; others will be tracheostomy dependent their
entire lives. We have one family with a child who has a tracheostomy and experiences many
negative health issues due to the fact that she is not being suctioned enough when the nurses are
not in the home. A tracheostomy tube that is obstructed even moderately causes severe breathing
difficulties. The significance of tracheostomy management is to ensure patency of the airway.
Neglecting to suction a child in need exposes the child to risks such as hypoxia, respiratory
compromise and pneumonia. (Lippincott Williams & Wilkins, 2013)
Interdisciplinary Team
Quality improvement is an attitude and culture that should resonate through the entire
interdisciplinary team. As such, “the foundation for a successful quality improvement program
is strong motivation, teamwork, and leadership. Potential motivators for quality improvement
programs are numerous” (Curtis et al., 2006). In this case a patient-specific safety issue is the
stimulus. The interdisciplinary team will be selected based on their contact with the child, their
involvement in the case, and their propensity to educate; this will allow for a multidisciplinary
team with a common goal of achieving the best possible outcome for this child. The
interdisciplinary team for this case and all other tracheostomy cases will consist of: service
coordinators who open the tracheostomy cases, the nurses who will be working the cases, the
durable medical equipment (DME) employees who supply equipment to tracheostomy cases, the
respiratory educators from the main hospital and the patient’s mother.
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Data Collection Method
According to Yoder-Wise (2011), “After the multidisciplinary team forms, the group
collects data to measure the current status of the activity, service, or procedure under review.
Various data tools may be used to analyze and present this information (p. 396). The tool most
helpful in this case is a flow chart diagramming the existing educational process of pediatric
tracheostomy suctioning. (See Appendix A)
Quality Improvement Goals
There are two very specific goals for improvement,
1.) Children who have a tracheostomy and are cared for by Home Services nurses will
maintain a patent airway as evidenced by,
a.) No mucus plug(s) witnessed in the tube and/or trachea.
b.) Child will experience no respiratory compromise from pooling secretions.
c.) Mechanical ventilator will show no increase in peak airway pressures during
volume controlled mechanical ventilation.
d.) Mechanical ventilator will show no decreased tidal volume during pressure
controlled ventilation.
2.) Mom will learn and demonstrate pediatric tracheostomy suctioning and maintain a
patent airway when nurses are not in the home as evidenced by,
a.) Attendance of quality improvement processes and completing demonstrations of
learned equipment and suctioning techniques.
b.) An improved patient picture observed by Home Services nurse upon entering the
home for shift work.
c.) No mucus plug(s) witnessed in the tube and/or trachea.
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d.) Child will experience no respiratory compromise from pooling secretions.
e.) Mechanical ventilator will show no increase in peak airway pressures during
volume controlled mechanical ventilation.
f.) Mechanical ventilator will show no decreased tidal volume during pressure
controlled ventilation.
Evidence-based practice promotes airway patency regarding pediatric tracheostomy
suctioning. “Airway patency is maintained in a child with a tracheostomy tube by periodically
suctioning excessive secretions and mucus plugs from the tube and the trachea” (Lippincott,
Williams & Wilkins, 2013). Proper suctioning technique ensures that the child doesn’t
experience respiratory compromise.
Implementation Strategies
Appendix B provided in this paper outlines a process for implementing a plan for change.
The plan integrates all members of the interdisciplinary team and focuses on education as well as
demonstration not only by the trainers, but also by the trainee’s. I perceive this plan as based
upon an action theory,
These theories may include motivational elements, but postulate that
other factors are necessary to predict behavior. Examples include operant
conditioning and implementation intentions. Operant conditioning proposes that
behaviors that have positive consequences for the individual (such as
remuneration) are likely to be repeated. For example, women are told to specify
where and when they will perform breast self-examination, and subsequently are
found to have followed through more frequently than those with no plan regarding
their intention to implement. While studies thus far have utilized this theory for
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patient behavior change, it may be just as applicable to provider behavior change
(e.g., a provider education QI strategy might incorporate a step that asks the
clinician to formulate a plan for implementing a change in practice). (McDonald,
K., Graham, I., Grimshaw, J., 2004)
If both the nurses and mom are taught using the specific equipment that is used in
the home and are learning what evidence-based practice teaches using proper suctioning
technique guidelines provided by Lippincott Williams & Wilkins the only other barrier
that needs to be addressed is the action theory’s application of repetition, which will start
with the initiation of demonstrating back in the training sessions and continue in the
home as evidenced by the child’s patent airway.
Evaluation
After attending the training for pediatric tracheostomy suctioning education a
“check and balance” system will be put into place. Documentation will be a strong
component. A log will be kept in the home specifically addressing the issue of
tracheostomy suctioning; it will include the indicators of why the patient needed
suctioning (patient picture), what time the suctioning was done, and what the results of
the suctioning were (again, patient picture). Client/family in this case mom, will also be
asked to document her actions on this log; she will then have documented evidence of the
outcomes of her efforts. Theoretically, she should see an improvement in her daughter’s
morning routine of needing an extreme amount of suctioning, percussion and breathing
treatments because she suctioned her throughout the night as needed. Home services will
follow up on the education with formal testing and informal testing,
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The formal examinations will focus on measuring the knowledge and
practices learned, they will be performed as written or verbal tests. All who
attend the education will demonstrate competency in pediatric tracheotomy
suctioning. Informal testing will include questions focused on specific aspects of
pediatric tracheotomy suctioning. Informal testing allows trainers to interact
directly with nurses and client/family and discuss general aspects of patient care.
It also allows nurses and client/family to ask questions and learn more about
challenging areas of training that they may be having difficulties with. Peer
assessment will allow nurses and client/family to evaluate each other and to learn
from one another. Peer assessments encourage communication and interaction
among one another, nurses and client/family will have increased opportunities to
share knowledge and information about patient care. On-the-job training
assessment will include evaluation of clinical competency, patient interactions
and the clinician's adherence to generally accepted clinical practice guidelines.
(Day, R., 2013)
The 4 different types of testing and assessments (formal and informal testing, peer
evaluation and on-the-job assessment) will be done throughout the year following the
initial education process. At the end of the year records shall show the nurses and
client/family have had documentation of each type of testing completed. If records show
that the testing disclosed unsatisfactory results, the tests will be retaken after completing
more training.
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Conclusion
At this point mom should have developed a routine suctioning her daughter
throughout the night and her efforts will be rewarded when she realizes the benefits to her
child as the action theory advocates. Evidence-based practice has been accomplished by
teaching and learning skillful pediatric suctioning techniques and following up on skill
retention. The quality improvement process developed in this paper addresses patient
advocacy by helping the mother of the child to understand the importance of developing a
routine of night-time suctioning as needed. Patient safety is addressed by providing
education to all involved in the patient’s care.
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Appendix A
Home Services manager
hires nursing staff
Written skills test is
given prior to hire
Steps diagramming the existing
educational process of pediatric tracheostomy
suctioning
Practical skills test is
given prior to hire
Orientation day touches
upon the fact that we
care for pediatric
tracheostomy patients
New nurse shadows
with current nurse in the
home of a pediatric
patient
Client/Family never receives formal
training and/or refresher training from
Home Services
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Appendix B
Service Coordinator
Determines
Date, time, and place for
training purposes
Steps diagramming the educational
process of pediatric tracheostomy suctioning
Informs interdisciplinary
team and confirms
availability
Meets with DME &
Respiratory Educators to
plan educational outline
Review of knowledge
gained from education
process
DME educates
specifically regarding
equipment
Respiratory Educator
trains suctioning
technique
Have nursing staff
demonstrate learned
equipment and suctioning
technique
Have mom
demonstrate learned
equipment and
suctioning technique
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References
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http://www.ehow.com/list_6939007_methods-training-primary-health-care.html
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