Quality management: Nursing

Nurse Reggie works in a unit at a skilled nursing facility and has noticed that clients aren’t receiving consistent mouth care as prescribed and rates of nursing home-acquired pneumonia have risen. Nurse Reggie knows mouth care is important in preventing pneumonia so he asks Leyla, a Nursing Assistant, or NA, about the barriers to mouth care. NA Leyla says, “Honestly, mouth care isn’t listed on our daily task list, so I forget to do it.” Nurse Reggie thanks her and responds, “I want to begin a quality improvement project to address this issue. Would you help me?” NA Leyla agrees, so Nurse Reggie plans to create an updated NA task list which includes performing and documenting mouth care. Nurse Reggie and NA Leyla will measure the success of their project by tracking NA documentation of mouth care as well as the rate of hospital-acquired pneumonia six-months after implementation. Nurse Reggie and NA Leyla will work alongside the other members of the healthcare team at the facility to use quality management to improve this process.

Healthcare facilities can achieve goals of improving the care delivered to clients through quality management and quality improvement. Quality management, or QM, is an overarching philosophy that focuses on optimizing patient care and outcomes. Healthcare institutions that adopt the QM philosophy use quality improvement, or QI, to implement these strategies by using specific processes to monitor and continually improve the quality of client care. Healthcare quality can be measured through identification of benchmarks, which are best practices for clinical care that can be compared between similar facilities to achieve outcomes such as client satisfaction and safety. QI consists of 6 steps,the first step is the identification of client needs, such as Nurse Reggie choosing mouth care as a clinical activity in need of improvement.

The next step is assembling a team, which can be made up of interprofessional members inside and outside the healthcare facility. For example, Nurse Reggie recruits NA Leyla as well as the unit manager, a local dentist, the facility physician, and the nurse informaticist for their QI project. After the team is assembled, it’s time to collect data on the current status of the procedure, activity, or outcome of interest, such as the frequency of mouth care. Nurse Reggie, with input from the interdisciplinary team, creates a fishbone diagram which helps to identify possible causes of the problem, and sorts them into categories. On Nurse Reggie’s fishbone, decreased rates of mouth care is the problem, so it is written on the center horizontal line. Then, all of the possible causes are listed around the problem. These causes include mouth care not being listed on the daily task list; high staffing ratios; and lack of mouth care kits on the unit during off-shifts, such as nights and weekends.