Running head: QUALITY IMPROVEMENT PROCESS

Quality Improvement Process

Nga Le
Ferris State University

QUALITY IMPROVEMENT PROCESS

Quality Improvement Process

According to Yoder-Wise (2014), quality management (QM) and risk management work
together in promoting quality and safe patient outcomes, emphasizing the prevention of adverse
events and patient care problems. Quality improvement (QI) is an ongoing process of
innovation, prevention of error, and staff development that is utilized by institutions (YoderWise, 2014). QI strategy consists of six structured series of steps that are designed to identify
healthcare needs, conduct and assemble a multidisciplinary team, collect data, and establish
outcomes by assisting in planning, implementing, and evaluating the process of change, centered
on improving patient care and reducing cost (Yoder-Wise, 2014). As healthcare organization
evolves, professional leadership and nursing excellence are encouraged. Nursing is to be
empowered, fostering the initiatives and accountability in improving processes and outcomes,
reducing waste and cost to patients and the organization in delivering effective and safe, quality
patient care (Yoder-Wise, 2014).
Clinical Need
Research has established the use of combination prophylaxis of mechanical venous
thromboembolism (VTE) devices along with pharmacologic prophylaxis as effective in
preventing VTE. Deep vein thrombosis (DVT) results from clot formation in a deep vein in the
legs that breaks loose and travels to the lungs, leading to a pulmonary embolism (PE), together
DVT and PE are known as VTE (Kahn et al., 2013). The focus of this literature review will be
on patient compliancy and placement of mechanical VTE devices.
In this new scientifically high-tech era, the prevention of VTE has evolved, but no matter
how much advancement has been made, patients and nursing compliancy with mechanical VTE
device application and ensuring proper placement of mechanical VTE devices is still of a

QUALITY IMPROVEMENT PROCESS

focused issue despite its ease of application and use (Feist, Andrade, Nass, 2011). According to
Kahn et al. (2013) the prevention of VTE continues to be the number one preventable cause of
hospitalized death. The risk of developing venous thrombosis 24 hours post-orthopedic
procedure such as a total knee arthroplasty (TKA) can be as high as 86% (Windisch et al., 2011).
The purpose of quality and safety initiatives is to discuss the strategy that needs to be
implemented to ensure patients compliancy with VTE mechanical prophylaxis usage, such as
antiembolism stockings (AESs), intermittent pneumatic compression devices (IPCDs), foot
impulse devices (FIDs), and their correct placement and function post-orthopedic procedures.
The desired outcome is to increase patient compliancy and ensure the proper usage rate of VTE
prevention, which assists in reducing soft-tissue swelling. Additionally, this prevention can lead
to early patient mobilization, a shorter hospital stay, and lower treatment costs for both the
patient and the institution (Windisch et al., 2011).
Designing an Interdisciplinary Team
Most healthcare institutions operate as open systems, and are particularly receptive to a
wide variety of influences (Yoder-Wise, 2014). In order for change to take place, leaders,
managers, nurses, and other healthcare staff must be educated and be committed to the proposed
change, but ultimately the institution as a whole needs to be actively involved, holding top-level
leaders and managers accountable (Yoder-Wise, 2014). The role/responsibilities of Senior
Leaders is to lead, set patient health and staffing effectiveness outcomes, build infrastructure,
define procedures and treatments, and provide support to fellow staff (Yoder-Wise, 2014). The
role of the nursing manager is to be accountable for quality and safety performance with the
assistance of quality and risk management, monitoring and reporting progress, and forming and
submitting action plans (Yoder-Wise, 2014).

QUALITY IMPROVEMENT PROCESS

Data Collection Method
It was found that the Fishbone diagram can be utilized appropriately for the clinical data
of this literature review of patients and nursing compliancy with mechanical VTE devices. The
Fishbone diagram can be utilized to assist with ways to resolve the compliancy issue in a
summarized brainstorm session of possible problematic causes and resolution methods (YoderWise, 2014). This brainstorming session should include leaders, nursing managers, educators,
and the multidisciplinary team who are knowledgeable in caring for orthopedic patients.
Establishing Outcomes
Clinical observations reveal that more than often, VTE devices are not properly
positioned on patients as ordered. Based on this clinical observation, a plan was developed,
aiming at nursing staff, for it is a nurse-driven intervention. Nurses play a pivotal role in
ensuring safe, correct VTE use, and overall improved patient outcomes. After reviewing charts
and data, the interdisciplinary teams next step is to set goals and establish measurable patientcare outcomes or nursing-sensitive outcomes that are guided by the National Database of
Nursing Indicators. This is a shared standardized nursing classification data system that is used
to compare best practices and processes of other organizations, that is also known as
benchmarking (Yoder-Wise, 2014). In looking forward, the goal for quality improvement
outcomes of this review is to increase compliancy and proper usage rate of patients VTE
prevention. Thereby, preventing detrimental and near fatal complications following orthopedic
surgeries, leading to early patient mobilization, a shorter hospital stay, and lower treatment costs
for both the patient and the institution.

QUALITY IMPROVEMENT PROCESS

Implementation Strategies
According to AJN (2011) evidence-based practice (EBP) is a problem-solving approach
that integrates the best evidence from research studies, patient care data with clinician expertise
and patient preferences and values of those who will be affected. The implementation process
consists of four processes: planning, engaging, executing, and evaluating (Damschroder et al.,
2009). Overall, this process of planning and implementing strategies, along with the validity and
applicability of the focused issue will be critically reviewed. Where staff education will take
place with a safe environment, encouraging open communication, and where new policies and
procedures will be examined and possibly rewritten to reflect best, standard practice (YoderWise, 2014). The first step in the implementation process is for the multidisciplinary team to
meet and plan a course of action, then set up a meeting with the key stakeholders, administrators,
and the review board, securing support, and keeping them engaged by clearly identifying the
purpose and estimated cost of the VTE prevention on postoperative orthopedic patients,
measured outcomes, and condition of proposal (Gallagher-Ford, Fineout-Overholt, Melnyk, &
Stillwell, 2011). Next is the executing and evaluation of the steps, where the plan is carried out
with or without formal planning and is continuously reflected on before, during, and after
implementation to promote shared learning and improvements of the process (Damschroder et
al., 2009). The process should involve appropriate individuals that are essential in employing a
combined strategy of social marketing, reporting of key issues, and drafting of the unit
educational plans and trainings (Damschroder et al., 2009).

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6
Evaluation

In the evaluation phase, the outcomes are evaluated and revised endlessly to meet desired
outcomes or to prevent new problems (Yoder-Wise, 2014). The nursing managers
responsibilities during the evaluation phase are to publicize and reward success, and to
constantly evaluate the individual and team effort and performance (Yoder-Wise, 2014). In
ensuring effective integration of EBP, new and current active protocol models need to be
periodically inspected and monitored by risk management, quality improvement, including the
Joint Commission in ensuring the practice is up to standard in meeting the hospitals safety goals
in delivering safe and high-quality patient care (ECRI Institute, 2009).
Conclusion
As healthcare organization evolves, professional leadership and nursing excellence are
encouraged. Nursing is to be empowered, fostering the initiatives and accountability in
improving processes and outcomes, reducing waste and cost to patients and the organization in
delivering effective and safe, quality patient care. Being that VTE continues to be the number
one preventable cause of hospitalized deaths, this leads to the need for quality and safety
initiatives to implement a new protocol model to ensure patients compliancy with VTE
mechanical prophylaxis usage in an effort to prevent VTE complications. Countless fatal VTEs
are the consequence of patients failure to comply with DVT prophylaxis protocol due to the
discomfort of the device and lack of education to follow recommended guidelines. Healthcare
providers need to take the initiative in providing essential VTE prophylaxis education and
reinforcement, whether it be reviewing or checking placement with patients on routine
assessments or wrapping a pillowcase around the lower extremities to prevent direct skin contact
and enhancing device comfort for patients.

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7
References

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C.
(2009). Fostering implementation of health services research findings into practice: a
consolidated framework for advancing implementation science. Implementation Science,
4(50). http://dx.doi.org/10.1186/1748-5908-4-50
ECRI Institute (Ed.). (2009). Risk management, quality improvement, and patient safety [special
issue]. ECRI Institute, 2 Retrieved from
https://www.ecri.org/documents/secure/risk_quality_patient_safety.pdf
Feist, W. R., Andrade, D., & Nass, L. (2011). Problems with measuring compression device
performance in preventing deep vein thrombosis. Thrombosis Research, 128(3), 207-209.
http://dx.doi.org/10.1016/j.thromres.2011.04.005
Gallagher-Ford, L., Fineout-Overholt, E., Melnyk, B. M., & Stillwell, S. (2011). Evidence-based
practice, step by step: implementing an evidence-based practice change. AJN, American
Journal of Nursing, 111(3), 54-60.
http://dx.doi.org/10.1097/10.1097/01.NAJ.0000395243.14347.7e
Kahn, S., Morrison, D., Cohen, J., Emed, J., Tagalakis, V., Roussin, A., & Geerts, W. (2013).
Interventions for implementation of thromboprophylaxis in hospitalized medical and
surgical patients at risk for venous thromboembolism. The Cochrane Collaboration, (7),
1-186. http://dx.doi.org/10.1002/14651858.CD008201.pub2.
Windisch, C., Kolb, W., Kolb, K., Grutzner, P., Venbrocks, R., & Anders, J. (2011). Pneumatic
compression with foot pumps facilitates early postoperative mobilisation in total knee
arthroplasty. International Orthopeadics, 35(7), 995-1000.
http://dx.doi.org/10.1007/s00264-010-1091-8

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