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Evidence-Based Practice Carlton G. Brown, PhD, RN, AOCN®, NEA-BC, FAAN—Associate Editor Stimulating a Cultur
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e of Improvement: Introducing an Integrated Quality Tool for Organizational Self-Assessment Cathy Coleman, DNP, RN, OCN®, CPHQ, CNL As leaders and systems-level agents of change, oncology nurses are challenged by opportunities to guide organizational transformation from the front line to the board room. Across all care settings, reform and change initiatives are constants in the quest to optimize quality and healthcare outcomes for individuals, teams, populations, and organizations. This article describes a practical, evidence-based, integrated quality tool for initiating organizational self-assessment to prioritize issues and stimulate a culture of continuous improvement. decision making, and stimulate a culture of continuous improvement. Team Satisfaction Surveys opportunities to guide organizational changes (Day et al., 2014). In 2013, the author of the current article led a unit-based action research study in the ambulatory breast center at a community hospital in San Francisco, California, to assess the level of team engagement and delineate opportunities for improvement. A previously published conceptual framework for comprehensive breast care (see Figure 1) was used to focus the components of organizational development and quality improvement (Coleman & Lebovic, 1996). This article will describe an integrated tool with 11 quality domains that emerged as a practical necessity to categorize study findings. This tool offered a starting point for management to reflect on an organizational self-assessment, prioritize issues, aid Three published surveys were completed by 25 frontline staff (radiology technologists, RNs, schedulers, nurse practitioners, file clerks, residents, fellows, medical records clerks, laboratory aides, program administrators) to quantify levels of individual and team engagement. Results indicated a moderate level of stress, and the employees also stated that the clinic was not a better place to work than the prior year (Dartmouth Institute, 2015). Findings from an interdisciplinary survey suggested that healthcare team members did not feel free to question the actions of those with more authority (Upenieks, Lee, Flanagan, & Doebbeling, 2010). Results from a team assessment tool found that staff lacked several characteristics, including a clear purpose, feelings of safety for engaging in team conflict, common processes for getting things done, and specific performance goals (Tiffan, 2011). A baseline group discussion and SWOT (strengths, weaknesses, opportunities, and threats) analysis tool (http://bit .ly/1kPAIx5) were also incorporated (Harris, Roussel, Walters, & Dearman, 2011). Qualitative findings were elicited from two open-ended questions in the Dartmouth tool and results of the SWOT analysis. Of note, staff reported that the word team was infrequently or never used, and clarification about roles and responsibilities was absent. Employees described a reactive work environment; ineffective communication (e.g., listening, voice tone, giving and receiving feedback); and an overall culture of distrust, disrespect, and dysfunction. Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Evidence-Based Practice 261 At a Glance • Quality is complex and multidimensional. • Organizational improvement begins with self-assessment. • Management of change requires competent leadership. Cathy Coleman, DNP, RN, OCN®, CPHQ, CNL, is an assistant professor in the School of Nursing and Health Professions at the University of San Francisco in California. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Coleman can be reached at cathycoleman@msn.com, with copy to editor at CJONEditor@ons.org. Key words: organization; self-assessment; quality; improvement; leadership; tool Digital Object Identifier: 10.1188/15.CJON.261-264 A bout 1.6 million new cancer cases are diagnosed in the United States annually and, by 2030, this figure is estimated to reach 2.3 million (Bylander, 2013). These numbers are daunting and require new approaches for planning and implementing services throughout the continuum of care (Ferrell, McCabe, & Levit, 2013). For more than two decades, the U.S. healthcare system has been in flux as leaders in business, health, education, technology, and government grapple with the growth, complexity, and scale of change required to improve care delivery. Reform and change initiatives are important in the quest to optimize quality and outcomes for individuals, teams, populations, and organizations. Oncology nurses are well suited to be able to affect change and find Clinical program development Staff development and training Translational research Community outreach Business development Rehabilitation Early detection Patient and family Diagnosis Therapy Staging Pretreatment planning Facility development Continuing care Continuous quality improvement Prevention and risk analysis Psychosocial services Risk management Organizational development FIGURE 1. Conceptual Framework for Comprehensive Breast Care Note. From “Organizing a Comprehensive Breast Center” (p. 964), by C. Coleman and G. Lebovic in J.R. Harris, M.E. Lippman, M. Morrow, and S. Hellman (Eds.), Diseases of the Breast, 1996, Philadelphia, PA: Lippincott Williams and Wilkins. Copyright 1996 by Lippincott Williams and Wilkins. Reprinted with permission. The challenge for management was to categorize key findings to inform and initiate a timely action plan for quality improvement. Challenge of Defining Quality The Institute of Medicine ([IOM], 2011) stated that “quality of care depends to a large degree on nurses” (p. 26). What is the best definition of quality care? Although no universal, clear-cut definition for healthcare quality exists, oncology nurses must define quality care within a local and national context as they formulate action plans for improvement. Given the current focus on healthcare reform and value-based payment, it is desirable to align improvement efforts to measurement of value. Porter (2010) advocated that value improvement depends on results and benchmarking patient outcomes and costs longitudinally, and emphasized that current organizational 262 structures and inadequate health information systems inhibit the ability to prioritize, deliver, and track value. In contrast, other authors have published quality definitions, improvement domains, frameworks, or priorities that assist organizations to define elements that foster a culture of quality. During a literature review to identify surveys to evaluate staff engagement, several publications described quality domains and priorities. Although some surveys were simple, others were complex and multidimensional. Two meaningful definitions of quality were identified. • Quality care means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and cultural sensitivity (IOM, 1999; Coleman, 2013). • Quality care is “getting the right care to the right patient at the right time—every time” (Lillington et al., 2013, p. 584), as well as care that is consistently “safe, effective, patient-centered, timely, efficient, and equitable” (IOM, 2001, p. 6). Three national frameworks published by renowned organizations were reviewed and compared. Each framework defined six different dimensions of quality improvement; however, overlap was apparent. The IOM defined six aims for improvement in health care (Coleman, 2013; IOM, 2001). The U.S. Department of Health and Human Services (2013) generated six priorities for the National Quality Strategy. The American Association of Colleges of Nursing (2012) described six competencies to ensure Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2009; Dolansky & Moore, 2013). The overlapping definitions, domains, and priorities prevented the use of a single framework to contextualize quality related to levels of employee engagement and teamwork. Only the QSEN nursing competencies explicitly defined “teamwork and collaboration” as a distinct domain. Development of an Integrated Quality Tool and Template A structured, alphabetical template was subsequently developed to consolidate 18 domains and eliminate overlap. The template contained 11 well-established quality domains and was used to stratify survey data (see Table 1). This integrated quality tool served two purposes. First, the template offered a structure to categorize results. For example, no findings were generated relative to “informatics” in contrast with an abundance of data for teamwork and collaboration. Second, the tool could be used to incorporate practical resources. For example, teamwork and collaboration was determined to be a priority for unit-based improvement in the breast center because of a majority of responses in this category. A separate literature search for evidence-based resources was completed for each domain. For example, correlative resources for team development were listed in teamwork and collaboration (see Figure 2). As a starting point for discussion, integration of relevant quality domains into one standardized tool proved to be particularly useful for unit management and leadership. The compilation helped to guide leadership June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing reflection; prioritize patient, staff, and organizational concerns; aid in decision making regarding interventions; and forecast short- or long-term investments. Planning for Improvement According to Mitchell (2013), twothirds of organizational change projects fail because of unstructured implementation efforts. As organizational and systemslevel agents of change, well-intentioned leaders often do not know where to start. In this project, the synthesis of literature review, survey findings, and SWOT analysis led to valuable results that informed priorities for intervention and improvement. This integrated quality tool is one option available for organizational selfassessment, data categorization, and development of focused action plans. The Agency for Healthcare Research and Quality (2012) recommends seven steps for action planning: (a) understand your survey results, (b) communicate and discuss survey results, (c) develop focused action plans, (d) communicate action plans and deliverables, (e) implement action plans, (f) track progress and evaluate impact, and (g) share what works. This unit-based change management project was conducted to assess complex team dynamics and prioritize opportunities for improvement. The integrated quality tool emerged as a practical necessity and is recommended as a starting point to stratify issues and focus improvement efforts. Implications for Nursing Performance excellence and quality of care are at the top of the agenda for individual and organizational healthcare leaders, particularly nurses. In a recent introduction to the National Quality Strategy spawned by the Patient Protection and Affordable Care Act of 2010, Kennedy, Murphy, and Roberts (2013) suggested that nurses are crucial in driving the quality agenda through exemplary leadership and active participation. Grossman and Valiga (2013) emphasized that quality and achievement of positive outcomes requires interprofessional accountability for providing effective interventions. Mary Wakefield, PhD, RN, administrator of the Health Resources and Services Administration, posited the following about future nurses. [Nurses] must be well prepared to provide comprehensive, team-oriented, TABLE 1. Integrated Quality Tool for Organizational Self-Assessment Quality Domain Definition Care coordination Promoting effective communication and coordination of care Clinical processes and effectiveness Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit Evidence-based practice: Integrating best current evidence with clinical expertise, patient and family preferences and values for delivery of optimal health care Efficiency Avoiding waste, including waste of equipment, supplies, ideas, and energy Efficient use of healthcare resources: Working with communities to promote wide use of best practices to enable healthy living Equity Providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status Informatics Using information and technology to communicate, manage knowledge, mitigate error, and support decision making Patient and family engagement Ensuring that each person and family member is engaged as partners in their care Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions Patient-centered care: Recognizing the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs Patient safety Making care safer by reducing harm caused in the delivery of care Safe: Avoiding injuries to patients from the care that is intended to help them Safety: Minimizing risk of harm to patients and providers through system effectiveness and individual performance Population and public health Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models Quality improvement Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems Teamwork and collaboration Functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care Timely Reducing waits and harmful delays for those who receive and give care Note. Based on information from American Association of Colleges of Nursing, 2012; Cronenwett et al., 2009; Dolansky & Moore, 2013; Institute of Medicine, 2001; Kennedy et al., 2013; U.S. Department of Health and Human Services, 2013. patient- and population-based care and must be capable of harnessing technology in the process. Nurses’ knowledge will include the science of patient safety, quality improvement, systems design, and the deployment of navigational skills to support those facing the daily challenge of managing complex chronic illnesses. (Stone, 2012, para. 7) Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Evidence-Based Practice Given that the scope of cancer care ranges from prevention to palliation and is a major public health concern, oncology nurses will be continually challenged to deliver high-quality comprehensive care. Conclusion Quality is a multidimensional concept with many implications for promoting 263 Agency for Healthcare Research and Quality TeamSTEPPS®: National Implementation www.teamstepps.ahrq.gov American Nurses Association ANA Leadership Institute™ Competency Model http://bit.ly/1GDzRhS American Organization of Nurse Executives Resources www.aone.org/resources/index.shtml California HealthCare Foundation Team meetings in a clinical environment http://bit.ly/1zjiL6u Chief Learning Officer® The Four Pillars of Trust http://bit.ly/1EMMZB7 IPEC® Interprofessional Education Collaborative www.ipecollaborative.org Oncology Nursing Society Leadership Competencies http://bit.ly/1do4RGo FIGURE 2. Teamwork Resources for Integrated Quality Tool for Organizational Self-Assessment organizational change and professional excellence. According to Kennedy et al. (2013), “nurses can lead from any chair” (para. 25). To stimulate a culture of quality improvement, oncology nurses are encouraged to enhance their individual leadership competencies for personal growth and use evidence-based approaches to optimize quality, team effectiveness, and system redesign across settings (Berwick, 2011; Day et al., 2014; Fessele, Yendro, & Mallory, 2014; Oncology Nursing Society, 2012). The foundation for transformation in healthcare delivery begins and ends with quality. References Agency for Healthcare Research and Quality. (2012). Chapter 8. What’s next? Action planning for improvement. Retrieved from http://1.usa.gov/1b9TNLi American Association of Colleges of Nursing. (2012). Graduate-level QSEN competencies: Knowledge, skills and attitudes. Retrieved from http://bit.ly/1QEBrD3 Berwick, D.M. (2011). Preparing nurses for participation in and leadership of continual improvement. Journal of Nursing Education, 50, 322–327. 264 Bylander, J. (2013). Confronting a crisis in cancer care delivery. Health Affairs, 32, 1695–1697. doi:10.3928/0148483420110519-05 Coleman, C. (2013). Integrating quality and breast cancer care: Role of the clinical nurse leader. Oncology Nursing Forum, 40, 311–314. doi:10.1188/13.ONF.311-314 Coleman, C., & Lebovic, G. (1996). Organizing a comprehensive breast center. In J.R. Harris, M.E. Lippman, M. Morrow, & S. Hellman (Eds.), Diseases of the breast. Philadelphia, PA: Lippincott-Raven. Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner, J., Moore, S., Sullivan, D.T., . . . Warren, J. (2009). Quality and safety education for advanced nursing practice. Nursing Outlook, 57, 338–348. Dartmouth Institute. (2015). Outpatient specialty workbook. Retrieved from http://bit.ly/1IiYeAQ Day, D.D., Hand, M.W., Jones, A.R., Harrington, N.K., Best, R., & LeFebvre, K.B. (2014). Oncology Nursing Society leadership competency project: Developing a road map to professional excellence. Clinical Journal of Oncology Nursing, 18, 432–436. Dolansky, M.A., & Moore, S.M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. Retrieved from http://bit.ly/1FujEdz Ferrell, B., McCabe, M.S., & Levit, L. (2013). The Institute of Medicine report on high-quality cancer care: Implications for oncology nursing. Oncology Nursing Forum, 40, 603–609. doi:10.1188/13 .ONF.603-609 Fessele, K., Yendro, S., & Mallory, G. (2014). Setting the bar: Developing qualit y measures and education programs to define evidence-based, patient-centered, high-quality care. Clinical Journal of Oncology Nursing, 18 (Suppl.), 7–11. doi:10.1188/14.CJON.S2.7-11 Grossman, S., & Valiga, T. (2013). The new leadership challenge: Creating the future of nursing (4th ed.). Philadelphia, PA: F.A. Davis Company. Harris, J.L., Roussel, L., Walters, S.E., & Dearman, C. (2011). Project planning and management. A guide for CNLs, DNPs, and nurse executives. Sudbury, MA: Jones and Bartlett. Institute of Medicine. (1999). Ensuring quality cancer care. Washington, DC: National Academies Press. Institute of Medicine. (2001). Crossing the quality chasm. Retrieved from http:// bit.ly/1krmVAW Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Kennedy, R., Murphy, J., & Roberts, D.W. (2013). An over view of the National Quality Strategy: Where do nurses fit? Online Journal of Issues in Nursing. Retrieved from http://bit.ly/1HTunQB Lillington, L., Scaramuzzo, L., Friese, C., Sein, E., Harrison, K., LeFebvre, K.B., & Fessele, K. (2013). Improving practice one patient, one nurse, one day at a time: Design and evaluation of a quality education workshop for oncology nurses. Clinical Journal of Oncology Nursing, 17, 584–587. Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20, 32–37. Oncology Nursing Society. (2012). Oncology Nursing Society leadership competencies. Retrieved from http://bit.ly/ 1P2hN04 Porter, M.E. (2010). What is value in health care? New England Journal of Medicine, 363, 2477–2481. doi:10.1056/ NEJMp1011024 Stone, A. (2012, July 10). HRSA administrator talks about importance of nurses. ONS Connect. Retrieved from http://bit.ly/ 1Ozepiu Tiffan, B. (2011). The art of team leadership. Physician Executive, 37, 78–80. Upenieks, V.V., Lee, E.A., Flanagan, M.E., & Doebbeling, B.N. (2010). Healthcare team vitality instrument (HTVI): Developing a tool assessing healthcare team functioning. Journal of Advanced Nursing, 66, 168–176. U.S. Department of Health and Human Services. (2013). 2013 annual progress report to Congress: National strategy for quality improvement in health care. Retrieved from http://1.usa.gov/1DH1l02 Do You Have an Interesting Topic to Share? Evidence-Based Practice offers information to help nurses integrate research-based findings into practice. Length should be no more than 1,000–1,500 words, exclusive of tables, figures, insets, and references. If interested, contact Associate Editor Carlton G. Brown, PhD, RN, AOCN®, NEA-BC, FAAN, at cgenebrown@gmail.com. June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Evidence-Based Practice Carlton G. Brown, PhD, RN, AOCN®, NEA-BC, FAAN—Associate Editor Stimulating a Culture of Improvement: Introducing an Integrated Quality Tool for Organizational Self-Assessment Cathy Coleman, DNP, RN, OCN®, CPHQ, CNL As leaders and systems-level agents of change, oncology nurses are challenged by opportunities to guide organizational transformation from the front line to the board room. Across all care settings, reform and change initiatives are constants in the quest to optimize quality and healthcare outcomes for individuals, teams, populations, and organizations. This article describes a practical, evidence-based, integrated quality tool for initiating organizational self-assessment to prioritize issues and stimulate a culture of continuous improvement. decision making, and stimulate a culture of continuous improvement. Team Satisfaction Surveys opportunities to guide organizational changes (Day et al., 2014). In 2013, the author of the current article led a unit-based action research study in the ambulatory breast center at a community hospital in San Francisco, California, to assess the level of team engagement and delineate opportunities for improvement. A previously published conceptual framework for comprehensive breast care (see Figure 1) was used to focus the components of organizational development and quality improvement (Coleman & Lebovic, 1996). This article will describe an integrated tool with 11 quality domains that emerged as a practical necessity to categorize study findings. This tool offered a starting point for management to reflect on an organizational self-assessment, prioritize issues, aid Three published surveys were completed by 25 frontline staff (radiology technologists, RNs, schedulers, nurse practitioners, file clerks, residents, fellows, medical records clerks, laboratory aides, program administrators) to quantify levels of individual and team engagement. Results indicated a moderate level of stress, and the employees also stated that the clinic was not a better place to work than the prior year (Dartmouth Institute, 2015). Findings from an interdisciplinary survey suggested that healthcare team members did not feel free to question the actions of those with more authority (Upenieks, Lee, Flanagan, & Doebbeling, 2010). Results from a team assessment tool found that staff lacked several characteristics, including a clear purpose, feelings of safety for engaging in team conflict, common processes for getting things done, and specific performance goals (Tiffan, 2011). A baseline group discussion and SWOT (strengths, weaknesses, opportunities, and threats) analysis tool (http://bit .ly/1kPAIx5) were also incorporated (Harris, Roussel, Walters, & Dearman, 2011). Qualitative findings were elicited from two open-ended questions in the Dartmouth tool and results of the SWOT analysis. Of note, staff reported that the word team was infrequently or never used, and clarification about roles and responsibilities was absent. Employees described a reactive work environment; ineffective communication (e.g., listening, voice tone, giving and receiving feedback); and an overall culture of distrust, disrespect, and dysfunction. Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Evidence-Based Practice 261 At a Glance • Quality is complex and multidimensional. • Organizational improvement begins with self-assessment. • Management of change requires competent leadership. Cathy Coleman, DNP, RN, OCN®, CPHQ, CNL, is an assistant professor in the School of Nursing and Health Professions at the University of San Francisco in California. The author takes full responsibility for the content of the article. The author did not receive honoraria for this work. No financial relationships relevant to the content of this article have been disclosed by the author or editorial staff. Coleman can be reached at cathycoleman@msn.com, with copy to editor at CJONEditor@ons.org. Key words: organization; self-assessment; quality; improvement; leadership; tool Digital Object Identifier: 10.1188/15.CJON.261-264 A bout 1.6 million new cancer cases are diagnosed in the United States annually and, by 2030, this figure is estimated to reach 2.3 million (Bylander, 2013). These numbers are daunting and require new approaches for planning and implementing services throughout the continuum of care (Ferrell, McCabe, & Levit, 2013). For more than two decades, the U.S. healthcare system has been in flux as leaders in business, health, education, technology, and government grapple with the growth, complexity, and scale of change required to improve care delivery. Reform and change initiatives are important in the quest to optimize quality and outcomes for individuals, teams, populations, and organizations. Oncology nurses are well suited to be able to affect change and find Clinical program development Staff development and training Translational research Community outreach Business development Rehabilitation Early detection Patient and family Diagnosis Therapy Staging Pretreatment planning Facility development Continuing care Continuous quality improvement Prevention and risk analysis Psychosocial services Risk management Organizational development FIGURE 1. Conceptual Framework for Comprehensive Breast Care Note. From “Organizing a Comprehensive Breast Center” (p. 964), by C. Coleman and G. Lebovic in J.R. Harris, M.E. Lippman, M. Morrow, and S. Hellman (Eds.), Diseases of the Breast, 1996, Philadelphia, PA: Lippincott Williams and Wilkins. Copyright 1996 by Lippincott Williams and Wilkins. Reprinted with permission. The challenge for management was to categorize key findings to inform and initiate a timely action plan for quality improvement. Challenge of Defining Quality The Institute of Medicine ([IOM], 2011) stated that “quality of care depends to a large degree on nurses” (p. 26). What is the best definition of quality care? Although no universal, clear-cut definition for healthcare quality exists, oncology nurses must define quality care within a local and national context as they formulate action plans for improvement. Given the current focus on healthcare reform and value-based payment, it is desirable to align improvement efforts to measurement of value. Porter (2010) advocated that value improvement depends on results and benchmarking patient outcomes and costs longitudinally, and emphasized that current organizational 262 structures and inadequate health information systems inhibit the ability to prioritize, deliver, and track value. In contrast, other authors have published quality definitions, improvement domains, frameworks, or priorities that assist organizations to define elements that foster a culture of quality. During a literature review to identify surveys to evaluate staff engagement, several publications described quality domains and priorities. Although some surveys were simple, others were complex and multidimensional. Two meaningful definitions of quality were identified. • Quality care means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and cultural sensitivity (IOM, 1999; Coleman, 2013). • Quality care is “getting the right care to the right patient at the right time—every time” (Lillington et al., 2013, p. 584), as well as care that is consistently “safe, effective, patient-centered, timely, efficient, and equitable” (IOM, 2001, p. 6). Three national frameworks published by renowned organizations were reviewed and compared. Each framework defined six different dimensions of quality improvement; however, overlap was apparent. The IOM defined six aims for improvement in health care (Coleman, 2013; IOM, 2001). The U.S. Department of Health and Human Services (2013) generated six priorities for the National Quality Strategy. The American Association of Colleges of Nursing (2012) described six competencies to ensure Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2009; Dolansky & Moore, 2013). The overlapping definitions, domains, and priorities prevented the use of a single framework to contextualize quality related to levels of employee engagement and teamwork. Only the QSEN nursing competencies explicitly defined “teamwork and collaboration” as a distinct domain. Development of an Integrated Quality Tool and Template A structured, alphabetical template was subsequently developed to consolidate 18 domains and eliminate overlap. The template contained 11 well-established quality domains and was used to stratify survey data (see Table 1). This integrated quality tool served two purposes. First, the template offered a structure to categorize results. For example, no findings were generated relative to “informatics” in contrast with an abundance of data for teamwork and collaboration. Second, the tool could be used to incorporate practical resources. For example, teamwork and collaboration was determined to be a priority for unit-based improvement in the breast center because of a majority of responses in this category. A separate literature search for evidence-based resources was completed for each domain. For example, correlative resources for team development were listed in teamwork and collaboration (see Figure 2). As a starting point for discussion, integration of relevant quality domains into one standardized tool proved to be particularly useful for unit management and leadership. The compilation helped to guide leadership June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing reflection; prioritize patient, staff, and organizational concerns; aid in decision making regarding interventions; and forecast short- or long-term investments. Planning for Improvement According to Mitchell (2013), twothirds of organizational change projects fail because of unstructured implementation efforts. As organizational and systemslevel agents of change, well-intentioned leaders often do not know where to start. In this project, the synthesis of literature review, survey findings, and SWOT analysis led to valuable results that informed priorities for intervention and improvement. This integrated quality tool is one option available for organizational selfassessment, data categorization, and development of focused action plans. The Agency for Healthcare Research and Quality (2012) recommends seven steps for action planning: (a) understand your survey results, (b) communicate and discuss survey results, (c) develop focused action plans, (d) communicate action plans and deliverables, (e) implement action plans, (f) track progress and evaluate impact, and (g) share what works. This unit-based change management project was conducted to assess complex team dynamics and prioritize opportunities for improvement. The integrated quality tool emerged as a practical necessity and is recommended as a starting point to stratify issues and focus improvement efforts. Implications for Nursing Performance excellence and quality of care are at the top of the agenda for individual and organizational healthcare leaders, particularly nurses. In a recent introduction to the National Quality Strategy spawned by the Patient Protection and Affordable Care Act of 2010, Kennedy, Murphy, and Roberts (2013) suggested that nurses are crucial in driving the quality agenda through exemplary leadership and active participation. Grossman and Valiga (2013) emphasized that quality and achievement of positive outcomes requires interprofessional accountability for providing effective interventions. Mary Wakefield, PhD, RN, administrator of the Health Resources and Services Administration, posited the following about future nurses. [Nurses] must be well prepared to provide comprehensive, team-oriented, TABLE 1. Integrated Quality Tool for Organizational Self-Assessment Quality Domain Definition Care coordination Promoting effective communication and coordination of care Clinical processes and effectiveness Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit Evidence-based practice: Integrating best current evidence with clinical expertise, patient and family preferences and values for delivery of optimal health care Efficiency Avoiding waste, including waste of equipment, supplies, ideas, and energy Efficient use of healthcare resources: Working with communities to promote wide use of best practices to enable healthy living Equity Providing care that does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status Informatics Using information and technology to communicate, manage knowledge, mitigate error, and support decision making Patient and family engagement Ensuring that each person and family member is engaged as partners in their care Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions Patient-centered care: Recognizing the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs Patient safety Making care safer by reducing harm caused in the delivery of care Safe: Avoiding injuries to patients from the care that is intended to help them Safety: Minimizing risk of harm to patients and providers through system effectiveness and individual performance Population and public health Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new healthcare delivery models Quality improvement Using data to monitor the outcomes of care processes and using improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems Teamwork and collaboration Functioning effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care Timely Reducing waits and harmful delays for those who receive and give care Note. Based on information from American Association of Colleges of Nursing, 2012; Cronenwett et al., 2009; Dolansky & Moore, 2013; Institute of Medicine, 2001; Kennedy et al., 2013; U.S. Department of Health and Human Services, 2013. patient- and population-based care and must be capable of harnessing technology in the process. Nurses’ knowledge will include the science of patient safety, quality improvement, systems design, and the deployment of navigational skills to support those facing the daily challenge of managing complex chronic illnesses. (Stone, 2012, para. 7) Clinical Journal of Oncology Nursing • Volume 19, Number 3 • Evidence-Based Practice Given that the scope of cancer care ranges from prevention to palliation and is a major public health concern, oncology nurses will be continually challenged to deliver high-quality comprehensive care. Conclusion Quality is a multidimensional concept with many implications for promoting 263 Agency for Healthcare Research and Quality TeamSTEPPS®: National Implementation www.teamstepps.ahrq.gov American Nurses Association ANA Leadership Institute™ Competency Model http://bit.ly/1GDzRhS American Organization of Nurse Executives Resources www.aone.org/resources/index.shtml California HealthCare Foundation Team meetings in a clinical environment http://bit.ly/1zjiL6u Chief Learning Officer® The Four Pillars of Trust http://bit.ly/1EMMZB7 IPEC® Interprofessional Education Collaborative www.ipecollaborative.org Oncology Nursing Society Leadership Competencies http://bit.ly/1do4RGo FIGURE 2. Teamwork Resources for Integrated Quality Tool for Organizational Self-Assessment organizational change and professional excellence. According to Kennedy et al. (2013), “nurses can lead from any chair” (para. 25). To stimulate a culture of quality improvement, oncology nurses are encouraged to enhance their individual leadership competencies for personal growth and use evidence-based approaches to optimize quality, team effectiveness, and system redesign across settings (Berwick, 2011; Day et al., 2014; Fessele, Yendro, & Mallory, 2014; Oncology Nursing Society, 2012). The foundation for transformation in healthcare delivery begins and ends with quality. References Agency for Healthcare Research and Quality. (2012). Chapter 8. What’s next? Action planning for improvement. Retrieved from http://1.usa.gov/1b9TNLi American Association of Colleges of Nursing. (2012). Graduate-level QSEN competencies: Knowledge, skills and attitudes. Retrieved from http://bit.ly/1QEBrD3 Berwick, D.M. (2011). Preparing nurses for participation in and leadership of continual improvement. Journal of Nursing Education, 50, 322–327. 264 Bylander, J. (2013). Confronting a crisis in cancer care delivery. Health Affairs, 32, 1695–1697. doi:10.3928/0148483420110519-05 Coleman, C. (2013). Integrating quality and breast cancer care: Role of the clinical nurse leader. Oncology Nursing Forum, 40, 311–314. doi:10.1188/13.ONF.311-314 Coleman, C., & Lebovic, G. (1996). Organizing a comprehensive breast center. In J.R. Harris, M.E. Lippman, M. Morrow, & S. Hellman (Eds.), Diseases of the breast. Philadelphia, PA: Lippincott-Raven. Cronenwett, L., Sherwood, G., Pohl, J., Barnsteiner, J., Moore, S., Sullivan, D.T., . . . Warren, J. (2009). Quality and safety education for advanced nursing practice. Nursing Outlook, 57, 338–348. Dartmouth Institute. (2015). Outpatient specialty workbook. Retrieved from http://bit.ly/1IiYeAQ Day, D.D., Hand, M.W., Jones, A.R., Harrington, N.K., Best, R., & LeFebvre, K.B. (2014). Oncology Nursing Society leadership competency project: Developing a road map to professional excellence. Clinical Journal of Oncology Nursing, 18, 432–436. Dolansky, M.A., & Moore, S.M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. Retrieved from http://bit.ly/1FujEdz Ferrell, B., McCabe, M.S., & Levit, L. (2013). The Institute of Medicine report on high-quality cancer care: Implications for oncology nursing. Oncology Nursing Forum, 40, 603–609. doi:10.1188/13 .ONF.603-609 Fessele, K., Yendro, S., & Mallory, G. (2014). Setting the bar: Developing qualit y measures and education programs to define evidence-based, patient-centered, high-quality care. Clinical Journal of Oncology Nursing, 18 (Suppl.), 7–11. doi:10.1188/14.CJON.S2.7-11 Grossman, S., & Valiga, T. (2013). The new leadership challenge: Creating the future of nursing (4th ed.). Philadelphia, PA: F.A. Davis Company. Harris, J.L., Roussel, L., Walters, S.E., & Dearman, C. (2011). Project planning and management. A guide for CNLs, DNPs, and nurse executives. Sudbury, MA: Jones and Bartlett. Institute of Medicine. (1999). Ensuring quality cancer care. Washington, DC: National Academies Press. Institute of Medicine. (2001). Crossing the quality chasm. Retrieved from http:// bit.ly/1krmVAW Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Kennedy, R., Murphy, J., & Roberts, D.W. (2013). An over view of the National Quality Strategy: Where do nurses fit? Online Journal of Issues in Nursing. Retrieved from http://bit.ly/1HTunQB Lillington, L., Scaramuzzo, L., Friese, C., Sein, E., Harrison, K., LeFebvre, K.B., & Fessele, K. (2013). Improving practice one patient, one nurse, one day at a time: Design and evaluation of a quality education workshop for oncology nurses. Clinical Journal of Oncology Nursing, 17, 584–587. Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20, 32–37. Oncology Nursing Society. (2012). Oncology Nursing Society leadership competencies. Retrieved from http://bit.ly/ 1P2hN04 Porter, M.E. (2010). What is value in health care? New England Journal of Medicine, 363, 2477–2481. doi:10.1056/ NEJMp1011024 Stone, A. (2012, July 10). HRSA administrator talks about importance of nurses. ONS Connect. Retrieved from http://bit.ly/ 1Ozepiu Tiffan, B. (2011). The art of team leadership. Physician Executive, 37, 78–80. Upenieks, V.V., Lee, E.A., Flanagan, M.E., & Doebbeling, B.N. (2010). Healthcare team vitality instrument (HTVI): Developing a tool assessing healthcare team functioning. Journal of Advanced Nursing, 66, 168–176. U.S. Department of Health and Human Services. (2013). 2013 annual progress report to Congress: National strategy for quality improvement in health care. Retrieved from http://1.usa.gov/1DH1l02 Do You Have an Interesting Topic to Share? Evidence-Based Practice offers information to help nurses integrate research-based findings into practice. Length should be no more than 1,000–1,500 words, exclusive of tables, figures, insets, and references. If interested, contact Associate Editor Carlton G. Brown, PhD, RN, AOCN®, NEA-BC, FAAN, at cgenebrown@gmail.com. June 2015 • Volume 19, Number 3 • Clinical Journal of Oncology Nursing Copyright of Clinical Journal of Oncology Nursing is the property of Oncology Nursing Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Running head: QUALITY IMPROVEMENT Quality Improvement Your Name (without credentials) Chamberlain College of Nursing NR351: Transitions in Professional Nursing March 2018 NOTE: No abstract NOTE: This is a template and guide. Delete all yellow highlighted words. 1 QUALITY IMPROVEMENT 2 Quality Improvement (paper title) (No heading of Introduction) Introduce your assigned paper topic. Type and properly cite the definition of your topic in relation to professional nursing. Roles of Professional Nurses in Quality Improvement (first main point) Type statements about this first main point here. This paper should be based on facts from Hood and the assigned article. Most of these facts should be paraphrased (including proper citations). One or two direct quotations (with appropriate citations) can be used in this paper. There should be no prior knowledge, experience, or opinion in this paper. All facts must be cited to one of the two assigned sources. Add paragraphs here as needed. Improving Nursing Quality in the Healthcare Setting (second main point) Type statements about this second main point here. This paper should be based on facts from Hood and the assigned article. Most of these facts should be paraphrased (including proper citations). One or two direct quotations (with appropriate citations) can be used in this paper. There should be no prior knowledge, experience, or opinion in this paper. All facts must be cited to one of the two assigned sources. Add paragraphs here as needed. Conclusion Summarize the main ideas and major conclusions from the body of your paper. Do not add new information in the conclusion. QUALITY IMPROVEMENT 3 References (centered, not bold) Type your references here alphabetized by the first author of each source using hanging indents (under “Paragraph” on the Home toolbar ribbon). See your APA Manual and the resources in the APA folder in Course Resources under Modules for reference formatting.
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