Research Corner: Focus Is on Continuous Quality Improvement Process
By Lyn Wooten, RN, MSN
Member, Research Work Group
Continuous quality improvement is fast becoming a major focus of healthcare organizations. The process is extremely important, because it not only contributes to the survival of healthcare institutions in a rapidly changing market, but also ensures that patients remain the primary focus of care delivery.
According to Kowal, et al,1 the process “provides an environment conducive to the continuous improvement of the quality of all products and services.” Encouraging collaboration among multiple departments and healthcare fields, as well as the ownership of patient-experienced processes, are additional benefits that can be recognized through the quality improvement process.
Ideas for quality improvement projects are generated through several avenues. Benchmarking is one. Because benchmarking involves “measuring internal practices against external measures to improve existing processes,”2 the institutions under comparison must be as similar as possible for information to be relevant. The second means of discovery is using institutional performance indicators, clinical and financial data, such as patient satisfaction surveys and admission data that monitor where the institution is in relation to its mission, values and goals. Relevant research findings is the third mechanism for stimulating quality improvement project ideas. Reports in publications on new or improved processes that may be replicated in another institution can trigger project development.
Typically, quality improvement projects require change. For this reason, “change theory” components must be applied when researching, developing and implementing a project. To maximize a project’s success or acceptance, apply the following rules of thumb:
• Projects should be linked to the mission of the institution.
• Projects should be capable of advancing the strategic objectives of the institution.
• Projects should be highly visible and motivating to staff members.
• Projects should be resolvable by a quality improvement team within a reasonable amount of time.
• Projects should be multidepartmental by design.
• Projects should be likely to receive significant commitment and support from the leadership of the institution.2
There are six steps to follow in the quality improvement process.
1. Organize a quality improvement team. The team must be multidisciplinary and contain members from all areas affected by the project. A clear mission and budget guidelines must be provided and
communication strategies should be delineated at the beginning of the project.
2. Research the process and collect input from all areas affected to identify potential barriers and develop strategies for project implementation. Because multiple methods of implementation are available,
each institution must decide the best “fit” for it and adapt the process as needed.
3. Develop the quality improvement project plan, including details of the improved process and how education will be provided to the members of the institution. Project outcomes and means to measure them
should also be determined at this time. Although this area may be the most time consuming, it is crucial to the success of the project.
4. Begin implementing the project with a “pilot program,” so that revisions can be made prior to fully using the “improved process.” Implementation requires assistance from all team members, effective use
of communication strategies and, possibly, additional staff education.
5. Collect data immediately to accurately assess the improved process. Outcomes must be measurable, patient-focused and independent of outside influence to maximize the evaluation process.
6. Evaluate the “improved process” within a reasonable time frame and disseminate the results to all departments involved. This facilitates continued motivation of all departments. The efficacy of the quality
improvement project must be assessed and progress toward goal achievement established.1,3-6
The continuous quality improvement process is extremely rewarding when the “improved process” is well accepted and optimizes the products or services of our institutions. To ensure positive outcomes, follow these steps:
1. Choose quality improvement projects carefully.
2. Encourage a view of the institution as a “system,” instead of as “linear” departments.
3. Give teams clear goals.
4. Use “best practices” in the project plan.
5. Set measurable, attainable goals.
6. Provide relevant, succinct staff training.
7. Provide the quality improvement team members with the tools they need.
8. Design mechanisms to continue the project after the quality improvement team has disbanded.
9. Provide the staff members who were involved with the process information on the success of the project.3
The continuous quality improvement process is “meant to be a way of doing things, not another thing to do.”3 As nurses, we must have the courage not only to question how things are done, but also to change “the norm” to offer patients the best we have to give. Embrace the theme of AACN President Denise Thornby, RN, MS, and “make waves.”
1. Kowal C, Kagen-Fishkind J, Sherlin M, Newell G, McCaffrey E , Gentes J. An educational model to introduce staff nurses to continuous quality improvement/total quality management concepts. J Nurs Staff Dev. 1997;13(3):144-148.
2. McKeon T. Benchmarks and performance indicators: Two tools for evaluating organizational results and continuous quality improvement efforts. J Nurs Care Qual. 1996;10(3):12-17.
3. Carefoote R. Total quality management implementation in home care agencies.
J Nurs Adm. 1994:24(10):31-37.
4. McLaughlin C, Kaluzny A. Total quality management issues in managed care.
J Health Care Finance. 1997;24(1):10-16.
5. Messner K. Barriers to implementing a quality improvement program. Nurs Manage. 1998;29(1):32-36.
6. Page C. Performance improvement integration: A whole systems approach.
J Nurs Care Qual. 1999);13(3):59-70.
Practice Resource Network: Frequently Asked Questions
Q:Our hospital administration wants us to develop a performance improvement strategy to enhance the leadership skills of our nurse managers. Where can we find reliable and valid instruments to measure existing leadership attributes (e.g., conflict resolution, autonomy, job satisfaction, etc.)? We want something that is quick and easy to fill out, that is tailored to nurses and that has a history of prior use and validation. We would like something we can administer before and after the intervention to demonstrate improvement.
A:A variety of resources for measurement tools in nursing is available. The Journal of Nursing Measurement, which can be accessed online at www.springerjournals.com/jnm/home.htm, is an excellent place to start. This biennial publication provides a wide range of instruments for measurement of nursing.
Another excellent online source that provides a variety of articles on outcomes research and measurement is the Outcomes Management for Nursing Practice journal at www.nursingcenter.com.
If you are looking for well-known psychological instruments, check out the following Web sites:
www.metadevelopment.com—This site offers a variety of psychological instruments developed by the noted psychologist, Harold Miller, PhD. Topics include self-concept, stress, anxiety and motivation.
safetynet.doleta.gov/choose.htm—This is a fun, commercial site that will allow you to complete the Keirsey Temperament Sorter on-line. This tool is frequently used to determine personality types in a work setting. The site provides immediate scoring for free and access to further reference material regarding the validity and reliability of the test. It also provides information on interactions between different personality types.
www.apa.org/science/faq-findtests.html—This site by the American Psychological Association provides detailed information on how to access a wide variety of psychological and healthcare-related research tools and instruments. In addition, it provides resources for accessing both published and unpublished tests. Individuals with little research experience would be wise to start here.
Finally, ask your local university library if it has the Health and Psychological Instruments (HAPI ) computerized database. This database, which is updated quarterly, contains more than 15,000 instruments developed from 1985 to the present. A search engine that searches on MESH headings is provided. If your library does not have access to it, contact Behavior Measurement Database Services, PO Box 110287, Pittsburgh, PA 15232-0787; phone, (412) 687-6850.
Do you have a practice-related question? Contact the Practice Resource Network at (800) 394-5995, ext. 217, or visit the "Infolink Discussion" area of the AACN Web site at
Apply for Nursing Research Grant
AACN offers grants to AACN members for research or projects that are relevant to critical care nursing. Unless otherwise specified, all grant proposals must be relevant to critical care nursing practice, address one or more of AACN’s research priority areas and link with AACN’s vision. Following is information about available grants for which application deadlines are approaching.
Datex-Ohmeda-AACN Research Grant
This $5,000 grant to study the issue of nutritional assessment in critically ill patients is funded by Datex-Ohmeda.
Examples of study topics might include the impact of continuous metabolic monitoring; the assessment of the nutritional and metabolic condition of the critically ill patient; current practices of nutritional assessment of the critically ill patient; the use of the Harris-Benedict Equation vs. indirect calorimetry in nutritional assessment; and the evaluation of the accuracy or efficacy of continuous metabolic monitoring in the critically ill patient.
To qualify for this grant, the principal investigator must be a regular or affiliate member of AACN and not currently conducting a study funded by another AACN research grant.
Proposals must be received by Feb. 1, 2001.
AACN Critical Care Grant
This grant awards up to $15,000. The funds may be used to support project expenses and may include research assistance or secretarial support, equipment, supplies and consultation assistance. Principal investigators must be current AACN members. The proposed research may not be used to meet requirements of an academic degree. The principle investigators cannot currently be conducting a study funded by another AACN research grant.
Proposals for this grant must be received by Feb. 1, 2001.
AACN Mentorship Grant
This $10,000 grant provides research support for a novice researcher who is working under the direction of a mentor with expertise in the area of proposed investigation. The funds may be used to support project expenses and may include research assistance or secretarial support, equipment, supplies and consultation assistance.
The mentor cannot serve as a mentor on an AACN Mentorship Grant for two consecutive years. Principal investigators must be current AACN members. The proposed research may not be used to meet requirements of an academic degree.
Proposals must be received by Feb. 1, 2001.
AACN Certification Corporation Grant
Up to four $10,000 grants are funded by AACN Certification Corporation to support research related to certified practice. Examples of eligible projects include studies that focus on continued competency, the Synergy Model, the value of certification as it relates to patient care or nursing practice and credentialing concepts. The proposed research may be used to meet the requirements of an academic degree. Membership in AACN is not required to apply for this grant.
Proposals must be received by Feb. 1, 2001.
Data-Driven Clinical Practice Grants
This grant funds up to six $1,000 awards to stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice.
New projects, projects in progress and projects required for an academic degree are eligible for funding.
The principal investigator must be a member of AACN and not currently conducting a study funded by another AACN research grant
Applications must by received at AACN by March 1, 2001.
For more information about these and other AACN nursing research grants, or to obtain application materials, instructions and information regarding restrictions, call (800) 899-AACN (2226), or visit the “Research” section of the AACN Web site at
Family Trust Can Open Dialogue Toward Consensus
By Christine Westphal, RN, MSN, CCRN
Member, Ethics Work Group
Although G.M. was only 56 years old, he had a lengthy medical history that included hypertension, diabetes, coronary artery disease, two myocardial infarctions with placement of two stents one month prior to this admission, mild congestive heart failure and chronic obstructive pulmonary disease. His health was further compromised by having smoked two packs of cigarettes a day for more than 35 years. Despite these health problems, G.M. continued to work full time in a shipping and receiving department and enjoyed coaching a Little League team.
History seemed to be repeating itself when G.M. presented in the emergency department with chest pain and evidence of ischemia. However, this time G.M. required a quadruple coronary artery bypass. His postoperative course was tenuous, requiring intra-aortic balloon pump support, vasopressors, inotropes and mechanical ventilation. On postoperative day four, G.M. went into cardiac arrest, but within a few minutes was resuscitated successfully. When he arrested again later that day, resuscitation efforts continued for almost 30 minutes before a rhythm and blood pressure could be maintained, though not without continued vasopressors and balloon pumping. Unfortunately, despite minimal hemodynamic recovery, G.M. suffered anoxic encephelopathy, which left him able to gag, cough and blink, but little else. Applying the Synergy Model to assess G.M., the nursing staff identified that he exhibited minimal resiliency, high vulnerability and low physiologic stability.
As G.M.’s condition worsened, family members began gathering at the bedside, mobilizing their resources for support and decision making. Initially, it was thought that G.M.’s only support was from his wife of 15 years and her family. However, several days after surgery, two adult sons and two adult daughters appeared. All these family members seemed to be a highly supportive, cohesive group.
Because G.M. had neither an advance directive nor a designated advocate, his decision-making capacity was low. In the absence of a designated advocate, his relatives were asked to make decisions, based on the best-interest standard. After G.M.’s second cardiac arrest resulted in an increased need for hemodynamic and respiratory support, his wife stated that she felt God was calling him and that in the event of another arrest, the medical team should not try to resuscitate him. The consensus of G.M’s family members was that current therapies should be continued, but that treatment should not be escalated. They agreed that if G.M. showed signs of neurological recovery during the following few days, they would reconsider their decision. The family members demonstrated a good knowledge of the situation, strong support of what they believed would be in G.M.’s best interest and a high level of participation in decision making.
Unfortunately, three days later, G.M. showed no neurologic improvement and experienced intermittent, brief episodes of hemodynamic compromise. When his wife began to talk about withdrawing life support, the family became fiercely divided. G.M.’s children threatened to take legal action if the physicians withdrew support and to seek guardianship of G.M. and a restraining order against G.M.’s wife. The individual family members tried to keep their distance from each other and when they arrived for the same visiting time, terse comments and angry accusations were exchanged. They sought information from a variety of team members, in the hope that it would help them build their own cases for either withdrawal of treatment or continued support. Family dynamics became increasingly complex as values conflicts emerged about what would be in G.M.’s best interest. This sudden family division was disconcerting and difficult to understand. Why did it happen? What prompted the difference in opinion?
Taking time to learn more about the family, we discovered that the children were all from G.M.’s first marriage and that the oldest two had been estranged from him for many years. Although the younger two children lived out of state, they had remained in contact with their father. They implied that they felt G.M.’s wife was not thinking of G.M.’s best interest, but only of herself and the potential burden his care would place on her. Feelings of suspicion, guilt and abandonment were expressed. The family that at first seemed intact apparently was not. Could this family be “healed” and helped to make a consensual decision on behalf of G.M.?
One nurse decided to try to facilitate a family meeting. She invited a physician to provide the medical information and a pastoral minister to provide support for her as well as the family. The nurse emphasized that the decisions that needed to be made should be based on what G.M. would decide for himself, if he were able. Although the family members requested that the meetings be separate, the nurse insisted that consensus could be achieved only if all parties talked and worked together. However, she agreed to separate meetings if consensus could not be reached.
The nurse opened the meeting by asking each family member to share stories about G.M. Through sharing the past, directions for the present emerged. Everyone described G.M. as an out-going, fun-loving, people-oriented person. They laughed about his seemingly endless energy and his penchant for “oldies” rock ’n’ roll. G.M.’s wife revealed that, as his health deteriorated over the past several years, he had discussed life support and end-of-life issues with her. She said that he would not want to live if he could not be independent and live a life of helping others. Tearfully, the eldest daughter said that she did not want G.M. to suffer, but wanted the chance to talk with him one last time to resolve issues that had not been settled. The other siblings, though supportive of their sister’s position, affirmed the wife’s belief that G.M. would not want to be neurologically impaired and dependent upon machines. Finally, the physician shared her knowledge of G.M.’s condition, prognosis and treatment options.
The nurse then asked: “If G.M. had 15 seconds to be awake, alert and tell you what decision to make, what would he say?” The family was silent until G.M.’s wife tearfully responded that he would say, “Let me go.” Struggling to fight back tears, each of the children nodded in agreement. The eldest daughter buried her head in G.M.’s wife’s shoulder, and they held each other tight.
A plan of care was developed that would allow each family member private time with G.M. before support was withdrawn. As the family members hugged each other and the nurse, they expressed feelings of gratitude and relief that the battle was over not only for G.M., but also among them. G.M. died within 24 hours with his entire family at his side.
In this case, the nurse was sought out by the physician to intervene with G.M.’s family when other members of the healthcare team felt frustrated and powerless in their attempts to gain family trust and agreement. This nurse was able to effectively translate the language of critical care into lay terms to explain what G.M. faced and the available treatment options. Her sensitivity to the unique experiences of each family member and her therapeutic communication skills engaged the family members in a trusting relationship with her. This trust helped to create a compassionate environment for open dialogue, which helped the family to achieve consensus about the goals of G.M.’s care at a time when other members of the healthcare team felt powerless to intervene. The nurse integrated her knowledge, skills, experience and caring practices to create safe passage for G.M. and his family, which allowed G.M. to die peacefully and his family to find comfort in a death with dignity.
Christine Westphal is a clinical nurse specialist in the coronary care unit at Oakwood Healthcare Systems, Dearborn, Mich.
Geriatric Corner: Try This: Nutrition and Hydration
More than two years ago, the John A. Hartford Foundation Institute for Geriatric Nursing established the Specialty Nursing Activities Partnership Program (SNAPP) for Care of Older Adults. This collaboration is part of an effort to promote best practices in the care of the older adult and to share resources with nurses who care for acute and critically ill older adults.
Following is a tool from the September 2000 posting of the Try This: Best Practices in Nursing Care to Older Adults series, which appears monthly on the institute's Web site at
www.nyu.edu/education/nursing/hartford.institute. This site can also be accessed through the AACN Web site at
www.aacn.org. Click on “Practice Resources,” then “Clinical Practice Links,” “Gerontology” and “John Hartford Foundation Institute for Geriatric Nursing.”
Nutrition and Hydration
By Cora Zembrzuski
Why: Nutrition and hydration in older adults are areas that have been under-researched relative to their significance to clinical implications for older adults. Current literature suggests that normal age-related changes include decrease in total body water, thirst response, muscle mass, overall food and fluid intake and metabolic rate, and a redistribution of fat to the abdomen, upper arms and thighs. The hypothesis is that, although these changes are partially due to aging, they can be dramatically delayed or offset by positive lifestyle changes. In-depth assessment of hydration and nutritional status will provide the information needed for nursing interventions aimed at maximizing wellness and identifying problems for treatment.
Best Tools: Assessment instruments, which vary in both format and content, reflect the diversity and debate surrounding the factors that contribute to nutritional and hydration status in older adults. The two that are recommended are the Nutritional Screening Initiative Checklist (NSI), and the Hydration Assessment Checklist.
Target Population: The NSI is a self-administered, scored checklist aimed at nutritional awareness of the noninstitutionalized older adult. The Hydration Assessment Checklist is a lengthy, in-depth assessment designed to screen for hydration problems. Older adults, either in the community or in a nursing home institution, are grossly under-hydrated, ingesting on average less than 1000cc/day, which is substantially lower than recommended. Of the 1000cc, few take in water, an essential element supporting cellular and organ health, electrolyte imbalance, medication absorption and distribution, as well as kidney, bladder and integumentary functioning.
Reliability and Validity: Although these instruments have been used clinically in the field, only the NIS has undergone psychometric testing and reported acceptable levels of validity and reliability. Further testing is needed on both instruments.
Strengths and Limitations: Although the NSI is not yet clinically diagnostic, it is brief and may be self-administered by the older adult. The Hydration Assessment Checklist is lengthy and requires access to a patient’s lab results, history and intake/output for three days.
Dwyer JT. Screening older Americans’ nutritional health: Current practices and future responsibilities. Washington, DC, Nutritional Screening Institute; 1991.
Dwyer JT, Gallo JJ, Reichel W. Assessing nutritional status in elderly patients. Am Fam Physician. 1993;47(3):613-620.
Posner BM, Jette AM, Smith KW, Miller DR. Nutrition and health risks to the elderly: the Nutritional Screening Initiative. Am J Public Health. 1993;83(7):972-978.
Zembrzuski CD. A three-dimensional approach to hydration of elders: administration, clinical staff, and in-service education. Ger Nurs. 1997;18(1):20-26.
Have you made any changes to your practice because of reading the information presented in this column? Do you have suggestions regarding this feature? Contact AACN Practice Director, Justine Medina, RN, MS, at
(800) 394-5995, ext. 401; fax, (949) 448-5520; email,
Justine.Medina@aacn.org to share your feedback.
NSI Checklist to Determine Nutritional Health
The older adult fills out the following questions, 2
which have associated points.
I have an illness or condition that made me 3
change the kind or amount of food I eat.
I eat fewer than two meals/day. 2
I eat few fruits or vegetables, or milk products. 2
I have three or more drinks of beer, liquor 2
or wine almost every day.
I have tooth or mouth problems that make 2
it hard for me to eat.
I don’t always have enough money 4
to buy the food I need.
I eat alone most of the time. 1
I take three or more different prescribed 1
or OTC drugs a day.
Without wanting to, I have lost or gained 2
10 pounds in the last 6 months.
I am not always physically able to shop, 2
cook, or feed myself.
Total Nutritional Score 21
0-2 indicates good nutrition
3-5 indicates moderate risk
6 or more indicates high nutritional risk
This form has been summarized. The full checklist is available through the Nutritional Screening Initiative, 2626 Pennsylvania Ave., NW, Suite 301. Washington, DC 20037.
Hydration Assessment Checklist
Pertinent items are checked off. The more factors or severity of factors that are checked off, the greater the risk for diminished hydration.
1. Symptoms of hydration warranting immediate medical and nursing interventions (fever, thirst, dry warm skin, furrowed tongue, decreased urinary output, etc.)
2. Associative factors (>85 years old, physical immobility, cognitive impairment, fluid intake of 1500cc or less, unaware of thirst)
3. Problems of increased vulnerability (medical problems such as osteoporosis, CHF, dementia, etc.)
4. Dietary restrictions of fluids, salt, potassium, protein
5. Medications (diuretics, tricyclic antidepressants, laxatives)
6. Medical history of dehydration, infections, difficulty swallowing, etc.
7. Immediate return from one-day hospitalizations, dental or eye surgery, NPO procedures, etc.
8. Laboratory reports showing steady increases in sodium, blood urea nitrogen, creatinine, hematocrit, serum osmolality, and urine specific gravity.
Note: This checklist has been abbreviated. The full version can be found in Zembrzuski CD. A three-dimensional approach to hydration of elders: administration, clinical staff and in-service education. Ger Nurs. 1997;18 (1), 20-26.
Vox Populi: AACN Online Quick Poll Update
Have you designated yourself as an organ donor?
Number of Responses: 1,277
The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. Participate by visiting the AACN Web site at