In this course you will learn about the importance of quality in healthcare and how you can contribute by implementing a quality improvement (QI) project to improve processes of care and patient outcomes. You will learn about powerful tools to add to your QI ‘toolbox’ during short lectures and reflective exercises. You will apply these tools to the implementation of a QI project in your own practice setting or an area of personal improvement. At the completion of the course, you will have a storyboard that captures your QI project success to share with others.
The QI project will be considered within the context of interprofessional teams and from a systems perspective. The objective of this course is to empower you, the working healthcare professional, to improve your knowledge and skills in the science of quality improvement so that you can take action in your own clinical setting to improve the quality of care for your patients and their families.
Associate Professor, Frances Payne Bolton School of Nursing; Director, QSEN Institute; VA Quality Senior Nurse Fellow, Louis Stokes Cleveland VA
Shirley Moore, PhD, RN, FAAN
Edward J. and Louise Mellen Professor of Nursing and Associate Dean of Research Frances Payne Bolton School of Nursing
Mamta K Singh, MD, MS
Physician Director of the Center of Excellence in Primary Care Education, Louis Stokes Cleveland VA; Associate Professor of Medicine, School of Medicine
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For module one, we thought we would give you a case study.
This is a really great study, because it's about a physician who was frustrated with
the care that was being delivered in the emergency room department where he worked.
When he presented this project as part of his VA qualities scholar's work, and
he's given me the permission to share this with you just so
you can get an overview of what the outcome of this course will be for you.
This is Wes Self.
He's a physician through the VA Quality Scholars Program, and
his particular project was a quality improvement program to
reduce blood culture contamination in the emergency department.
And the background to this problem is that blood cultures is the test of
choice to determine if a patient has bacteraemia.
And contamination occurs quite frequently where there's a growth of bacteria in
the culture that doesn't originate from the patient, but
originates from poor blood draw.
And so he does list here the potential contaminants of blood culture drawing in
the emergency department, just as a little bit of background.
And then he does talk a little about it in
his presentation that contamination is confusing.
That there's diagnostic uncertainty for clinicians where the bacteremia kind of
comes from or where the bacteria comes from.
And so he also notes in his background that when there is contamination,
this causes some co-morbidity.
Contamination of the blood draw in the emergency department can
lead to greater length of stay, hospital admissions, unnecessary antibiotics,
repetition of blood cultures, unnecessary procedures and really just delays in care.
So if you think about our six components of quality, it impacts many of
those six components: safe care, effective care, efficient care, timely care.
He also notes that this contamination is pretty costly,
each contaminated culture costs about $8,500 in patient charges.
So you can see that it also impacts the triple aim.
Blood cultures are common in our healthcare, 3.1 million cultures are done
in US emergency departments across the country and
20% of admissions have blood cultures.
So you can see this is a common procedure that can cause a lot of
problems if not done properly.
Dr. Self does talk about how we can minimize contamination and
that if we do minimize contamination that it'll lead to better quality.
Now he's talking about his local problem.
So he's doing a system analysis of his unit, and
he looks at his emergency room department and notes that they do
about 7,000 cultures per year, and of those about 8.26 were contaminated.
The QI team that he formed consisted of physicians, nurses, administrators, and
infectious control specialists, and
his specific gain was to decrease the proportion of
blood cultures collected in the ED with potential contaminants, less than 3%.
So, he was moving the mark from 8% contamination to
3% contamination through this improvement project.
He does list then in his assessment of the system why in his
unit cultures get contaminated.
So he did an assessment of the system, and
then he looked at the process of how blood cultures were collected.
And this is another system tool that you're going to learn in this course,
as to how you can better understand your system using process flow charts.
Here again is just his process flow chart for
potential ways that, blood cultures can get contaminated.
And then he does this fishbone diagram,
which you learned in the module one in that,
the fishbone diagram helps you to collect the data to better understand the system.
Then after he did his assessment of the system, he then developed through this
analysis of the system, sort of like what the intervention would be and
he determined that he would do a QI bundle.
And the bundle would consist of blood culture collection using a sterile kit,
of which they didn't have, and that the sterile technique training would be
done specifically for registered nurses because he found that there was
some knowledge gaps with the nurses when they were collecting the sample.
And then he also in his bundle added feedback of contamination rate.
So he would let the professionals know how many of their samples were
being contaminated.
And the last part of his bundle then for the intervention was to do
booster training for the RNs who do collect the cultures.
And you can see then he did another fishbone identifying which components of
his system analysis he was going to intervene on.
He then created these blood culture collection sterile kits which they
implemented and a checklist to make sure that the kits were in place.
And then here's some feedback that he got weekly.
So he was collecting data on the implementation of his intervention.
And here's a little bit of data on how he did the booster training for
the registered nurses when he implemented this bundle.
And this is another process diagram to show then the process and
how this process changed in his improvement initiative.
The bundle was implemented and they did continue as quality improvement where they
got feedback from the registered nurses after the education,
they got feedback after the booster intervention.
And then they collected their data and
demonstrated that from pre to post results, pre intervention to post intervention, they
were able to actually reduce their percent contamination to what their goal was.
And then he demonstrated his data using a control chart,
which you're going to learn in this course.
And there again demonstrating how the intervention had a huge impact on
the reduction of contaminated samples.
He also notes some of the limitations of his study, and
then he acknowledges all the team members that are at his institution.
This case study demonstrated all the components of quality improvement.
It really had all the different tools and techniques and
strategies of a quality improvement professional.
Through this course, you're going to be learning all these techniques.
We're really looking forward to the next modules so
that you can learn these techniques and
then apply them into the care that you deliver in your own institutions.
Looking forward to that journey ahead.
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Mary A. Dolansky, PhD, RNAssociate Professor, Frances Payne Bolton School of Nursing; Director, QSEN Institute; VA Quality Senior Nurse Fellow, Louis Stokes Cleveland VA
Shirley Moore, PhD, RN, FAANEdward J. and Louise Mellen Professor of Nursing and Associate Dean of Research
Mamta K Singh, MD, MSPhysician Director of the Center of Excellence in Primary Care Education, Louis Stokes Cleveland VA; Associate Professor of Medicine, School of Medicine
