Quality Improvement

Quality Improvement Process

Charissa Deur, Kayla Dishon, Rebecca Sherborne, & Katie LaPrairie
Ferris State University

Quality Improvement
Quality Improvement Process
It is important for nurses to continuously strive to improve the quality and safety of
patient care within the health care systems in which they work. In order to improve patient
outcomes, nurses must focus on the six competencies outlined by the Quality and Safety
Education for Nurses. These competencies are patient-centered care, teamwork and
collaboration, evidence-based practice, quality improvement, safety, and informatics (YoderWise, 2015). The purpose of this paper is to develop a quality improvement approach to
inadequate staffing, by using a leadership strategy. This strategy includes elaborating on the
clinical need, identification of interdisciplinary team members, data collection methods, desired
outcomes, and designing a method to evaluate improvement.
Clinical Need
According to the American Nurses Association, reductions in nursing budgets as well as a
greater demand for nurses has resulted in fewer nurses caring for sicker patients while working
longer hours. There is a large emphasis on patient outcomes in the healthcare field, specifically
relating to staffing best practices. This is an area with an ongoing and widespread concern
throughout many hospital organizations. Research suggests that increasing the numbers of
registered nurses results in many positive benefits to patients, such as a reduction in hospital
related mortality and failure to rescue (Yoder-Wise, 2015). Being understaffed not only
increases the chances of medical errors, patient infections, pressure ulcers, and pneumonia, but it
also increases nurse burnout, and fatigue (Dorning, 2016). Adequate nurse staffing goes beyond
just the nurse to patient ratio. Staffing is also determined by education levels, experience, and
the critical thinking skills the nurses have (Wallace, 2013). Factors such as severity of illness,

Quality Improvement
observation and intervention requirements, and hours per patient day should also be considered
when making staffing decisions (Douglas, 2010).
Interdisciplinary Team
The use of interdisciplinary teams who work in hospitals are important to limit adverse
events, improve outcomes, and increases the overall patient and employee satisfaction.
Communication is key when there is an area of healthcare that is in need of improvement. The
team consists of employees who work in the healthcare setting who can work together to come
up with a quality improvement process. According to evidence-based practice, Quality
improvement members should represent a cross-section of workers who are involved with the
problem (Yoder-Wise, 2011, pg. 95). When there is inadequate staffing in hospitals, job
satisfaction goes down, which can affect the patients overall satisfaction. Every professional
that is involved in the team brings perspective and knowledge to how we can improve inadequate
staffing.
The finance department will be responsible for the financial direction, planning,
budgeting, and reporting of the current costs that are included with inadequate staffing. They
will also provide the affordability of the change within the hospital. Members of the quality
improvement team will be needed to contact JACHO to provide information of the regulations
that are included in the policy changes within the facility. A member of the Board of Trustees
will be a part of the team to ensure proper communication between all members regarding the
situation. Nurses play a very important role in the team as they are the ones who deal with
inadequate staffing the most and they are the ones with the patients throughout the entire shift.
Nurses hold the healthcare system together and they have a greater understanding of how
inadequate staffing can affect their job and overall patient satisfaction. Physicians will also be

Quality Improvement
involved in the team as they are also in contact with the patients as well as the nurses. Their
authority and leadership will help keep the team on track and will provide insight on what goes
on throughout the floor as well. With the entire interdisciplinary team working together, staffing
issues within the facility can be properly analyzed and changes can be implemented to ensure
quality improvement in the healthcare organization.
Data Collection Method (appendix A)
In order to monitor staffing issues, we developed a chart for the charge nurse to fill out
during each shift as shown in Appendix A. At the beginning of the shift the charge nurse would
be responsible for identifying the number of RNs present on each shift along with how many
patients are on the unit. He or she would also be responsible for determining the average patient
to nurse ratio and logging this in the chart. At the end of the shift any adverse events should be
tallied up and a description of the event also included. At the end of each week these reports
should be submitted to the nurse manager so the information can be evaluated. The nurses will be
required to take random questionnaires (Appendix B) throughout the weekly regarding their
opinion of the staffing for their shift, they will also be able to make recommendations on what
could have been done better. The nurse manager will take both of these forms into account when
it comes to evaluating what works best to provide proficient staffing conditions.
Outcomes (GOAL):
Research has shown that higher nurse to patient ratios can not only improve patient
outcomes but it can reduce nurse injury rates by one-third(Professionalism Safety, 2015).
California was the first state to implement minimum nurse to patient ratios and sparked the
research studies in this area. Although there are still many debates about what the right ratio is,
the standard is approximately one nurse for every five patients(Professionalism Safety, 2015).

Quality Improvement
We propose that a maximum ratio of four patients to one nurse on general med surg floors be
implemented in order to reduce the frequency of adverse patient outcomes. Upon mandating this
ratio, we hope to decrease adverse events such as adverse events such as: falls, CAUTIs,
pressure ulcers, patient light useage by ten percent in three months. We also hope that by
implementing better working conditions this will increase nurse satisfaction and staff retention
and lastly increase patient satisfaction by 10 percent in the same time period.
Implementation Strategies
To implement the proposed change of addressing a standard ratio of 4:1 on medical
surgical floors we will start by identifying the cause of inadequate patient to staff ratio. If hiring
is necessary, and available within the budget, the first change will be trying to staff according to
recommended staffing per floor. A theory used to guide this plan of change will be The Theory
of Planned Behavior. This theory explores the link between beliefs and behaviors. The theory
states that, attitude of those implementing the change are affected by their
attitude, behavior, subjective norms and behavioral control together to
shape behavioral intentions and behaviors to perceive a need for change
(Ajzen, 2016). The first step will be to link the behavior of intention of
change to an expected outcome, which is standard 4:1 staffing. The subjective
measure will be how the manager in charge of hiring perceives the needs for more staff. If the
manager believes its healthcare norm to work short or compares working with 4:1 as
unreasonable, then the behavior will likely affect the process of change. Perceived behavioral
control determines a persons perception and ability to perform a given behavior. Based on the
behavioral, attitude, subjective, and normative beliefs, not including the actually need based on

Quality Improvement
objective measures such as patient satisfaction surveys, risk assessments, and staff satisfaction
surveys and intention and action will likely result.

Evaluation
In order to evaluate the implementation of our designated method and strategies weve
developed two weekly surveys to identify possible causes and behaviors towards inadequate
patient to staff ratios. First, we need to identify a safe patient to staff ratio which we suggest to be
4:1. Our weekly staff to patient report will identify number of staff, patients, ratios, acuity,
adverse events, and a detailed report of the event including time of incident, number of times of
occurrence, who was involved, what the patient was doing, medication, patient diagnosis and
other factors needed to determine reason for occurrence . Second, we will evaluate adverse
effects that are occurring and record the number of incidents and graph financial reports to give
objective reasoning as to why financially staffing a med/surg floor is more beneficial than
inadequately staffing and causing nosocomial incidents.
The second way we will evaluate towards our desired goal will be administering a weekly
staff questionnaire, which asks the RN about number of patients in assignment, how they felt the
unit was staffed, quality of care given, teamwork ability, stress level, and job satisfaction along
with any other suggestions and comments. Both these surveys will be implemented while
striving toward a 4:1 ratio and continued for 6 months to a year after adequate staff/patient ratio
is set to determine the effectiveness in reducing hospital related incidents and finances.
Those involved and asked for their feedback throughout this implementation and
evaluation process will be awarded by a unit party which celebrates the success and help of those
involved to make the unit safer for both staff and patients. Yoder-wise states, one of the most

Quality Improvement
crucial tasks for a nurse manager or leader is to reward the success of staff when working
towards quality improvement (2015).
Conclusion
The need for nurses to continuously strive is extremely important to improve the overall
quality and safety in the health care systems. By implementing the clinical needs,
interdisciplinary team, a data collection method, an outcome, implementation strategy, and
evaluation process, initiatives can be achieved and quality and safety can be improved. As nurses
we have an ethical duty to promote good for our patients. Following the quality improvement
process will ensure adequate staffing and create a positive impact to improve the overall patient
care.

Appendix A

Quality Improvement

Weekly Staff to Patient Report

Date:________
Number of
staff

Number of
Patients

Ratio Acuity

Adverse
events

Detail of
Events

Day
1
Day
2
Day
3
Day
4
Day
5
Day
6
Day
7

Appendix B
Weekly Staff Questionnaire
1. How many Patients did you have during your shift? How many of those were partial
care? Total care? Independant?

Quality Improvement
2. Do you feel the unit was staffed adequately today?

Yes / No

On a scale of 1-5, with 5 being the best, answer the following:

3. Quality of care given today

012345

4. Your teamwork ability today

012345

5. Stress level today

012345

6. Job satisfaction today

012345

7. Do you have any other comments or insights to add:

References
Ajzen, I. (2016). Theory of planned behavior Received from
http://people.umass.edu/aizen/tpb.html
n.d (2015, July). Higher Nurse to Patient Ratios Reduces Injuries. Professionalism Safety.
Dorning, J. (2016, May). Safe-Staffing Ratios: Benefiting Nurses and Patients - DPEAFLCIO.

Quality Improvement
Retrieved July 21, 2016, from http://dpeaflcio.org/programs-publications/ issue-factsheets/safe-staffing-ratios-benefiting-nurses-and-patients/#_edn12
Douglas, K. (2010). Ratios: If it were only that easy. NursingEconomics, 28(2), 119125.
Safe Staffing - American Nurses Association. (n.d.). Retrieved July 21, 2016, from
http://www.rnaction.org/site/PageServer?pagename=nstat_take_action_safe_staffing_about
Wallace, B., (2013). Nurse staffing and patient safety: Whats your perspective? Nursing
Management, 44(6), 49-51.doi: 10.1097/01.NUMA.0000430406.50335.51
Yoder-Wise (2015). Leading & Managing in Nursing (6 ed). St. Louis, MO: Saunders
th