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.
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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.
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Evidence-Based Practice offers information to help nurses integrate research-based
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of tables, figures, insets, and references. If interested, contact Associate Editor Carlton
G. Brown, PhD, RN, AOCN®, NEA-BC, FAAN, at cgenebrown@gmail.com.
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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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attachment