Lecture Notes: Quality Improvement and Evidence-Based Practice

Levels of Evidence

• Higher levels: Robust studies such as RCTs, meta-analyses
• Lower levels: Opinions of respected authorities
• Important to base practice on robust evidence rather than anecdotes

Quality Improvement (QI)

• Mindset: Continuous improvement is essential even when outcomes are positive
• Receptivity: Be open to change but avoid turmoil
• Continuous Quality Improvement (CQI): Partners well with evidence-based practice

Tools for QI

• PDSA (Plan Do Study Act):
  • Plan: Identify issue, gather information, propose solutions
  • Do: Implement the solution
  • Study: Assess outcomes, analyze effectiveness
  • Act: Retain or revise changes
• FOCUS PDSA:
  • F: Find a process to improve
  • O: Organize improvement process
  • C: Clarify knowledge about the process
  • U: Understand sources of the process problems
  • S: Select the process improvement
• PDCA (Plan Do Check Act): Similar to PDSA but 'Study' phase is 'Check'
• DMAIC (Define Measure Analyze Improve Control): Define problem, Measure impact, Analyze causes, Improve solutions, Control changes

PICO(T) Process

• P: Problem/patient/population - Identify issue (e.g., patient falls)
• I: Intervention - Consider treatment (e.g., bed alarms)
• C: Comparison - Evaluate alternative interventions (e.g., signs, sitters)
• O: Outcome - Desired result (e.g., no falls)
• T: Time frame - Time to achieve outcome (ASAP for falls)

Healthcare Informatics

• Purpose: Use technology to gather and communicate information, enhance decision-making, improve patient safety
• Tools: Internet, RFID systems, point of care devices (e.g., glucometers), lab analyzers

Clinical Judgment

• Model by Tanner: Mirrors nursing process
• Steps: Recognizing, Analyzing, Prioritizing, Generating solutions, Taking action, Evaluating outcomes
• Appropriate vs. Inappropriate Judgment: Good patient outcomes vs. negative outcomes from poor clinical judgment
• NCSBN Framework: Recognize clues, Analyze clues, Prioritize, Generate solutions, Take action, Evaluate outcomes
• Systems Thinking: Understand interdependence and Continuum of healthcare
• Equity: Providing fair and impartial care considering individual needs

Health Disparities

• Factors: Access to care, quality of care, outcomes, insurance coverage
• Social Determinants of Health: Environments affecting quality of life
• Vulnerable Groups: Defined by race, ethnicity, culture, etc. Recognize biases and knowledge deficits

Ethics in Healthcare

• Individual Ethics: Personal foundational principles (honesty, respect)
• Organizational Ethics: Principles guiding workplace decisions
• Professional Ethics: Principles from professional bodies (State Boards, organizations)
• Ethical Principles:
  • Autonomy: Patients' right to make decisions
  • Beneficence: Do good
  • Non-maleficence: Do no harm
  • Fidelity: Keep promises
  • Veracity: Tell the truth
  • Social Justice: Fair and equal treatment
• Ethics Committees: Handle justice, fairness, duty to care issues

Sample Questions (Competency and Teamwork)

1. Teamwork and Collaboration: Paging surgical team for consultation
2. Delegated Hygiene Care: All aspects (soft toothbrush, comb hair, dry skin, electric razor, etc.)
3. Readmissions for Heart Failure: Evaluate trends and develop a plan for improvement

Conclusion

• Recap of the importance of evidence-based practice, continuous quality improvement, informatics, clinical judgment, and ethics in healthcare.