Quality Improvement, Evidence-Based Practice, and Patient Safety
Quality and safety items test the vocabulary and mechanics of improvement work: how you measure, how you test a change, and how you learn from harm.
Improvement framework
- Model for Improvement: three questions (what are we trying to accomplish, how will we know a change is an improvement, what changes will result in improvement) plus Plan-Do-Study-Act cycles.
- Use a family of measures: outcome, process, and balancing measures.
- Run charts and statistical process control separate real signal from common-cause variation.
Safety tools
- Root cause analysis after a sentinel event; failure mode and effects analysis prospectively.
- CLABSI bundle: hand hygiene, maximal sterile barrier, chlorhexidine skin prep, optimal site selection, daily review of line necessity, prompt removal.
- Pressure injury risk: Braden Q. Falls: Humpty Dumpty Fall Scale. Hand hygiene: WHO five moments.
- Just culture: console human error, coach at-risk behavior, sanction reckless behavior.
- SBAR for handoffs and escalation.
Evidence-based practice
- Form a PICO question, search, appraise for level and quality, then integrate with family preference and available resources.
- QI is not human subjects research; it usually does not need IRB review, but it does need ethical oversight and data protection.
Worked example
A unit's CLABSI rate is 3.2 per 1,000 central line days. The team tests daily line-necessity review with a PDSA cycle on one shift, plots weekly rates on a run chart, and tracks a balancing measure (unplanned line removal). After eight weeks the rate falls, and the change is spread with a second cycle.
Traps
- Blaming an individual for a system failure.
- Calling a QI project research and abandoning it.
- Declaring improvement from one data point without a run chart.
- Choosing only an outcome measure, with no process or balancing measure.