1 Running head: LEADERSHIP STRATEGY ANALYSIS

Leadership Strategy Analysis- Quality Improvement Process Michelle M. Johnston Ferris State University

2 LEADERSHIP STRATEGY ANALYSIS Abstract This paper will lead its reader through a Quality Improvement (QI) Process that takes place within this writers organization. The leadership strategy will be introduced and the process of quality improvement will be reviewed and analyzed as it follows guidelines regarding the strategy of leadership. A problem is presented and its history is unveiled to reveal the need for improved practices. A team will be formed to work on the quality improvement process and its members roles within the team and improvement process are then analyzed. The Quality Improvement team will create a process to gather data and define the goals and interventions of change to be implemented. A system for implementing change will be created with an evaluation process to keep quality and safety of foremost importance to all nursing staff working with patients.

3 LEADERSHIP STRATEGY ANALYSIS Leadership Strategy Analysis- Quality Improvement Process Quality and safety initiatives are a critical standard of care. Within the Institute of Medicines (IOM) report To Err is Human, it was revealed that At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented (Institute of Medicine [IOM], 2000, p. 1). According to IOM (2000), a medical error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim (p. 1). Medical errors are deserving of attention to bring our patients the highest quality of safe care. One medical error that is commonplace but preventable is patient falls. Patient fall prevention initiatives are a standard of care that protects the safety of patients and the quality of their health care. Nursing leaders can help to prevent falls through providing other team members with the tools needed to ensure proper intervention through transformational leadership. Transformational leadership, according to Yoder-Wise (2011) is an act of encouraging followers to follow the leaders style and change their interests into a group interest with concern for a broader goal (p. 40). Clinical Need Each year, one in every three adults age 65 and older falls. Falls can cause moderate to severe injuries, such as hip fractures and head injuries, and can increase the risk of early death (Centers for Disease Control and Prevention [CDC], 2012b, para. 1). Patient fall prevention initiatives are a standard of practice within my organization. Falls can be costly to the patient and the facilities caring for them. According to the CDC (2012a), In 2000, the total direct medical costs of all fall injuries for people 65 and older exceeded $19 billion (para. 4). $0.2 billion was accounted to fatal falls, of all fatal falls, nursing home residents account for 20% (CDC, 2012c, para. 2). Falls among nursing home residents can cause debility, a lower quality

4 LEADERSHIP STRATEGY ANALYSIS of life, fear and anxiety leading to depression and further debility, and social isolation (CDC, 2012c, para. 3). My organization is a sub-acute rehab/long-term care facility that cares for those aged 65 and older. In my organization, the total number of falls for the month of May was 11. The amount of falls can be reduced using a process improvement team to discover the best practices for safety interventions. The physical injury and emotional turmoil that falls often produce along with the large cost that falls create are reason for quality improvement (QI) processes in this subject matter. The Team The QI process for fall prevention will be carried out through a team of members from my organization. The QI team will include the Quality and Infection Prevention Director, Director of Nursing, Clinical Care Nurse, Registered Nurse (RN) Unit Manager, Shift Supervisor, the Staff Education Director, Physician, and Physical/Occupational Therapy Director. Each member of the team will have specific roles to carry out and those roles will be clearly defined. The Quality and Infection Prevention Director has the role of leading the QI team through the QI process. The Quality and Infection Prevention Director will run the meetings, provide information about evidence-based practices for fall prevention and present the data that has been collected and gathered. The Director of Nursing will present current fall prevention practices and collect data about what interventions have and have not worked in the past as well as ensure that interventions follow the states Nurse Practice Act and oversee policy. The Clinical Care Nurse will help the Quality and Infection Prevention Director select a QI tool to use as a framework for the interventions and ensure that interventions developed are evidencebased and following standards of care. The RN Unit Managers role is to present any ideas of further intervention and to give input as to what interventions would be practical with the flow of

5 LEADERSHIP STRATEGY ANALYSIS the unit as well as to be sure that current policy is being carried out. The role of the Shift Supervisor would be similar to the RN Unit Managers in the way that he/she will also provide feedback and suggestions of interventions that would work well with the flow of the unit, but he/she will also ensure that implementation is delegated appropriately on the units. The Staff Education Director will help with the implementation phase of the process by initiating inservices and creating competencies for all nursing staff to educate and evaluate them over new practices and processes and to support them if they are in need of further education. The Physician will identify fall risks and analyze patient medical history. The Physical/Occupation Therapy Director will work to assess new patients for strength and balance and identify the need for therapies to assist in fall prevention. Data Collection In the data collection process, the five whys strategy can be used to help better explain the problem. The five whys strategy was originated within Toyota as they developed their manufacturing methodologies and it was a large part of their employee problem solving training (NHS Institute for Innovation and Improvement, 2008). All nursing staff will be involved by organizing an optional meeting that will explain the problem and emphasize the importance of improvement. The nursing staff will be asked to help with data collection by answering the five whys as well as continuing to accurately chart behaviors and falls as they happen. This will evoke leadership by involving subordinate staff in the improvement process and it empowers staff through having their voices heard. The Quality and Infection Prevention Director, the Clinical Care Nurse and the Director of Nursing will all monitor the number of falls and the Quality and Infection Prevention Director will chart the falls and their characteristics monthly. Variables of a fall could be the patients location, time of day, need for toileting, alarms in place,

6 LEADERSHIP STRATEGY ANALYSIS diagnoses, how the patient is transferred or their mobility, patients level of consciousness, medications the patient is taking, behaviors, Morse fall risk score, patients clothing, adaptive equipment, equipment failure, injuries etc. For the identified problem, the following information was collected: 11 total falls in the month of May, all were on a single unit, eight took place on second shift, three took place on third shift, none resulted in injury, nine of the patients have diagnoses of dementia, all need assistance of one for transfers, six needed toileted, five had unknown causes, there was no equipment failure or breakage, all alarms that were care planned were in place. The five whys can then be asked about the problem of falls: Why were there falls? The majority of people needed to use the bathroom and didnt have help in time before they fell. Why? The Certified Nurses Aide was busy assisting another patient whose alarm was sounding. Why? The patient was a fall risk and there are other fall risks on that unit. Why? All fall risks were moved to the same unit. Why? To better manage falls. Why is it not working? There needs to be more staff supervision. Outcomes Once the problem is identified, a goal can be made for improvement. The goal is to decrease falls by 70% in the following month by implementing hourly rounds and the four Ps which are: pain, placement, position, and potty beginning after 5pm ending at 6am each day, bedside rounds at shift change, and safety huddles monthly. Every patient will be assessed using the four Ps every hour after 5pm and ending at 6am each day. The patients will be assessed for pain, placement of their call light or other items they may need, their position to be sure they are comfortable, and whether or not they need the bathroom. Certified Nursing Assistants will do bedside rounds at shift change with the on-coming staff to ensure that patients are cared for and have all care planned alarms in place and call lights within reach. Safety huddles will take place

7 LEADERSHIP STRATEGY ANALYSIS monthly with the shift supervisor to overview any safety concerns or areas of focus and improvement that month. A study by Payson, Currier and Streelman (2011) showed that with the interventions listed, the fall rate throughout one organization dropped from 2.9 to 2.1 falls per 1,000 patient days (para. 6). Implementing Change The process for implementing change will take place using a Transformational Leadership approach and consider those who are directly affected by the new intervention (Yoder-Wise, 2011, p. 40). It is important that the QI team effectively leads the intervention so others will follow suit. The team has taken into consideration the extra time that the interventions will take and the possible disruption of the flow of the unit that the interventions will cause. The intervention will first be carried out by the QI team beginning with selected days of the week ranging in hours from 5pm to 1am, and then regular floor nursing staff will be expected to help conduct the hourly rounds from 5pm-6am nightly. The implementation of the new interventions will have a gradual appearance as to not overwhelm the nursing staff. Members of the QI team will document their hourly rounds and make note of which patients needed assistance during the rounds. The data collected by the QI team will be presented to the nursing staff by the Staff Education Director through inservice and competency of the new intervention will be shown through a short quiz after the inservice. Licensed floor nurses will be expected to complete the documentation of the hourly rounds as well as note the patients that were in need of assistance during the rounds. The QI team will monitor the documentation in order to ensure that it is implemented and effective as well as to note any areas that may need to be improved upon. Through the Transformational Leadership strategy, the QI team will

8 LEADERSHIP STRATEGY ANALYSIS empower and inspire the floor nursing staff to make this change for the better quality and safety of their patients. Evaluation The intervention will be integrated into the work load after it has been tested using a tool called a Plan, Do, Study, Act (PDSA) cycle which will quickly evaluate the interventions. The PDSA cycle is a tool that will be used to test the interventions to see if they will be effective (NHS Institute for Innovation and Improvement, 2008). The PDSA cycle can be used to temporarily trial a change and assess its impact (NHS Institute for Innovation and Improvement, 2008). This tool will be used before the interventions have been fully implemented on the unit by floor nursing staff to ensure the interventions effectiveness and flow on the nursing unit. Evaluation is continuous as the QI team members are continuously monitoring the documentation of the hourly rounds as well as any documented behaviors and/or falls. The PDSA cycle is meant to center in on the patient and it involves studying data before and after the change was implemented. This way, it will clearly show whether or not improvements have been made. Evaluation of the intervention without the PDSA cycle will be done by collecting the same data that was collected before the improvements began and assessing if the organization has met the goal or not. If the organization has not met the goal, the QI team will regroup and study the documentation to find holes or areas that could be improved. The goal time was one month so the time in between should be used to monitor current activity and continuously look for areas of improvement in quality and safety. The leadership strategy used by the members of the QI team should resemble Transformational Leadership. Floor nursing staff should feel supported and empowered in their positions and they should feel that what they do makes all the difference in the improvement of

9 LEADERSHIP STRATEGY ANALYSIS their organization. There is always room for improvement within any process and it will take leadership and teamwork to make those necessary changes.

10 LEADERSHIP STRATEGY ANALYSIS References Centers for Disease Control and Prevention (CDC). (2012a). Costs of falls among older adults. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html Centers for Disease Control and Prevention (CDC). (2012b). Falls among older adults: An overview. Retrieved from http://www.cdc.gov/homeandrecreationalsafety/Falls/adultfalls.html Centers for Disease Control and Prevention (CDC). (2012c). Falls in nursing homes. Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html Institute of Medicine.(2000). To err is human: Building a safer health system. The National Academy of Sciences. NHS Institute for Innovation and Improvement. (2008). Plan, Do, Study, Act (PDSA). Retrieved from http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service _improvement_tools/plan_do_study_act.html NHS Institute for Innovation and Improvement. (2008). Root cause analysis using five whys. Retrieved from http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service _improvement_tools/identifying_problems_-_root_cause_analysis_using5_whys.html Payson, C., Currier, A., & Streelman, M. (2011). Focusing on staff awareness and accountability in reducing falls. American Nurse Today, 6(2). Yoder-Wise, P. S. (2011). Leading and managing in nursing (5th ed.). St. Louis, MO: Mosby