Running head: QUALITY IMPROVEMENT PAPER

Quality Improvement Paper

Alicia Wheeler
Bon Secours Memorial College of Nursing
NUR 4144 Professional Role Development: Servant Leadership
3/30/2015

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Contrast-induced nephropathy, or CIN, is a disorder that has been recognized as a

common cause of hospital acquired renal failure. CIN is diagnosed when the onset of acute renal
failure has occurred within a twenty-four to seventy-two hour window after the administration of
a contrast agent. Symptoms of this disorder may include renal failure, along with other
substantial disturbances in patient lab values. An increased risk of myocardial infarction and
death is associated with CIN. Patients who are at an increased risk for developing this disorder
include those already diagnosed with renal failure, diabetes, and congestive heart failure. In
2014, the incidence of CIN in this population was thought to be greater than 20 to 30%, whereas
the general population was limited to just greater than 2% (Golshahi, Nasri, & Gharipour, 2014).
The Coronary Care Unit at St. Marys hospital is planning to initiate a quality
improvement project related to this iatrogenic disorder, which will include ideas for prevention
strategies, information on how contrast-induced nephropathy directly affects nursing practice,
and systematic strategies to improve the outcomes for patients served on this particular unit.
This paper will offer information on how the Coronary Care Unit intends to implement these
ideas, utilizing the four domains of leadership as discussed in a book title Lead Like Jesus, by
Ken Blanchard. These domains include the head, the hands, the heart, and the habits. My paper
will also include information regarding the use of the five practices of exemplary leadership, as
discussed in the Student Leadership Practices Workbook. I will use information from this
workbook to demonstrate how I would implement this project as the nurse manager of this unit.
Key practices include modeling the way, challenging the process, encouraging the heart,
enabling others to act, and inspiring a shared vision.

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In my application of the first leadership domain, the team members of this unit would use
their knowledge (the head), to review the policies and procedures specifically related to
hospital acquired infections. A thorough investigation of these standards might answer questions
regarding the efficacy of having these operating procedures in place. Such a review might also
reveal failures in procedural compliance or enforcement.
Current policies at St. Marys Hospital state that a supervising physician must be familiar
with a patients history, including any risk factors for an adverse reaction to a contrast agent.
These policies also state that this physician must order labs and review all of the lab results, prior
to injecting the patient with the contrast. If any of these lab results are high, this irregularity
must be communicated immediately to the physician conducting the procedure. The first
preventative method, therefore, would require that patients complete a thorough health history to
determine if any modifiable or un-modifiable risk factors exist.
The second leadership domain focuses on the hands, or the specific actions being
performed in a specific event or situation. CCU does not currently have any statistics related to
the number of patients who have acquired CIN after being cared for on their unit. However,
there are preventative strategies which unit personnel can implement in their efforts to reduce or
eliminate the number of patients who acquire CIN as a result of being exposed to contrast
medium. Like the head, the hands could also be used to assess pre-existing patient risk factors
which are likely to contribute to the development of contrast-induced nephropathy. Other
preventative measures include: educating the patient and staff, keeping the patient hydrated, and
monitoring the patients vital signs before, during, and after the contrast is given.

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Patients being given any contrast agent should have the risks of this procedure fully
explained to them beforehand, and should understand the importance of being compliant with the
treatment regimen. If risk factors for acquiring contrast induced nephropathy exist, the patient
should be taught preventive strategies and the importance of implementing them. All staff
members giving a contrast agent, or caring for a patient who has received one, should know the
risks and understand the protocol for caring for a patient who has been given contrast medium.
As the nurse manager of this unit, desiring to utilize the heart domain of leadership, I
would take ownership of the project I implemented. Taking ownership would demonstrate my
willingness to take initiative, thus modeling a positive example for my team to follow. During
this process, I would remain humble. One of my primary goals would be to ensure that I
exhibited behaviors and provided leadership opportunities that would boost my teams
confidence and empower them to achieve their best. Recognizing that the collaborative effort of
my team would be greater than any contribution to the project I could make on my own, would
be a critically important concept for me to accept and understand.
The habits domain could be used to aid unit personnel in their quest to substantiate
their quality improvement project ideas and plans. Within this domain, team members might
take time to reflect on their accomplishments and shortcomings. At times, frustration and
reduced morale can fester amongst members. A specific amount of time, dedicated to quiet
meditation, prayer or team discussion, might be beneficial to the group members. In cases like
these, the chaplain could also be called to offer words of encouragement and support.
A good team project is only effective when the teams leader is able to model the way. In
doing so, the leader sets personal examples for members of the team, thus giving them a concrete
demonstration of how ones behavior should coincide with his or her beliefs and values. I would

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implement this project using the Plan Do Study Act (PDSA) Method. In planning for this
project, Id need to find a process that needed improvement, and research the data currently
available. The do segment of this method requires execution of the plan. This would involve
my recognizing my current knowledge about the process, and pinpointing changes that could be
geared towards improving patient outcomes. After implementing the changes I would study the
results of the project. I would be sure to take the appropriate actions to make sure that patient
outcomes continue to improve. As nurse manager, I would begin this quality improvement
project by discussing my reasons for wanting to look into contrast-induced nephropathy. Team
members would need to know why this became an issue, how it affects the nursing practice, how
it can be prevented, and what outcomes I hoped to achieve as a result of this project. As the
nurse manager, I would also benefit from taking part in teaching sessions and training courses
related to the prevention of CIN. In doing so, I would earn the trust and respect of my staff
because my actions would show my willingness to backup my words with actions. This hands
on approach to learning might also help me to establish a better rapport with my team. Their
realization that I would not encourage them to take part in things that I have not done (or
wouldnt be willing to do) myself, could potentially be very empowering.
The Coronary Care Unit has already challenged the process by recognizing that contrastinduced nephropathy is a problem that needs to be addressed. This unit has a plan to begin a
quality improvement project for this issue, and will assess current policies in place to determine
if they are beneficial and, if not, how they can be fixed. Challenging the process is a great way
to foster improvement and growth in the organization by determining better ways of carrying out
specific processes.

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As a leader, it is important to encourage the hearts of others. Actions that I would take on
related to this domain would include providing support to my team members and showing them
my sincere appreciation for their contributions. I would want each person to know that I valued
their unique talents and individuality, and that they were a very important part of the team. Staff
members feel motivated and want to be a part of the team when they have a well-developed
sense of self worth. In my role as manager, I would provide reassurance and encouragement as
much as possible, and certainly whenever it was needed.
After formulating a plan to implement the quality improvement project, I would have to
enable others to act. Enabling others to act would involve providing staff members with the
resources and tools necessary to thoroughly research CIN. I would establish committees whose
sole purpose would be to evaluate hospital policies and procedures related to hospital acquired
infections and methods of prevention. I would also empower members of the committee by
actively listening to their ideas, offering feedback, and supporting their decisions.
My plan for getting others on board with my idea for preventing cases of CIN would
begin with inspiration. I would be prepared to communicate with staff members about the
purpose and meaning of the project that I hoped to pursue. During my discussion with the group
Id illustrate my vision and goals for the quality improvement project. To do this, I would need
to relate my vision to the mission of Bon Secours, showing my co-workers that I took the
mission seriously and will follow through on the policies that had already been set forth by the
organization. As we worked towards improving what was happening in the hospital currently,
we would continue to prepare for the unexpected and any changes which could occur over time.

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Nursing practice is greatly affected by contrast- induced nephropathy. Some of the most
common ramifications of a patient having CIN include an increased hospital stay, increased
patient costs, and increased patient mortality rates. These factors affect patient satisfaction
ratings and their overall feelings about their healthcare experience. The implementation of this
project would affect nursing practice by requiring nurses to become more proactive and diligent
during their patient assessments. They would need to continuously monitor and treat their
patients who were at an increased risk for the development of CIN. Nurses would also have to
allot more time for conducting more thorough, head-to-toe assessments to ensure that all of their
patients body systems were closely evaluated. Continuous patient monitoring would be
essential because nurses, being the ones who usually spend the most time with patients, would be
the first to notice a change in a patients condition. These strategies have the potential to
minimize the consequences associated with this illness.
In closing, the methods for the prevention of hospital acquired infections like CIN are
important for improving patient outcomes. A majority of the patient population served on CCU
are cardiac intensive care patients. As a result of this project, morbidity and mortality rates
would decrease, patient costs and length of stay would decrease, and overall patient satisfaction
would improve on the unit. These changes would all be very rewarding outcomes for CCU
patients because they are usually in critical medical states when they arrive to the unit.
Prevention of CIN could potentially prevent the occurrence of medical complications in this
population which are unrelated to their chief hospital complaint. Healthcare personnel must be
made aware that contrast-induced nephropathy is a disorder that can often be prevented with the
use of specific and consistent strategies. Once these methods are understood and utilized, patient
recovery can begin with a very limited risk for infection complications.

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References
Blanchard, K. & Hodges, P. (2005). Lead like Jesus. Nashville, TN: Thomas Nelson.
Bon Secours Health System, Inc. St. Marys Hospital Policy (2014.). Contrast Agents, Use of.
Unpublished internal document
Golshahi J, Nasri H. Gharipour M. (2014). Contrast-induced nephropathy; A literature review.
Journal of Nephropathology, 3(2): 51-56. DOI: 10.12860/jnp.2014.12
Kouzes, J.M. & Posner, B.Z. (2002). The leadership challenge. San Francisco, California:
Jossey-Bass
Wood, S. (2012). Contrast-Induced Nephropathy in Critical Care. Critical Care Nurse, 15-24.