Implementing continuous daily improve¬ment is a standardized approach to reducing clinical variability in patient care delivery. The CLIPSE model engages frontline providers using a collaborative, peer review process, and may positively impact patient outcomes, cost of care, and quality improvement initiatives

1. QUALITY & SAFETY
Aligning Clinical Practice and Process Improvement Using the CLIPSE Model
BY KATE O’NEILL, MSN, RN
Implementing continuous daily improvement is a standardized approach to reducing clinical variability in patient care delivery. The CLIPSE model engages frontline providers using a collaborative, peer review process, and may positively impact patient outcomes, cost of care, and quality improvement initiatives.
CURRENT HEALTHCARE CHALLENGES
The healthcare system is undergoing unprecedented change. Patients, providers and policy leaders are coming together to redesign care delivery, expand services, improve patient safety, reduce errors, and decrease total cost of care.1,2 At the same time, professional associations and regulatory agencies are striving to close gaps in care by adopting new technologies, building creative care models, and developing collaborative learning programs.2,3,4,6
According to the recent IOM report, The Future of Nursing,7,8 nurses can play a key role in the healthcare transformation process. Organizations such as the American Nurses Credentialing Center,9,10 the American Nurses Association11 and Magnet programs have supported and strengthened the mission to improve the nursing profession through education, advanced degrees and certifications. Central to the transformation process is self-regulation and accountability for clinical practice (Code of Ethics, ANA12).
NURSING PEER REVIEW
The peer review process affirms the nurse’s duty to being accountable for professional practice, competence in skills and knowledge in evidence-based care delivery.13 Professional peer review is often used in many advanced nursing cultures and is supported by the ANA and Magnet career advancement process. When implemented properly, peer review creates a nonpunitive culture and supports experimental and shared learning. Peer review provides a healthy means for obtaining critical feedback and compliance measures for clinical performance in care delivery.13
A robust peer review process (PRP) is achieved through direct, real-time clinical observations or through retrospective chart review. Peer-to-peer observations measure the current practice against industry standards and reduce care variability. Continuous performance improvement fosters the refinement of knowledge, skills and clinical decision-making processes to enhance individual competencies and enterprise capabilities.14 Thus, peer feedback promotes patient safety, reduces the likelihood of errors, and addresses the human factor element in patient care delivery.13 PRP brings additional benefits by meeting professional requirements to various organizations, such as Magnet designation for evaluating learning effectiveness, the employer for improved patient outcomes, and society by making care affordable.
THE CLIPSE MODEL: ACHIEVING ACCOUNTABILITY AND TRANSPARENCY
Unexplained gaps in care are often seen in complex, high-volume, fast-paced areas in healthcare. These critical gaps in practice can lead to unnecessary care variability and medical errors.15 To close care gaps and incorporate evidence into action, clinical checklists and peer review observations may be a combined, simple solution used by previous industry leaders.4,16 Toyota and the airline industries have revolutionized the consumer experience by systematically simplifying, standardizing, combining and automating processes and raising the bar to zero error defects. Healthcare is now realizing the benefits of such evidence- based practice models16 and incorporating checklists, bundles, Lean, Six Sigma and Crew Resource Management to improve frontline care delivery.17, 18
The Clinical Learning Improvement Program through Staff Engagement (CLIPSE) is a quality improvement program that combines peer review and clinical observation checklists at the bedside. This process improvement model includes four key components: staff engagement; targeted clinical learning; nonpunitive peer review; and real-time process observations for continuous daily improvement.
Implementation of a successful CLIPSE model was based on the popular book “Checklist Manifesto”(2010) by Dr. Atul Gawande.18 Checklists are a quick and simple tool to conduct quality improvement projects on the frontline. Checklists are easy, practical and concise. According to AHRQ, “a checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten.
Leading the Care Coordination Team with Knowledge, News and Learning
December 2013 | Vol. 11, No. 12
Reprinted From:
Reprinted from the December 2013 issue of Case In Point magazine. © 2013 Access Intelligence, LLC
To find more articles that improve your practice, subscribe to the Case In Point Learning Network http://www.dorlandhealth.com/subscriptions/

2. QUALITY & SAFETY
Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factor engineering and have played a major role in some of the most significant successes achieved in patient safety.”
In the CLIPSE model, best practice checklists are taken from the academic literature and available in the public domain from Institute for Healthcare Improvement19 (www.ihi.org/explore/ CMSPartnershipForPatients/Pages/default. aspx) and HRET20 (www.hret-hen.org).
These checklists are used in peer-to- peer assessments by frontline providers to measure staff compliance to best practice standards in the healthcare industry. Checklists can be used to measure compliance to best practices involving hospital-acquired conditions (HAC), such as pressure ulcers, surgical site infections, or falls, etc. In October 2014, HACs will negatively impact hospital reimbursement. CMS will reduce payments by 1 percent to hospitals who have high HAC rates for their patients. Thus, clinical compliance checklists that drive practice accountability and transparency are critical in order to measure ongoing quality improvement efforts.
Hence, CLIPSE translates to “better bedside care” that supports the Triple Aim framework. By engaging patients, providers and nursing staff, organizational leaders can support a quality patient safety program using a model that is nonpunitive with real- time learning feedback. Implementing a QI program is difficult but achievable with proper leadership, education and support. However, the main challenge is how to sustain it. The CLIPSE model allows for a new paradigm that incorporates best practice information, care standardization, professional accountability and staff engagement. Clinical audit checklists using the CLIPSE model are the answer to continuous daily improvement (CDI) by engaging frontline staff to monitor their practice through professional peer review process to improve patient outcomes.
CONCLUSION
The culture of patient safety, quality and transparency is central to improving care delivery at every level in the organization. Overcoming current healthcare challenges will require new skills, new technology, and novel ways of care delivery at the hospital and system level.
The CLIPSE model provides a simple solution to deploy best practices to frontline nurses by using standardized checklists, staff engagement, and peer review to drive accountability and transparency. Continuous pursuit of quality improvement means incorporating real- time information from routine patient care; disseminating this critical information through shared learning; trending key metrics that impact patient outcomes; and analyzing care delivery costs at the micro and macro levels.
Implementing the CLIPSE quality improvement model at the bedside will require innovative thinking, applications of human factor engineering, and patient voices who demand better. Patients are counting on us to make care delivery safer today for a better patient experience tomorrow.
REFERENCES
1.
Report of the Lucian Leape Institute Roundtable. Order from Chaos. Website: www.npsf.org/wp-content/ uploads/2012/10/Order_from_Chaos_ final_web.pdf. Accessed April 20, 2013.
2.
Berwick, D. Hackbarth, A. Waste in Healthcare. JAMA. 2012;307(14):1513-1516. Website: www.hta.hca.wa.gov/documents/ Waste_in_Healthcare_JAMA_2012. pdf. Accessed April 20, 2013.
3.
HHS. Report to Congress (2012) National Strategy for Quality Improvement in Healthcare. Website: www.ahrq.gov/ workingforquality/nqs/nqs2012annlrpt. pdf. Accessed April 20, 2013.
4.
IOM Consensus Report (2012). Better Healthcare at Lower Cost. Website: www.iom.edu/Reports/2012/Best- Care-at-Lower-Cost-The-Path-to- Continuously-Learning-Health-Care- in-America.aspx. Accessed April 20, 2013.
5.
Stiegel M, Nolan K. A Guide to Measuring the Triple Aim. IHI Innovation Series white paper, 2012. www.ihi.org/ knowledge/Pages/IHIWhitePapers/ AGuidetoMeasuringTripleAim.aspx. Accessed April 20, 2013.
6.
IOM Core Metric for Better Care, Lower Cost and Better Health (2012). Website: www.iom.edu/Activities/ Quality/VSRT/2012-DEC-05.aspx Accessed. April 20, 2013.
7.
IOM Report Brief. The Future of Nursing, Leading Change Advancing Health (2010). www.iom.edu/~/media/ Files/Report%20Files/2010/The- Future-of-Nursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf. Accessed April 20, 2013.
8.
IOM Consensus Report. The Future of Nursing, Leading Change Advancing Health (2011). www.iom.edu/ Reports/2010/The-Future-of-Nursing- Leading-Change-Advancing-Health. aspx. Accessed April 20, 2013.
9.
ANCC’s Commission on Accreditation (2012). The Value of Accreditation for Continuing Nursing Education. Website: www.nursecredentialing. org/Accreditation/ResourcesServices/ Accreditation-WhitePaper2012.pdf. Accessed. April 20, 2013.
10.
ANCC’s Commission on Accreditation. ANCC Primary Accreditation Application Manual (2013). www.nursecredentialing. org/Accreditation/2013- PrimaryAccreditationManual.html. Accessed April 20, 2013.
11.
ANA. ANA Scope and Standards of Practice Nursing, 2nd edition (2010). http://library.brcn.edu/ upload/docs/BRCN/Library/ANA/ eBk_SL%20Nursing%20Scope%20%20Standards%202e%202010.pdf Accessed April 20, 2013.
12.
Nursing World. ANA, Code of Ethics with Interpretive Statements (2010). www.nursingworld. org/MainMenuCategories/ EthicsStandards/ CodeofEthicsforNurses/Code-of- Ethics.pdf. Accessed April 20, 2013.
13.
Diaz, L. Nursing Peer Review: Developing a framework for patient safety. Journal of Nursing
“CLIPSE tranSLatES to ‘bEttEr bEdSIdE CarE’ that SuPPortS thE trIPLE aIm framEwork.”

3. Administration (2008) Nov. 38(11) 475-9.
14.
IOM Workshop Summary . Digital Data Improvement Priorities for Continuous Learning in Healthcare (2012). www.iom.edu/Reports/2012/ Digital-Data-Improvement-Priorities- for-Continuous-Learning-in-Health- and-Health-Care.aspx. Accessed April 20, 2013
15.
Hospital Survey on Patient Safety: 2012 User Database Comparative Report by AHRQ. www.ahrq.gov/legacy/ qual/hospsurvey12/hospsurv1223. pdf Accessed April 20, 2013.
16.
Closing the Gap: From Evidence into Action (2012). The International Council of Nurses. www.icn.ch/images/ stories/documents/publications/ind/indkit2012. pdf. Accessed April 20, 2013.
17.
Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper, 2012. www.ihi.org/ knowledge/Pages/IHIWhitePapers/ UsingCareBundles.aspx. Accessed April 20, 2013.
18.
Gawande, Atul, MD. The Checklist Manifesto. Picador Publishing (2011) (ISBN 10: 0312430000 / ISBN 13: 9780312430009).
19.
IHI Gap Analysis Map, 2013. Accessed October 20, 2013. www.ihi.org/offerings/ Initiatives/Improvemaphospitals/ Documents/IHIGapAnalysis.pdf.
20.
HRET-HEN Content Core Areas for Improvement: Accessed on October 20, 2013. www.hret-hen.org/index. php?option=com_content&view=article&id=7&Itemid=175. Kate O’Neill, MSN, RN, patient safety officer with CCG, a Patient Safety Organization based in Springfield, Pa., is a nursing and LEAN leader with over 20 years of healthcare experience in regulatory compliance, quality improvement, patient safety, HIT integration, staff development, organizational change, clinical effectiveness, informatics, and patient care delivery. Contact: kaoneill1@ yahoo.com