Evidence Based Practice & Clinical Audits at the Frontline 2013

Continuous Daily Improvement
in healthcare with
Transparency and Accountability
Abstract
Continuous Daily Quality Improvement (CDI) is the cornerstone for delivering high quality and cost
effective care by frontline providers in the healthcare setting. The challenge is to implement a quality
improvement program within a learning organization framework.1
This white paper advocates an
alternative quality approach that permits a typical healthcare worker to convert 10 to 15 minutes blocks
of unstructured work time to structured improvement work that can be allocated to CDI. The results of
CDI quality initiatives by the front-line, can be measured through objective clinical outcomes, professional
growth, and total cost of care while keeping hospital operating budgets cost neutral.

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© Copyright iCareQuality Inc. 2013 www.iCareQuality.org
Close Care Gap is a component organization of iCareQuality, Inc.
Close Care Gap is federally designated Patient Safety Organization
Copyright© 2013 iCareQuality, Inc.
All rights reserved.
CloseCareGap, CCG is a trademark of iCareQuality,Inc. All other brand, company,
and product names are used for identification purposes only and may be
trademarks that are the sole property of their respective owners.
"Continuous Daily Improvement Program with Transparency and
Accountability"
Document No. 2013-02-011
Published by iCareQuality Inc.
Any comments relating to the material contained in this document may be
submitted to:
Email: customerservice@iCareQuality.org
761 West Sproul Road,
Suite #301 Springfield,
PA 19064 USA

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Background and Context of the Problem
Dr. Atul Gawande, in his recent TED talk, "How do we Heal Medicine",
described how the science of medicine, has made great discoveries in the
last 60 years.3
The future challenge for the healthcare industry is this - how
do we deliver "new advances in medicine" to the general public, with the
right technology, price, quality, and simplicity that we can all afford? 4-5
"Better care" means - engaged patients, providers and organizations that
support the quality mission in a learning organization. Overcoming this
challenge will require new skills, new technology, and new ways of care
delivery that incorporates real-time information from routine patient care,
disseminates this critical patient data using electronic methods and e-tools
to help analyze and trend key metrics to improve care at the micro and
macro levels. 1,5,6,7
The continuous pursuit of quality improvement (QI), in many industries,
has proven to lower costs, customizable product offerings, better
customer service and improved satisfaction. Successful companies have
achieved improved outcomes and lowered costs by engaging their staff,
leading by example, being transparent in actions, with a priority focus on
quality and safety. 6,8,9
In healthcare, employees are primarily "knowledge workers" with a
"human touch" factor that is essential for the delivery of patient-centric
care. How then, can we leverage our best asset, our employees, to deliver
high quality care that that is cost effective, timely and efficient? How can
we engage all stakeholders - including populations, patients, providers, and
family members, to govern the CDI program in a transparent, accountable
and patient-centric way?
-----------------------------------------------------------------------------
Considerations for Implementing CDI
In this paper, we examine the process of implementing a CDI program
within a hospital or long term care setting to promote the 2013 National
Definition of
Standardized
Work is:
"The current one
BEST way to
safely complete
an activity with
the proper
outcome, and the
highest quality,
using the fewest
possible
resources".2

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Quality Strategy 4
triple aim. Listed below are some important questions
to consider with key stakeholders and leadership:
1. What are the main obstacles to implementing a CDI program?
2. What should be the key characteristics of this quality solution?
3. What would a model CDI program look like?
4. What results can we expect from deploying this program to front-
line staff?
5. How do we (patients, providers and organizations) pay for it?
If such a program can be defined, implemented and leveraged, then policy
makers and leaders can begin to address the specific challenges of Dr.
Gawande's dilemma in medicine - how can we afford the "future state" of
healthcare to improve the population and deliver better, cost-effective
services?
---------------------------------------------------------------------------------
Obstacles in Quality Improvement Performance
Patient safety, rising costs, healthcare outcomes, targeted measures, and
improvement efforts, are much talked about concepts in government,
academia, and senior leadership circles. Healthcare workers, at all levels,
agree to the need for Continuous Daily Improvement, however, many
challenges exist to implementation and sustainability on the unit. Research
frequently lists leadership, unit culture and staff engagement as reasons
why CDI programs fall short in the work place setting. Common beliefs
and views from staff and management are listed below:
 CDI can be done by staff in their spare time
 QI isn’t my job, it’s someone else’s
 Staff don’t make the connection between their work and QI
 Don’t want to get peers in trouble for not doing a good job
 Too many unit projects and nothing gets done
 We’re busy with direct patient care
 Staff as unit brown-noser for being engaged
 Too many metrics to track and confusing
If we always DO
what we’ve
always DONE,
We will GET,
what we’ve
always GOT.
~ Adam Urbanski

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---------------------------------------------------------------------------------
CloseCareGap, PSO Safety Solution
For CDI programs to be successful, all of the obstacles noted above need
to be defined and addressed with key stakeholders. The organization's
solution cannot be a compromise between these requirements. But rather-
a new strategy, a new paradigm needs to evolve into a satisfactory solution
to meet the needs of Gawande's goal.
Thus, we advocate an innovative Continuous Daily Improvement (CDI)
program, that embodies the principles of the Patient Safety Act (2005) 10
that can be managed at the individual hospital and unit level by
collaborating with our Patient Safety Organization (PSO). 11
The main advantages of our patient safety solution are:
1. Meaningful Engagement of Frontline: Front-line staff spends most of
their shift in direct patient care activities, and to a lesser extent in
meetings, research and process improvement. Using industrial
engineering techniques, a brief time study conducted in 2013 revealed
that work productivity by front-line staff is approximately 70%
occupied. The challenge with the remaining 30% of "unoccupied" time
is that it is not contiguous. It is often unpredictable and materializes in
short spurts (roughly 5, 10 or 15 minutes intervals) scattered
throughout the day. CloseCareGap, PSO, has a user friendly online
safety program that provides simple tools, techniques, and support to
frontline staff to convert these brief time blocks into meaningful quality
improvement activities.
2. Transparency and Accountability: The cornerstone of any CDI program
is explicit transparency and accountability. Both are required to get the
program off the ground and to ensure its long term sustainability.
CloseCareGap, PSO provides real-time dashboards that allow staff and
unit managers to measure capability performance and tangible
outcomes. These two performance measures are essential and
necessary to achieve lasting behaviour change at all levels of the
enterprise.
3. Life Long Learning and Professional Reward: Physicians, Nurses and
other healthcare professionals are required to earn continuous
education credits to maintain their medical and nursing licensure. Close
Care Gap, PSO enables healthcare providers to earn CNE and CME
credits when participating in quality improvement activities.
Work SMARTER,
not HARDER is
the key to
building CDI with
peer review audit
observations for
frontline staff.
~ Carl Banks

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---------------------------------------------------------------------------------
How the Safety Improvement Program Works
This safety improvement program is specifically designed for Healthcare
Professionals in the acute and long term care settings in collaboration with
Close Care Gap (CCG) PSO. Specific features of our unique program
include:
1. Engage with CCG to begin your new safety program
2. Select from a catalogue of care delivery process (CAUTI, CLABSI, Falls,
Pressure Ulcers, VAP and more)
3. Use our online tool to perform real-time clinical audits of common
care practices
4. Investigate important patient safety events using our secure portal
5. Use our electronic tool to conduct professional peer reviews
6. With our tool, you can evaluate your quality improvement plan that
aligns with specific best practice interventions
7. Obtain continuing education credits by submitting quality
improvement activities
8. Our tool allows for Real-Time Performance Reporting
9. CCG will assign a Mentor to assist your quality safety team.
10. The Mentor will collaborate with all levels of your organization to
support quality improvement and safety targets
-----------------------------------------------------------------------------
Results and Impact Areas for CDI
Taking a balanced scorecard approach to defining results, we defined
results in three broad categories as outlined below along with their specific
performance measures.
1. Clinical Outcomes for Key Process Measures such as CAUTI, VAP,
VLABSI, etc. Examples of key metrics for CAUTI include:
– Number of CAUTI per 1000 catheter-days
– Number of BSI secondary to CAUTI per 1000 catheter-days
Quality is
EVERYONE'S
responsibility.
~ W. Deming

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– Catheter utilization ratio (urinary catheter-days/pt-days) x 100
2. Cost of Care and Continuing Nursing Education
Nursing units generally allocate 24 hours per staff/per year for
Continuing Nursing Education (CNE) activities that is traditionally
delivered in a class room setting. During this time, the RN is away from
direct patient care and frequently is covered by another staff member.
The cost of this education model is estimated below. See Figure 1.
3. Transfer of Unstructured Time into Structured Time for CDI:
Typically staff nurses work 8 hour shifts. During that shift, approximately
70% of the day is occupied with patient care activities, including handoff,
report and charting. Thus, a significant amount of work-time 30% is
downtime (12% for lunch/breaks + 18% unstructured).
We advocate using this 18% or 1.4 hours = 84 min per staff/ shift to engage
in direct unit quality improvement activities that is "patient centric". See
example below calculating CDI for a typical general medical/surgical unit.
Assume you average 10 RN staff per unit per day = 840 min of quality
time available per day for CDI.
840 X 365 days = 306, 000 minutes/year = 5, 110 hours
Thus, almost 5000 hours of quality work can be done on each unit
per year for CDI.
Thus, our solution is an alternative quality approach that permits a typical
healthcare worker to convert 10 to 15 minutes blocks of unstructured work
time to structured improvement work that can be allocated to CDI. This
approach is consistent with PDSA 12
and rapid cycle improvement to
improve care delivery with a quick test of change.13
Staff nurses can
 THPPD X BUDGETED PT HOURS/UNIT
 Includes 24 CNE hours/RN/year
 Med/Surg Unit with 60 Nursing FTE's X 24 hours/year = 1440 CNE hours
 shourshrs/yr
 1440 CNE hours/year X $40.00/hr = $56, 000 needed/year for unit
On Average
each staff nurse
on general
ward has 84
min of
unoccupied
time per day to
do Quality
Improvement
Activities

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participate in quality improvement activities on their respective units
(without leaving the floor) to expedite change and demonstrate positive
results, while keeping unit operating costs budget neutral.
4. Nursing Education Credit for Quality Activities
Since the average nurse manager spends $56,000 per year on outside
education activities where staff are off the unit, our solution advocates
translating those 24 hours of education into "unit specific quality
activities". Using the CCG, PSO platform, staff can complete quality audits
(CAUTI, VAP, CLABSI, etc), conduct peer reviews and submit their projects
for continuing nursing education credits that are required by most states to
maintain nursing licensure. Quality Improvement activities submitted for
education credit is a common practice in CME and is now becoming a focus
area by ANCC, Nursing Accreditation Committee. As per the new 2012
guidelines, "a clearly defined method is used to evaluate the effectiveness
of an educational activity - such as, "observation of performance".14
"Observation of performance" is also know "Peer Review" and "Clinical
Process Audits" , are of which are built into the CCG platform for CDI.
5 . Staff Reward and Unit Recognition
The unit manager can re-allocate the $56K dollars saved on nursing
education and distribute these monies to fund a staff reward and
recognition program for quality. Such a reward system can offer positive
financial benefits for having: highest number of audits submitted per
month, best percentage on process compliance for CAUTI, most positive
peer reviews, etc.
6. Professional Accountability and Transparency
Professional accountability is a fundamental principle in the ANA
nursing code ethics. Central to the transformation process is self-
regulation and accountability for clinical practice (Code of Ethics,
ANA) 15
Peer Review and nursing observation, as part of the CDI
program, affirms the nurse's duty to being accountable for professional
practice, competence in skills and knowledge in evidence-based care
delivery. The NSQ Principles 16
also support ways to improve provider
performance where healthcare professionals evaluate their own
practice and their colleagues performance. Here they can quickly
learn how interventions work in the "real-world and see the benefits of
innovation, change and best practice. With this framework the NQS
supports a culture of learning and builds team work, trust and
collaboration at the unit level.

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7. Team Work and Staff Engagement
As part of the CDI program, nursing staff can participate in various quality
improvement projects that are meaningful to their patient and specific to
their own needs. Together, staff can work towards common unit goals and
collaborate as professionals assuming complementary roles and
cooperatively working together as a team, to share responsibility for
problem-solving and making decisions to formulate and carry out plans of
care for their patients. Engagement and quality go hand in hand. Both have
a positive effect on patient care and patient satisfaction. Using the CCG
quality tools, staff can use the audit tools and submit peer reviews with
real-time feedback and track daily dashboards.
------------------------------------------------------------------------------------------------
Conclusion
The culture of patient safety, quality, and transparency is central to promoting
learning at every level in the healthcare industry. Creating short, individualized
learning opportunities that focus on quality will require new leadership
thinking, applications of system engineering minds, and operational models
that reward quality improvements and better patient outcomes. Our safety
program supports a culture of transparency and may reduce healthcare
education costs, while improving patient outcomes. To that end, achieving the
discipline of CDI will depend on these critical factors: deliberate actions of
front-line individuals (patient and providers); strategic planning of high
reliability organizations to lead the way; industry partners that support open
exchange of electronic health information; and policy makers with a population
health focus. Together we can make incremental kaizen changes for the good
at the unit , hospital, and systems level. These small changes can positively
impact our patients of today that have a big impact for healthcare of
tomorrow.

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About CloseCareGap
CloseCareGap (CCG) is a federally approved Patient Safety Organization. Our mission and vision is to
"close gaps in care" delivery by: developing a sustainable quality engagement framework; and
collaborating with key organizational stakeholders, physicians, nurse, and clinical leaders to ensure high
quality, cost effective, patient centric care in the US, Canada and abroad.
How can CCG, PSO help?
Using our online portal, Providers can use smart tools to measure best practice, standardize processes,
reduce variations, and improve care quality through real-time audits and continuous learning. CCG, PSO
has adopted the HRET - Partnership for Patients campaign and the IHI Triple Aim strategies to help
improve quality of care through real-time audits and continuous learning.
Our Focus Area:
At CCG, PSO we focus on targeted opportunities for improvement, such as: high risk events, high volume
events, patient outcomes, problem prone events, and hospital acquired conditions (HAC's) - CAUTI,
Pressure Ulcers, CLABSI, VAP, Surgical Site Infections, and Falls.
Benefits of Working with CCG, PSO:
 Engage frontline staff in quality and patient safety initiatives
 Develop a safety culture by building transparency and accountability
 Perform real-time peer reviews from approved list of clinical processes
 Analyze process variance for CAUTI, CLABSI, Pressure Ulcer, Falls, VAP, SSI
 Benchmark process performance against organization and industry standards
 Obtain Professional Continuing Education Credits for quality projects
For More Information Contact:
Kate Oneill, MSN, RN
VP of Quality and Safety
CloseCareGap, PSO
761 Sproul Road, Suite 301
Springfield, PA 19064
kate.oneill@iCareQuality.org
Phone: 610.505.0996

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References
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path to continuously learning health care in America. Washington, DC: The National
Academies Press. SBN 978-0-309-26073-2
http://www.iom.edu/~/media/Files/Report%20Files/2012/Best-Care/BestCareReportBrief.pdf
2. Graban M (2012). Lean Hospitals. Improving Quality, Patient Safety, and Employee Engagement.
CCR Press, Boca Raton FL. ISBN: 978 1 4398 7043
3. Gawande A. (2012) Ted Talk: How Do We Heal Medicine?
http://www.ted.com/talks/atul_gawande_how_do_we_heal_medicine.html
4. Agency for Healthcare Quality and Research (2013). Annual Progress Report to Congress: National Strategy for Quality
Improvement in Health Care. Retrieved 8-10-13. http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm
5. Anderson KM, Marsh CA, Flemming AC, Isenstein H, Reynolds J. Quality Measurement Enabled by Health IT: Overview,
Possibilities, and Challenges (Prepared by Booz Allen Hamilton, under Contract No. HHSA290200900024I.) AHRQ Publication
No. 12-0061-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2012.
http://healthit.ahrq.gov/sites/default/files/docs/page/final-hit-enabled-quality-measurement-snapshot.pdf
6. Lighter D (2013). Basics of Healthcare Performance Improvement: A Lean Six Sigma Approach. Jones and Bartlet Learning,
Burlington, MA. ISBN13: 978 0 7637 7214 7
7. Nash D (2006). The Quality Solution: A Stakeholder Guide to Improving Healthcare. Jones and Bartlett.
ISBN13: 987 0 7637 2748 2
8. Langley G (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossy-Bass,
San Francisco, CA. ISBN: 978 470 19241 2.
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Constraints Management. Mcgrall-Hill, ISBN13: 978-0071761628
10. Patient Safety and Quality Improvement Act , Public Law 109-41, United States Government (2005). Retrieved 8-15-13.
http://www.gpo.gov/fdsys/pkg/PLAW-109publ41/pdf/PLAW-109publ41.pdf
11. Agency for Healthcare Quality and Research (2009). Your Partner in Improving Healthcare Quality.
http://www.pso.ahrq.gov/psos/psopartners.pdf
12. Walton M (1988). The Deming Management Method. Pedigree Books. ISBN13: 978-0399550003
13. PDSA: Plan-Do-Study-Act – Quality Improvement at MDH. Office of Performance Improvement
www.health.state.mn.us/qualityimprovement. Retrieved 8-10-13
14. ANCC: Primary Accreditation Manual (2012). American Nurses Credentialing Center, Silver Springs, MD
15. Nursing World. ANA, Code of Ethics with Interpretive Statements (2010).
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf
16. Agency for Healthcare Quality and Research (2013). Principles for National Quality Strategy 2013.
Working for Quality. http://www.ahrq.gov/workingforquality/nqs/principles.htm Retrieved 8-10-13.

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