1. Frontline Nursing Performance:
How to improve care and reduce costs
Abstract
Continuous Daily Improvement (CDI) is the cornerstone for delivering high quality, 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 implementation are organization dependent, but may include: targeted “unit- specific” initiatives, engagement of front-line staff, measured objective clinical outcomes, professional growth, and hospital operating budgets that are cost neutral.

2. © iCareQuality Inc. 2 | P a g e
Copyright © 2014 iCareQuality Inc.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the copyright owners.
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.
Document No. 08201402
Published by iCareQuality Incorporated® 2014
Any comments relating to the material contained in this document may be submitted to:
 761 West Sproul Road, Suite #301 Springfield, PA 19064
 Phone: 610 732 8500
 PR@iCareQuality.org

3. © iCareQuality Inc. 3 | P a g e
Table of Contents
Abstract ................................................................................................................. 1
Background and Context of the Problem .......................................................... 4
Continuous Daily Improvment Program ............................................................ 5
Obstacles in Quality Improvement Performance ............................................... 5
CloseCareGap, PSO Safety Solution ................................................................... 6
How the Safety Improvement Program Works ..................................................7
Results and Impact Areas for CDI ...................................................................... 8
Conclusion to Support Change .......................................................................... 12
References ........................................................................................................... 13
About iCareQuality ............................................................................................. 14
About Our Team ................................................................................................. 14

4. © iCareQuality Inc. 4 | P a g e
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. 6,8,9In 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?

5. © iCareQuality Inc. 5 | P a g e
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 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 sustainable CDI program?
2. What should be the key characteristics of this critical quality improvement solution?
3. What could a robust model CDI program look like?
4. What results can leaders expect from deploying this program to front-line staff?
5. How do we (patients, providers and organizations) pay for a novel CDI program?
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

6. © iCareQuality Inc. 6 | P a g e
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.
 Quality isn’t my job, it’s the managers job..
 My peers might get in trouble for doing a poor job.
 There are too many unit projects and nothing gets done.
 We’re busy with direct patient care, we don’t have time.
 I don’t want to be seen as a brown-noser on the unit.
 There are too many metrics to track and it’s confusing.
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

7. © iCareQuality Inc. 7 | P a g e
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.
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).

8. © iCareQuality Inc. 8 | P a g e
3. Use our online tool to perform real-time clinical audits of common care practices or load your own checklists
4. Investigate important patient safety events using our secure portal for Adverse Event Reporting.
5. Use our electronic tool to conduct professional peer reviews and interprofessional team audits.
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. 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, and others include:
– Number of CAUTI per 1000 catheter-days
– Number of BSI due to CAUTI per 1000 catheter-days
– Catheter utilization (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

9. © iCareQuality Inc. 9 | P a g e
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.
Figure 1: Average CNE Nursing Education Hours per Unit/Year
3. Transfer Unstructured Time into Structured CDI Time:
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 Figure 2 below to calculate CDI for a typical general medical/surgical unit.
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 participate in quality improvement activities on their respective units (without leaving the floor)
 THPPD x Budgeted Patient Hours /Unit
 Includes 24 CNE Nursing Education hours per Nurse/year
 Med/Surgical Units with 60 Nursing FTE's x 24 hours/year = 1440 CNE hours per year per unit
 1440 CNE hours/year X $40.00/hour = $56, 000 education dollars needed/year for each patient care unit

10. © iCareQuality Inc. 10 | P a g e
to expedite change and demonstrate positive results, while keeping unit operating costs budget neutral.
Figure 2: Estimated Time for CDI Activities per Year
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
Assume you have an average of 10 Staff Nurses per unit/ per day = 840 minutes of
Quality Improvement time available for CDI activities.
840 min x 365 days per year = 306,000 minutes /year = 5,110 hours for CDI activities
Thus, almost 5000 hours of Quality Improvement work can be done on each nursing unit per year for specific QI activities that are directly related to that patient ward.

11. © iCareQuality Inc. 11 | P a g e
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, 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 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.
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.

12. © iCareQuality Inc. 12 | P a g e
Conclusion to Support Change
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.

13. © iCareQuality Inc. 13 | P a g e
References
1. IOM , Institute of Medicine (2013). Best Care at Lower Cost: The
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.
9. Inozu B (2012). Performance Improvement for Healthcare: Leading Change with Lean, Six Sigma, and 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.

14. © iCareQuality Inc. 14 | P a g e
About iCareQuality Organization
iCareQuality Inc, is a benefit corporation registered in state of Delaware United States with head office in Springfield Pennsylvania. We believe systematic engagement of care providers is key to building a sustainable healthcare system globally. To support our mission we build provider engagement tools, enable care providers develop new knowledge and freely disseminate this knowledge to care providers globally. As a benefit corporation, we pledge 40% of our profits to to our providers, 50% for reinvestment and 10% for our investors.
About Our Team
Chief Architect
 Jason Uppal, P.Eng.
 Jason.Uppal@iCareQuality.org
Clinical Support
 Kate ONeill, MSN, RN
 Kate.Oneill@iCareQuality.org
Sales and Business Development
 Bryan Weston
 Bryan.Weston@iCareQuality.org