Implementing a continuous daily improvement (CDI) program is a simple standardized approach to reducing clinical variability in patient care delivery settings. The CLIPSE model engages front-line care providers using a collaborative, professional peer-peer process, and may positively impact patient outcomes, cost of care, patient safety, and quality improvement initiatives at the point of care (POC).

1. www.iCareQuality.org 1
Improve Nurse Performance, Outcomes and
Engagement using the CLIPSE Model
Kate O'Neill, MSN, RN
Current Healthcare Challenges
The Healthcare system is undergoing unprecedented change. Patients, providers
and policy leaders are coming together to re-design care delivery, expand services,
improve patient safety, reduce errors, and decrease total cost of care.3
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 recent IOM reports,
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, ANA 12
).
Abstract
Implementing a continuous daily
improvement (CDI) program is a
simple standardized approach to
reducing clinical variability in
patient care delivery settings.
The CLIPSE model engages
front-line care Providers using a
collaborative, professional peer-
peer process, and may positively
impact patient outcomes, cost of
care, patient safety, and quality
improvement initiatives at the
point of care (POC).

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Professional 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 non-punitive 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, ANCC for
evaluating learning effectiveness, the employer for improved patient outcomes, and
society by making care affordable.
Practice Accountability and Transparency Using the "CLIPSE" Model
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 errors15
. 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 leaders4,16
. 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
CLIPSE is an acronym that stands for - Collaborative Learning Improve
Performance through Staff Engagement. CLIPSE is a comprehensive quality
improvement program that combines professional peer review, education, and
clinical checklist observations at the bedside. This process improvement model
includes four key components: staff engagement, targeted clinical learning, non-

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punitive peer review, and real-time best practice observations for continuous daily
improvement.
Implementation of a successful CLIPSE model was based on the popular book
"Checklist Manefesto"(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. Although a seemingly simple intervention, checklists
have a sound theoretical basis in principles of human factors engineering and have
played a major role in some of the most significant successes achieved in the
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
http://www.ihi.org/explore/CMSPartnershipForPatients/Pages/default.aspx
and HRET20
http://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.
Checklist can be used to measure compliance to best practice involving Hospital
Acquired Conditions (HAC), such as Pressure Ulcers, Surgical Site Infections, or
Falls, etc. In October 2014, Hospital Acquired Conditions will negatively impact
hospital reimbursement. CMS will reduce payments by 1% 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 non-
punitive with just in time learning and 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 is the answer to Continuous Daily Improvement (CDI) by engaging
frontline staff to monitor their practice through professional peer review process to
improve patient outcomes.

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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 (QI) 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.
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References
1. Berwick, D. Hackbarth, A. Waste in Healthcare. JAMA. 2012;307(14):1513-1516. Website:
http://www.hta.hca.wa.gov/documents/Waste_in_Healthcare_JAMA_2012.pdf
Accessed April 20, 2013.
2. Report of the Lucian Leape Institute Roundtable. Order from Chaos: Accelerating Care Coordination
(2012) Website: http://www.npsf.org/wp-content/uploads/2012/10/Order_from_Chaos_final_web.pdf
Accessed April 20, 2013.
3. Department of Health and Human Services. Report to Congress (2012) National Strategy for Quality
Improvement in Healthcare. Website: http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf
Accessed April 20, 2013.
4. IOM Consensus Report (2012). Better Healthcare at Lower Cost: The Path to Continuously Learning
in Healthcare in America. Website: http://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: Population Health, Experience of Care, and
Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for
Healthcare Improvement; 2012.
http://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
http://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).
http://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).

5. www.iCareQuality.org 5
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
Accessed April 20, 2013.
9. American Nurses Credentialing Center’s Commission on Accreditation (2012). The Value of
Accreditation for Continuing Nursing Education: Quality Education Contributing to Quality Outcomes.
Silver Spring, MD: American Nurses Credentialing Center.
http://www.nursecredentialing.org/Accreditation/ResourcesServices/Accreditation-
WhitePaper2012.pdf Accessed April 20, 2013.
10. American Nurses Credentialing Center’s Commission on Accreditation. ANCC Primary Accreditation
Application Manual (2013) http://www.nursecredentialing.org/Accreditation/2013-
PrimaryAccreditationManual.html Accessed April 20, 2013.
11. American Nurses Association. 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).
http://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
Administration (2008) Nov. 38(11) 475-9.
14. IOM Workshop Summary . Digital Data Improvement Priorities for Continuous Learning in
Healthcare (2012). http://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.
http://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.
http://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. Cambridge, Massachusetts: Institute for Healthcare Improvement;
2012. http://www.ihi.org/knowledge/Pages/IHIWhitePapers/UsingCareBundles.aspx
Accessed April 20, 2013.
18. Gawande, Atul, MD. The Checklist Manifesto: How to Get Things Right. Picador Publishing (2011)
(ISBN 10: 0312430000 / ISBN 13: 9780312430009)
19. Institute for Healthcare Improvement Gap Analysis Map, 2013. Accessed October 20, 2013.
http://www.ihi.org/offerings/Initiatives/Improvemaphospitals/Documents/IHIGapAnalysis.pdf
20. HRET-HEN Content Core Areas for Improvement: Accessed on October 20, 2013
http://www.hret-hen.org/index.php?option=com_content&view=article&id=7&Itemid=1752
Kate O'Neill, MSN, RN
VP of Quality and Patient Safety, CCG
kate.oneill@icarequality.org
May 2014