NUR 410 Midterm Review - Week 4 PDF

NUR 410 Midterm Review -- Week 4 ================================ **[Week 4 Learning Objectives ]** - *Differentiate between quantitative and qualitative data* - *Select measures that support the plan for evaluation* - *Explain run chart rules and how they can indicate changes in data...

NUR 410 Midterm Review -- Week 4 ================================ **[Week 4 Learning Objectives ]** - *Differentiate between quantitative and qualitative data* - *Select measures that support the plan for evaluation* - *Explain run chart rules and how they can indicate changes in data (no need to memorize but know how to apply them)* - *Apply the PDSA cycle* - *Discuss the importance of sustainability in quality improvement* **QI vs. Research** **Quality Improvement** **Research** ------------------- ------------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------------------------- **Purpose** Learn and improve processes, practices, costs, or productivity Test hypotheses, contribute to or generate new knowledge **Study Designs** Iterative design, randomization not usually involved Systematic and rigorous designs, may involve randomization **Sample** Involves all or most of the population. Involved in process/practice; may also include convenience samples Inclusion and exclusion criteria, may involve sample size calculations **Measures** Usually simple, easy to administer, confounding variables acknowledged but not measured. Valid and reliable instruments, confounding variables are measured and/or controlled **Timelines** Short, rapid cycles, often weeks to months Depends on size and scope, generally longer than QI **Project and PDSA Measures** - **Project Level Measures** - Collected and monitored throughout the project - Collected again on project completion to determine the overall impact - Support decisions around sustainability - **PDSA Level Measures** - Collected to determine whether a change is working - Understand the changes that we're testing - AKA temporary measures **Data** +-----------------------------------+-----------------------------------+ | **Quantitative Data** | **Qualitative Data** | +===================================+===================================+ | - Can be measured numerically | - Information that can be | | | observed and recorded that is | | - Quantity, amount etc. (e.g., | not numerical | | number of nosocomial | | | infections) | - Perspectives, opinions, | | | feelings, meaning (e.g., | | - Can be visualized over time | patient experience of | | using run charts | waiting) | | | | | - Sometimes analyzed using | - Often analyzed using | | descriptive and inferential | qualitative methods such as | | statistics | thematic or content analysis | +-----------------------------------+-----------------------------------+ **Family of Measures** +-----------------------------------+-----------------------------------+ | **Structure** | - Healthcare setting | | | | | | - Physical environment | | | | | | - Human resources | +===================================+===================================+ | | - Describe the setting and | | | environment, including | | | resources. Not always | | | measured in QI | +-----------------------------------+-----------------------------------+ | | Examples: | | | | | | - Nurse to patient ratio | | | | | | - Use of Electronic Medical | | | Record | | | | | | - Model of Care | +-----------------------------------+-----------------------------------+ | **Process** | - Delivery of care | | | | | | - Activities of healthcare | | | system | +-----------------------------------+-----------------------------------+ | | - Offer more precise | | | reflections of what is | | | happening as process measures | | | reflect what needs to happen | | | to accomplish project aim | | | | | | - Likely to see changes in | | | process measures before | | | outcome measures | +-----------------------------------+-----------------------------------+ | | Examples: | | | | | | - \% of patients with | | | intentional rounding | | | completed on schedule | | | | | | - \% of patients whose | | | hemoglobin A1c level was | | | measured twice in the past | | | year | +-----------------------------------+-----------------------------------+ | **Outcome** | - Impact of care | | | | | | - Disease outcomes | +-----------------------------------+-----------------------------------+ | | - Related to project aim | | | | | | - Demonstrate the impact vs. | | | activity | | | | | | - Take longer to show | | | improvement | +-----------------------------------+-----------------------------------+ | | Examples: | | | | | | - Adverse drug events per 1000 | | | doses | | | | | | - Average hemoglobin A1c level | | | for patients with diabetes | | | (what's the overall avg and | | | does it go down over time?) | +-----------------------------------+-----------------------------------+ | **Balancing** | - Consequences of improvement | | | efforts | +-----------------------------------+-----------------------------------+ | | - Highlights consequences in | | | other parts of the system -- | | | intended or unintended | +-----------------------------------+-----------------------------------+ | | Examples: | | | | | | - Readmission rates (if trying | | | to reduce length of stay) -- | | | is it good if people are | | | coming back the next day to | | | the ER? | | | | | | - Workload or staff | | | satisfaction (if introducing | | | new processes) | +-----------------------------------+-----------------------------------+ **Variation** - Random: natural variation inherent in any process - Non-random: Atypical variation +-----------------------------------+-----------------------------------+ | **Random/Common Cause** | **Non-Random/Special Cause** | +===================================+===================================+ | - Variation that is inherent in | - Variation that is not typical | | processes and systems | | | | - Caused by changes to a | | - Will continue unless there | process or system | | are changes (e.g. weight, | | | blood pressure) | - Not always intended -- may | | | reflect unstable processes | | | | | | - May be intended when change | | | introduced | +-----------------------------------+-----------------------------------+ Run Chart X axis --- usually time Y axis --- measure of interest Central line --- median 10 or more points Annotations (Gußa 2020; 2017; m 14) ED \"Walk-Aways\" (Percent Left Without Being Seen) PDSA PDSA 1 - Note: need approximately 10-15 data points for run chart **Median** - Midpoint in the data set - Same \# of points above and below - If even number of points, add the 2 middle numbers and divde by 2 - Median is not influenced by outliers in the data **Run Chart Rules** - Shift: 6 or more consecutive data points above or below the median - Trend: 5 or more sequential data points in a row all increasing or decreasing -- can cross the median - Number of runs: a run is a series of points on one side of the median line. Too few or too many based on probability tables - Count the \# of data points - Count the \# of runs = \# of times the data line crosses the median + 1 -  consult data table - Astronomical point: clear outlier from the remaining points - Relies on opinion of team **Benefit of Run Charts** - Help monitor how things are going O/T - Can help to evaluate the project as it is happening - Can provide insight into what interventions have the most impact - Easy to use and share with team members **Sequential PDSA Cycles** Best used when: - Adapting an existing approach - Testing individual program/project components - Scaling change ideas **Concurrent PDSA Cycles** Best used when: - Testing multiple change ideas - Scaling multiple change ideas **Common Errors with PDSA Cycles** - Plan lacking detail - Failure to make predictions - Insufficient data collection plan - Lack of team member engagement - Failure to learn from findings **Steps for Applying Model for Improvement: Fundamental Principles** 1. Know what you want to improve 2. Have a feedback mechanism in place to tell you if improvement is happening 3. Develop an effective change that will result in improvement 4. Test a change before you attempt to implement it 5. **Know when and how to implement a change and make it permanent** **Sustainability** - Ensuring gains are maintained beyond the life of the project - Sustaining the ideas, beliefs, principles, or values underlying an initiative, or "when new ways of working and improved outcomes become the norm" - Nurses are a driving force in sustainability **Benefits and Drawbacks of QI** **Benefits** - Pragmatic approach - Provides flexibility - Promotes learning - Data driven - Builds evidence for change - Can provide opportunities to engage stakeholders **Drawbacks** - Not a silver bullet - Often implemented with poor fidelity - Can be led by individuals with limited expertise, power and/or resources - Focus on local improvement - Lack of rigour in evaluation