Continuous Organizational Improvement and High Reliability

In the United States, healthcare costs are increasing with little improvement to the quality and efficiency of care. Dynamic healthcare organizations recognize the need for continuous organizational improvement and high reliability of services delivered to achieve quality outcomes, efficiency, and patient satisfaction. Organizations that are not able to adapt to changes externally, with internal mobilization, will not be sustainable over time.

The main driver of continuous organizational improvement is the customer: patients. Research shows that successful organizations are very similar to their competitors, but what sets them apart is that they are better in adapting quickly to meet or exceed patient needs, and evaluating frequently to sustain the change or initiate a new improvement (Bastian et al., 2016). Consequently, healthcare organizations who have mechanisms that support continuous organizational improvement not only excel in their outcomes but are also resilient regarding changes in healthcare.

Healthcare organizations are complex, but must provide high quality care to succeed regardless of associated risk factors (Davenport et al., 2018). These healthcare organizations have few to zero adverse events despite operating daily under hazardous conditions. In high reliability environments, the focus on safety is paramount and methods to prevent accidents or errors are well defined and followed by all levels of the organization. The result is an organization that a patient can trust.

Reflection

How can the DNP-prepared nurse contribute to both continuous organizational improvement and high reliability performance?

Culture of Safety

DNP practice scholars create high-reliability organizations and are committed to safety. In these organizations, everyone is aware of the interconnected and dynamic nature of daily operations and that a change in one area or process can ripple to other areas within the organization. DNP practice scholars speak directly with frontline nurses and caregivers through executive rounds and open forums and focus on resources the employees need to provide safe care to patients and families.

One challenge to safety and quality practices in healthcare is the complex regulatory entities that set goals for organizations to achieve and systematically collects and analyzes reports for broad dissemination to ensure that safety best practice and safety alerts are communicated across all healthcare settings.

Review the activity below to discover various organizations impacting a culture of safety:

Value-Based Purchasing

Important drivers of quality improvement include payors and purchasers, regulators, certifiers and creditors, professional organizations, and technical support organizations. Purchasers and payors have considerable influence on quality and make decisions about the selection of health plans to be offered to their constituents, especially with the implementation of the Affordable Care Act and the increased obligation of employers to offer health insurance to employees. As the cost of health insurance increases, those charged with paying for coverage are looking more closely at the value of that which is offered in exchange for their money.

The U.S. healthcare system is the most expensive in the world, yet outcomes are continually less acceptable than those obtained in other developed countries that proportionally spend less on healthcare. Especially since 2010, there have been attempts to improve outcomes in a variety of ways. The greatest impetus to quality improvement efforts has been through the implementation of the concept of value-based purchasing, particularly by the federal government through the Centers for Medicare and Medicaid Services, since the implementation of the Affordable Care Act (Barton, 2010).

Value-based purchasing looks not at the number of procedures performed but instead focuses on outcomes accomplished (Spaulding et al., 2018). Success under this methodology will be determined through performance in patient quality measurements through various patient satisfaction scores, and these measurements will be assessed from available national benchmark quality metrics.

One way to implement improvement in the delivery of healthcare is through the development of Accountable Care Organizations (ACO). This is a new mechanism for the delivery of healthcare designed to manage the care of an entire organization at a fixed cost. If the organization can accomplish the measure for less than the contracted rate, it will be more profitable; if it fails to achieve designated goals, the cost of the deficiency falls to the organization. A key factor in defining accountable-care organizations is that the organizations need to have a robust quality measurement and improvement capacity across settings.

Quality Measures and HCAHPS

Benchmarking is a method that assists in comparing outcomes of two or more entities. Benchmarking is an excellent tool to share improvements not only in a place or time but how patient and nurse outcomes in one hospital compare to others.

Over the past few years, the stakes have been raised as more knowledgeable consumers actively select where they will receive care, and their evaluation of their care experience begins to have an effect on payment patterns. The federal government uses its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) (Centers for Medicare & Medicaid Services, n.d.) survey to measure patients’ perceptions of their hospital experience. Publicly available posts may be found here (Links to an external site.).  This is the first tool to help consumers compare hospitals nationally on key variables that include communication, responsiveness, cleanliness, noise and specifically related to nursing performance. This allows for comparisons across organizations. New accreditation standards and federal regulations for hospitals provide a powerful stimulus toward culture of patient and family-centered care.

Strategies and Frameworks for Change

The DNP leader will play a critical role in change at this macrosystem level, as well as at the mesosystem and microsystem levels. A sound assessment of organizational culture is a method DNP leaders can use to identify and mitigate risk stemming from the organization’s culture and subcultures.  Organizational culture is an abstract conception of an organization’s values, beliefs, and assumptions.

 Although these basic values, beliefs, and assumptions are difficult to identify, they can have a strong effect on how a project is perceived and whether staff members are willing to collaborate on the project. Culture can be overtly apparent, such as in the case of an organization that displays a value statement in the entry of the hospital, stating that the organization values employee input. However, culture is more subtly manifested, such as the observation that an employee hesitates to offer a viewpoint that differs from that of upper management. The DNP leader has an essential role in understanding the way culture influences projects and must be prepared to intervene to guide projects toward completion within a variety of organizational subcultures. 

Reflection

Examine your organizational culture. Does it have the hallmarks of a culture of excellence? If not, what is lacking? What changes could you, as a DNP leader, institute to improve the culture? This next portion of this lesson gives recommendations on how a DNP leader can influence the culture of an organization.

Leadership is the first component in the transformational model and the fundamental currency of cultures of excellence. The DNP leader is the driver for instigating change. Leadership begins with a respectful environment and the creation of trust that creates the potential for relationships. The second major component of creating a culture of excellence, beyond leadership and people, is embedding a process for continuous improvement into the culture. The component for building excellence is using models and guiding principles. Magnet Recognition Program (ANCC, 2013) is an excellent performance model that considers the dynamic flow of organizations. Criteria-based programs provide a map for the journey. These programs with their integrated models can be templates, applied to, or assessed against.

Change requires strong DNP leadership and commitment to engage followers. Changing a culture, moving it from mediocrity to excellence or from chaos to stability, can require an extended period of time because it involves adjustments in every aspect of the structure and function. For successful change, there are several key roles that must be identified, and the DNP leader must adequately consider who is in what role, whether they are clear in their role, and how their participation can be optimized in support of the change.

Readiness for change is perhaps the most difficult to achieve but is essential for successful quality and safety transformation. In order for change to happen, the workforce’s motivation must align with the goals and the process of the organization. Readiness depends on a culture of learning. Change is a continuous process, and DNP leaders have many forces to consider. Transition has three steps, as detailed below.

• Ending—letting go of the old
• Neutral zone—the stage between when the old is gone and the new is not in place
• Beginning

The neutral zone can be a dangerous place where old weaknesses return, historical resentments flourish, and an increase in errors, illness, and absenteeism occurs. During this period of time, organizational performance can deteriorate, and it is vitally important to be clear about the new process, communicate constantly and supportively, and keep the neutral zone as short as possible.

There are multiple proven strategies that can be applied to assist with performance improvement activities. It is important for the DNP leader to begin with Donabedian’s quality framework when instigating change (1980). Donabedian stated that structural factors of the organization influence the process of care, which then impacts the effect of changes in care on the outcomes. Each element in this chain produces an effect on the element that follows and is affected by the element that precedes it. Donabedian defined structure as the relatively stable characteristics of the system, including providers of care, tools and resources they have at their disposal, and the physical and organizational setting in which they work. Processes of care refer to the activities in which professionals engage to provide services to patients. They indicate the mechanisms responsible for producing the intended outcomes and include continuity of care and technical and interpersonal management of patient care. As such, these factors explain the processes responsible for producing the desired outcomes and subsequently the effectiveness of the organization. Donabedian noted that good structure increases the likelihood of good process, which increases the likelihood of good outcomes.

Plan-Do-Study-Act Model (PDSA) (NHS Institute for Innovation and Improvement, 2008) is a successive cycle that starts off small to test potential effects on process but then gradually leads to larger, more targeted change.

National and International Practices and Health System Framework

DNP-prepared nurses should thoroughly understand that the delivery of patient care within their system will be directly linked to the macro-, meso-, and microsystems that create the care. They will be challenged with the task of transforming and creating the culture within the organization that enables the intertwined linkages of the macro-, meso-, and microsystems to function successfully and recognize that improvement necessitates change.

Following are national frameworks and health system practices that have been developed and popularized to optimize the three levels of the healthcare system.

Organizational Needs Assessment

As a DNP-prepared nurse, one must assess the organizational environment to determine practice gaps. Assessment of the system at all levels allows the nurse to identify organizational gaps or problems and then identify and prioritize opportunities for improvement.

SWOT

Typically, when conducting a needs-based organizational assessment, a SWOT analysis is used to determine what impacts an organization.  A SWOT analysis is a tool used to evaluate the strengths, weaknesses, opportunities, and threats to a project. It will identify the internal and external factors that affect this to achieving that objective with an overall look at the project in areas that will support the project and areas that may need more attention (Waxman, 2020, pp. 156-159).

• Strengths – Of the organization, advantages in the industry
• Weaknesses – Of the organization, areas with underperformance and vulnerability
• Opportunities – Underserved areas, areas for growth or new services
• Threats – External issues including regulatory, competition, and outdated services or practices

Six Sigma

The demands or standards that currently exist in the organization, contextual factors, (trends), and identification of resources needed to address the problem (processes, people, finance, and means) should be considered. The traditional Six Sigma 6 Ms method includes machines, methods, materials, measurements, Mother Nature (environment), and manpower (people) when assessing a problem.

FAME

The FAME approach to evaluating a project may help inform the wording and strength of a recommendation (The Joanna Briggs Institute, 2014).

F – Feasibility; specifically:

• What is the cost effectiveness of the practice?
• Is the resource/practice available?
• Is there sufficient experience/levels of competency available?

A – Appropriateness; specifically:

• Is it culturally acceptable?
• Is it transferable/applicable to the majority of the population?
• Is it easily adaptable to a variety of circumstances?

M – Meaningfulness; specifically:

• Is it associated with positive experiences?
• Is it not associated with negative experiences?

E – Effectiveness; specifically:

• Was there a beneficial effect?
• Is it safe? (i.e., is there a lack of harm associated with the practice?

The source credited as expressly stated “The Joanna Briggs Institute Levels of Evidence and Grades of Recommendation Working Party*. Supporting Document for the Joanna Briggs Institute Levels of Evidence and Grades of Recommendation. The Joanna Briggs Institute. 2014 View the Supporting Document for the Joanna Briggs Institute Levels of Evidence and Grades of Recommendation (Links to an external site.).

Click each step to review details.

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Transcript

ADPIE Organizational Needs Assessment

ADPIE is an acronym that stands for assessment, diagnosis, planning, implementation and evaluation. DNP-prepared nurses use ADPIE to remember the process and order of the steps they need to take when assessing the organizational need and planning a practice-change project.