2021 Annual Conference

CNS Improving Outcomes
CNS as Project Manager
Quality Initiatives
Interprofessional Collaboration

Background

In a time of increasing public transparency and resulting competition within and between healthcare systems to achieve public recognition from accreditation and quality organizations, individual metric performance is often assigned to a single discipline. Unfortunately process and outcome measurements in the hospital environment are often influenced by the processes and workflows of interdisciplinary team members. 

In response to changes in the pain management standards introduced by The Joint Commission in 2018, a large University Medical Center with two acute care hospitals developed a process metric to monitor nursing compliance with matching dose of analgesic administered with numeric pain rating indications. Several attempts were made to address nursing compliance with this metric with lack of sustained improvement beyond 70%. Physician ordersets were identified as a key root cause by nursing but the team was reluctant to consider changes to them as this option would require extensive work by pharmacy, physician, informatics and nursing stakeholders.

Evaluation methods

The pain management Clinical Nurse Specialist proposed and completed a cross sectional analysis of the variation in the current state of analgesic orders using Six Sigma methods. Active analgesic orders from 5 medical surgical units were evaluated for presence of errors defined by the system’s Pain Management Steering Committee’s interdisciplinary stakeholders.

Outcome

Analysis of 130 charts for medical surgical patients with active analgesic orders yielded 76% error rate and variation at the 1.9S level. Based on results the interdisciplinary stakeholders determined the analgesic ordersets would need to be addressed to ensure nursing success in complying with the dose to score metric. The team investigated different options and through newly established collaboration with the larger university health system, identified a solution for pilot to address the identified root cause.

Implications

Highly reliable organizations reject oversimplified explanations for problems and seek to effectively uncover root causes for chronic underperformance for key metrics. Improvements in these systems are aimed at identifying failure points and mistake-proofing processes instead of simply attributing problems to individual non-compliance. Six Sigma methods focused on quantifying process variation, can help provide a compelling argument to address root causes directly impacted by the workflows of other disciplines that may be otherwise resistant to change.