Discuss about the Work Environment and Patient Outcomes.
An increase in number of ageing population with multiple medical conditions along with medico technical advancements adds lots of pressure to the healthcare system. Quality improvement is one of the possible solutions to these challenges. These days, quality improvement science has been translated and adapted to healthcare context. Quality improvement in health care is meant to improve the patient safety, efficiency and effectiveness of system (Batalden & Davidoff, 2007). In healthcare setting, there is a tendency to be solution focused. Sometimes leaders tend to focus on short term solution without identifying the root cause of the problems (Heifetz, Grashow, & Linsky, 2009). Analyzing the process and understanding the problem are the initial steps of a quality improvement process (Health Quality Ontario, 2012). In this report, we will identify a quality issue within our organizations and do a root cause analysis of it using various problem analysis methods and tools based on the evidences. We will also explore various problem analysis methods based on the literature review. At this end, we will do a quality improvement recommendation to address the problem identified.
During the recent staff meetings, registered nurses (RNs) raised their concerns about the increased workload and were requesting for extra staff. As part of the discussions within our quality improvement project group, we have identified that the above mentioned problem is a common issue in all our workplaces. So we have decided to do further investigation and problem analysis of the issue as part of our quality improvement project. We are going to do a literature review on various problem analysis methods. Then we will do a root cause analysis of the above mention problem using the chosen problem analysis methods.
Fishbone, five whys, process mapping, check sheets and pareto charts are five most commonly used problem analysis tools in the healthcare sector (Health Quality Ontario, 2012). In the following discussion, we will assess these tools further:
The ‘5 whys’ procedure is a standout amongst the most generally encouraged ways to deal with main driver investigation (RCA) in social insurance. The WHO, the English National Health Service, the Institute for Healthcare Improvement, the Joint Commission and numerous different associations in the field of medicinal services quality and security, advances its utilization. As most such devices, however, its ubiquity in not the aftereffect of any proof that it is compelling. Rather, it likely owes its place in the educational modules and routine about RCA to a blend of family, effortlessness and instructional method.
According to Joan (2008), ‘five whys’ is a simple brainstorming technique used to establish cause of a deficiency problem or an error. It is a repetitive question asking technique to examine the cause and effect relationship underlying a specific issue or a problem. The answer to a problem often leads to another question. By repeatedly asking ‘why’, you can peel back layer of the issue. It is effective to investigate simple and moderate problems. For complex issues, it can be used along with other detailed approach such as fishbone and process mapping. It is also effective when human factors or interactions are involved. It is robust technique and more likely to prevent the problem from recurring (Health Quality Ontario, 2012). According to Fogle & Kandler (2017), if we need more clarity, we can also ask ‘why not?’
Confirmation bias is one of the limitations of this technique. Monitoring the measure throughout the process may reduce the risk of confirmation bias. It can be achieved by reviewing the effective of counter measure by checking if the solution will eliminate or reduce the initial problem and review accordingly. Another limitation is that, the conclusion can be subjective and open to interpretation. It can be biased and incorrect, as it may be subjective and not evidence based. As explained above, ‘5 whys’ is more effective when it is used with other tools (Card, 2016).
A circumstances and end results outline, otherwise called an Ishikawa or “fishbone” diagram, is a realistic apparatus used to investigate and show the conceivable reasons for a specific impact. Utilize the exemplary fishbone chart when causes assemble normally under the classifications of Materials, Methods, Equipment, Environment, and People. Utilize a procedure compose circumstances and end results graph to indicate reasons for issues at each progression all the while. It was pioneered by Dr. Kaoru Ishikawa. It is an easily understandable visual tool which aids critical thinking (Wong, 2011). The initial step is to quality problem statement or effect is documented on the center right and draw a box around it and draw a central line to the left of that box. Then draw diagonal lines off the central line which represents various causes of that issue. Different brainstorming techniques such as five why can be used to identify those causes. All possible causes of the problem need to be explored (Ilie & Ciocoiu, 2010). After that, each of those causes has to be brainstormed further to identify the reason or root cause for that effect. It is important to ensure the systemic review of each and every causes instead of focusing on a few. Once this process is complete, the irrelevant causes to the problem can be eliminated based on the evidences or investigation outcomes (HQSC, 2016 & Health Quality Ontario, 2012).
Process mapping is a visual presentation of series of actions that is involved in a process. It assists in root cause analysis of a problem or barriers to deliver quality care. It gives an outline of current practice. In other words, it explains what is actually happening in a process rather than what should ideally happen. When it is used in a quality improvement process, it will help to understand gaps in the process, various steps involved, lack of efficiency, and potential areas of complexity in the process. Different shapes can be used to represent different types of steps involved in the process (HQSC, 2016 & Health Quality Ontario, 2012).
There is a wide range of approaches to convey a similar proof based pharmaceutical to each patient, each time they associate with the social insurance framework. Associations vary in their instruments and experience, yet their point is the same: to convey a similar level of restorative care to each patient, unfailingly. The advantages of dependable procedures drive the Triple Aim: enhanced results for a populace, upgraded quiet involvement, and lessened expenses. For instance, if the pre-conceding medical attendant inaccurately pre-registers a patient, it can cause noteworthy deferrals upon the arrival of medical procedure, signifying 30 minutes of extra work to the everyday exercises of the pre-medical procedure nurture. This thusly can bring about a deferral getting the patient to the working room, squandering specialist time that would some way or another be gainful. Human services frameworks need to make sense of how to adjust procedures to convey reliably brilliant to each patient amid each experience. Understanding the present procedure through process mapping and perception is a place to begin.
Check sheet is a simple tool used to collect and analyze the data. It helps to identify the pattern of events based on the data. It is used to identify or prioritize the problem based on the number of occurrence, when a various problems are identified. Once the problem is identified, we need to decide what events need to be observed or what data needs to be collected and for how long. This needs to be clearly communicated. The check is structured based on that decision (HQSC, 2016 & Health Quality Ontario, 2012).
Pareto chart is a visual representation of the data on a graph in a descending order. It is mainly used to identify the largest contributing factor or factors of the problem. It is based on ’80-20 principle’. That is, 80% of the problems is caused by minority. In another words, one or two contributing factors have major impact to that problem. Pareto charts is used along with other problem analysis tools like fishbone diagram to reiterate the root cause using the pictorial representation of data (HQSC, 2016 & Health Quality Ontario, 2012).
As discussed above, as a analysis on ‘increased workload of nurses in 2 aged care facilities’ using five whys, process mapping, check sheets, pareto chart and fishbone diagram. As an initial step, we have decided to get further information on the issue from the RNs using ‘five whys’. According to Joan (2008), ‘five whys’ is a simple tool for problem analysis. During the next staff meeting, we have asked the RNs that, “Why do they think, there is an increase in workload?” They believe that increased paperwork and workload with the changes in legal requirements, that is, Health and Disability. But we have identified that it is not the real issue, as the standards has not been changed since 2008 (health and disability services standard, 2008).
We have decided to explore this issue further by using process mapping. As part of this process, we did a visual representation of the nurses’ routine during an 8 hour day shift. We have asked the RNs to explain their daily routine which is shown in the process map below
Then we have reviewed the process mapping with the nurses and identified that ‘unplanned events’ are main reason for the increased paperwork. The word ‘unplanned event’ represents accidents or incidents such as falls, challenging behavior, infections skin tears and bruises, pressure injury, medication error and other incidents.
|
Area |
Infections |
Falls with injury |
Falls without injury |
Other |
Wandering & Challenging Behaviour |
Pressure Injury |
Skin tear & Bruises |
Medication error |
|
Area 1 (January) |
0 |
3 |
1 |
4 |
||||
|
Area 1 (February) |
2 |
3 |
7 |
1 |
||||
|
Area 1 (March) |
2 |
3 |
3 |
1 x Grade 2 |
||||
|
Area 2 (January) |
2 |
2 |
2 |
3 |
1 |
|||
|
Area 2 (February) |
2 |
1 |
5 |
12 |
1 |
1 |
||
|
Area 2 (March) |
3 |
2 |
10 |
1 |
3 |
1 x Grade 2 |
||
|
Area 3 (January) |
2 |
2 |
2 |
4 |
1 x Grade 1 |
1 |
||
|
Area 3 (February) |
1 |
2 |
3 |
6 |
||||
|
Area 3 (March) |
0 |
2 |
1 |
4 |
6 |
|||
|
Area 4 (January) |
0 |
1 |
1 |
2 |
||||
|
Area 4 (February) |
3 |
4 |
2 |
|||||
|
Area 4 (March) |
1 |
2 |
3 |
1 |
1 |
1 x Grade 2 |
||
|
Area 5 (January) |
3 |
7 |
6 |
3 |
1 x Grade 3 |
3 |
||
|
Area 5 (February) |
0 |
1 |
4 |
6 |
1 x Grade 2 |
2 |
||
|
Area 5 (March) |
2 |
2 |
1 |
4 |
1 x Grade 2 |
|||
|
Total |
23 |
36 |
49 |
3 |
56 |
3 |
14 |
1 |
|
Number of incidents in last quarter |
Percentage |
|
|
Infections |
23 |
12.4% |
|
Falls (with and without injuries) |
85 |
46% |
|
Other incidents |
3 |
1.6% |
|
Wandering & Challenging behaviour |
56 |
30.3% |
|
Pressure Injury |
3 |
1.6% |
|
Skin tear & Bruises |
14 |
7.6% |
|
Medication error |
1 |
0.5% |
Based on the data from check sheet, we have created a bar graph (figure. 3). According to ’80-20 principle’ or ‘pareto effect’ as explained in the above literature review, graph and check sheet indicate that falls (46%) and wandering & challenging behavior (30.3%) are major contributing factors of the quarterly data (76.3%), that is nearly 80% of the incidents in last quarter.
By using fishbone diagram (Figure 4), we are now identify how do falls and challenging behaviors increased the nurses’ workload.
The fishbone diagram indicates a significant increase in work load of nurses as result of a fall or an incident of challenging behavior during their shift.
According to TAS (2017), 37% of residents in the long term care facilities (LTCFs) has dementia. It also indicates that the percentage of residents with cognitive performance issues triggered with behaviour, communication, mood and delirium Clinical Assessment Protocols (CAPs) were significantly higher, compared to the people without cognitive issues. According to the same report, national data indicates nearly 35% residents in LTCFs has triggered with behavioural CAPs and nearly 25% residents were triggered with falls CAPs. According to Health Quality and Safety Commission (2018), 25% of people at the age of 85 and above had at least one or more claim with ACC related to fall in 2016.
According to Duffield, Diers, O’Brien-Pallas, Aisbett, Roche, King & Aisbett (2011), nursing workload has negative impact on patient outcome such as increased falls, infections, and medication errors. As part of this assignment, we have read a number of articles which supports that statement. But based on the root cause analysis of increased nursing workload in our facilities, we have identified unplanned events like falls and challenging behaviour are some of the causes of increased nursing workload. From our personal experience as nurses, we also agree that those unplanned events increase the nurses’ workload. Further studies are needed to identify the effectiveness of measures to reduce or eliminate these root cause on reducing nursing workload.
According to Gee, Bergman, Hawkes & Croucher (2016), 30 to 50% of challenging behaviour related to delirium can be prevented by implementing simple assessment and management tools. Escalated endeavors are in progress over the world to enhance the nature of social insurance. It is essential to utilize assessment techniques to distinguish change endeavors that function admirably before they are reproduced over a wide scope of settings. Assessment strategies need to give a comprehension of why a change activity has or has not worked and how it can be enhanced later on. In any case, change activities are perplexing, and assessment are not generally very much lined up with the purpose and development of the intercession, along these lines constraining the pertinence of the outcomes. A multifactorial post fall assessment and interventions based on it can prevent falls or reoccurrence of falls in older people (Cameron, Gillespie, Robertson, Murray. Hill, Cumming & Kerse, 2012).
As you have discussed during the RN Forum, regarding the significant increase in nurses workload. As you have also mentioned it has a huge impact on the quality of care that is delivered to the residents. We have had various discussions about it with the management team and quality initiative project group.
As per your feedback the reason for increased workload is due to increased documentation and legislative requirements. Based on your feedback we have decided to do a problem analysis using some tools.
The problem analysis has indicated the root cause of the increased workload is due to unplanned events such as falls and challenging behavior. Data on unplanned events from January to March shows 76.3% residents with challenging behavior and falls.
Conclusion
In conclusion, three of us work in nursing management roles in two different organisation. The common problem identified is ‘increased nursing workload’. In this report, we have done a literature review of various problem analysis methods. Then we used process mapping, five whys, pareto chart, check sheets and fishbone diagram to do the root cause analysis of that issue. Based on that we have identified that, unplanned events such as falls and challenging behaviours are two main causes for increased nursing workload. Some of the literatures states that falls and challenging behaviour are significant issues in older population in New Zealand. As mention in this report, some studies suggest that falls and challenging behaviour could be prevented by proactive approach.
Healthcare is a complex system. Most problems identified in this sector are adaptive challenges which requires innovative solution. “In order to thrive in tomorrow’s world, quality improvement teams must develop ‘next practices’ while excelling at today’s best practices.” (pp. 65, Heifetz et al., 2009). One of the biggest learning from this group work is that initial problem identified and the real cause of the problem may be entirely different. Being solution focussed and trying to solve the initially identified problem may not be the real long term solution for it. After doing this root cause analysis, we would like to explore further: Is nurses’ workload the reason for an increase in resident incidents or the increase in preventable resident incidents causes increase in nurses’ workload?
References
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Cameron, I. D.., Gillespie, L. D., Robertson, M. C., Murray, G. R., Hill, K D., Cumming, R. G., & Kerse, N. (2012). Interventions for preventing falls in older people in care facilities and hospitals. Pubmed, 12(12). 1-181 doi: 10.1002/14651858.CD005465.pub3
Card, A. J. (2016). The problem with ‘5 whys’. BMJ Quality & Safety, 9 (1). 1-7. Doi:10.1136/bmjqs-2016-005849
Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, M., & Aisbett, K. (2011). Nursing staffing, nursing workload, the work environment and patient outcomes. Applied nursing research, 24(4), 244-255.
Fogle, A., & Kandler, E. (2017). Five whys and a why not. Quality Progress, 50(1), 63. Retrieved from https://ezproxy.auckland.ac.nz/login?url=https://search-proquest-com.ezproxy.auckland.ac.nz/docview/1860948354?accountid=8424
Gee, S., Bergman, J., Hawkes, T. & Croucher, M. (2016), Think delirium: Preventing delirium amongst older people in our care. Tips and strategies from the Older Persons’ Mental Health Think Delirium Prevention project
Christchurch, New Zealand: Canterbury District Health Board.
Health and disability services (core) standards (2008). Standards New Zealand. Retrieved from https://www.standards.govt.nz/assets/Publication-files/NZS8134.1-2008.pdf
Health Quality Ontario. (2012). Quality improvement guide. Retrieved from https://www.hqontario.ca/portals/0/Documents/qi/qi-quality-improve-guide-2012-en.pdf
Health Quality & Safety Commission (2016). Quality improvement toolkit for use in age related residential care. Retrieved from https://www.hqsc.govt.nz/assets/Falls/PR/ARRC-QI-toolkit/ARRC-quality-improvement-toolkit-Apr-2016.pdf
Health Quality & Safety Commission (2018). Update with 2016 data. Retrieved from https://www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/atlas-of-healthcare-variation/falls/
Heifetz, R., Grashow, A., & Linsky, M. (2009). Leadership in a (permanent) crisis. Harvard Business Review, 87(7-8), 62-69, 153. Retrieved from: https://web.b.ebscohost.com.ezproxy.auckland.ac.nz/ehost/pdfviewer/pdfviewer?vid=1&sid=0c8ba8ce-b147-43a1-b4de-18712b6de3b3%40sessionmgr104
Ilie, G., & Ciocoiu, C. N. (2010). Application of fishbone diagram to determine the risk of an event with multiple causes. Management research and practice, 2(1), 1-20. Retrieved from https://mrp.ase.ro/no21/f1.pdf
Joan, A. (2008). The five whys. Supply house times, 51(10), 16. Retrieved https://catalogue.library.auckland.ac.nz/primo-explore/fulldisplay?docid=TN_gale_ofg191475445&context=PC&vid=NEWUI&lang=en_US&search_scope=Primo_Central&adaptor=primo_central_multiple_fe&tab=articles&query=any,contains,Five%20whys&offset=0
Levinson, W, A. (2006). Bringing the Fishbone Diagram Into the Computer Age. Quality Progress, 39 (12). 88. Retrieved from https://search.proquest.com/openview/3819e900df73983d51766828a90caef0/1?pq-origsite=gscholar&cbl=34671
TAS (2017), Annual report. Retrieved from https://www.interrai.co.nz/assets/Documents/Publications-and-Reports/Annual-Report-2016-17-web-version.pdf
Wong, K. C. (2011). Using an Ishikawa diagram as a tool to assist memory and retrieval of relevant medical cases from the medical literature. Journal of Medical Case Reports, 120(5), 1-3. Doi:10.1186/1752-1947-5-120
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