There's growing evidence from healthcare systems around the world about the role of performance data in quality improvement (QI) efforts. Performance data collected in the course of care delivery can be used to 1) monitor and target healthcare delivery interventions aimed at meeting patients' needs, 2) learn from care experiences, 3) inform healthcare decisions in daily practice to avoid errors and improve patient care and population health, and 4) facilitate clinical and health services research. Given the close and constant contact that clinical nurses have with patients and other clients, engaging them in local QI and patient safety initiatives is critical. Supportive and dedicated leaders, particularly frontline managers, are pivotal to fostering the involvement of clinical nurses in QI.
Managers create conditions and invest in infrastructure, including committing to and securing resources (such as release time for clinical nurses to participate and funds for project-related costs) that make QI efforts successful. They also motivate and inspire clinical nurses to get involved in unit-level QI, and promote senior management buy-in for investing in QI projects. Managers must understand QI methods and tools, along with having the data analysis, interpretation, and presentation skills to shepherd projects and enable clinical nurses to navigate their QI efforts through, at times, political waters.
However, coverage of QI content in graduate-level nursing administration programs is often light and QI may be offered only as an elective. Such was the case at the university where we taught (LJ) and were students (LS, AJL). This led to the development of the Knowledge Translation of Performance Data for Frontline Nurses and Leaders Project (PERFORM KT) for graduate students to 1) work with managers and clinical nurses in healthcare organizations to help them acquire sophisticated competencies in using performance data to drive care quality and 2) lead QI efforts in their respective future career endeavors.
Learning in action
Each PERFORM KT team selected a clinical problem or practice issue that needed improvement. Over two cycles of projects, topics included falls, pain assessment, skin integrity, aggressive patient behaviors, and discharge planning. Similar to other postlicensure initiatives, such as Transforming Care at the Bedside, the PERFORM KT teams used the Plan-Do-Study-Act cycle and other QI, change management, and knowledge translation tools as templates to guide the small tests of change that the teams carried out locally.
The education component of PERFORM KT drew on principles about learning in organizations and QI collaboratives, and involved monthly communities-of-practice (CoPs), which consisted of a combination of theory bursts around key concepts in QI, change management, and knowledge translation; interactive learning exercises; and open-ended discussions of key issues and project updates. The majority of the managers on units where the QI projects were undertaken by clinical nurses also attended the monthly CoPs. Each local team had an assigned mentor. The learning content was refined from five learning modules to three (moving data to action, sustaining data use, and translating data) in the second iteration.
The setup of PERFORM KT also built in a knowledge translation strategy for putting information back in the hand of clinicians and decision makers, and ensuring lessons learned were captured and communicated to nurse managers, clinical nurses, and nurses with QI expertise. To date, three symposiums have been organized and hosted at two hospitals, with an open invitation to hear about the teams' project topics, progress, and impact. Also, because the project was a collaboration between the university and hospital, two graduate students who had taken the quality and safety elective course were recruited to help design the project-one as part of a knowledge translation fellowship (AJL) and the other (LS) as part of the final graduate practicum.
Harnessing expertise and interest
Because they were exposed to QI principles in their coursework, the two graduate students helped deliver some of the learning modules (LS, AJL) and one (AJL) served as a mentor to several teams. One of the graduate students (LS) enhanced a learning module by incorporating content on how to use social media to sustain QI efforts. The student reviewed literature and provided an overview of important concepts and principles, as well as an interactive learning session on how to tweet key messages about the various teams' QI projects. The second graduate student (AJL) guided a number of the teams as they put the knowledge and skills from the learning modules into action in their CoPs.
Since finishing their master's programs, the two students have been able to continue applying what they learned from the graduate course and learning-in-action QI experiences to their current leadership roles. One (LS) became a unit manager who went on to recruit a team to participate in the second offering of PERFORM KT and continues to support clinical nurses and other staff in QI efforts. The second (AJL) took on a professional practice middle management role and is now considered a corporate resource person for practice initiatives, including applying QI methods.
Taking stock
Overall, the program was well received and evaluated positively by all participants, including the teams who did the work, managers, mentors, and the two graduate students. Evaluation of the program identified the essential role of managers in supporting local QI projects and mentors to keep teams focused and guide them to conduct small tests of change.
The PERFORM KT teams valued the content of the sessions and the teaching approach, and found the monthly CoPs to be a safe learning environment. The involvement of knowledgeable graduate students interested in developing leadership skills helped the nurses and managers who participated in the project to conduct sophisticated projects that "dove deep" into local data regarding their clinical quality areas of interest. Not surprising, managers who attended the monthly CoPs were able to better support their team in reaching performance targets. Further, they supported clinical nurses to engage in accountable practice and improve outcomes, including ensuring patient safety by decreasing falls and skin tears, enhancing the patient experience by managing pain more effectively, and improving functional status.
Next steps
It's clear that clinical nurses and nurse leaders need more exposure to QI and patient safety core concepts, methods, and tools in formal graduate education programs, as well as continuing education, in-services, and other professional development programming. PERFORM KT's positive reception led to material that was originally in an elective course becoming core content in required courses for the administration stream of the master's program in nursing. In this program, there's a focus on the fundamentals of patient safety and QI (such as critical incident review and QI methods and tools) that shifts to advanced topics in the second year (such as integrated risk management and high-reliability organizations).
Lessons from PERFORM KT have been brought together in a toolkit to guide future work with clinical nurses and managers. We'll continue to bring graduate students into the program and strongly encourage other practice settings to establish partnerships with both clinical training and management/leadership graduate programs.