More Circles in Your Practice


Last week’s post reflected on how the nursing process and SOAPIE documentation are circular processes in correctional nursing practice.  This week, a third circular process that is part of every correctional nurse’s tool bag is considered. This is Continuous Quality Improvement (CQI), known to most correctional health care professionals in both positive and negative ways.

The goal of CQI is to improve quality of care and build efficiency into processes and procedures. An article I read recently described the feelings of many family practice providers about CQI as “the mere mention of the words quality improvement can evoke dread in the minds of many physicians” and I would add nurses also.  Often CQI is mistakenly thought of as more work ;focusing on problems and not solutions. However, if you look at CQI as what you do every day to make things better, it takes on a new light. For example when your washing machine stops working, you evaluate the problem, look at what went wrong and fix it. If the machine still does not work, you examine and try again. Out of all this you put in place practices or changes that will prevent the washer from having the same problem again. That is CQI. No matter if you work in a small jail or a large prison system – it only takes ONE person to improve the effectiveness of health care delivery.

What is CQI Anyway?
The National Commission on Correctional Health Care (NCCHC) describes CQI as a pathway to improve health care by identifying problems, implementing and monitoring corrective action and studying its effectiveness. In short, it is a method of continuously examining effectiveness and improving the outcome of care or procedures to deliver service.

There are volumes written about CQI and it can seem very complex but if you think of CQI as a simple process that is done all the time, you will be able to find areas of health care delivery or patient care that can be improved and take steps to find and implement solutions.

A Little History
Even before health care began looking at ways to improve systems, industry had in place methods to look at products that did not work correctly. W. Edwards Deming, PhD., a statistician who revolutionized management theories in Japan and the US, developed the following principles of quality improvement:
• A strong focus on customers—in our case, patients.
• Continuous improvement of all processes.
• Involvement of the entire organization in the pursuit of quality
• Use of data and team knowledge to improve decision making.
In the 1980’s, the Joint Commission set standards for hospital systems to establish a formal program to monitor the delivery of care. The effort to improve the health care provided to patients spread to all health care institutions, hospitals, clinics, care homes and correctional facilities. When the National Commission on Correctional Health Care (NCCHC) developed standards for jails, prisons and juvenile facilities, in the early 1980”s, quality improvement was an essential standard.

Components of CQI
The CQI model requires that you identify the problem area, and your aim or what you want to improve or change. Some common methods for identifying areas for improvement are routine chart reviews by members of the care team, targeted audits to see if forms are completed, referrals made, and labs reviewed. Others might be staff concerns such as equipment not on the emergency cart, missing charts, emergency send outs, or patients not coming to clinic. NCCHC suggests that the areas to study be those that are high-risk, high volume or problem prone aspects of health care. Some program processes to look at are intake, continuity of care through incarceration, emergency care as well as adverse patient events.

Once you have identified the problem area and goal for improvement you bring about the desired changes using the CQI circular model of going through the steps 1. plan 2. do 3. study/check 4. act. Each step is very simple as you can see in the following description:
Plan: Analyze the process, determine what changes would most improve the process, and establish a plan for making the improvement.
Do: Put the changes into motion on a small scale or trial basis.
Check/Study: Check to see whether the change is working.
Act: If the change is working, implement it on a large scale. If the change is not working, refine it or reject it and begin the cycle again.

If you have experience in a quality improvement, you have heard about outcome studies and process studies. If you are new to quality improvement, these two types of studies help to focus quality improvement efforts. An Outcome Study looks at the outcome of a patient’s condition after an intervention has occurred. Examples include: are infections healed with antibiotics, is the A1C in the normal zone, and are chest pain emergency visits reduced when nitroglycerine is kept on person. A Process Study: focuses on procedural or policy oriented issues, such as timeliness of intake screening, physician review of diagnostic results, health assessments completed before day 7 or 14, and TB skin tests read on time.

Documentation and communication of CQI results are extremely important. Each CQI study should be written up and shared with others along with the changes in practice, procedures or training. Most important is to CELEBRATE the successes with staff and be PROUD of the CQI work the team accomplishes.thumbs-up-picture

In summary, the key points of Quality Improvement are:
• It is focused on making processes better.
• The first step is finding key problem areas.
• Identify and prioritize potential change projects. Then use the PDSA cycle to study and implement the change

On reflection of nursing practice, the American Nurses Association, Standards of Correctional Nursing Practice, Standard 10, Quality of Practice, talks about the contributions to quality practice is a responsibility for all of us. One of the competencies is to participate in quality improvement activities with the purpose of improving nursing practice, healthcare delivery and the corrections system.

CQI is a continuous and ongoing part of correctional nursing practice, like the use of the nursing process and SOAPIE documentation discussed in the last week’s post. At the center of each of these processes is the NURSE and the important, skilled and thoughtful care nurses deliver.

Have you participated in CQI projects that improved patient care? We learn from each other so please share with us your successes and examples in the comment section below.

Read more about the practice of nursing in the correctional setting in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo Credit: © canbedone- & © naruedom-