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Chapter 5

Mary Maven Chapter 5

We Can Do This!

End-of-Chapter Questions  


1. Identify a quality improvement issue for your organization. Ask three people who might potentially be on your QAPI committee to write a “SMART” aim statement independently for your identified area for improvement. Compare your answers and come to agreement on the exact AIM statement you would use.

Answer: Question 1

Sometimes we are all sure we are talking about exactly the same thing until we begin to look at the details. It is important to get everyone moving your quality project towards the same goal so make sure there is clarity and understanding about the goal of your project. If you ask 3 people to improve pain management independently you are likely to end up with 3 different projects.

Work together defining the problem and setting your aim statement. Using “SMART” will help get everybody on the same page so you will end up with a measureable outcome.

  • Specific – Specify which patients/staff and how many will attain what goal.
  • Measurable – Something has to be measured or you have no way of knowing if your aim was met- what will be different if the change(s) is/are made?
  • Achievable – 100% may not be achievable, sometimes 50% is an achievable interim goal for a project
  • Realistic – Can this project really be done with existing resources?
  • Time-bound- State the end date for the project so you have a target and some motivation to achieve your aim by a certain date.

2. How will you know when you have reached your Aim? What measure will you use to demonstrate quality improvement? Why use percentages? Why not use actual counts? What is the difference between an outcome measure and a process measure? Why do you need to keep track of both?

Answer: Question 2

If you set a SMART aim, and measure your outcome you will see when your measure matches your aim.

Outcome measures for aim statements are usually phrased in patient or family experience, for instance, “family will state they were very confident” or “patient will say he met comfort level within 4 hours”.  Make sure the outcome measure you select is a good indicator of the aim. For instance, if you are aiming to increase family confidence when the patient is dying, then don’t use a test of knowledge for signs and symptoms of death as an indicator.

Process measures do just that…measure how the process is going. You may want all the nurses to use a better pain assessment tool because your hunch is that using the new tool will lead to better and more timely pain interventions which in turn will lead to meeting the patient’s comfort level. You will want to know if the nurses are using the new pain assessment tool –the process you are changing- every time a patient states they have pain.

Percentages give you a way to compare your results over time. For example: your outcome measure is the number of patients who reach their targeted pain goal within four hours/ the number of occasions patients  are identified in pain. Two months ago you had 15 occasions of patients identified with pain and 7 of those times the nurse used the new tool. Last month there were 32 occasions of pain and 15 of those times the nurse used the new tool. How will you know if that is an improvement? You can change both into percentages and compare:

7/15 = 46%

15/32 = 47%

By using percentages you can easily see that there is little improvement in your process measure and that your next challenge will be using the new pain tool on more occasions. If you don’t look to see whether the change you want to test is actually being tested, you will not be able to make a correlation between the use of the new tool and the pain improvement outcome.

3. What changes can you test in your organization to see if they result is an improvement? What is the value of testing the changes in different circumstances under different conditions? Why not just implement your good idea throughout the hospice?

Answer: Question 3

Each organization is different and the new process/tool/change may need to have policies and procedures specific to your organization. Testing on a small segment of the population with only a few staff involved at first will give you the opportunity to test the change, see how people react to it, get buy in and adapt the tool, or how it is used, before trying it with more and more people. Not only do you get a chance to enhance the change you are testing before it goes out to the larger population but you also engender buy in from the staff who are testing the tool. They become more invested in the outcome and the process of improvement.