NURS 8301 Week 11 QI Leadership Reflection Example

Three Shifts and the Revisions That Show Them: A Reflection on Leading Improvement Across One Term's Cancellation Project

Student Name

College of Nursing, Walden University

NURS 8301: Effectively Leading Organizations in Quality Improvement Initiatives

Instructor Name

Month Day, Year

Three Shifts and the Revisions That Show Them: A Reflection on Leading Improvement Across One Term's Cancellation Project

Introduction

A reflection at the end of an improvement course can drift into gratitude. I want to stay with evidence: what changed in how I lead improvement, and where each change shows up in the final proposal for reducing avoidable day-of-surgery cancellations in our composite outpatient surgery department. I trace three shifts across the term: from a research register to an improvement register, from expert to convener and from proving to learning. For each, I point to a specific revision between my first draft in week three and the executive proposal in week ten.

Shift 1: From Research Register to Improvement Register

I came to this course from research methods, and my first aim statement read like a hypothesis. It proposed to compare cancellation rates before and after an intervention, controlling for case mix, and to report whether the difference was statistically significant. My instinct was to design the project so it could prove something.

Batalden and Davidoff (2007) describe improvement as the combined effort of everyone involved to make changes that lead to better outcomes, better system performance and better professional development, and they distinguish that effort from research aimed at generalizable knowledge. Reading that, I saw that my draft asked the wrong question for a department that simply needed fewer patients sent home unready.

The revision. The week ten proposal replaces the comparison with an aim, a set of run charts and a testing ramp. It says that the evaluation will show whether the department reached and held its target, not whether the change would work everywhere. It also states the project's quality improvement determination openly, which my first draft did not address at all.

Shift 2: From Expert to Convener

In my first draft, I listed the changes I thought would work: an earlier call, a new checklist, a medication guide. I had written them before talking to the preoperative nurses, schedulers or surgeon offices. When I shared the draft, the nurses told me the department had tried an earlier call before and it faded, which I had not known, and a scheduler pointed out that half the missing escorts traced to instructions given at surgeon offices, which were not in my plan at all.

The culture work in week four made the reason clearer. The nurses were committed to fewer cancellations but doubted they could make a change stick, and they held an assumption that patient readiness was someone else's job. A leader who arrives with answers confirms that assumption. A leader who convenes the people who do the work, including the offices across town, gives them a stake in the answer.

The revision. The week ten proposal names a chartered team that includes two surgeon office managers and a scheduler, gives the team decision rights for testing within the department and lists my role as project lead rather than as the source of changes. The driver diagram's change ideas now come from the process map the team built, and two of them, text follow-up in the patient's language and escort confirmation at scheduling, were not in my original list.

Shift 3: From Proving to Learning

My early PDSA plans were really small pilots of a finished idea. I wanted each test to succeed. Reed and Card (2016) argue that teams too often run PDSA as a formality on the way to a decision already made, missing that the method's value lies in iterative learning, including learning from cycles that do not go as predicted. The week eight plan was the first place I wrote down what would make us drop an idea: if the evening call reached fewer than 14 of about 20 patients, we would switch to texting patients a number they could call back.

The revision. The executive proposal now presents the testing ramp as a sequence of learning cycles with predictions recorded in advance, and it tells the sponsor that some changes are expected to fail or need adaptation. My first draft presented the changes as a package to implement. The difference matters to executives, because it sets their expectations: a failed test is part of the plan, not a sign that the project is failing.

How the Shifts Showed Up in Meetings

The shifts were visible in team meetings before they reached the proposal. Early in the term, I opened meetings by presenting data and my interpretation. By the middle, I opened with a question, usually about what had happened on the calls that week, and the preoperative nurses did most of the talking. The first time a test missed its prediction, when evening calls took longer than expected because patients had more questions than we anticipated, my first reaction was to defend the idea. The nurses' reaction was to ask what the questions were, and their answer became the basis for a short list of common questions added to the checklist. That meeting taught me more about leading improvement than any reading did, because it showed me the team treating a missed prediction as information while I was still treating it as a threat.

What Has Not Changed Enough

One area still needs work. I remain more comfortable with the technical plan than with the relational work of leadership. The proposal assigns the sponsor the job of securing surgeon office agreement, which is appropriate, but I noticed that I delegated that conversation rather than preparing to have it myself. In the project, I will ask to join the sponsor's first meeting with the office managers, so that I learn how agreement across organizational boundaries is actually negotiated.

Conclusion

Across the term, I moved from designing a study to leading an improvement, from supplying answers to convening the people who have them and from trying to prove a change works to learning how it works here. The final proposal carries the evidence of each shift in its aim, its team charter and its testing ramp. The Model for Improvement's questions about aim, measurement and change (Langley et al., 2009) now read to me less as a template and more as a discipline of honest learning, which I expect to carry into the DNP project.

References

Batalden, P. B., & Davidoff, F. (2007). What is "quality improvement" and how can it transform healthcare? Quality and Safety in Health Care, 16(1), 2-3. https://doi.org/10.1136/qshc.2006.022046

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Reed, J. E., & Card, A. J. (2016). The problem with Plan-Do-Study-Act cycles. BMJ Quality & Safety, 25(3), 147-152. https://doi.org/10.1136/bmjqs-2015-005076