NURS 8301 Week 5 QI Framework Selection Paper Example

Letting the Project's Constraints Vote: Selecting the Model for Improvement, With Two Lean Tools Inside It, for a Surgery Cancellation Aim

Student Name

College of Nursing, Walden University

NURS 8301: Effectively Leading Organizations in Quality Improvement Initiatives

Instructor Name

Month Day, Year

Letting the Project's Constraints Vote: Selecting the Model for Improvement, With Two Lean Tools Inside It, for a Surgery Cancellation Aim

A Different Argument From Last Time

Choosing a framework for one's own project is a different argument from comparing frameworks in general, because the project's constraints now vote. The project's aim, set in an earlier paper for the general surgery and urology cases of a composite outpatient surgery department, is to bring avoidable patient-readiness cancellations down from an illustrative 3.8% of scheduled cases to no more than 1.5% of scheduled cases within nine months, using illustrative baseline figures. This paper states five weighted criteria, scores three candidate approaches against them and selects one: the Model for Improvement, with two Lean tools embedded in it. The candidates are the Model for Improvement on its own terms, a Six Sigma project run through its five DMAIC phases and a stand-alone Lean rapid improvement event, a concentrated week of redesign.

Criteria and Weights, Stated Before Scoring

The criteria follow from the project's constraints. The team is small: two preoperative nurses, a scheduler, an anesthesia representative and a surgeon office manager, meeting for an hour a week. The problem crosses organizational boundaries, since instructions begin in surgeon offices outside the department. Several candidate changes, such as altering medication-hold instructions, carry safety risk. Data are limited to a monthly cancellation log with reason codes. And the department has little prior experience with formal improvement methods.

From those constraints come five criteria. Fit with a cross-boundary process problem (weight 3) asks whether the approach can see and change a process spanning several groups. Safe testing of changes (weight 3) asks whether changes can be tried on a small scale before adoption. Feasibility for a small, part-time team (weight 2) concerns training and time demands. Fit with available data (weight 1) asks whether the approach can work with a monthly log and simple counts. Support for learning in a department new to improvement (weight 1) asks whether the approach builds capability as it goes. Each approach is scored from 1, poor fit, to 3, strong fit, and weighted scores are summed.

Scoring

Table 1 shows the results.

Table 1

Weighted Scores for Three Approaches

Scores in parentheses are weighted. The Model for Improvement scores highest, but the Lean event scores highest on process fit, which shapes the final design.

Why the Model for Improvement Leads

The Model for Improvement leads on the criteria this project weights most heavily after process fit. Its structure of an aim, measures and changes tested through Plan-Do-Study-Act cycles lets the team try a change, such as an evening readiness call for one surgeon's patients, on a few patients before spreading it (Langley et al., 2009). That matters because some changes touch medication instructions, where an untested change could cause harm. It suits a small team meeting weekly, works with simple monthly counts and run charts and builds the department's capability through repeated cycles.

The method is often applied loosely, however. When Taylor and colleagues examined how published projects had used PDSA, many did not report key features such as iterative cycles, predictions or data collected over time (Taylor et al., 2014). Choosing the model therefore commits the team to documenting each cycle's prediction and result, not just calling its work PDSA.

Why Six Sigma Does Not Lead

Six Sigma's strength is reducing variation in a defect through statistical analysis of causes. The cancellation problem can be framed as a defect, a case that did not proceed, but its causes are largely known from the reason codes, and the bigger challenge is changing a process across groups, not identifying causes statistically. Six Sigma projects also typically require trained belts and more detailed data than a monthly log provides. Published Six Sigma work in hospitals mostly reports success, but the studies behind those reports tend to be weakly designed (DelliFraine et al., 2010), which gives no reason to prefer it here over a lighter method.

Why Not a Stand-Alone Lean Event

A Lean rapid improvement event scored highest on process fit, because mapping the flow of instructions from surgeon office to patient to department is exactly what Lean does well. Reviews of Lean in health care report improvements in process measures across many settings (D'Andreamatteo et al., 2015). But a week-long event would require pulling surgeon office staff and preoperative nurses away for days, which the department cannot staff, and events tend to implement changes quickly rather than test them, which scores poorly on safe testing.

The Hybrid: Two Lean Tools Inside the Model

The selected design uses the Model for Improvement as its frame and embeds two Lean tools. The first is a process map of patient preparation, from the surgeon's decision to operate to arrival on the day, built in two short sessions with each group. It will show where instructions are given, repeated, contradicted or lost. The second is standard work with error-proofing, a single readiness checklist and script used by every nurse on the readiness call, designed so that fasting, medications, escort and testing are confirmed every time. Both tools will generate change ideas that are then tested through PDSA cycles rather than adopted outright.

This design keeps Lean's strength in seeing a cross-boundary flow while meeting the project's need for safe, small tests and a light burden on a small team.

The scores also carry a warning. The hybrid depends on the process map being built with the surgeon office staff present, since the scoring gave Lean its highest mark for seeing the whole flow. If the offices do not take part, the map will show only the department's half of the process, and the change ideas will cluster there. The team's first task is therefore to secure two hours from each participating office, and the project sponsor has agreed to make that request directly.

References

D'Andreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015). Lean in healthcare: A comprehensive review. Health Policy, 119(9), 1197-1209. https://doi.org/10.1016/j.healthpol.2015.02.002

DelliFraine, J. L., Langabeer, J. R., II, & Nembhard, I. M. (2010). Assessing the evidence of Six Sigma and Lean in the health care industry. Quality Management in Health Care, 19(3), 211-225. https://doi.org/10.1097/QMH.0b013e3181eb140e

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.

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862