Acclaimed Clinical Leader Offers 4 Steps to Quality Improvement

1. Prioritize quality improvement

To truly improve quality, it must come before everything else, she says.

“When financials are spoken about first, then you’re really not valuing quality,” Scanlon says. “For us, quality is the No. 1 thing that’s discussed first and then financials. Financials are always important—don’t get me wrong—but really, the No. 1 imperative is for quality improvement across the organization.”

Quality improvement will translate into dollars saved, as it did for Northwell Health when some $46 million in direct costs were saved in a single year, she says.

“Our chief financial officer Frank Rizzo [senior vice president and CFO of Northwell Health’s Central Region] really understood this and bought into this and what’s so phenomenal is that our CFOs and our finance individuals truly understand,” she says. “The dollars will come. Quality has to come first.”

2. Create a structure

“The first thing is you have to have an interprofessional collaboration approach to quality improvement,” she says. “You need to bring in exceptional quality improvement leaders—those that are looked at in the organization in terms of respect, in terms of getting the methodology, so that you’re not going in a million places.”

A nursing quality improvement coordinating group should be comprised of both leadership and frontline staff who understand performance improvement modeling, she says. They should: understand how processes and systems will be examined; look at information and data; and talk to stakeholders, which are staff, she says.

She applied these principles as a deputy chief nurse executive when she was seeking to reduce catheter-associated UTIs [CAUTI]. They tested minimally invasive devices that prevented incontinence for incontinent patients, along with trials around ambulation, bladder training, bladder scanning, and intermittent catheterizations, she says.

“Our catheter-associated UTI rate dropped over 60%,” she says. “It was something we were extremely proud of and have been able to sustain and continue to improve across the health system.”

Some hospitals in the Northwell Health system haven’t had a CAUTI all year, she adds.

3. Begin with small steps

“Start with a microsystem,” she says. “Start with small. A test of change. If that test of change works, grow that test of change, but then have a methodology to expand it.”

Many times, clinicians may see, validate, and replicate a change, but they don’t spread the change appropriately, and that must be part of the process, Scanlon says.

Years ago, she used a dashboard for performance improvement that included quality, professional development, certification, baccalaureate rates, master’s rates, operational matrices, turnover vacancy, overtime dollars spent, and patient experience. Because of its success, that dashboard tool eventually was developed and spread within the health system to more than 120 nursing units and 21 hospitals, she says.

“I see a structure process outcome as a constant circle,” she says. “You have this structure; you’re looking at performance improvement; you’re installing processes; then you’re looking at the data and the outcome. And then the structure starts again. So how do I spread that to the next 30 units that I have in a hospital? You have to have buy-in. You have to have discipline in doing this. And you have to have exquisite project management skills.”

4. Engage everyone in quality improvement

Engagement is one of the most crucial elements for performance improvement, and it starts with management and leadership, Scanlon says.

“You have to have leaders that promote shared governance, that promote staff bringing forth ideas, staff doing self-scheduling, and staff being involved. You have to let staff know that you care,” she says. “Mutual respect is everything.”

When Scanlon refers to staff involvement, she means more than clinicians.

“The housekeeper who keeps a room clean and prevents infection is, in my opinion, as important as the nurses and the doctors that care for the patient,” she says. “Every staff member is part of the solution in terms of improving your organization, whether it be quality or engagement or financial performance or patient experience.”

Developing an engaged staff can produce profound quality improvement results, as Scanlon experienced when she sought to reduce pressure ulcers in patients. One way she does this is by enlisting RNs and  patient care assistants (PCA) as frontline champions.

Of Northwell Health system’s 2,600 nurses and PCAs, more than 1,500 of them are some type of champion—facility champion, pressure ulcer, skincare, patient experience, CAUTI, CLABSI [central line-associated bloodstream infections], and quality, she says.

For the pressure ulcer work, more than 100 staff members wanted to be champions in the effort.

“When I came, the [pressure ulcer] numbers were very high,” she says. “We had an exquisite wound care and ostomy nurse, Mary Brennan, and we created an entire process around pressure ulcer and skincare champions.”

“We had over a 90% reduction in pressure ulcers,” she says, crediting the nursing care.

As a result, the “very extremely acute” Northwell hospital with liver and cardiac transplant departments, ended up with just 10 cases of pressure ulcers for an entire year, she says.

“This was really something that I was so most proud of because that’s part of the structure—how to get the frontline staff involved and engaged. But we not only got them engaged, we enriched them. We gave them the tools, the education, and the ongoing support,” she says.

The best quality improvement outcomes occur when everyone is working toward the same goal, she says.

“Everything is team. You can’t do anything by yourself,” she says. “The true heroes of this are nurse managers and our frontline staff—the registered nurses and PCAs. They are the ones who are making this happen every day.”

Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.