Linking quality measures to clinical practice

Continuous Quality Improvement (CQI) is a process of creating an environment in which administration, healthcare workers, and ancillary staff strive to generate consistent quality outcomes. Many long-term care facilities establish benchmarks associated with state and federal regulatory compliance, staff turnover, budgets, occupancy, and quality care. Long-term care staff strives to address problems in a timely manner with the goal of avoiding a repeating occurrence. However, positive outcomes can best be achieved by linking quality measures to clinical practice. This 5-step pyramid design is just one example of a problem-solving process using a bottom-up approach to achieving quality outcomes.

Step one

The first step at the base of the pyramid starts with data collection of an identified problem or concern within the healthcare facility. This information is queried from a computer database or from a file folder of variance reports. Most problems are prioritized based on resident safety and department goals.

Step two

The next step of the problem-solving process is aimed at identifying the root cause of problems as opposed to merely addressing the immediate obvious symptoms in a reactive format. To determine an effective corrective course of action for a problem it is necessary to conduct an investigation and draw conclusions supported by the documented evidence. A fishbone diagram (also known as a cause-and-effect tool) is used to show the causes of an event. It is one technique used to frame a problem for causal analysis.

Step three

Once the root cause of the problem is determined, the third step is to implement research findings as a means of increasing the quality of care in the most cost-efficient manner. The John A. Hartford Foundation has translated qualitative research and clinical practice into evidence-based geriatric assessment tools known as the “Try This” series ( These evidence-based practice tools provide knowledge and enhance nursing skills at the bedside when providing care to older adults.

Step four

Once the root cause has been identified, the interdisciplinary team comes together in a shared decision-making process known as shared governance. The interdisciplinary team uses the principles of partnership, equity, accountability, and ownership developed by Tim Porter-O’Grady, EdD, APRN, FAAN, ( to select and implement the most appropriate action plan or evidence-based practice tool. Shared governance empowers all staff at the time of decision making and with implementation of new ideas and evidence-based protocols when striving for quality care outcomes.

Step five

Next, members of the interdisciplinary team and quality assurance committee, along with administrative support, come together to establish benchmarks aimed at improving or eliminating the identified problem. This final step involves monitoring internal compliance of established systems and processes, setting performance goals, and ongoing evaluation using a measurement matrix. Implementing a measurement matrix tool will encourage and reinforce the delivery of evidence-based practices and assures healthcare delivery system transformation to achieve efficient and positive quality care outcomes.

In the face of healthcare reform today, directing, managing, and delivering nursing care remains a challenging and ever-evolving task in any healthcare facility. Equipping nurses and members of the interdisciplinary team with a simple five-step CQI (pyramid) process will not only strengthen critical-thinking skills but guide them into safer practice at the bedside and on their units.

Thus, at the end of the day, we all go home feeling good about the care provided for each resident, and for achieving the quality standards established by the healthcare administrative team.

Nancy Kollmann, RNC, MSN, MBA/HCM, FNGNA, is Chief Operating Officer at Cherrywood Advanced Living in Sauk Rapids, Minnesota. For more information, call (320) 257-1647 or e-mail Long-Term Living 2010 September;59(9):18-19

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