Guest Editorial

Article Outline

• Copyright

The goal in choosing the topic of this month's journal was based on my own past experience and apprehension surrounding quality improvement. I always believed that quality improvement was what occurred behind closed doors in meetings held by nursing management, then communicated to us so we could speak to our improved care and safety during surveys. In my quest to comprehend and appreciate quality improvement (QI) and its goal of creating a culture of safety and improving outcomes, I realized that the QI process and my personal focus on providing excellent care at the bedside were one and the same. Quality improvement and safe practice could not occur without a frontline staff, those who are most involved with the patients that are cared for. Another realization was that QI often required change; change from the way we have always done things. Effecting change requires engaging people, which can be a difficult task. It requires recognition of routines, rituals, and the way a culture believes something should be done. It requires leaders, of which we all are, to encourage, motivate, and understand behavior of all staff involved. If I am to spread this culture as a change agent, I realized that QI had to make sense and focus on things we did every day. At its most basic level, quality is doing the right thing, at the right time, in the right way, for the right person. The challenge is knowing what the right thing is, when the right time is, and what the right way is.

Evidence is crucial in the QI process; it is the basis for what the right thing is. Many QI projects are initiated because of inconsistent application of evidenced-based practice. The consequences are unwanted variations in care. This disparity can often be linked to missed opportunities to improve care and at the other end of the spectrum, associated with safety issues and near misses that occur every day.

Although quality is everyone's responsibility and requires a multidisciplinary team approach, nurses are vital in improving the quality of health care delivery. The University of Iowa Hospitals and Clinics present major principles to illustrate the role of the nurse in QI. The first principle is that education is necessary but not enough to change practice behaviors. The second is that implementation is not sustainable unless there is constant tracking of the improvement for the likelihood of sustained change. The third principle is to facilitate doing the right thing. It is okay to encourage intolerance of the status quo. The fourth is that data are transformed into useable and actionable information. The fifth principle is to have a clear focus for implementation. The sixth is coordination among all players (multidisciplinary approach). Finally, the improvement should have a pilot phase or test of change before carrying it out system wide.

In the QI experiences described in this journal, you will see common themes throughout each process improvement. A change was initiated with a single-minded focus identified through a system not working, staff “hunches” regarding practice efficiency, staff observations of practice variation (which are not inevitable but rather preventable), inconsistencies in documentation or parent complaints. Each goal focused on safety and improved outcome. Once the process was chosen, the next step was to educate. It included consistency in evidenced-based content, innovative teaching strategies, and education provided to all who enter the NICU world or who take part in care. Ongoing education was also a key factor utilized for clarification and complete understanding of the process change. Another common theme was empowering the frontline staff to lead the practice change as teams. Staff feedback/buy-in was solicited about the process and practice for consistency and its effectiveness until staff moved from a culture of effort to a culture of results and improved outcome.

“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution” (William A Foster). In this months' journal, our authors demonstrate this skillful execution. The first and final article discuss medication safety. Robin Clifton Koeppel begins by discussing “What nurses can do right now to reduce medication errors in the NICU.” She reminds us that studies have shown a decrease in medication errors through use of technology through Computer Physician Order Entry and a focused awareness by each nurse when administering medications. The final article “Distractions and interruptions: development of a healthcare sterile cockpit” by Susan M. Hohenhaus discussed distractions in health care and our acceptance of “that's the way we do business,” then suggested it be replaced by the adoption of aviations “sterile cockpit” model. Amy Knupp and Kimberly Firestone in “Utilizing consistent education strategies to implement a process change for clinically significant cardiopulmonary events” shared how process improvement in a large NICU can be challenging, but by creating a focused, creative, and consistent education plan, can be accomplished and can ultimately minimize the variability in practice and documentation. Mindy Morris discussed the use of proven QI methods in “Improving nutrition in extremely low birth weight infants: a quality improvement project.” Their approach helped improve nutrition of extremely low birth weight infants, ultimately decreased central line days, and improved infant growth. Sue Ludwig, Jean Steichen, and Jane Khoury shared, “Quality improvement analysis of developmental care in infants less than 1500 grams at birth” and their success with a broad developmental care QI education program. Its effect on infant outcomes revealed a significant increased weight of infants at 36 weeks and a decreased length of stay. Finally, Suzanne Smith's article provided a comprehensive method to train unit technicians/formula technicians in the NICU setting; which further improves quality in the preparation of human milk and specialty formulas.

The practice changes described direct our focus on getting “back to the basics” of daily care. Each example illustrates how focused patient care can improve quality and positively affect patient outcomes. Creating a culture of quality every day with every interaction will make the difference. Aristotle stated, “We are what we repeatedly do. Excellence then is not an art but a habit.”