Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring Its Effect On Nurses' Practice of Patient Safety Goals
Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring Its Effect On Nurses' Practice of Patient Safety Goals
Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring Its Effect On Nurses' Practice of Patient Safety Goals
Abstract
Background: Implementing PDCA (plan- do- check – act) management can improve
patient safety and satisfaction. Head nurse should create and maintain their safety management to
increase the quality of nursing practices regarding patient safety goals practice. The aim of the
study was to investigate the effect of head nurses' and staff nurses' use of PDCA on their patient
safety practices.Design: One group pre-post assessment is used to carry out this study.Subjects:
Two study subjects – head and staff nurses‟.Setting: The study was conducted at inpatient units
in Nasser institute hospital, which affiliated to Specialized Medical Centers of ministry of health.
Tools of data collection: four tools were used for collecting data.Namely:Patient safety and
PDCA knowledge questionnaire for head nurses and staff nurses, Observation checklist for
performance of PDCA process related to patient safety goals for head nurses and staff nurses.
Result:head nurses‟:all head nurses had low satisfaction with patient safety .both before and after
the intervention.none of the head nurses had total adequate practice of PDCA before the
intervention, which increased to 86.7% after the intervention (p<0.001).The intervention, was a
significant positive predictor of the practice scores, whereas age, experience in current
department, and attendance of infection control courses were negative predictors.Staff nurses:
none of the" staff nurses had satisfactory knowledge of patient safety before the intervention,
compared to after the intervention (p<0.001).No staff nurse had adequate practice of PDCA
'before the Intervention, compared to after the intervention (p<0. 001).Conclusion:both head
nurses and staff nurses in the study settinghad deficient knowledge and practice of PDCA as
applied to patient safety goals.Recommendations: The PDCA quality improvement cycle should
be implemented in patient safety as well as in various areas of patient care. The training program
should be applied to all head and staff nurses in the study setting, and should be extended to other
similar setting. Creating and sustaining a culture of quality improvement by using PDCA cycle.
Key words: PDCA, patient safety goals, head and staff nurses.
EJHC 218
Motiaa Farahat Seliem, Mona Mostafa Shazly, & Hemat Abdelazim
methods of improvement. The PDCA Patient safety widely used
cycle is effective in doing a job and definition of patient safety is provided by
managing a program. The PDCA cycle the WHO, in which patient safety is
enables two types of corrective action – defined as the absence of preventable
temporary and permanent (Sokovic, harm to a patient during the process of
Pavletic, &Pipan, 2010). health care (World Health Organization
[WHO], 2009)
Then explained the mode steps as
follows: Plan. In the PDCA cycle, Patient safety is not only the task
planning is the first step. Planning of individual nurses but it is also the
requires processes to identify hazards, responsibility of the head nurse as a
risks and shortcomings in a patient safety leader in their ward. The head nurse
management system, and establish and performs as a manager in the ward and
implement plans for improvement. Do. has a duty toward improving patient
This phase involves several activities, safety. Leadership and management are
such as generating possible solutions, the organizational components to enhance
selecting the best of these solutions, and patient safety (IOM 2004). Meanwhile, in
perhaps using techniques like impact some cases, nurses occasionally make
analysis to scrutinize them. Check: In mistakes because systems, tasks and
this phase, head nurses verify whether processes are poorly designed (Leape et
processes achieved desired results and al., 2002).
effectiveness of the "do" step. Verifying
could mean any form of monitoring or Patient safety goals as a condition
measurement of the activity. Act. If there to be applied in all hospitals are
are discrepancies found between what accredited by the Commission on
was planned and what was done, head Accreditation of Hospitals. Joint
nurses need to analyze the cause and act Commission International (JCI, 2011)
to improve the situation (Yuswardi, published international patient safety
2013). goals consisting of 6 key items, (Identify
Patients Correctly, Improve Effective
The most common methods used Communication, Improve the Safety of
for measuring patient safety are High-Alert Medications, Ensure Correct-
retrospective medical chart review, Site, Correct-Procedure, Correct-Patient,
incident reporting systems, automated Reduce the Risk of Health Care–
surveillance, and administrative or claims Associated Infections - Reduce the Risk
data. Retrospective medical chart review of Patient Harm Resulting from Falls).
remains the "gold standard" for
identifying adverse events. Although Head nurses are responsible for
medical records contain detailed clinical ensuring all staff nurses within their
information on patients, and often contain sphere of responsibility are aware of
information about the safety events and policy, protocol and procedure to identify
the circumstances surrounding it, using patients correctly. They are responsible
them to systematically detect and measure for investigating all incidents of patients'
safety events is not practical. Medical misidentification, ensuring action to
record reviews, particularly when the prevent reoccurrence are implemented
records are paper based rather than (Lucas, 2010).
electronic, are costly, labor-intensive, and
typically involve one or more clinicians Nurses are an important part of the
(Yuswardi, 2013). healthcare system and can improve
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Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring its Effect on Nurses'
Practice of Patient Safety Goals
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Motiaa Farahat Seliem, Mona Mostafa Shazly, & Hemat Abdelazim
services and the second building includes First Part: This part is intended to
all oncology outpatient services, inpatient the head nurse's socio-demographic data
one-day chemotherapy, and pain such as age, gender, qualification,
management clinics. experience (total and in management),
marital status, etc.
Subjects:-
Second part: This part is intended
The study subjects consisted of to assess head nurses' pre-post knowledge
two groups, namely head nurses and staff about Patient safety goals that consisting
nurses. of 6 key items, 1) Identify Patients
Correctly, 2) Improve Effectiveness of
1- Head nurses group: All the head Communication, 3) Improve the Safety of
nurses working in the above- High-Alert Medications, 4) Ensure
mentioned settings was included in Correct-Site, Correct-Procedure, Correct-
the study. Their total number is 30 Patient, 5) Reduce the Risk of Health
head nurses. Care–Associated Infections and 6)
Reduce the Risk of Patient Harm
2- Staff nurses group: total number of Resulting from Falls, and PDCA process
staff nurses was participated in the that included four-step improvement
study (n= 50 staff nurses) this process that begins with planning the
number according to criteria for intervention, implementing the change,
inclusion in the main study sample measuring results, and using the result to
(experience more than one year plan further improvements in the system.
working in the current department
and work full time). Tool 2
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Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring its Effect on Nurses'
Practice of Patient Safety Goals
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Motiaa Farahat Seliem, Mona Mostafa Shazly, & Hemat Abdelazim
Preparatory phase: Planning Phase: during this phase
the researcher was analyzed the data
This stage started from August collected to identify the knowledge
2016 till February 2017 It took 6 months; deficiencies and gap between head and
the researcher reviewed the national and staff nurses, which considered during
international related literature concerning developing the training program.
the topic of the study and developed the
study tools .Tools were validated by jury Implementation Phase: The
group which consists of, two professors researcher divided the head and staff
of nursing faculty from Cairo university, nurses into small groups according to
three doctors worked as quality availability and workload for conducting
consultant, and two pharmacist worked as the training. Each group had two sessions
quality consultant. The necessary on Saturdays and Thursdays, and one
modifications of the tools were done session on the other days of the week.
based on jury opinion. The duration of each session was two
hours. The program sessions were from
Pilot study: 8:00 am to 10:00 am and from 10:00 am
to 12:00 pm. This program was divided
A pilot study was carried out on a into two parts, one for head nurses and
sample of (3) head and (5) staff nurses another one for staff nurses. For head
from another setting representing about nurses, each subgroup had 20 hours
10% of study sample. The aim is to test training (13 theoretical and 7 practical).
the clarity and applicability of the tools For staff nurses, each subgroup had 18
and the time needed for filling them in. hours (12 theoretical and 4 practical). The
Necessary modifications were done program was implemented throughout
according to the results of the pilot study. one and half month, from April first to
The reliability of the tools was tested at March 15 2017. They were divided into
this phase as applicable.The reliability of subgroups. Each subgroup was given two
the practice checklists was assessed using sessions per week. Sessions included
Guttman split-half method. The analysis group discussions, mini-lectures, and
demonstrated very high reliability for the actual practice.
head nurse form, with coefficient 0.94.
For staff nurse form, the reliability was Evaluation phase: after
just acceptable with a coefficient 0.50. completion of the training program, the
effectiveness of the program was assessed
Field Work: through posttest for knowledge and
practice of head and staff nurses.
Data collection of the study was
started at the beginning of March 2017, Statistical Design:
and completed by the 15thof June 2017
through four phases: Data entry and statistical analysis
were done using SPSS 20.0 statistical
Assessment Phase: up on software package. Data were presented
securing all permission to conduct the using descriptive statistics in the form of
study. The data was collected during this frequencies and percentages for
phase constituted the pretest or baseline qualitative variables, and means and
for the study. standard deviations for quantitative
variables. Qualitative categorical
variables were compared using chi-square
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Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring its Effect on Nurses'
Practice of Patient Safety Goals
Table (1): Demographic characteristics of head nurses in the study sample (n=30)
Frequency Percent
Age:
<40 16 53.3
40+ 14 46.7
Range 29.0-57.0
Median 38.5
Nursing qualification:
Diploma 11 36.7
Bachelor 19 63.3
Experience years (total):
<20 17 56.7
20+ 13 43.3
Range 6.0-40.0
Median 15.5
Experience years (current dept.):
<5 14 46.7
5+ 16 53.3
Range 1.0-35.0
Median 5.0
Experience years (current position):
<10 12 40.0
10+ 18 60.0
Range 3.0-35.0
Median 14.5
Attended training courses in:
Infection control 21 70.0
Patient safety 12 40.0
Quality 1 3.3
Total courses attended:
Range 0-3
Median 1.0
Table (1): The head nurses in the study sample were all females whose age ranged
between 29 and 27 years, median 38.5. Their medians years of total, current department, and
current position experience were 15.5, 5.0, and 14.5 respectively. Slightly more than two-
thirds of them had previously attended training courses in infection control (70.0%), while
only one (3.3%) had training in quality.
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Motiaa Farahat Seliem, Mona Mostafa Shazly, & Hemat Abdelazim
Table (2): Satisfaction with knowledge of patient safety goals as reported by head
nurses before and after the intervention
Table (2):illustrated the scores of head nurses' satisfaction with patient safety were
low before the intervention, and. even decreased after the intervention. The decreases were
statistically significant regarding patient identification (p=0.02), bed sores (p=0.004) and
patient fall (p<0.001). In total, the total score of satisfaction decreased from 51.4 to
38.81froma maximum of 100 (P=0.00 1).
Table (3): Total practice of PDCA in patient safety goals among head nurses before
and after the intervention
Time
Practice of PDCA in: Pre (n=30) Post (n=30) X2 test p-value
No % No %
Identify patient correctly:
Adequate (60%+) 0 0.0 23 76.7 37.30 <0.001*
Inadequate (<60%) 30 100.0 7 23.3
Effective communication:
Adequate (60%+) 0 0.0 27 90.0 49.09 <0.001*
Inadequate (<60%) 30 100.0 3 10.0
High alert medications:
Adequate (60%+) 0 0.0 19 63.3 27.80 <0.001*
Inadequate (<60%) 30 100.0 11 36.7
Correct procedures:
Adequate (60%+) 0 0.0 27 0.0 55.00 <0.001*
Inadequate (<60%) 28 100.0 0 100.0
Nosocomial-infections reduction:
Adequate (60%+) 0 0.0 27 90.0 49.09 <0.001*
Inadequate (<60%) 30 100.0 3 10.0
Fall risk reduction:
Adequate (60%+) 0 0.0 28 93.3 25.50 <0.001*
Inadequate (<60%) 30 100.0 2 6.7
(*) Statistically significant at p<0. 05
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Table (4): Correlation between head nurses' knowledge and practice scores and their
characteristics
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Motiaa Farahat Seliem, Mona Mostafa Shazly, & Hemat Abdelazim
Frequency Percent
Age:
<30 20 40.0
30+ 30 60.0
Range 19.0-55.0
Median 32.0
Gender:
Male 3 6.0
Female 47 94.0
Marital status:
Unmarried 16 32.0
Married 34 68.0
Nursing qualification:
Diploma 49 98.0
Bachelor 1 2.0
Experience years (total):
<20 35 70.0
20+ 15 30.0
Range 1.0-28.0
Median 10.5
Experience years (current dept.):
<5 17 34.0
5+ 13 66.0
Range 1.0-20.0
Median 7.0
Experience years (current position):
<10 23 46.0
10+ 27 54.0
Range 1.0-28.0
Median 10.0
Attended training courses in:
Infection control 32 64.0
Patient safety 14 28.0
Quality 2 4.0
Total courses attended:
Range 0-1
Median 0.0
Table (5): The sample of staff nurses consisted mainly of females (94%) whose age
ranged between 19 and 55 years, median 32.0. Almost all of them were diploma degree
nurses (98%), and the majority was married (68%). Their medians years of total, current
department, and current position experience were 10. 5, 7.0 and 10.0 respectively. Slightly
less than two-thirds of them had previously attended training in infection control (64.0%),
while only two (4.0%) had training in quality.
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Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring its Effect on Nurses'
Practice of Patient Safety Goals
Table (6): Satisfaction with knowledge of patient safety goals as reported by staff
nurses before and after the intervention
Table )6(:As displayed in, the scores of staff nurses' satisfaction with patient safety
tended to be high before the intervention, and decreased after the intervention The decreases
were statistically significant in all areas of patient safety (p<0.001) The total score of
satisfaction decreased from 80.9 before the intervention to 50.4 after the intervention from a
maximum of 100 (p<0.00 1).
Table (7): Practice of PDCA in patient safety goals among staff nurses before and
after the intervention
Time
Adequate (60%+) practice in: Pre (n=50) Post (n=50) X2 test p-value
No. % No. %
General patient safety solutions:
Two-way identification 0 0.0 40 83.3 70.40 <0.001*
Hand hygiene 0 0.0 25 52.1 34.38 <0.001*
Single injection devices use 0 0.0 49 98.0 96.08 <0.001*
Critical value tests list 5 10.4 50 100.0 79.81 <0.001*
Verbal/telephone orders 0 0.0 19 67.9 26.44 <0.001*
Catheter/tubing misconnection 0 0.0 35 79.5 54.55 <0.001*
Fall risk reduction 0 0.0 26 74.3 39.69 <0.001*
Reduce pressure ulcers 0 0.0 21 80.8 28.77 <0.001*
Handover communication 0 0.0 42 84.0 72.41 <0.001*
Medication management:
Look-like sound-like medications 1 2.1 30 62.5 40.07 <0.001*
Concentrated electrolytes 1 2.0 48 96.0 88.40 <0.001*
Concentrated medications 1 2.0 50 100.0 96.08 <0.001*
All medications labelled 0 0.0 33 66.0 47.76 <0.001*
Operative/invasive procedures: Correct 0 0.0 40 97.6 71.08 <0.001*
patient
(*) Statistically significant at p<0.05
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Motiaa Farahat Seliem, Mona Mostafa Shazly, & Hemat Abdelazim
Concerning staff nurses' practice of PDCA in patient safety, Table 16 indicates that
none or almost none of them had adequate practice in any of the areas before the
intervention. At the post-intervention phase, there were statistically significant improvements
in all areas. This reached 100% adequate regarding critical value test list, and concentrated
medications
Table (8) Total practice of PDCA in patient safety goals among staff nurses before
and after the intervention
Time
Adequate (60%+) practice in: Pre (n=50) Post (n=50) X2 test p-value
No. % No. %
General 0 0.0 45 90.0 81.82 <0.001*
Medications 0 0.0 46 92.0 85.19 <0.001*
Operative/invasive 0 0.0 40 97.6 71.08 <0.001*
(*) Statistically significant at p<0.05
Table (9): Correlation between staff nurses' knowledge and practice scores and their
characteristics
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Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring its Effect on Nurses'
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Motiaa Farahat Seliem, Mona Mostafa Shazly, & Hemat Abdelazim
intervention was due to their deficient this, a study in Brazil highlighted the
knowledge about PDCA. Thus, when importance of staff development activities
their knowledge was improved after the in enhancing nurses‟ performance related
intervention, this was positively reflected to patient safety (Paranaguá et al., 2016).
on their practice scores. Similar findings
were reported by Bauer et al. (2015) in a Conclusion
study on operating room nurses in
Germany. The study results lead to the
conclusion that the implementation of a
Concerning head nurses‟ personal training program is successful in
characteristics having significant effects improving head and staff nurses‟ related
on their knowledge and practice, the knowledge and practice. Moreover, the
present study results revealed a negative program is effective in increasing the
correlation between their age and the reporting of incidents related to patient
knowledge scores. Moreover, the safety. The score of head and staff nurses‟
multivariate analysis demonstrated that knowledge and practice are positively
head nurses‟ age and experience in correlated.
current department were negative
predictors of their practice scores. This Recommendations
might be explained by that the younger
age head nurses who have been relatively
more recently appointed to managerial The PDCA quality improvement
positions might be more aware of cycle should be implemented in patient
innovative approaches and techniques to safety nursing as well as in various areas
better patient safety management due to of patient care.
more freshness of their knowledge and
also due to more innovative graduate and The training program should be
postgraduate nursing recent curricula. In applied to all head and staff nurses in the
line with this, a study in the United States study setting, and should be extended to
demonstrated the success of training other similar setting.
nursing students in PDCA as a quality
improvement tool in enhancing their Conduct a hospital wide
related competencies (Flores et al., awareness campaign to increase
2013). healthcare providers as (head nurses, staff
nurse) with importance of patient safety
According to the current study goals and PDCA posters, videos and
results, almost none of the head nurses as meetings.
well as the staff nurses had adequate
practice of PDCA as applied to patient Periodical meeting must be
safety. While the finding could be conducted to discuss barriers that inhibit
expected among staff nurses, it was not implementation of patient safety goals,
expected that almost all head nurses had and solve any incident report related
no awareness of this important approach medical errors and set action plan to help
to quality care in patient safety. This the organization to improve patient safety
could be again due to lack of staff practice.
development activities to improve their
knowledge and skills in quality as shown Periodical assess level of
by the scarcity of attendance of such knowledge related to patient safety
training among them. In congruence with ,quality and PDCA
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Implementation of (Plan-Do-Check-Act) Process of Quality and Measuring its Effect on Nurses'
Practice of Patient Safety Goals
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