In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of performance improvement and risk management in order to:

  • Define performance improvement/quality assurance activities
  • Participate in performance improvement/quality improvement process
  • Report identified client care issues/problems to appropriate personnel (e.g., nurse manager, risk manager)
  • Utilize research and other references for performance improvement actions
  • Evaluate the impact of performance improvement measures on client care and resource utilization

Measuring the quality has evolved, further developed, and become more regulated and refined over the last decades. It has transitioned and transformed from quality control, to quality assurance, to quality improvement, to performance improvement and continuous quality improvement. It has also transitioned from an emphasis on structures, to an emphasis on process, and now to an emphasis on outcomes, including patient outcomes.

The goal of performance improvement and performance improvement studies is to enhance and improve the outcomes of care, to insure client safety, to increase the efficiency of patient care and related processes, to reduce costs and to reduce risks and liability.

Additionally, performance improvement activities are mandated by external regulatory and credentialing agencies and bodies like the state departments of health, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and the Centers for Medicare and Medicaid (CMS).

Performance improvement activities include the:

  • Identification of an opportunity for improvement
  • Convening and organizing a group or team to work on the quality improvement activity. This team should have members who are close to the process under study.
  • Collection and analysis of data and information including, but not limited to, individual client data, aggregated data for populations of clients, best practices, standards of care, evidence based practices, research studies and the professional literature
  • Close and collaborative examination and exploration of the process at hand that is being explored
  • Elimination of variances that adversely affect client care and the quality of the client care provided

The most effective quality improvement activities should focus on areas that have the greatest risk, the greatest costs in terms of both human and monetary costs, the greatest volume, and/or the most problem prone.

Defining Performance Improvement/Quality Assurance Activities

Some of the terms and concepts relating to performance improvement that you should be familiar with and able to apply for your NCLEX-RN examination include:

The Culture of Safety

The healthcare organization must establish and maintain a culture of safety within it in order for the organization to benefit from effective performance improvement activities to promote high quality and safe care for its clients. This culture and the associated values and beliefs must be integrated into all of the healthcare organization's staff members from upper management to the front line employees.

A Blameless Environment

Performance improvement and risk management activities must be conducted in a blame free environment that focuses on the issues and ways to improvement processes and NOT who made the mistake. Errors and problems in a blameless and blame free environment are viewed as opportunities for improvement and not opportunities to blame and punish those who erred. These activities aim to prevent problems and concerns by making all processes fail safe and NOT subject to human error.

Root Cause Analysis and A Blame Free Environment

Root cause analysis, a process that is used with and for performance improvement activities, within the blame free environment of the healthcare organization and in keeping with its philosophy and culture of safety, explores and digs down to the roots of the problem, its root causes and the things, not people, that are the real reasons why medical errors and mistakes are made.

These root causes are typically faulty processes and processes and procedures that have some points of risk and vulnerability and that place the healthcare organization at risk for errors and future errors. For this reason, the question "Why", rather than "Who", is asked repeatedly during root causes analyses to dig down to the root causes of the problem to find out why and NOT to find out who is the source of the problem.

Sentinel Events

A sentinel event is an event or occurrence, incident or accident that has led to or may possibly lead to client harm. Even near misses, that have the potential for harm, are considered sentinel events because they have the potential to cause harm in the future.

Some sentinel events, like the suicidal death of a client, are legally mandated to be reported to the state; other sentinel events should additionally be reported to the Joint Commission on the Accreditation of Healthcare Organizations. All sentinel events, however, should be studies, explored and investigated in order to prevent future events, occurrences, incident or accident.

Some of the most commonly occurring medical error sentinel events that affect healthcare organizations can include medical errors such as falls, adverse drug reactions, medication errors, suicide, infant abduction, the retention of a foreign body when surgery has been done, wrong patient, wrong site and wrong procedures and treatments, treatment delays, and complications like infections and other unanticipated events that can occur after a treatment or procedure.

Variance Tracking

Identifying variances and analyzing variances are integral to performance improvement and performance improvement activities. As previously mentioned, variances can include patient related, healthcare provider and organizational variances from the expected.

Variances are also described as "specific" or "random". Random variances happen when the process is faulty and/or prone to human error; and random variances occur when one part of the process is faulty and/or prone to human error. Specific variances occur whenever the faulty process is carried out; and random variances occur at sporadic, unpredicted and random times when the faulty process is carried out.

Performance and Quality Indicators

Core Measures: Quality indicators can be classified as core measures and outcome measures. Core measures are standardized measures of quality put forward by the Joint Commission on the Accreditation of Healthcare Organizations' (JCAHO) ORYX National Hospital Quality Measures that address populations of clients such as the geriatric and pediatric populations, diseases such as pneumonia, sepsis and heart failure and pneumonia, and also organizational measures like those used in the intensive care areas and the emergency departments

Performance and Quality Indicators

Outcome Measures: Outcomes measures explore and study the outcomes of client care. For example, lengths of stay, MRSA infection rates, the effectiveness of falls risk screening in terms of identifying clients at risk of falls, the effectiveness of falls risk interventions to prevent falls, mortality rates, morbidity rates, infection rates related to healthcare acquired infections, and readmissions may be explored and studied as an outcome measure.

Risk Management

Risk management focuses on decreasing and eliminating things that are risky and place the healthcare organization in a position of liability.

Risk management activities focus on healthcare related hazards and adverse events such as patient falls, infant abduction, medication errors, healthcare acquired infections, wrong site/wrong person surgeries and other invasive treatments and tests. identifies and eliminates hazards relating to basic safety such as falls, hospital acquired infections and infant abduction, a wide variety of medical errors such as wrong site surgery, wrong patient surgery and medication errors.

JCAHO has requirements relating to medical errors in terms of reporting sentinel events and the elimination of hazards using root cause analysis. Risk assessments of the client, their condition, and the environment of care are done to decrease liabilities and potential lawsuits. A falls risk assessment and a risk assessment for skin breakdown are two mechanisms that decrease liabilities and risks associated with the client and their condition.

Participating in Quality Improvement (QI) Activities

Registered nurses are often asked to participate in performance improvement/quality improvement activities.

Often, nurses participate in quality improvement activities as part of a team. A team is a group of people who work together to achieve a common goal. Some of the professional roles and responsibilities that a nurse can assume in terms of quality improvement include identifying and reporting problems and opportunities for improvement, collecting performance improvement related data, serving on a performance improvement/quality improvement group or team, implementing performance improvement/quality improvement recommended corrective actions into their nursing practice, and measuring and collecting data that evaluates the outcomes of performance improvement activities and corrective actions.

Teams and group work are highly beneficial to performance improvement and performance improvement activities, particularly when those closest to the process under study are included as valued members of the group.

These group or team members have the most knowledge about the process under study and how and when it negatively impacts on client care. Unlike members of upper level management and administration, these group members at the front line are exposed to the issue at hand on a regular and frequent basis, and its nuances within the context of care. They are also highly skilled in terms of their abilities to clearly identify not only established discrepancies in the formalized, and documented, process and procedure but also able to identify discrepancies and inconsistency in terms of how people execute and deviate from the formalized, and documented, process and procedure.

The seventeen characteristics that effective team members possess, according to Maxwell, include:

  1. Dependability: They can be counted on to participate and contribute to the group and their group work without fail.
  1. Adaptability: Group members must be flexible, able to adapt to changing situations and circumstances and achieve the group's goals and fulfill its mission.
  1. Awareness of the Mission: Members must be motivated by and thoroughly knowledgeable about the mission of the group.
  1. Superior Communication Skills: Effective and respectful communication and active listening without any judgments are essential to group success.
  1. Effective Collaboration Abilities: Cooperation is not enough; active and effective collaboration is essential to group success.
  1. Self – Discipline: Teams members must be disciplined enough to want to succeed and produce the expected goals of the group.
  1. Selflessness: The team member values and has loyalty to the group and its work despite the fact that they have personal goals and interests.
  1. Commitment: Group members must be committed to the mission, goals and work of the group despite potential barriers such as interpersonal conflicts.
  1. Enthusiasm: Effective group members are not only committed to the group and its work, but they are also energized with their participation and enthusiastic about the group and its work.
  1. Competency: The person has the knowledge, skills and abilities to perform both clinically and as a group member who has had some formal or informal education relating to groups, group development and how to function as a group member and group leader.
  1. The Ability to Add Value: Group members are effective when they have the knowledge, skills and abilities to add value to the group and the work of the group.
  1. The Ability to Be Prepared: Team members must be prepared and ready to serve as a member of the group, attend all meetings and to perform their assigned tasks in relationship to the group's mission and goals.
  1. Intention: All team members must be able to do the right thing in all aspects of group work.
  1. The Ability to Improve Self and Self-Reflect: Self-reflection entails the constructive criticism of self and changing oneself when this self-reflection indicates the need to do so. These actions promote and facilitate not only individual growth but also group growth and development.
  1. The Ability to Focus: Group members must be able to focus and maintain focus on the mission and the goals of the group without distraction. Team members must be able to maintain their focus on the group and its work, and NOT on people that may have led to the problem or concern that is being explored by the group.
  1. Perseverance and Tenaciousness: Members of the team must persevere and be tenacious when they act as a member of a team.
  1. The Ability to Form and Maintain Relationships: Lastly, effective team members must be able to form and maintain interpersonal relationships with others inside and outside of the group in order to achieve group goals.

Although there are several different types of teams, all effective teams, including performance improvement teams, have several common characteristics including:

  • A mission or charter that is clear and not ambiguous
  • A common shared mission that is bought into by all team members
  • Formal and informal roles within the team such as a group leader or facilitator
  • The ability to access data and information
  • Open communication and the free expressions of members' perspectives, thoughts, beliefs and opinions
  • An open environment of trust, mutual support, cooperation, respect and respect
  • An environment and norms that promote divergent thought and differences of opinions without any judgements

Teams are synergistic; the group as a whole has collective wisdom, powerful and additive interactions, and the ability to produce more than one individual alone. The whole is greater than the sum of the parts.

Although teamwork and group work are more time consuming than solo work, teams maximize the many and diverse skills of different healthcare disciplines, especially when teams are used for performance improvement activities.

Performance improvement activities can follow several methods including the PDCA cycle which is Planning, Doing, Checking and Acting, Six Sigma method that includes definition of the problem, measurements, analysis, improvements and control to achieve zero defects, and any other currently popular "method de jour", however, all performance improvement activities have these general steps:

  • The definition of the problem or opportunity for improvement
  • The collection of data and information relating to the problem or opportunity for improvement
  • The organization and analysis of the collected data and information that includes, but is not limited to, the comparison and contrasting of this data to standards of care, best practices, benchmarks, legal mandates and the recommended standards put forth by agencies such as the Joint Commission on the Accreditation of Healthcare Organizations.
  • Root cause analysis to dig down to the possible causes of the problem
  • Generating a list of possible solutions and alternatives of action to solve the problem and/or improve the quality of care
  • Selecting the solution or alternative of action that is not only feasible but also the one that has the greatest possibility of success
  • Initiating and implementing the best solution or corrective action
  • Measuring the effectiveness of the implemented solution or corrective action in terms of its success.

All performance improvement/ quality improvement activities are documented. For example, data is collected and documented, the minutes of committee meetings and corrective action plans are documented.

Reporting Identified Client Care Issues and Problems to Appropriate Personnel

Nurses must immediately report a client care issue, concern or problem to the supervising nurse, the charge nurse and/or the performance improvement or risk management department according to the reporting policies and procedures of the particular facility.

Although the formal mechanisms that can be used by nurses to report identified client care issues, problems, sentinel events that have caused harm in addition to "near misses", may vary somewhat among different healthcare facilities, however, they are many commonalities. Most facilities have mechanisms that define and describe:

  • The channels of oral communication through which client care issues, concerns or problems are orally communicated as soon as they are discovered.
  • The forms and the other documents that are used to formally document and report client care issues, concerns or problems
  • The names of and/or the departments that will receive oral and written notification and reporting of client care issues and problems. Some of these people and departments are the nursing supervisor, the quality assurance staff, the risk management department and the nurse manager.

Utilizing Research and Other References for Performance Improvement Actions

Some of the pertinent research and other references that nurses, and other healthcare providers, utilize include:

  • Published articles in the professional literature
  • Valid and sound research studies
  • Benchmarks
  • Standards of practice
  • Standards of care
  • Published evidence based practices
  • Pertinent laws
  • Pertinent ethical codes
  • Pertinent standards and regulations such as those of the Joint Commission on the Accreditation of Healthcare Organizations

Evaluating the Impact of Performance Improvement Measures on Client Care and Resource Utilization

The impact of performance improvement activities and performance improvement measures to increase the quality of care can be measured using a number of different measurement techniques and strategies including:

  • The comparison of pre and post corrective action data
  • A determination of whether or not action plans were effective in terms of client safety, increasing levels of effectiveness and timeliness of care and services to the individual client or groups of clients, decreasing levels cost, a decrease in terms of patient related incident and accidents such as healthcare acquired infection rates and falls that result in injury.
  • A determination of whether or not action plans were effective in terms of eliminating waste, decreasing the use of unnecessary services, and properly using the appropriate resources at the appropriate level of care


SEE – Management of Care Practice Test Questions

Alene Burke, RN, MSN
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