Module 1

CARE QUALITY

The Provincial Perspective

Health Quality Ontario (HQO) is a provincial agency that advises the government and
healthcare providers regarding strategies to “support high-quality care, to support improvements
in quality, and to monitor and report to the public on the quality of healthcare provided in
Ontario” (MOHLTC, 2010, p. 1). The agency received this mandate through the Excellent Care
for All Act (ECFAA), 2010. The goal of ECFAA “... is to transform the healthcare system by
creating greater public accountability, increasing the focus on quality, bringing patient
satisfaction to the forefront and basing patient care decisions on the best scientific evidence
available.” (MOHLTC, p. 1 ).

HQO (2017a) has identified six elements of a quality care system. These words used to
describe these elements are:
●​ Safe
●​ Effective
●​ Patient-centred
●​ Efficient
●​ Timely
●​ Equitable
Safe Care

●​ Client perspective
○​ I will not be harmed by the health system – physically, emotionally, or otherwise.
●​ Nurse perspective
○​ The care my patient receives does not cause harm.
○​ I am not at risk of injury or accidents while providing care.

Effective Care

●​ Client perspective
○​ I receive the right treatment for my condition, and it contributes to improving my
health.
●​ Nurse perspective
○​ The care I provide is based on best evidence.
○​ The care I provide produces the desired outcomes.

Patient-centred Care

●​ Client perspective
○​ My goals and preferences are respected.
○​ My family and I are treated with respect and dignity.
●​ Nurse perspective
○​ Decisions about my patient’s care reflect the patient’s goals and preferences, as
well as those of their family or caregivers
Efficient Care

●​ Client perspective
○​ The care I receive is well coordinated and not duplicated.
○​ The value of my time is respected.
●​ Nurse perspective
○​ I deliver care using available human, physical, and financial resources efficiently,
with no waste to the system.

Timely Care

●​ Client perspective
○​ I know how long I have to wait and why for any tests or treatments.
○​ I am confident that the wait time is safe and appropriate.
●​ Nurse perspective
○​ My patient can receive needed care within an acceptable timeframe after the
need is identified.

Equitable Care

●​ Client perspective
○​ No matter who I am or where I live, I can access services that benefit me.
○​ I am fairly treated by the healthcare system.
●​ Nurse perspective
○​ Every individual receives high-quality care that is fair and appropriate, regardless
of location, background, or socioeconomic status.

The Nurse’s Role in Quality

The healthcare system is complex, and it will take all of us in the system to create changes that
will improve the quality of care that is delivered. It is no longer the responsibility of just the
formal leaders to create change. Given that nurses are the largest group of healthcare providers
and have the most contact with patients, nurses are in an ideal situation to observe and address
quality gaps. Furthermore, nurses’ participation in any improvement process can be critical to
the ongoing efforts to improve the quality and efficiency of our healthcare system.

How can YOU be involved in ensuring and improving quality care?

●​ Be aware of quality standards of care (developed by your organization and/or
professional organizations).
●​ Speak up to your colleagues and manager when quality standards are not followed.
●​ Speak up to your colleagues and manager when quality gaps are observed.
●​ Participate in the development and revision of quality standards.
●​ Include the patient/family’s perspectives about gaps in quality.
●​ Become involved in unit-based or organization-wide initiatives to improve quality.

What does it look like?

 ●​ Acute care setting
○​ Reducing nursing interruptions to prevent medication errors.
●​ Long term care setting
○​ Reducing unplanned hospital re-admissions from long term care homes through
a community-based geriatric team.
●​ Community care setting
○​ Increase hospice, pain management, and advance-care planning for palliative
clients in the community.
●​ Public health/primary care setting
○​ Increase the numbers of new clients seen by the Diabetes Care Program, by
identifying and addressing barriers to referrals and booking.
●​ Rehab centre setting
○​ Improve patient and family education across the continuum of stroke care using a
Stroke Passport.

Patient Engagement

Given that patient-centred care is a key element of care quality, healthcare providers need to
understand how to engage with patients in ways that will meet their unique needs at the
individual, unit, organization and system levels.

Providing individualized patient-centered care includes getting to know the patient, their story,
family context, needs and goals and then co-designing a plan of care to meet their goals and
values. To accomplish patient-centered care, you will have “engaged” the patient and their
family by listening, learning together, empowering them to make decisions about their care and
being responsive to their needs.

Beyond engagement at the level of direct care, the concept of “patient engagement” has
evolved to include the active collaboration with patients and their families at the unit,
organization and system level to capitalize on their experiences to improve care delivery. For
example, a 42-year-old patient named Mr. Lewis was asked to attend a pre-operation
educational session to help prepare him for upcoming cataract surgery. At this session, the
participants (mainly seniors) were asked to view a video. Mr. Lewis provided feedback to the
team to let them know that the video was not an effective strategy for individuals with poor sight
and hearing. As you can tell from this example, patients and their families, as consumers of
health care services, are in an ideal position to provide feedback on opportunities for
improvement.

Why is Patient Engagement Important?

Patient engagement has been shown to result in:

●​ Improved patient experience and self-management (Rathert et al., 2013)

●​ Better health outcomes for patients (Hibbard & Greene, 2013)
●​ Decreased cost of care (Charmel & Frampton, 2008; Smith et al., 2013)
“...putting patients in positions of real power and influence, and using their wisdom and
experience to identify issues and to inform and redesign care to improve processes and
systems, provides the most important force for driving change and has the greatest potential for
achieving long-term transformation of the healthcare system.” (Reinertsen et al., 2008 cited in
Baker et al., 2017, p. 18)

How can patients/families be engaged in their care?

Patients and families bring a unique perspective of their experience that can be used to inform
or co-design improvements in care delivery. Engaging the patient/family can occur at various
levels to answer the following questions:

●​ Direct Care: What care works for me?

●​ Program/Organizational Level: How should care be designed and delivered for
all patients like me?
●​ System Level: What services should be available, for whom and in what way?
(Baker et al, 2017)

Health Quality Ontario (HQO) has developed a framework to help healthcare providers identify
ways in which engagement activities can be planned and implemented.
Health Quality Ontario’s Patient Engagement Framework (2017b)

Source: Health Quality Ontario

The ”Guiding Principles” found to be critical to successful engagement were based on

consultations with over 1,000 individuals across the province including patients, families and
healthcare providers. As you review the principles, consider how you could apply these
principles when interacting with patients to develop their plan of care.

These six principles are:

●​ Partnership: Meaningful patient engagement requires authentic, timely and

mutually beneficial relationships forged between patients, their family members,
other informal caregivers, health professionals and the organizations they work
with.
 ●​ Learning: All participants in patient engagement should expect to learn – about
each other’s perspectives and experiences, about facts about the issue at hand,
and about how things may improve and be better.
●​ Empowerment: Patients and their caregivers need to feel empowered to openly
express their needs, perspectives and concerns without fear of reprisal, and to
make informed decisions with confidence.
●​ Transparency: This means that healthcare professionals and organizations are
honest about their apprehensions, resource limitations, and knowledge gaps when
it comes to engaging with patients and caregivers.
●​ Responsiveness: Being responsive means that healthcare professionals and
organizations act upon the voices of patients, their caregivers and the general
public in ways that demonstrate the positive impact of this input.
●​ Respect: Healthcare professionals and organizations demonstrate respect for
their patient and caregiver partners by actively showing signs of appreciation for
their time, ideas, lived experiences, various worldviews and cultural locations.

(Health Quality Ontario, 2017).

Patient Engagement in Action!

Kingston General Hospital created a Patient and Family Advisory Council (PFAC), where
members were involved in annual organizational planning. They received regular reports on the
hospital’s progress related to the plans, including critical-incident reports and patient satisfaction
surveys. To support direct care, the PFAC developed five core standards to support
partnership and improved communications, safety and risk reduction at bedside. The standards
include:

1.​ Identification badges to be worn at the chest level to facilitate patients identifying who is
engaging with them.
2.​ Purposeful hourly rounds to ensure minimal assessment and comfort measures on a
regular and predictable basis.
3.​ Effective communication (Communicate with H.E.A.R.T. program).
4.​ A bedside communication/whiteboard updated every shift with key information that staff
and patients/family want to share.
5.​ Patient-led feedback forums where former patients share their hospital experience with
their providers. Staff then co-design and conduct quality improvement cycles.

THE CRITICAL LINK B/W QUALITY AND SAFETY

Two Worthwhile Goals

The figure below shows the link between the goals of quality improvement and and patient
safety. In quality improvement, you are trying to “raise the ceiling”, or enhance the quality of care
delivered to patients to increasingly higher standards. On the other hand, the goals of patient
safety are to “raise the floor” or raise the minimum standard for what constitutes safe care.
Overall, efforts to enhance quality and reduce risk are intertwined for the benefit of the patients
and the healthcare system.

The current state of patient safety

Canadian Adverse Event Study (Baker, 2004)

●​ 7.5 per cent of adult patients suffered from mistakes made by health professionals
●​ Almost 40 per cent of errors were potentially preventable
●​ Between 9,000 and 23,000 patients died annually from preventable error

Updates to this Study

●​ Overall hospital standardized mortality rates declined by almost 15% between 2009 and
2013 (Baker & Black, 2015)
●​ 185,000 Canadian patients suffer unintended harm while in hospital (Baker & Black,
2015)
●​ The percentage of Ontario long-term care home residents who fell in the 30 days prior to
data collection remained stable at approximately 14% between 2009/10 and 2012/13
(HQO, 2014).

Patient Safety Competencies

The Canadian Patient Safety Institute (CPSI) has created a framework to describe the
necessary abilities or competencies expected of students upon graduation. “The Safety
Competencies can be used as a framework to support the evolution of quality improvement
processes for patient safety (p. 33).” For detailed background on the competencies framework,
refer to the full report listed in the recommended reading for this module

Highlights of the Safety Competencies Framework are provided below. As you review each
competency and related definition, consider what nursing actions you could engage in to
demonstrate this competency. Once you’ve considered these nursing actions, click to reveal
some possible examples.

Patient Safety Competency #1: Contribute to a culture of patient safety.

Definition: A commitment to applying core patient-safety knowledge, skills and attitudes to

everyday work, to promote well-being of patients and staff, minimize harm, reduce risk of
adverse events and communicate safety concerns.

Patient Safety Competency #2: Work within interprofessional teams to optimize patient safety.

Definition: Collaborative patient-centred team practice is designed to foster safe and effective
patient-, family- and community-centred health outcomes.

Patient Safety Competency #3: Communicate effectively for patient safety.

Definition: High-quality and safe care depends on the ability of healthcare providers to
communicate well with patients and with other professionals. (Fast Fact: In a U.S. Joint
Commission report of sentinel adverse events [2004 to 2015], errors in communication were a
frequent root cause.

Patient Safety Competency #4: Manage safety risks.

Definition: Anticipating, recognizing, and managing situations that place patients at risk. Design
the healthcare work system in a manner that anticipates and recognizes situations that place
individuals and groups at risk.

Patient Safety Competency #5: Optimize human and environmental factors.

Definition: Managing the relationship between individual and environmental characteristics to

optimize patient safety.

Patient Safety Competency #6: Recognize, respond to and disclose adverse events.

Definition: Recognizing the occurrence of an adverse event or close call and responding
effectively to mitigate harm to the patient, ensure disclosure, and prevent recurrence. Adverse
events and close calls should be considered learning opportunities to reduce system failures
and improve professional performance.

Properties of a patient safety culture, with examples

Accreditation Canada
Property* Example*
Patient Safety ROPs**

1. Leadership: Leaders align ●​ Accountability ●​ Accountability for

vision/mission, staff competency, ●​ Commitment quality
and fiscal and human resources ●​ Executive rounds
from the boardroom to the ●​ Resources
frontline. ●​ Role model
●​ Vigilance

2. Teamwork: A spirit of ●​ Mutual respect

collegiality, collaboration, and ●​ Psychological safety
cooperation exists among ●​ Readiness to adapt
executives, staff, and ●​ Supportive
independent practitioners.
Relationships are open, safe,
respectful, and flexible.
3. Evidence-based: Patient ●​ Best practices ●​ Antimicrobial
care practices are based on ●​ High reliability stewardship
evidence. Standardization to ●​ Outcomes driven ●​ Heparin safety
reduce variation occurs at every ●​ Standardization ●​ High-alert
opportunity. Processes are ●​ Protocols and medications
designed to achieve high guidelines ●​ Hand-hygiene
reliability. ●​ Technology compliance
●​ Reprocessing
(Sterilization
processes)

4. Communication: An ●​ Assertive, speak up ●​ Client-safety

environment exists where an ●​ Safety quarterly reports
individual staff member, no briefings/debriefings ●​ Adverse events
matter what his or her job ●​ Communication disclosure
description, has the right and the structure techniques ●​ Adverse events
responsibility to speak up on such as SBAR reporting
behalf of a patient. ●​ Infection rates
●​ Client and family
role in safety
●​ Dangerous
abbreviations
●​ Information transfer
●​ Medication
reconciliation at
care transitions
●​ Safe-surgery
checklist
5. Learning: The hospital learns ●​ Awareness ●​ Hand-hygiene
from its mistakes and seeks new ●​ Informed education and
opportunities for performance ●​ Data driven training
improvement. Learning is valued ●​ Education ●​ Client safety
among all staff, including the ●​ Learn from mistakes education and
medical staff. ●​ Mentor training
●​ Proactive
●​ Root-cause analysis
●​ Share lessons learned

6. Just: A culture that ●​ Blame free

recognizes errors as system ●​ Disclosure
failures rather than individual ●​ Non-punitive reporting
failures and, at the same time, ●​ Analysis of system not
does not shrink from holding just individual
individuals accountable for their ●​ Trust
actions.

7. Patient-centered: Patient ●​ Grassroots

care is centered around the involvement
patient and family. The patient is ●​ Compassion/caring
not only an active participant in ●​ Empower patients and
his own care, but also acts as a family and participate
liaison between the hospital and in care
the community. ●​ Patient stories

Other: Worklife/Workplace ●​ Client safety plan

(Accreditation Canada) ●​ Equipment
preventive-maintena
nce program
 ●​ Workplace violence
prevention

Other: Risk Assessment ●​ Falls-prevention

(Accreditation Canada) strategy
●​ Home-safety risk
assessment
●​ Pressure ulcer
prevention
●​ Skin and wound
care
●​ Suicide prevention
●​ Venous
thromboembolism
(VTE) prophylaxis

What happens when competencies and culture break down?

1.​ Identify factors that contributed to avoidable patient harm, even at a renowned
organization.

This case is an example of “failure to rescue”, where a death arose from a treatable
complication but the team missed key red flags that the patient was deteriorating. Some of the
factors that influenced this outcome are as follows:

●​ Communication: the nurses should have paid attention or even double checked when
the mother was showing concern. When the parent or patient refuses or questions an
order, the nurse should recheck with physicians and review existing orders. The
healthcare team did not transcribe orders in the chart regarding holding the narcotics.
●​ The nurses didn't assess the patient in greater detail, nor did they notice that the patient
was so dehydrated. They did not assess the patient and picking up on physiological
cues of dehydration including lab work.

Refer back to the chart on patient safety competencies:

●​ Work within your own knowledge limitations and seek assistance when needed.
●​ Meaningfully engage patients in their plan of care.
●​ Use effective written communications for patient safety.
●​ Identify individual and environmental factors that can affect human performance e.g.
work-life balance, sleep deprivation/sleep debt, fatigue, etc.
 ●​ Apply techniques in critical thinking to make decisions safely e.g. recognize common
types of cognitive biases (i.e. “everything will be fine”).

From a patient-safety culture perspective, the nurse needs to be assertive and speak up when
safety concerns arise e.g. a deteriorating patient.

2.​ Consider how patient-centered care can help prevent adverse events.

As noted above, if the nurse valued the parent as a key contributor to the plan of care, more
attention would have been paid to her voiced concerns. According to the principles of a patient
safety culture, patient-centred care involves compassion/caring, empowering the family to
participate in care, and to listen and learn from patient stories.

3.​ List specific things you can do to make patients feel respected and included in decisions
about their health care?
○​ Listen to the concerns of the family.
○​ Assess the situation further to address their concerns and rule out anything
untoward that may be happening (e.g. review the chart and labwork, additional
patient physical assessment).
○​ Communicate back to the family what actions you have taken.
○​ Encourage the family to discuss any further observations or changes with the
next shift of nurses.
○​ Facilitate an opportunity for the family to speak with the physician to have their
questions answered in more detail.
○​ Document the concerns and your actions in the patient record.

A SYSTEM’S MODEL FOR PATIENT SAFETY AND QUALITY CARE

The Donabedian Framework

Based on systems theory, Donabedian’s conceptualization of a “system” includes the following

components (1988):

Structures: The context within which care is delivered (e.g. roles, reporting relationships,
worker characteristics, etc.) that influence how care is provided (also referred to as “inputs” or
the “socio-technical work system”).

Processes: Transactions or work processes that are undertaken to deliver care (e.g. admission
process, medication administration process, discharge process, etc.).

Outcomes: Effects of the care provided or products of the system that are influenced by the
structures in place and the work processes used to deliver care (e.g. patient outcomes,
symptom management, satisfaction, readmission rates, falls, etc.), nurse outcomes (job
satisfaction, commitment, health) and organization or system outcomes (cost, quality e.g. length
of stay, turnover rates, etc.).

This framework has been used extensively to examine health services and evaluate the quality
of healthcare. Each factor in this model can be designed to achieve the intended outcomes for
patients, professionals and for the healthcare organization as a whole. Poor design in the
system will compromise performance and outcomes. As a healthcare professional, you will
experience many different efforts to improve aspects of the healthcare system. It is crucial that
in these efforts, that whatever part is being changed, will still work seamlessly with all the other
elements. For example, if a new technology is difficult to use, or doesn’t match the current
procedures, then errors may occur once the technology is implemented. Front-line healthcare
professionals can see where these problems emerge, and should be part of helping to ensure
that any change will not have an inadvertently negative impact on care delivery.

The Systems Engineering Initiative for Patient Safety (SEIPS) Model

The Systems Engineering Initiative for Patient Safety (SEIPS) model is an extension of the
Donabedian framework and was conceived to also include concepts from engineering science
related to improving performance, and also human-factors engineering to consider not only the
patient but the healthcare professional in the system, thus making the model “person-centred”.
(Human factors will be described in more detail in the next section.) According to Holden,
Carayon, et al. (2013), “efforts must be taken to support people through the design of work
systems that fit their capabilities, limitations, performance needs and other characteristics.” This
model can be used to inform process improvement so that better work systems can be
designed.

Please study the model depicted in the image below and tour through the details in the
description that follows. As you read the description of the model, consider how these factors
would influence your ability to perform or deliver care.

The Systems Engineering Initiative for Patient Safety Model (SEIPS) 2.0
Source: Holden, R., Carayon, P., Gurses, A., Hoonakker, P. Schoofs Hundt, A., Ozok, A. &
Rivera-Rodriguez, A. (2013) SEIPS 2.0: a human factors framework for studying and improving
the work of healthcare professionals and patients, Ergonomics, 56:11, 1669-1686, DOI:
10.1080/00140139.2013.838643

First, the work system refers to structures/inputs or the context within which the professional
works. Each of these factors can be designed to optimize the performance of the healthcare
provider. The work system is comprised of the following components:

●​ Tasks: Attributes or characteristics of the task (e.g. difficulty, complexity, variety,

ambiguity, etc.)
●​ Tools and technology: Supplies, equipment, medical devices (e.g. usability,
accessibility, functionality, etc)
●​ Organizational factors: How your time, space and activities are organized (e.g. work
schedules, patient assignments, training, staffing levels, etc.)
●​ Internal environment: Physical environment (e.g. temperature, lighting, noise, etc.)
●​ Personal factors: Skills and behaviours (e.g. education level, age of workforce,
teamwork, etc.)
●​ External environment: Social, political and economic context (e.g. provincial budget,
professional regulations)

Each of the components of the sociotechnical work system influence your ability to perform and
deliver care. For example, if you do not have enough infusion pumps or they are malfunctioning,
your will be less able to manage medication administration in a timely manner which could then
impact patients if their medications are not received when scheduled.

Next are the work processes that include physical, cognitive and social/behavioural
components that impact performance. Examples of work processes are as follows:

●​ Professional work: Work specific to the scope of practice for each professional (e.g.
medication administration, physical assessment)
●​ Collaborative work: Care processes that involve many disciplines collaborating
together (e.g. patient rounds, care planning)
●​ Patient work: Active engagement of the patient/family and the nurse is minimally
involved (e.g. managing medications at home, independent deep breathing and
coughing exercises)

Finally, outcomes refer to products of the work processes and may be performance indicators.
Examples are provided below:

●​ Patient: Quality of care, patient satisfaction, survival, overall health quality of life, errors,
etc.
●​ Professional: Stress, fatigue, illness, job satisfaction, etc.
●​ Organizational: Within budget, meet ministry performance targets, staff turnover,
absenteeism rates, etc.

The Healthcare Innovation Model

Currently, most process-improvement approaches aim to improve the quality of care (including
patient safety) and to achieve efficiencies (reduce cost and enhance productivity). By applying
the SEIPS model, we are advocating that a third aim of process improvement should be
optimizing a healthy work environment. In this way, system design (re-design) can be more
person-centred and will be more likely to achieve positive outcomes for the patient/family, the
nurse and the organization.

To guide process-improvement work, we have developed a model that applies the concepts in
the SEIPS framework. The Healthcare Innovation Model below indicates that a human-centred
approach to system design and improvement must always address the aims of care quality,
efficiency and work environment as complementary rather than competing goals. If a
patient-care unit is designed to optimize the work system and work processes, then there is
increased likelihood of positive outcomes for the healthcare provider e.g. (the nurse) and the
patient. Outcomes relevant to the healthcare provider might include pain, workload,
psychosocial, knowledge utiilization, job satisfaction and project engagement, while outcomes
relevant to the patient might include care quality, patient satisfaction, resource use, and care
time received.

Healthcare Innovation Model to Guide Process Improvement

The feedback loop proposes that “healthcare provider” outcomes can influence the patient care
unit and, in turn, can impact patient outcomes.

Think About It

Here is an example to make this proposition clearer.

As you work you will gain experience and knowledge; these will improve your ability to deliver
care and avoid errors in care delivery. If however, you become overly fatigued or stressed, for
example, then the quality of care delivered will decline and the chance you will make an error
will increase. These effects act as a feedback loop in the healthcare system, which, as time
goes on, can gradually improve or compromise care quality.

Another example ... if you develop back pain from patient handling (and we hope you don’t!)
your ability to deliver safe care will be compromised and your patients outcomes may also
degrade. It is important to ensure that health hazards and workloads for HCPs are improved
with every process improvement effort. Engaging in the improvement process is therefore
important both for your own wellbeing, as well as that of your patients. You owe it to your
patients to be healthy and feeling well at work.

In summary, if a better work system can be created, better care can be delivered. This
relationship and the value of the SEIPS model will become even clearer as you review the final
section on human factors.

HUMAN FACTORS AND PATIENT SAFETY

What is Human Factors (HF)?

What is Human Factors (HF)?

Understanding how the brain processes information and functions under varying conditions is
part of the science of human factors. Now let’s review human factors in more detail to
understand how to design systems and workplaces in healthcare to promote patient and worker
safety.

“Human Factors or Ergonomics is the scientific discipline concerned with the understanding of
interactions among humans and other elements of a system, and the profession that applies
theory, principles, data and methods to design in order to optimize human well-being and overall
system performance.” (International Ergonomics Association).

Note that, in this definition, human factors and ergonomics are synonymous. In these modules,
the terms can be used interchangeably. The important concept is that the design of the
healthcare system affects how people act, what their injury risks are, and how well they perform
their duties.

Recall from the SEIPS model that we use the term “system” to refer to any aspect of delivering
care, including the organization of work, the use of technology or other devices, etc. HFE
(Human Factors and Ergonomics) impacts the worker’s well-being and impacts performance. If
you are sick, injured, or working in pain then your ability to deliver high quality care will be
compromised.

How a person interacts and responds with the environment can be thought of as a continuous
loop of information, beginning with perception, followed by cognition or processing of the
information and deciding on an appropriate response, and then responding (see the video
below). The external environment, be it a machine (e.g. heart monitor) or another person (e.g.
patient or family) receives the response via a physical, verbal, or visual means of
communication. The information is then processed and then a response is displayed visually,
audibly, or physically. The person perceives this information and the cycle continues.

How Organizational Factors Impact Human Factors

The three stages (perception, cognition, motor response) introduced in the video on the
previous page are the core of all of human factors. Problems can occur in any one of the three
domains resulting in missing critical information, misunderstanding or misinterpretation of a
signal, or errors in executing a care delivery task.

Individual performance can also be impacted by organizational factors such as organizational

structures, policies, and processes. Examples include: communication, work design, shift length
or schedule, teamwork, and telework.

The stages and interactions introduced in the video can also be used to help with diagnosing
system problems. Understanding where in the chain of information and action that the problem
occurred can help to reach the root cause of a problem, understand the mechanism behind the
problem, and then design an appropriate control to prevent it from happening again.

Overload in any aspect of the caregiver’s perception, cognition, and motor demands in care
delivery can lead to fatigue, errors or even injury. For example, a misperception of the
information written in a small font can lead to the wrong decision and response. Similarly a
complicated decision making process requiring holding information in your head can result in an
incorrect response. Likewise, poor motor control and execution of the necessary motor output
can mean a typing error or mishandling of a tool or perhaps inability to support a heavy patient.
The organization of the healthcare system can have many different effects on the caregiver and
the quality of care delivery.

HF and Caregiver Health: Psychological and Physical Job Demands

Psychosocial factors and stressors

Stress and burnout are serious problems for healthcare professionals. In a 2007 study of over
68,000 RNs in the United States, a high degree of burnout (emotional exhaustion) was
experienced by 35% of hospital nurses, 37% of nurses working in long-term care and 22% of
nurses working in other settings (McHugh et al., 2011). Laschinger and colleagues (2013) found
severe levels of burnout in an Ontario sample of new graduate nurses, and burnout levels
among experienced nurses was even higher. Critical aspects at work include the psychological
demands of the work, including time pressure and task complexity. The level of monotony of
work, our level of control over work, and the extent to which we can influence how we do the
work can also increase or decrease our stress levels.
Stress can have many unwanted effects. It can affect your health negatively with symptoms
ranging from muscle tension and digestive tract problems, sleep disturbances and illnesses
leading to more serious heart disease problems.

Stress also increases your probability of error. If you are not feeling well, if you are sick, if you
are tired, then your ability to deliver quality care is diminished. Presenteeism is the term used
to refer to employees who come to work when they are ill, and proceed to work at less than
100% capacity. Presenteeism is associated with decreased work performance, efficiency loss,
and declines in care quality.

Stress at work can be counterbalanced by a good social support system from your colleagues
and supervisor. Even your support at home from family and friends, and exercise and lifestyle
factors can affect your stress levels.

Experience: With experience a person improves physical and mental skill competence.
Increased competency allows tasks to occur more naturally and with less mental effort.
Experience also provides a person with exposure to a range of situations which improves their
ability to adapt to unexpected circumstances. With minimal experience, tasks happen less
naturally and require more effort to complete, which can put someone in a state of feeling
overwhelmed. The mental requirements of a task can also seem like it takes more of an effort,
meaning that an inexperienced person could feel more fatigue relative to a more experienced
worker. If a nurse is injured at work, the replacement caregiver may not have the same
experience as the injured nurse, with possible declines in care quality as a result.

Work design should also include appropriate psychosocial support, meaning a person will feel
that they are contributing valuable, meaningful work with appropriate time demands, and that
their efforts are both rewarded and supported by colleagues and the organization. These
considerations ensure an appropriate level of stress, are less likely to cause an employee to
experience burnout, and improves their sense of worth to the organization.

Physical job demands

Effective design of work systems minimizes the physical risk exposure to the worker and
maximizes psychosocial factors for well-being. When work systems are effectively designed, the
person’s work tasks will provide the proper amount of work and recovery to offset unhealthy
levels of fatigue and the location of work will position the person to maximize their strength and
reach capabilities to reduce the risk of injury. In the figure below, note the potential for strain on
the lower back and shoulders using different lift positions.
Lifting from a) Floor, b) Appropriate height with moderate reach, c) With far reach

Source: Toronto Metropolitan University 2017

Physical job demands are a function of not only the loads that are moved or the force required
for a task, but are also a function of the postures that are needed, the frequency of tasks and
the length of time an exertion is held. Looking again at the image above, combinations of force,
repetition, and time of exertion can make any of those postures challenging and with an
elevated risk of injury. Can you think of some tasks that make the physical job demands different
for the same posture? For example, when lifting from the floor, think of the differences of picking
up a pencil versus lifting a heavy box, versus pulling weeds for a couple hours in the garden.
How would each of these task demands be with respect to a person’s well being as well as their
ability to perform at the peak of their ability? Hopefully you can see that there is a relation
between well being and performance, and that the interaction of the factors of physical demands
need to be considered for any design of the work environment along with the psychosocial
factors.

HFE, Care Quality and Patient Safety

Fatigue

Fatigue is a naturally occurring phenomena in the cycle of stress and relaxation of material or a
biological system. There is little consequence to fatigue below a threshold level when there is an
appropriate balance between stress and recovery. However, if there is inadequate recovery then
problems can arise and the system can become damaged or impaired. Mechanically, it means
things break, which for a person means an injury like a strain or sprain. Physiologically, it means
the performance capability is reduced, such as not being able to continue with a task because
you are running out of energy to effectively move and think. The impact of fatigue in the latter
case can create effects similar to intoxication (Dawson and Reid, 1997) – not ideal if you are
late on your shift or starting your shift at a care facility. What should not be overlooked then is
how fatigue can contribute to physical and mental errors.

It is important to note that fatigue is multidimensional for people, and has mental and physical
implications. Åhsberg et al. (1997) identified five different dimensions in their questionnaire
assessing fatigue. The dimensions were:

1.​ Lack of energy

2.​ Physical exertion
3.​ Physical discomfort
4.​ Lack of motivation
5.​ Sleepiness

These dimensions reflect the general (dimension 1), physical (dimensions 2 & 3), and mental
(dimensions 4 & 5) factors of fatigue.

Fatigue is an outcome of actions being taken and work being done. The action and work
required are a result of what the environment dictates. A work environment that properly
accounts for the demands imposed on the people interacting with the system should effectively
consider the implications of fatigue on system outcomes.

Errors

You might make an error of commission when providing care, like inserting a needle
incorrectly into the patient. You might also make an error of omission – when you forget to
perform a task. This can happen when you are too busy in your shift with too many patients and
forget, for example, to change a dressing on a patient. There are many different factors that
contribute to both kinds of medical error.

Recall the human interaction video from earlier. Remember that a person perceives the
environment, creates a plan on how to respond, and then executes a response. Conceivably, an
error can occur in any of these steps. For example, someone could incorrectly perceive the
colour of a colour-coded vial or incorrectly read crowded or messy text on a chart. They could
also incorrectly remember the steps required to execute a treatment or miscalculate a medicine
dose for a patient’s weight. Even with successful perception and planning, they could still poorly
execute a task such as miss the glass while pouring water or missing the vein with the needle.

Sometimes errors occur in isolation, other times they can be a series of errors. Often, people
want to classify mistakes as “human error”. However, when you get to the true root cause of the
error, you will find that the error is due to the system and the way it was designed. The error is a
reflection of how the response of the person to information that the system presented or
predisposed them to, which, at its core, is a function of the design. In future modules we will get
more into approaches to root out these sources of errors and methods on how to evoke good
change. In the meantime, take a minute to reflect on something you have experienced where a
mistake, or near mistake, that you have made was an error brought on by poor design and poor
inclusion of HFE, and then proceed to the exercise that follows.

Recall the human interaction video from earlier in the module. If you remember, errors can come
from perception, cognition, and/or execution, meaning how someone interprets their
environment, chooses a response and then executes the response.

For example, a perception error could be made due to the font size used in the design of
labels. The font could be difficult to read, which could slow down a process or cause someone
to interpret the information incorrectly. A cognition error could be a simple math error, such as
when incorrectly converting a person’s weight from pounds to kilograms. It could also be from
having to remember multiple pieces of information to transfer information from one system and
re-enter it in another. Systems that are not designed to easily “talk” to each other and require
the manual transfer of data increases the chances of someone misremembering potentially
important information. Lastly, an execution error could be when someone is re-entering or
transcribing information into a system and mistypes characters.
Module 3
THE MODEL FOR IMPROVEMENT
Overview of the MFI

According to the Model for Improvement, quality improvement is a process that begins with
three key questions:

1.​ Aim: What are we trying to accomplish?

2.​ Measure: How will we know that a change is an improvement?
3.​ Change: What change can we make that will result in improvement?

These questions help focus your attention on where and how the change needs to take place
over time. The questions also serve to reinforce the need for ongoing evaluation, which is a
foundation of any improvement initiative.

The Model for Improvement that includes the PDSA cycle is depicted below. The diagram from
Health Quality Ontario has been adapted from the Institute of Healthcare Improvement (IHI).

Problem/Opportunity Statements

The purpose of these statements is to describe the current situation, with an emphasis on:

●​ Identifying the conditions, problems, or issues that are leading you to propose a plan of
action.
●​ Communicating/motivating the need and will to act.
●​ Facilitating an aim that truly addresses the problem.

Examples of Problem/Opportunity Statements

Acute Care Context

Problem Statement: About 25% of people spend more time in the emergency department than
is desirable and wait times are longer than in many other geographical areas due to:

1.​ Backlogs elsewhere in the hospital preventing patients from being admitted.
2.​ Inefficient processes with the department.
3.​ Inappropriate demands for service from patients with low acuity conditions that could be
seen elsewhere.

Long-Term Care Context

Problem Statement: Nineteen percent of residents in LTC experience worsening bladder

control due to resident/staff's unfamiliarity with strategies to maintain bladder control in older
adults.

Primary Care/Public Health Context

Problem Statement: In Ontario, 16% of the population over the age of 12 smoke daily (1 in 6
people) due to poverty, low education, neighbourhood norms, motivation issues and healthcare
providers forget or don’t have time to discuss healthy behaviours.

Aim Statements

The problem/opportunity statement, in turn, provides a basis for developing an aim statement.
The key purpose of the aim statement is to address the question of what you are trying to
accomplish. This helps keep those involved in the initiative on the same page and focused on a
common outcome. The aim statement is specific and measurable, and helps answers the
following questions:

●​ How good? (Measure)

●​ By when? (Time)
●​ For whom (or for what system)? (Population)

To address these questions, the aim statement needs to be SMART:

●​ Specific
●​ Measurable
●​ Attainable/Actionable
●​ Relevant/Realistic
●​ Time-bound

Examples of Aim Statements

Aim Statement: To reduce the incidence of infections present in medical inpatients from MRSA,
VRE and C. diff. by 30% within 12 months.

Note how this example includes the measure (reduce the incidence by 50%), the time (within
12 months) and the population (medical inpatients). A subject-matter expert who has
knowledge of infection control and the healthcare facility would be able to determine if this aim
is attainable and realistic.

Now you try. From the examples below, identify aim statements that are good vs. bad.

Measures

Another key component is the development of measures, which will provide a basis for
assessing progress towards or away from the key aim and supporting goals. Measures will
therefore provide an indication if adjustments are necessary to ensure the overall aim and
related goals are achieved. In quality improvement, four key aspects of measurement are often
considered: outcome, process, balancing, and spread. These are summarized in the figure
below.
Project Charter

The problem/opportunity statement, aim statement, and key measures inform the development
of a project charter. The purpose of a project charter is to:

●​ Describe the current situation.

●​ Identifies the conditions, problems, or issues that are leading you to propose a plan of
action.
●​ Communicate/motivate the need and will to act, and facilitates an aim that truly
addresses the problem.
●​ Establish the scope of the project and ensure the right team membership.
●​ Establish a common understanding of the aims, measures and plan.
●​ Keep the team on track and recognize progress and milestones.
●​ Avoid common pitfalls – goal creep, measurement avoidance, loss of focus or
momentum.
●​ Communicate effectively with senior leadership and other stakeholders.

Change Concepts and Ideas

You will notice that the Charter Tool also includes a section on “Change Ideas”. To seed your
thinking about what changes ideas are possible, it is helpful to consider different types of
changes (change concepts) that might solve the problem. Broad types of change concepts
include strategies to reduce waste (Lean thinking), promoting efficiency by improving patient
flow (such as patient patient flow through a department), improving the reliability of a process
(Six Sigma), and improving access by managing supply and demand.

In the table below are some examples of change concepts and related change ideas described
in the Quality Improvement Guide (Health Quality Ontario, 2012) that was included in your
required reading. Refer to pages and 11-12 and 43-44 for further details.

CHANGE CONCEPT CHANGE IDEAS

Manage time
●​ Reduce steps
Reduce Waste ●​ Reduce wait time

Improve workflow
●​ Synchronize
●​ Minimize handoffs

Efficiency Change the work

●​ Move related steps together
environment
●​ Position equipment to reduce
steps and distance walked

Reminders and alerts

●​ Generate a reminder when a step
needs to be done

Improve Reliability
(Mistake-proofing)
Forcing functions
●​ Design the system to make it
impossible to make an error
 Increase continuity
●​ Improve communication to
reduce the need for repeat visits

Improving Access
(Supply and demand)
Create contingency
●​ Have a plan B to manage
plans
fluctuating demands

PDSA cycle
The PDSA Ramp

It is also important to note that the PDSA cycle can be employed as an ongoing, iterative
process. One demonstration of this is the concept of the PDSA ramp. A PDSA ramp is the use
of planned multiple cycles to test and adapt change. This allows a team to be innovative and
test feasibility. It also allows for the collection of data at each step to see if the change is an
improvement. Small tests of change can be a low-risk way to try new ideas that people might be
hesitant about at first. A ramp can be used to refine a change, or break down a component of
the change. The quality improvement team can implement PDSA ramps one after the other or
simultaneously. An illustration of this concept is shown in the figure below.

PDSA Ramp

Source: Institute for Healthcare Improvement

An example of the application of the PDSA ramp is found in the two-part series “Using a PDSA
Quality Improvement Cycle Approach to Implement an Oral Feeding Progression Guideline for
Premature Infants” (listed in the recommended readings). The ramp concept is found in part 1
and a more detailed description of each of the three PDSA cycles is found in part 2.​

When a problem is complex, the team may want to implement multiple PDSA ramps in order to
address several facets of the problem. An example is provided below that is based on a case
from the Quality Monitor: 2010 Report on Ontario’s Health System (Ontario Health Quality
Council).

Change 1 Change 2 Change 3

Problem: Need to Problem: Inefficiencies in Problem: Non-urgent
develop better care emergency department cases using the
coordination and move processes emergency department
patients who no longer instead of Family
need in-hospital care to Focus of PDSA cycles: Physician
the right place as soon as Design the department to
possible. minimize wasted staff time Focus of PDSA cycles:
walking back and forth; create Educate public to use
Focus of PDSA cycles: a fast track area for less Telehealth, work with
Create unit to manage serious cases. family physicians to
alternative levels of care ensure better access to
(ALC) patients; start after-hours care.
discharge planning
earlier.

Multiple cycles were used

until optimal outcomes
were achieved through
these strategies. The
project can then tackle
the next root cause i.e.
Change 2 and 3 in order
to achieve overall aims
and targets.

DMAIC
Overview of DMAIC

DMAIC has become quite closely associated with 6 Sigma, but it is a fairly generic approach
that can be used with any quality improvement effort. The DMAIC process is a structured
approach to quality improvement and consists of the following steps:
 Identify the Implement
Define the Quantify the Maintain the
cause of the and verify
problem problem solution
problem the solution

●​ Identify ●​ Determine ●​ Analyze ●​ Gener ●​ Develop

and or what to data to ate ongoing
validate measure. understa and process-ma
the ●​ Manage nd quantif nagement
improveme data reasons y plans.
nt collection for potenti ●​ Mistake-pro
opportunity for variation al of the
. measures. and solutio process.
●​ Define ●​ Develop identify ns. ●​ Monitor and
critical and possible ●​ Evalua control
customer validate root te and critical
requireme measurem causes. select process
nts. ent ●​ Determi final characteristi
●​ Document systems. ne cycle solutio cs.
or map ●​ Determine time for n. ●​ Develop
processes. sigma-leve the ●​ Verify “out of
●​ Establish l process and control”
project performan to be gain action
charter ce. complet approv plans.
and build ed. al for ●​
the team. ●​ Verify final
root-cau solutio
se n.
hypothe
sis.

PDSA and DMAIC Compared

Now that you have been introduced to two different QI planning tools, you might be wondering
how they are the same and how they differ. The table below has been designed to answer that
question. Note that in the DMAIC process; more explicit steps are built into the planning phase
when compared to the PDSA process.

PDSA DMAIC

Plan Define

●​ Identify objectives to solve the ●​ Define the problem, identify the

problem improvement opportunity
●​ Make predictions ●​ Establish the project charter
●​ Plan who does what, when, where
Measure

●​ Quantify the problem

●​ Determine what to measure
●​ Define the performance standards

Analyze

●​ Analyze the data to understand the

root causes

Do Implement (Improve)

●​ Carry out the plan ●​ Generate and quantify potential

●​ Document problems and solutions
unexpected observations ●​ Evaluate and select final solution
●​ Begin the analysis
Study Control

●​ Complete data analysis ●​ Develop ongoing process

●​ Compare data to predictions management plans
●​ Summarize what was learned ●​ Mistake-proof the process
●​ Monitor and control critical process
Act characteristics

●​ Are we ready to implement?

●​ Should we try something else?
●​ Next cycle: adapt, adopt or
abandon?

Tools used for the PDSA and DMAIC processes

DMAIC is a very flexible approach to quality improvement. There are a number of tools that may
be used to help guide improvement teams through each step. An illustrative summary of a
selection of tools linked to specific steps is provided in the table below. Note how these same
tools can be utilized in the PDSA approach.

Study -
Plan Do
Act

Tool

Define Measure Analyze Improve Control

Project charter X
Fishbone (Ishikawa X
Diagram)

Process maps and X

flowcharts

5 Whys X

Failure Mode and X

Effects Analysis
(FMEA)

Leadership X
Walkarounds

Safety Huddles X X

Checklists X X

X X
5S Organizational
Development and
Visual Controls
Standardizing work, X X
Mistake-Proofing
(Poka-Yoke)

Brainstorming, X
Tabletop Simulation,
Photo-Safari