Critical Thinking Tools for Quality Improvement Projects

As in the nursing process, the first step in any quality initiative is to assess the process or problem that needs to be improved. An early initial step is to form an interprofessional team of caregivers. The team should include stakeholders whose practice could be involved in or changed by the initiative. Consider forming an interprofessional team including bedside nurses; physicians; respiratory, physical, and speech therapists; nursing assistants; and unit-based secretaries as well as patients and their families. Improving clinical practice and sustaining those improvements require leadership support from all levels within the organization.³ 

Once the team has been assembled, it should thoroughly assess the problem or quality issue. When problems occur in the workplace—either as a clinical issue, such as an increase in the number of medication errors, or as a need for improvement, such as a change in workflow—health care workers often want to identify the cause and remedy the situation quickly. Solving complex problems, however, requires in-depth exploration of both the issue and the factors contributing to it. Investing the time necessary to complete a thorough assessment is an essential step in improvement. Include as many means of examining the problem as possible, such as unit or hospital data, observations of current practices, conversations with caregivers and stakeholders, and information specific to the local problem. Clinical nurses who provide direct care to patients are in a unique position to identify quality issues.⁸ 

In addition to clinical nurses identifying quality issues, hospital data—such as quality or risk reports that reveal, for example, an increase in the number of infections or falls—often alert nursing leaders to clinical triggers for improvement, but triggers can also arise from interactions with patients and families or from new knowledge.⁹  Examples of improvement opportunities arising from interactions with patients are a request for a family to be present during resuscitation¹⁰  and frequent requests from patients or family members for educational materials.¹¹  The release of new or updated practice guidelines, such as the 2016 update to the sepsis guideline¹²  and subsequent changes in the 2018 update,¹³  are examples of new knowledge that might prompt the need for practice changes.

Despite the type of trigger for a quality initiative, once the team has identified a problem, the next nursing actions are the same: Complete an inquiry to determine whether the event was a 1-time occurrence or a continuing problem. Explore current practices to determine the scope of the problem. Also, determine whether this issue is a priority for the organization. In general, selecting continual problems that are a high priority for the organization will result in increased administrator and staff buy-in.¹⁴ 

After the scope of the problem has been evaluated and the problem determined to be a priority, clinicians should review the current literature related to the problem. This step is still early in the QI process. During the literature review, look for background information to determine the characteristics of the problem, its prevalence at other centers, and factors that contribute to it.¹⁵  After completing the review of the literature, the team can use a variety of critical thinking tools to assess the problem. Many hospitals have adopted formal programs such as Lean methodology or Six Sigma to assess and manage improvement efforts. For nurses working in hospitals without a formal QI model, the Institute for Healthcare Improvement (IHI) has extensive free resources such as critical thinking templates, videos, and toolkits¹⁶ ; these assets are available to educate nurses about the IHI’s improvement model, the Model for Improvement. The items in the toolkits can be combined to best suit the improvement need. Scoville and Little¹⁷  suggest that no 1 method is superior to another and that a combination of tools that are specific to the problem, rather than to the QI method, might best serve patients.

A foundation for any assessment is built from targeted, direct observations that qualified clinicians make at the point of care. Clinicians can gather important information by going into clinical units, watching care being delivered, and asking questions of the direct caregivers. The purpose of these observations and questions to staff is not to assign blame but to understand fully the factors that have led to the clinical problem. Observation of units that do not have the same problem can often yield important information that helps determine what factors contribute to those units’ relative success.

When observing a unit, team members may find that more than 1 factor contributes to the quality issue. For example, a nurse manager in a medical intensive care unit noted a high rate of central catheter–associated bloodstream infection. The nurse manager convened a team that included a nurse leader, a critical care medicine physician, staff nurses, an infection control nurse, and nursing assistants. After being assembled, the team decided to observe the process of a nurse caring for central venous catheters on the unit. One team member observed the nurse searching for equipment both in the patient’s room and on the supply cart while changing a dressing. The team decided to investigate the workflow further to determine whether the multiple interruptions to care resulting from the nurse obtaining supplies was routine on the unit or an anomaly. Conversations with staff confirmed that supply carts were inconsistently stocked, and the bedside carts did not always have the supplies necessary for dressing changes. The process in place for replenishing supplies seemed to be broken. In this case, improving workflow to increase efficiency was not the only intervention necessary to solve the unit’s multidimensional problem with central catheter–associated bloodstream infections, but it was the first step in improving it.

The team decided to complete a Spaghetti Diagram, a visual tool that allowed them to examine the flow of people within the unit to determine whether the layout or organization of supplies could be improved. The team’s goal was to use the Spaghetti Diagram to redesign the work and processes—in this case, the supply and bedside carts—on the basis of how staff completed the work.¹⁸  To create a Spaghetti Diagram, the team started with a blank schematic of the area. They selected a nurse and recorded on the unit schematic that nurse’s movement from 1 area to another (Figure 1). In addition, they recorded the nurse’s step count.

After counting the lines on the diagram and the steps the nurse took to gather supplies, the team noted an excessive number of trips to the supply area; this finding indicated that the restocking process needed to be improved. The observations also illuminated other workflow problems, such as the need to call frequently for more supplies on busy days or to leave the unit to obtain equipment. The team collaborated with the hospital’s central supply department to change the par stock and the location of items. A second Spaghetti Diagram created after the reorganization depicts improvements in workflow (Figure 2).

After assessment, the next step in the nursing process, diagnosis, requires nurses to synthesize what they found during the assessment into information that is meaningful for patient care. For quality issues, after gathering the initial information, nurses attempt to determine all possible causes of the issue. Many nurses are familiar with root cause analysis (RCA), which The Joint Commission requires in response to a sentinel event.¹⁹  The purpose of an RCA is to identify any system-related problems that may have contributed to the adverse event in question and to allow changes to be made that will prevent a similar event in the future. An RCA involves identifying what happened, what should have happened, and the causes of the adverse event. Through efforts of the National Patient Safety Foundation, standard RCA has been modified to include an additional A for “action plan,” changing the acronym to “RCA2.”²⁰  This change emphasizes the need to both identify the root cause and create sustainable improvements in care delivery to prevent future harm.

The components of the RCA2 include factors related to communication, the environment, equipment, processes, staff performance, the team, management, and the organization. The RCA2 leads teams to think critically about the event, to uncover the contributing factor(s) that precipitated it, and ultimately to make plans to mitigate the current problem and prevent similar events in the future.²¹  Teams planning improvements related to sentinel events should collaborate with risk management to identify root causes and implement plans for mitigation. Fortunately, not all quality issues result in sentinel events, but in a learning culture, it is helpful for teams to consider less serious events and near-miss or “good catch” events as opportunities for improvement.²²  In addition to the RCA2, QI teams can use other tools to enhance critical thinking in relation to nonsentinel events, near misses, and good catches. Three critical thinking tools commonly used to diagnose quality issues are the 5 Whys, cause and effect diagrams, and Pareto charts.

The 5 Whys tool requires the team to examine the cause of a clinical problem in an attempt to discover the underlying cause; to do so, the team asks the question “Why?” 5 times.²³  Users must thoughtfully consider all aspects of the problem before deciding on a root cause. Often, what might initially seem to be the cause of a problem is actually only a symptom. Figure 3 shows an example of a 5 Whys process that was completed for a mucosal injury caused by an endotracheal tube holder. As seen in the figure, the initial cause of the injury was determined to be use of the wrong tube holder. The 5 Whys tool forced the team to search further for the root cause. At first, the use of the wrong tube holder seemed to be simply an error in nursing judgment; after completing the 5 Whys, however, the team determined the root cause of this problem to be poor communication about a newly stocked item.

The 5 Whys tool is useful for relatively simple problems. Not all problems require 5 steps, but users should attempt to fully explore causes in depth before ending the process. Alternatively, the exercise might require more than 5 steps. The strength of the 5 Whys tool is its ease of use; however, it may lead teams to oversimplify complex issues by suggesting that a problem arises from a single cause or that a search for a root cause will end after 5 steps.^24,25 

For complex problems, the 5 Whys tool might be inadequate or cumbersome. A Cause and Effect Diagram, also called a fishbone or Ishikawa diagram, helps clinicians examine complex clinical problems by considering that multiple causes may exist. This diagram has its roots in the manufacturing sector, and so the typical categories are materials, methods, equipment, environment, and people.²⁶  The categories, however, can be tailored to the specific problem. When completing a cause and effect diagram, enter the problem or adverse event in the “mouth” of the fish and work backward to identify causes within each main category. The 5 Whys method can then be used to determine a root cause within individual branches. The example in Figure 4 details the work of a team exploring the reasons for an increased number of catheter-associated urinary tract infections in the intensive care unit at their hospital.

A Pareto chart is based on the Pareto principle, which suggests that 80% of a problem stems from 20% of the causes, called the “vital few.” Identifying these vital few causes is intended to begin the improvement process by mitigating the causes of most of the events. The remaining causes—the “useful many”—can be fixed later.²⁷ 

After examining the multiple causes of a quality issue, the team may need to determine which to tackle first. For example, the nurse manager in a surgical intensive care unit noted an increased number of pressure injuries and formed a team to investigate. While reviewing the types of pressure injury that occurred throughout the previous year, the team discovered numerous sites of injury, including heels, coccyx, hips, elbows, back of the head, ankles, face, and ears. The team created a Pareto chart to display visually the frequency and cumulative percentage of pressure injuries at each location. Figure 5 shows the Pareto chart the team created; 80% of the pressure ulcers were located on the heels and coccyx. On the basis of this information, the team decided to explore the literature about how to prevent pressure injuries on the heel and coccyx.

When planning what causes to mitigate first, a team should consider other elements of the Pareto chart, such as events in the “useful many” category that can be easily fixed. An early win for the team not only encourages them to continue but can help gain buy-in from leadership and staff.^3,14  In our pressure injury example, the team noted that all stage 3 pressure injuries were injuries to the ears and had been caused by respiratory equipment.²⁸  Although ear injuries were not represented in the “vital few,” their severity was a concern. The team decided to include prevention of pressure injuries from respiratory equipment as a priority, along with prevention of those on the heel and coccyx.

As with the use of any tool for patient care, nurses bring their own unique insights to solving problems. Although a Pareto chart can aid nurses in critically thinking about an issue, their knowledge of patient care should still inform practice decisions.

After the quality issue has been assessed and diagnosed, return to the nursing literature to find evidence-based best practices and potential solutions. Organizations such as The Joint Commission, Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and many professional specialty organizations have published evidence-based practice guidelines and toolkits that are ready to be implemented in clinical practice. Such high-quality assets provide 1 way to ensure that interventions are based on evidence and are useful in practice, without requiring the team to reinvent the wheel and resynthesize the literature.³ 

To determine the quality of a clinical practice guideline, use the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.²⁹  This 23-item instrument is reliable and valid, and it is available online at no cost. It leads users through the evaluation of 6 quality domains: Scope and Purpose, Stakeholder Involvement, Rigor of Development, Clarity of Presentation, Applicability, and Editorial Independence. If the team determines that the guideline is of sufficient quality to use, a literature review should focus on identifying strategies to implement the guideline into practice. If no guideline exists, complete a standard review of the literature to find potential solutions.

Teams should use evidence-based practice skills to critically appraise and synthesize the literature. An evidence table is an evidence-based practice tool that summarizes the relevant literature in just a few pages.³⁰  Common column headings in the table include the citation, purpose of the study, sample and setting, methods, results, and a rating of the level and quality of evidence. Create a separate entry for each study within the rows of the table. Once the table has been completed, use the information it provides to identify recommendations for practice that are based on the literature. Use the level of evidence and quality ratings of individual studies to determine the overall strength of the evidence. For example, practice recommendations from numerous experimental studies are considered stronger than recommendations from an equal number of nonexperimental studies, on the basis of the rigor of the study design. Similarly, if most of the articles are of high quality, the overall quality of the evidence can be rated as high.³¹  When trying to obtain necessary support for a quality initiative from staff and leadership, the creator of the evidence table can easily share it with other team members, stakeholders, and administrators to provide a summary of the current evidence.³⁰ 

Once the team has determined evidence-based practice recommendations, they should use a gap analysis, another evidence-based practice tool, to compare best practices with their organization’s current practice. A template with instructions is available online from the Agency for Healthcare Research and Quality³² ; this template can help teams summarize the practice gap. Column headings in the gap analysis table include best practice, best practice strategies, how your practice differs from the best practice, barriers to implementing the best practice, and whether the best practice will be implemented. For problems that are guided by hospital policy, a 2-step gap analysis may be required: the team first compares the evidence-based best practices with the policy and then compares the policy with care delivered on the unit. If the policy is not congruent with best practices, it should be revised to reflect current evidence as an initial step in the quality initiative.

Completing a gap analysis requires that users not only assess how a practice differs from evidence-based best practice, but also identify organizational characteristics that might affect the implementation of change. Factors such as readiness for change within the environment or the ability to engage staff can be either drivers of or barriers to change, and they should be considered in a gap analysis. When deciding whether to implement best practices, consider how the organization’s strengths and weaknesses influence the team’s ability to embark on a QI initiative. Alternatively, consider possible threats to the organization if the initiative is not begun. When the gap analysis has been completed and the team has determined what actions will be part of the QI initiative, it is helpful to clarify the vision for the initiative by formalizing its purpose and goals.

A project’s purpose is directly related to the outcome that the team wants to achieve. For example, the purpose may be to improve patient safety by decreasing alarm fatigue among nurses. The project goals should flow directly from the gap analysis and target the best practices that are described in the literature but are missing from practice. For example, if the gap analysis for alarm fatigue noted that the unit lacked a standardized process for determining alarm limits, writing and implementing a policy for setting alarm limits would be a goal for the initiative.

Unfortunately, it is not always possible to implement immediately all the best practices noted in a gap analysis. In the alarm fatigue example, the team may have identified supply issues related to the quality of electrocardiogram electrodes, but implementation of the solution may need to be delayed as the team collaborates with members of the supply chain to evaluate options and select a new product. Other reasons for delaying full implementation might include financial limitations, inadequate staffing, or accessibility of equipment; however, making some progress toward improvement is usually better than waiting for perfect conditions before starting.³ 

Quality improvement requires an interprofessional team effort. Many models exist to guide the process of quality initiatives, including Lean methodology, Six Sigma, and the IHI’s Model for Improvement; however, QI remains the work of every nurse, and nurses can use the familiar nursing process in such initiatives. In this article we have provided an overview of 4 frequently used QI tools and 2 evidence-based practice tools teams can use in quality initiatives. When nurses use these tools in conjunction with their knowledge and expertise, they can help improve care delivery and patient outcomes.