Quality improvement (QI) is the framework that makes better the way care is delivered. It is a core clinical skillset needed in healthcare. Doctor of Nursing Practice (DNP)-prepared nurse practitioners (NPs) are competent in this skillset. They are capable leaders who understand the complex nature of healthcare and can identify and prioritize which QI processes are integral at the unit and organizational levels.

Students enrolled in a DNP program complete courses on a wide range of topics that collectively prepare them for their role as QI leaders. Examples include theoretical foundations of nursing practice, healthcare policy and economics, management of organizational systems, and health promotion and disease prevention. The premise of DNP education centers on successful implementation of QI initiatives set forth by collaborative input from the student, faculty, project mentor, agency or organization where the project is to be implemented, and educational institution. The DNP project is revered as the hallmark of the program because it demonstrates the synthesis of the experience in the classroom and clinical setting. On completion of the didactic and clinical education, DNP-prepared NPs have acquired the skills and knowledge to promote change improving the quality of care and health outcomes for individuals, communities, and populations.¹ They examine data and identify practice changes that address problems.²

With an increase in the number of NPs completing the DNP degree, we should see an increase in the number of QI initiatives in healthcare settings. It is imperative that these NPs continue this work after graduation. In reality, is this happening to the extent we might expect?

This article defines quality improvement, illustrates how the core clinical skillset is incorporated in DNP student QI projects with an example, describes barriers the DNP-prepared NP might encounter when trying to initiate QI projects after graduation, and offers strategies to facilitate success.

Quality improvement core clinical skillset

Quality improvement is the framework clinicians use to improve the delivery of care to patients.³ The purpose of QI initiatives is to improve efficiencies, reduce variations in patient care, address educational and/or administrative problems, and correct workflow processes.⁴ This makes healthcare safer by lessening harm, ensuring patients and family members are engaged in their care, and promoting care coordination and effective communication. The QI process includes continuous and systematic actions that lead to measurable improvement in the overall health status of the targeted patient population and health services.⁵ Essentially, QI initiatives close the gap between the evidence (often what is recommended in the national and local guidelines) and practice with evaluation of outcomes using data collected and analyzed after initiation.⁶

The core QI clinical skillset can be implemented in various clinical settings, including clinics, hospitals, ambulatory surgical centers, skilled nursing facilities, and community health agencies.⁵ It is a system-focused, teamwork-based, peer-review valued concept in which errors are viewed as opportunities for growth and learning.⁴

Students enrolled in DNP programs typically must design and implement a QI project using real-life improvement measurements as a deliverable for the successful completion of their program.⁷ The project meets scholarly standards. The American Association of Colleges of Nursing notes the key elements of scholarly work include identification of a problem, translating evidence to construct a suitable strategy to address the problem, designing and implementing a plan, and evaluating the experience.⁸ For the DNP student, QI initiatives foster an environment to develop leadership skills as well as establish rapport with colleagues in the assigned organization. The experienced DNP project mentor serves as the subject matter expert who guides the student to challenge the longstanding concerns regarding the way care is rendered, strengthening their QI skills.⁹ The student also develops dissemination skills through writing and oral presentations. After completing rigorous course work and the QI project, DNP graduates are expected to be proficient in QI strategies and in creating and sustaining changes at the organizational and policy levels.⁸

As one example of a successful DNP student QI project, an inaugural same-day walk-in contraception clinic was implemented in a robust Army military treatment facility. The initiative removed the identified barrier of requiring multiple office visits for counseling and placement of a long-acting reversible contraceptive (LARC). Additionally, the fully functioning, same-day walk-in clinic increased access to contraceptive care, decreased the likelihood of unwanted pregnancies among US armed forces, and improved staff and patient satisfaction.

For this project, the DNP student developed a goal statement that was both patient and systems focused. The goal statement clearly described the desired outcomes. The statement followed goal-setting principles of being specific, measurable, attainable, realistic, and time-bound (SMART). These SMART goals are the blueprint for QI projects. The applicable SMART goal for this QI project included decreasing the number of referrals to the obstetrics and gynecology clinic by 50%; improving access to contraceptives by 80% by establishing a same-day walk-in contraceptive clinic; and improving patient knowledge of available contraceptives by 85% by utilizing an evidence-based, birth control choices educational tool all within a 12-week timeframe. Outcomes based on this goal were measurable through selected evaluation methods.¹⁰ This QI project example epitomizes the idea that improving quality is not the work of an isolated healthcare department, in a single setting, by a single discipline of care, separate from the patients receiving care.¹¹

The same-day walk-in contraception clinic has been fully adopted as an integral component of the care rendered in the military treatment facility. The system-focused, teamwork-based collaborative effort yielded positive results warranting organizational wide dissemination. Since its inception, the initiative has been replicated in several like facilities. The successful replication of the concerted efforts speaks to the importance of developing sustainable QI initiatives as a vital domain in safe, quality healthcare.

Initiating projects after graduation: Barriers and strategies

Continuing the QI journey after successfully completing a DNP program is not without its challenges. Although the QI project process was not without its stressors, the student likely had support from faculty, project mentor, other students, and an organization that accepted the project upfront. The navigation of unexpected occurrences was not solely the student’s responsibility. Some graduates may find themselves in ongoing supportive environments for implementing QI initiatives and others may not. Whichever the case, the DNP-prepared NP can draw on all they have learned in their program to bolster confidence and move forward with work that ensures quality healthcare and patient safety for the populations with whom they work.⁸ Recognition of common barriers and utilization of strategies to facilitate success are imperative.

Barriers to successful implementation of QI projects are a reality. Themes revolve around issues that include: leadership, staff education and training, resource constraints (financial, time, workload, staffing), organizational culture, and overall resistance to change.¹² In a survey completed by over 400 attendees at a QI conference, relational issues such as lack of staff motivation, negative staff behaviors, poor quality of communication, and lack of leadership involvement were the most frequently identified QI barriers.¹³

Leadership support is crucial to obtain staff engagement in QI initiatives. Competing priorities of day-to-day clinical operations and managing limited organizational resources can cause those in leadership positions to overlook the importance of processes that can actually result in workflow efficiency and more effective use of staff. Inadequate staff knowledge of what QI is about is not uncommon. In a survey of 436 new entry-level registered nurses, nearly 40% responded they were poorly prepared about or unfamiliar with the QI process.¹² It is likely that other ancillary clinical staff also lack this knowledge.

The mentioned relational issues can cause and/or be a result of negative organizational culture. Lack of motivation and poor quality of communication are detrimental to the teamwork needed for successful QI. Resistance to change can also foster or be fostered by a negative organizational culture. It can sometimes be difficult to persuade team members that there are concerns or problems within their areas that require change. This can become more complex in larger institutions when siloed departments are isolated from one another, with each having variable values and attitudes regarding change and quality improvement.¹⁴

A noteworthy concept aligned with the resistance to change is what is referred to by some as the “sacred cow,” wherein clinicians continue outdated practices proven to be ineffective, unnecessary, or even dangerous.¹⁵ Sacred cows are revered as the standard of practice, seldom challenged, and are difficult to extricate from clinical practice. DNP-prepared NPs must often combat the widely known mantra of “this is how we’ve always done things here.”

Although barriers can seem daunting, a number of facilitators can be used to positively counter QI project implementation obstacles. DNP graduates can draw on what they learned in their program about leadership, communication, conflict, change, organizational culture, staff motivation, and more. The new DNP-prepared NP can develop mentoring relationships with experienced leaders who are positive about QI. As well, they can seek out staff members who are supportive and can be champions for evidence-based practice initiatives.

Taking time to identify and elicit input from stakeholders such as the frontline clinical staff and leaders at every level is essential. Frontline staff members are able to assist with identifying and clarifying the problem as well as provide informal historical information on previous QI efforts. Developing a shared understanding of the perceived problem promotes a unified front. Gathering input from clinical staff can be accomplished during informal conversations or formal gatherings such as the daily huddles and staff meetings.

Communicating clearly with leadership stakeholders is critical so they have the complete information needed for decision making and are able to assist with articulating the QI vision and its benefits. Developing a collaborative relationship fosters an environment in which leaders are encouraged to view QI initiatives as a key component within their prioritization of the day-to-day operations. Organizational leaders can be instrumental in allocating protected time and funds, thus preventing substantial delays in the roll out of an institution-wide change. The cognizant DNP-prepared NP is able to use organizational skills and knowledge, working with leadership to create opportunities for interdepartmental exchange and identify platforms to access shared data related to QI measures that can build teamwork among departments.¹⁶

Modeling positive QI behaviors and increasing the capability of each team member is important. A positive culture can be fostered when members embrace QI as the norm for promoting improved healthcare practices and patient outcomes. Employing a multidisciplinary group comprised of QI champions at all levels provides representation for each assigned area and allows an opportunity to discuss inherent concerns. Adequate staff education and training is another important facilitator for successful implementation and continuation of QI initiatives. Lack of knowledge about QI can be addressed by building competencies and standardizing training that helps others to realize the value in QI processes. DNP-prepared NPs can spearhead initial and ongoing training by developing and leading events such as a “Lunch and Learn,” sending emails with “QI terms of the month” to the multidisciplinary team, and hosting a formal staff education and training in which healthcare teams are led through the implementation of a unit-level QI initiative. The premise of the course would entail staff members gaining increased understanding of the rationale, expectations, and goals of their efforts in every step in the QI implementation process.¹⁷ Finally, a notable concept to improve staff collaboration and involvement is a strategy known as the LOCK method [Learn from the Bright spots, Observe, Collaborate in Huddles, and Keep it Bite-Sized].¹⁷

Conclusion

DNP-prepared NPs have the core clinical skillset to lead QI initiatives. Successful DNP-prepared NPs combine critical thinking, creative thinking, and systems thinking. They use role modeling of acceptance of change, staff education, and empathy to facilitate a positive environment where team players are inquisitive and eager to engage in initiatives to improve healthcare. The realistic DNP-prepared NP recognizes barriers and is able to engage in problem solving with staff and leadership to overcome obstacles. Finally, successful DNP-prepared NPs are continuous learners through engaging with mentors, analyzing experiences, and seeking out other learning opportunities. In a complex, ever-changing healthcare environment, we need them to lead initiatives for widespread and impactful change to improve healthcare and healthcare outcomes.

Ludrena C. Rodriguez is a women’s health nurse practitioner at the Fayetteville Veterans Affairs Health Care Center in Fayetteville, North Carolina. These views are those of the author and do not represent the Veterans Affairs. The author has no actual or potential conflict of interest in relation to the contents of this article.

References

1. Newland JA. Growth of the DNP degree: promoting change and improving quality of care. Nurse Pract.2019;44(4):8.
2. Beeber AS, Palmer C, Waldrop J, et al. The role of Doctor of Nursing practice-prepared nurses in practice settings. Nurs Outlook. 2019;67(4):354-364.
3. Agency for Healthcare Research and Quality. Practice facilitation handbook. Module 4. Approaches to quality improvement. May 2013.
4. Ginex P. The difference between quality improvement, evidence-based practice and research. 2017.
5. Berger K. An update on United States healthcare quality improvement efforts. 2015.
6. Kilkenny MF, Bravata DM. Quality improvement. Stroke. 2021;52(5):1866-1870.
7. Durham ML, Cotler K, Corbridge SJ. Facilitating faculty knowledge of DNP quality improvement projects: key elements to promote strong practice partnerships. J Am Assoc Nurse Pract. 2019;31(11):665-674.
8. American Association of Colleges of Nursing. The essentials: Core competencies for professional nursing education. 2021.
9. Jones B, Vaux E, Olsson-Brown A. How to get started in quality improvement. BMJ. 2019;364:k5408.
10. Rodriguez LC. Creation of a same-day, walk-in contraception clinic for active-duty women and military spouses. Poster presentation. AWHONN Convention, Atlanta, GA; 2019.
11. Schroeder P, Parisi LL, Foster R. Healthcare quality improvement: then and now. Nurs Manage. 2019;50(9):20-25.
12. Alexander C, Tschannen D, Hays D, et al. An integrative review of the barriers and facilitators to nurse engagement in quality improvement in the clinical practice setting. J Nurse Care Qual. 2022;37(1):94-100.
13. Baker N, Suchman A, Rawlins D. Hidden in plain view: barriers to quality improvement. Physician Leadership J.2016;3(2):54-57.
14. O’Donoghue SC, DiLibero J, Altman M. Leading sustainable quality improvement. Nurs Manage. 2021;52(2):42-50.
15. Miller J, Hayes D, Carey K. 20 questions: evidence-based practice or sacred cow? Nursing. 2015;45(8):46-55.
16. Leyenaar J, Andrews C, Tyksinski E, et al. Facilitators of inter-departmental quality improvement: a mixed-methods analysis of a collaborative improve pediatric community acquired pneumonia management. BMJ Qual Saf.2019;28(3):215-222.
17. Mills WL, Pimentel CB, Snow AL, et al. Nursing home staff perceptions of barriers and facilitators to implementing a quality improvement intervention. J Am Med Dir Assoc.2019;20(7):810-815.