Clemson University Course Faculty and Assisting Faculty/Students:

Janet Craig, RN, DHA, Assistant Professor, School of Nursing
Scott Shappell, PhD, Industrial Engineering (and Human Factors engineering expert), College of Engineering
Tobin Turner, PhD, Candidate, Operations Management, College of Business and Behavioral Science
Rosanne Pruitt, PhD, Professor and Director, School of Nursing, College of Health, Education, and Human Development (HEHD)
Leslie A. Thornton, Associate Academic Program Director, Center for Research on Health Disparities, HEHD
Shirley Timmons, PhD, Assistant Professor, School of Nursing

Sarah J. Lane, RN, BSN, Graduate Student
Cheryl Campbell, RN, BSN, Graduate Student
Joanne Wactor, RN, BSN, Graduate Student
Heather Colquitt, RN, BSN, Graduate Student
Crystal Hooper, RN, BSN, CEN, Graduate Student
Annie Trout, RN, BSN, Graduate Student
Jennifer Wallin, RN, BSN, CPAN, Graduate Student
Sherry Gravely, RN, BS, Graduate Student
Marian Crawford, RN, BSN, Graduate Student
Barry Fleming, RN, BSN, Graduate Student
Catherine Murton, RN, BSN, Graduate Student

Participating South Carolina Health Care Organizations:
Robert Pierce, CQM, Director of Quality Process Improvement, Industrial Engineering, AnMed Health (Anderson, SC)
Leigh Miller, RN, MS, Director of Outcomes Management, AnMed Health System (Anderson, SC)
Stephanie Cox, Director of Quality, Greenville Hospital System University Medical Center (Greenville, SC)
Kristen Hauck, RN, MSN, Patient Safety Coordinator, Greenville Hospital System University Medical Center (Greenville, SC)
Connie Steed, RN, MSN, CIC, Director of Infection Control, Greenville Hospital System University Medical Center (Greenville, SC)
Pam Melbourne, CEO, Hospice of the Upstate (Anderson, SC)
Gloria Black, RN, MS, CQI Coordinator, South Carolina Department of Health and Environmental Control Region 2 (Greenville-Spartanburg, SC)
Sharon Bartelt, RN, MSN, MBA, CPHQ, Director of Quality, Spartanburg Regional Health System (Spartanburg, SC)
Ancha Sturkie, RN, MN, CNS, Perioperative Services, Palmetto Health Baptist (Columbia, SC)
Diane Stepp, RN, CNO, Upstate Carolina Medical Center (Gaffney, SC)
Chris Parker, MSW, Director, Care Connections (Spartanburg, SC)

***Watch a video clip of Clemson University School of Nursing's improvement work shared at IHI’s 19th Annual National Forum.***

To foster interdisciplinary partnerships between relevant disciplines at Clemson University and related community experts to expand graduate student knowledge and application of performance improvement models, systems-engineering tools, safety design principles, and technology to enhance patient care processes with front-line staff in participating health care organizations.

• Graded academic work products for the course (such as the initial project plan, and final paper and presentations)
• Student evaluation of the impact of the course on practice, including three changes to be made by a specified date
• Participating health care organization rating of student performance
• Preceptor rating of each student on five defined indicators:
  1. Identification of opportunities
  2. Use of appropriate tools for data collection and analysis
  3. Systematic use of a performance improvement model
  4. Engagement of the staff and other stakeholders
  5. Final work product quality and timeliness 

• Developed a curriculum wherein students attended 15 two-hour classroom lectures/discussions and engaged in 30 hours of clinical practicum devoted to the design and implementation of performance improvement (PI) projects under the supervision of their community preceptors 
• Obtained grant funds to support the teaching assistance of a doctoral student in Operations Management and the purchase of selected educational materials and software for students and preceptors
• Matched students with Quality, Safety, or Risk Management Directors within upstate South Carolina health care organizations who agreed to support the course and precept students
• Students and preceptor selected appropriate patient care improvement projects that aligned with the organizations’ needs and had the potential to be integrated into the organizations’ continuing quality initiatives at the conclusion of the students’ experiences:
  • Improving the Efficiency of the Patient Discharge Process on a Renal Unit
  • A Systematic Review of Medication Reconciliation
  • Process Flows in the Operating Room: Interruptions to the Registered Nurse Circulator and Operating Room Case Surveillance
  • Factors That Impede Clinic Flow in a Preventive Health Clinic: Increasing Capacity by Increasing Efficiency
  • Using Lean Thinking to Improve Turnaround Times with Diagnostic Radiology in the Emergency Department 
  • Improving Contact Precaution Staff Practices to Reduce Methicillin-Resistant Staphylococcus aureus on a Pulmonary Floor
  • Improving Nurse-to-Patient Communication at the Bedside on a Vascular Unit
  • Performance Improvement for a Community-Based Geriatric Case Management Program
  • Choices at Hospice of the Upstate
• Designed projects based on the application of the scientific method using one of two performance improvement models:
  • Plan-Do-Study-Act (PDSA)
  • DMAIC (Develop-Measure-Analyze-Improve-Control), a Six Sigma tool
• Involved the health care organizations’ front-line staff whose roles were impacted by the projects in the project design, data collection, and/or analyses as appropriate

Partner health care organizations evaluated student performance (along with student self-evaluations) and all rated students on a standardized evaluation instrument as meeting or exceeding expectations. All preceptors believed it was a positive experience and indicated a willingness to take future students. They also agreed to participate in a six-month follow-up survey of the course and project impact in their organizations, which is currently in process. 

Some known examples of impact include the following:

• Bedside shift reporting (improving nurse-to-patient communication at the bedside) is being tested and considered for extension to other units and upstate hospitals
• Attention has shifted from radiology turnaround time to reliable implementation of nurse protocols in the emergency room as result of improvement project findings
• Process reliability in hospice has improved

Examples of anecdotal preceptor feedback:

• “This method (is one) that certainly can be replicated in other sites in our region...could benefit from (more education) on process improvement vs. cause and effect….this was a positive experience…I will look forward to working with other students.”
• “(The student) worked on a project that was beneficial to the organization…she was practical in her approach to addressing issues…related well to staff…commitment was apparent.”

As a part of their final exam students were asked to reflect on “your role and routines at work” and identify three things they would do to start the quality transformation in their work microsystems. Examples of student feedback follow:

• “I went to my director and asked if (my preceptor) could in-service the staff regarding quality process improvement and patient satisfaction. The charge nurses had a special mandatory meeting in which he spoke and now the staff is involved in meetings with him. Also we are starting walking rounds, which was one of my goals, not only to improve patient handoffs, but to hopefully improve patient satisfaction.”  —Crystal Hooper
• “I have five Pride Nurses who all want projects and I feel like their instructor getting them all started. It's a Strategic Management and Quality year for sure!!”  —Sarah J. Lane
• “(I) met with my Clinical Nurse educator (on my hospital unit), first to tell her that I was interested in helping to form a PI project to decrease the falls on our unit. I then recruited another staff nurse to help in this process. The CNS, the other staff nurse, and I then met with the Risk Manager to get together our falls data for the last quarter of the year.”  —Annie Trout  

Lessons Learned:

• From an academic perspective, the biggest issue was a lack of classroom time to cover all the content needed and required, especially as it related to practice and application of the tools of quality management. 
• The projects could well have extended beyond the boundaries of one semester and resulted in better data collection and analysis; perhaps, they could have even resulted in a student publications in nursing quality journals. 

Next Steps:

Based on results of the ratings by preceptors, student feedback, obstacles encountered with lack of sufficient classroom time to adequately cover content, and increasing IRB scrutiny of PI projects for presentations, the following changes will be implemented for the next course offering:

• Preceptors and projects will be selected in advance of the semester start date so that all 15 weeks of the semester can be used effectively
• IRB approvals will be obtained within the first 10 days of the course
• Course credits increased from 3 to 4 (course revisions and approvals by the University Curriculum Committees completed in December 2007)

Janet B. Craig, RN, DHA, Assistant Professor
Clemson University School of Nursing
janetc@clemson.edu

[Posterboard presentation at IHI's December 2007 National Forum]