Quality Improvement Projects in Practice

I’m Yvonne Commodore-Mensah, Board President for PCNA. I’d like to welcome you to Heart to Heart Nurses. PCNA supports your professional journey with accessible continuing education, practical patient resources and a vibrant community that understands the unique challenges and rewards of cardiovascular nursing. Together, we’re advancing the knowledge that defines excellence in cardiac care while celebrating the difference you make every day.

Geralyn Warfield (host): (00:20)

I’d like to welcome our audience today to our conversation with Kate Lew. Kate, could you introduce yourself to our audience, please?

Kate Lew (guest) (00:25)

Sure, thanks for having me back this year. I’m Kate Lew. I’m a nurse practitioner. I work in an outpatient cardiology practice and I see general cardiology patients and also patients with hypertrophic cardiomyopathy. I am also in a supervisory position for nurse practitioners and PAs in our practice. So, I wear multiple hats and I’m also very involved in PCNA and joining the board. So very excited about that.

Geralyn Warfield (host): (00:50)

Well, we’re excited to have you here. And I just wanted to give our audience a quick heads up that we are recording this at the 2025 PCNA Cardiovascular Nursing Symposium. And right next door, they’re having an exceptionally engaging kind of activity. So, in case you hear a little extra noise in the background, that’s what that is.

Well, Kate, you are here today to talk a little bit about quality improvement projects. And I know that depending upon your role in a facility, your role at a hospital, you may or may not have much experience with this. You might just see the end result of it, as a result of this QI project we’re going to change our policies or procedures or whatever those cases are. But what’s the process to actually get there?

Kate Lew (guest) (01:28)

Yeah, and I think this was something I learned a lot about over the last year or so as we embarked on this. I think many of us in the nursing profession, in any profession really, you identify things that are problems, right? You see it as a problem. It’s a pain point. It’s a sore spot. And many of us, myself included, are very quick to jump to, “I’ve got the solution. I know what the solution’s going to be. This is how this is going to work.”

And really when you look at the quality improvement, by no means am I an expert, but when you look at the quality improvement as a structure or a process to go through, it is very structured, right? They say, okay, you start with identifying the problem, then you gather all of the possible pieces that could be affecting it. And really the thing that I would say with summarizing it entirely is, don’t come up with a solution until you’ve sort of taken this systematic approach. So that was very interesting to me in my role.

And I’ll share the pain point, which I think may resonate with many people, which was as a provider, we get a lot of in-basket messages. So, these are messages and results and things that are coming into our EMR in-basket that need to be addressed.

We identified that that seemed to be a real challenge for the providers in a specific group. And so, in this specific group, it really seemed that there was something there that was different than other groups. It was really something that it seemed like in this group of nurse practitioners and PAs that this was a real pain point and different from what I was hearing from other groups. And that, guess, maybe was unique insight on my part that I wasn’t hearing that same concern or feedback from different parts of the practice.

And so, in this one group, we were hearing that, and this was causing a lot of stress and work after hours and a feeling of ‘I can’t get things done.’ And so, really a colleague of mine and I took on this project and said, OK, well, we need to start with gathering some data.

And I think this would be one of the things that I’ve said now after going through this is you need data to support where you think this issue is.

And so, we really started with the basics, like how many messages are you getting? How many messages is this group addressing? Is that different than other groups, right? Because I think if we had come out the other side and said, well, it’s actually the same across the board, that doesn’t mean that there’s not something going on, but maybe it’s a different factor, right? Maybe we’ve sort of put the blame on one thing, realizing, well, actually, the data doesn’t say that. You’re doing the same amount as another group.

But we did, out the other side of that, identify, they’re doing twice as many messages on average as some of their peers, kind of the peer group. So, all of that to say, it was really helpful to start with the data so we had something to jump off of and say, where do we go?

We also, as part of the project, had asked about staff satisfaction, those kinds of questions. It was a small group. We’re talking three or four, I think it was three to five, APPs. So not a large group, but still helpful information to kind of compare and contrast after we did an intervention.

So, in the quality improvement process, you sort of start with these sort of data points. Then the next step is really to think about multiple factors that go into why is that? Why is it that this group has a lot more messages and we’ve connected this potentially to this as the biggest source of their burnout or their concern.

Is it that the nursing team sends more than other groups? Is it that the prescription refills are more than other groups? Is it that you’re covering some more boxes than other groups? You’re kind of gathering all of that data, not putting the emphasis or the blame or the solution on any one of those, but you gather all of this information and then you consolidate and you really start to dig into maybe each of those aspects.

So, you can see how a project like this can sort of balloon quickly, right? You start with what you think is maybe a small piece of it, but then building on each of these steps, but it is helpful if you really go through that framework of kind of addressing each of those problems that you come across or areas that you come across.

Geralyn Warfield (host): (05:53)

So, before you tell us any more about that, can you describe for us what that, I know that you worked with one of your colleagues. Did you have a timeline in mind for this? Did you work on this as part of your workflow? How did it fit into everything else that’s happening in your setting?

Kate Lew (guest) (06:12)

That’s a great question. And so, in the beginning, we really hadn’t been able to, or really been diligent about carving out time for this. But we did eventually start to carve out little chunks of time where we really kind of put our heads together and worked on this project.

It was a lot of divide and conquer, if I’m being honest. You know, I would do maybe one piece. They would do another piece. But we had really advocated a couple of years back within our nurse practitioner and PA group that there would be time that you could apply for in our institution or, within our department actually, and use that time towards projects or towards professional development.

And so, it’s structured in that you have to apply for those hours, you’ve got to show that you’re using them. But that was a way that we were, and we may have talked about it last year, but that was a way we were really trying to promote nurse practitioners and PAs within our team to do different projects like this because I think that’s the number one challenge I think we all come across, whether it be you want to write a paper, you want to do a research project, you want to do a quality improvement project.

At the end of the day, there’s only so much time in the day. And sure, there are those people who will do it outside of work or have that capacity. But then there’s a lot of people who that’s just not going to be feasible. They need to be able to get home and move on to the next kind of job that they have.

That’s how we carved out time, was that we started to intentionally carve out some time to work on it.

Geralyn Warfield (host): (07:45)

I have one more question about the project itself specifically and that is what that data analysis looked like. Was that self-reported by the APPs or was it something that you looked at actual email numbers? How did you go about that data collection?

Kate Lew (guest) (07:59)

So, it was a bit of both, right? So, we kind of asked about a subjective volume from them, and I think that goes back to having data to support that, right? Because subjectively, I might say, “Oh my, I’ve got so many messages that come to me.” But then when you actually get the data, you might go, “Well, actually, your volume is pretty on average or comparable.” And so, we use the Epic EMR system. And so there’s a lot of data you can pull out of that.

And that’s where we got our data, is we looked at some of the averages and kind of averaged the groups. So, we had the standard of care group and how many they would get on average. We had the intervention group. How many did they get on average? In the system, we could pull those numbers.

Geralyn Warfield (host): (08:42)

We are going to take a quick break, and we will be right back.

Geralyn Warfield (host):

We’re back talking about quality improvement projects with Kate Lew. And Kate I know there’s a few more steps that we haven’t even addressed yet. Could you talk about those for us?

Kate Lew (guest) (08:53)

Sure. So, as we were talking about before, you gather this information, you think about maybe the areas, what are spaces that you can make an improvement upon? What are things that you realize are out of your control? Right. So, there’s only so much that we could control within our group.

So, one of the ways that we identified that we had control over that we could work on this problem or this project from within our group, realizing there are multiple things out of our control. We can’t control what a patient does. We can’t maybe control the nursing structure.

One of those that we identified was that needing more time, is time a piece of this when you only have so much time to do administrative tasks in the day. And so, we took our proposal using our numbers and showing this is the volume for this group. This is the feedback we’ve received. This is their low satisfaction scores.

And we put a proposal forward to do an intervention for six months of an additional amount of time to work on in-basket tasks. And we tracked the numbers throughout this process. We asked about satisfaction and all of those as we went. I think we did a three- and then a six-month follow-up.

And we took that to our leadership team and they were very supportive because we had all this data. And I think that was something that was really helpful that we could rely on the data to show this. Then we evaluated the information, the pre and post. And I would say to summarize, it was very interesting to see that the volume of messages did not change dramatically. So that just may speak to the work of this group that they just have more in-basket messages.

Neither group necessarily, whether it be the interventional group or the standard of care group, didn’t actually have a significant change in the volume that came in. But we were able to track some other metrics like the turnaround time for message results and then staff satisfaction, which was one of our big pushes. That all improved pretty dramatically with this intervention.

I would say one of the other big final takeaways from this is that then you do need to have that data. You need to bring that to your leadership team and show them this and show that what they supported you on had a positive impact. I’m happy to share that we have a very supportive leadership team and we were able to use these numbers, use this data to ask for a long-term intervention to say, this is an ongoing issue. This isn’t sort of a one-off thing. And this group may need more time to address these issues than other groups based on the volumes that come in. So that was a really exciting outcome from working through a project.

And I think it’s an ongoing thing. We’ll continue to trend the numbers and see. But I think one of the ideas that we’ve had is that as we do more and more of this with in-basket—and in-basket is not going away anytime soon—is there some sort of benchmarking or thresholding that at some point, if your in-basket or your volumes reach this consistent amount, is that then when we say, this person or group of people needs to have more dedicated time to address this because it is a part of patient care.

So, exciting things to think about for the future. And hopefully others listening know that in-basket is always a challenge for us.

Geralyn Warfield (host): (12:20)

And do you have any key takeaways that you would offer for individuals who are considering addressing a problem, offering the potential solution of doing a QI project, things that really worked for you? And I realize that every organization is different. Not everybody will have the, it’s not a luxury, but having the luxury of having set aside time for this, things that you might offer so that anyone anywhere might be able to do this kind of activity.

Kate Lew (guest) (12:48)

So, I think it starts with identifying something that’s a pain point, really identifying it. And then I would say really thinking about narrowing it down, taking off, getting to a smaller, more manageable piece maybe of a bigger issue.

And then I think one of the other things that we could have maybe done a bit more of was engage multiple partners in the project. We were just a small little group of two, but I do think it would have been helpful to have another nurse practitioner or PA on our project, have nursing maybe more engaged, our administrative partners. And so, I think there was others that could have helped us sort of think through some of the process.

And then certainly when you can spread out the workload over multiple, that helps with the volume and the work and things.

So, I would also say I think there’s so many different things now that we do all of our documentation electronically. Use your tools to help you rather than doing things in a manual process and in tracking numbers and volumes. There’s a lot out there that you don’t have to do it yourself.

Geralyn Warfield (host): (13:59)

Well, I appreciate your oversight of this particular quality improvement project and your encouragement for those of us that might be looking for that elsewhere. Is there any one last thing that you would like to leave with our audience as a key takeaway?

Kate Lew (guest) (14:12)

I think maybe the biggest takeaway I would share is to really empower or encourage people to think about areas of improvement. Because I think if it’s a pain point for you, it may very well be a pain point for multiple others. And bringing that idea forward and talking with other people about it and saying, “Hey, let’s come at this with an idea towards looking at the problem in more detail.”

I think, often, we may default into either solution-driven ideas, this is what’s going to be the solution, or the other way sometimes that people come and talk about problems is more just in a complaining fashion. And not that you want to jump straight to solutions, and granted there are some quality improvement type algorithms and metrics that I learned about where it is much more, let’s try this, let’s see how it goes, and you do things in a very rapid succession.

But I think really coming at it to say, we hear this as a problem. I’m not alone. We’re hearing other people say it. Let’s take a pause here. And instead of going down the path of I’m complaining about it, or there’s never going to be a solution, or there’s no answer to this, is there a solution? Or is there an opportunity to just gather more data maybe without putting any, without putting any qualifiers on the problem or the solutions and really coming at it from a more comprehensive approach?

Geralyn Warfield (host): (15:40)

Kate, thank you so much for being with us today and for sharing your experience. And we hope that our audience has a lot of emphasis now on trying to find solutions, and you’ve given us some great tools to use.

Kate Lew (guest) (16:08)

Thanks for having me.

Geralyn Warfield (host): (16:11)

This is your host, Geralyn Warfield, and we will see you next time.

Thank you for joining us for this episode of Heart to Heart Nurses. We invite you to visit pcna.net for education and resources that will empower you to provide preventive cardiovascular care with confidence and expertise.