Quality Improvement Project on Increased Nurses' Workload in Aged Residential Care Facility

This report discusses a quality improvement project on increased nurses' workload in an aged residential care facility. The report includes a literature review on problem analysis methods, a root cause analysis of the issue using various tools, and recommendations for quality improvement. The main cause of increased workload was identified as unplanned events such as falls and challenging behavior. Evidence-based recommendations are provided to manage these incidents and reduce nurses' workload.

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Assignment 4: Quality Improvement
Quality Improvement Project on increased nurses’ workload in an
aged residential care facility.

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Table of Contents
1. Executive summary…………………………………….3
2. Introduction and background issues………………...4
3. Literature review on methods of problems analysis..
4. Critical review of the method used…….
5. Problem analysis………..
6. Evidence based discussion of the identified problem…
7. Recommendations for quality improvement…..
8. Memo…………………………
9. Conclusion………………
10. References………..
11. Appendices…………

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Executive Summary
Health care needs of people have increased and it is a challenge for
organisations to meet the needs of people through the provisions of high
quality care and at the same time ensuring the safety of the people. Challenge
in age care is driven by people living longer with more complex problems,
increasing expectations of people and increasing cost of treatment and
technology.
Our organisation supports staff and identifies the challenges that staff comes
across in delivering the safe and quality care to our residents. Recent staff
survey shows our organisation fosters a culture where staff feel they are
valued and their concerns are addressed by the management team.
During the RN forum Registered nurses raised concerns about increased
workload. Also nurses mentioned that the increased work load was due
changes legislative requirements which led to increased documentation which
took time away from nurses to deliver direct patient care.
Problem analysis was done by quality project team using various tools and data
to find the root cause of the increased work load of nurses. The main cause of
increased work load that was identified was unplanned events such as falls and
challenging behaviour.

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Evidence shows that this incidents can be prevented by applying preventative
measures.
This report focusses on issues and recommendations to improve the quality of
care and manage nurse’s workload. The recommendations in this quality
report should be considered and implemented. By using evidence based
practise to manage falls and challenging behaviour nurses workload can be
reduced and there will be greater improvement in patient outcome.

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Introduction and background to issues
An increase in number of ageing population with multiple medical
conditions along with medico technical advancements adds lots of
pressure to the healthcare system. Quality improvement is one of the
possible solutions to these challenges. These days, quality
improvement science has been translated and adapted to healthcare
context. Quality improvement in health care is meant to improve the
patient safety, efficiency and effectiveness of system (Batalden &
Davidoff, 2007). In healthcare setting, there is a tendency to be
solution focused. Sometimes leaders tend to focus on short term
solution without identifying the root cause of the problems (Heifetz,
Grashow, & Linsky, 2009). Analyzing the process and understanding
the problem are the initial steps of a quality improvement process
(Health Quality Ontario, 2012). In this report, we will identify a
quality issue within our organizations and do a root cause analysis of
it using various problem analysis methods and tools based on the
evidences. We will also explore various problem analysis methods
based on the literature review. At this end, we will do a quality
improvement recommendation to address the problem identified.

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During the recent staff meetings, registered nurses (RNs) raised their
concerns about the increased workload and were requesting for extra
staff. As part of the discussions within our quality improvement
project group, we have identified that the above mentioned problem is
a common issue in all our workplaces. So we have decided to do
further investigation and problem analysis of the issue as part of our
quality improvement project. We are going to do a literature review
on various problem analysis methods. Then we will do a root cause
analysis of the above mention problem using the chosen problem
analysis methods.
Literature review on methods of problems analysis
Fishbone, five whys, process mapping, check sheets and pareto charts
are five most commonly used problem analysis tools in the healthcare
sector (Health Quality Ontario, 2012). In the following discussion,
we will assess these tools further:
Five Whys
The '5 whys' procedure is a standout amongst the most generally
encouraged ways to deal with main driver investigation (RCA) in

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social insurance. The WHO, the English National Health Service, the
Institute for Healthcare Improvement, the Joint Commission and
numerous different associations in the field of medicinal services
quality and security, advances its utilization. As most such devices,
however, its ubiquity in not the aftereffect of any proof that it is
compelling. Rather, it likely owes its place in the educational modules
and routine about RCA to a blend of family, effortlessness and
instructional method.
According to Joan (2008), ‘five whys’ is a simple brainstorming
technique used to establish cause of a deficiency problem or an error.
It is a repetitive question asking technique to examine the cause and
effect relationship underlying a specific issue or a problem. The
answer to a problem often leads to another question. By repeatedly
asking ‘why’, you can peel back layer of the issue. It is effective to
investigate simple and moderate problems. For complex issues, it can
be used along with other detailed approach such as fishbone and
process mapping. It is also effective when human factors or
interactions are involved. It is robust technique and more likely to
prevent the problem from recurring (Health Quality Ontario, 2012).

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According to Fogle & Kandler (2017), if we need more clarity, we
can also ask ‘why not?’
Confirmation bias is one of the limitations of this technique.
Monitoring the measure throughout the process may reduce the risk of
confirmation bias. It can be achieved by reviewing the effective of
counter measure by checking if the solution will eliminate or reduce
the initial problem and review accordingly. Another limitation is that,
the conclusion can be subjective and open to interpretation. It can be
biased and incorrect, as it may be subjective and not evidence based.
As explained above, ‘5 whys’ is more effective when it is used with
other tools (Card, 2016).
Fishbone Diagrams
A circumstances and end results outline, otherwise called an Ishikawa
or "fishbone" diagram, is a realistic apparatus used to investigate and
show the conceivable reasons for a specific impact. Utilize the
exemplary fishbone chart when causes assemble normally under the
classifications of Materials, Methods, Equipment, Environment, and

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People. Utilize a procedure compose circumstances and end results
graph to indicate reasons for issues at each progression all the while.
It was pioneered by Dr. Kaoru Ishikawa. It is an easily understandable
visual tool which aids critical thinking (Wong, 2011). The initial step
is to quality problem statement or effect is documented on the center
right and draw a box around it and draw a central line to the left of
that box. Then draw diagonal lines off the central line which
represents various causes of that issue. Different brainstorming
techniques such as five why can be used to identify those causes. All
possible causes of the problem need to be explored (Ilie & Ciocoiu,
2010). After that, each of those causes has to be brainstormed further
to identify the reason or root cause for that effect. It is important to
ensure the systemic review of each and every causes instead of
focusing on a few. Once this process is complete, the irrelevant causes
to the problem can be eliminated based on the evidences or
investigation outcomes (HQSC, 2016 & Health Quality Ontario,
2012).
Process Mapping

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Process mapping is a visual presentation of series of actions that is
involved in a process. It assists in root cause analysis of a problem or
barriers to deliver quality care. It gives an outline of current practice.
In other words, it explains what is actually happening in a process
rather than what should ideally happen. When it is used in a quality
improvement process, it will help to understand gaps in the process,
various steps involved, lack of efficiency, and potential areas of
complexity in the process. Different shapes can be used to represent
different types of steps involved in the process (HQSC, 2016 &
Health Quality Ontario, 2012).
There is a wide range of approaches to convey a similar proof based
pharmaceutical to each patient, each time they associate with the
social insurance framework. Associations vary in their instruments
and experience, yet their point is the same: to convey a similar level
of restorative care to each patient, unfailingly. The advantages of
dependable procedures drive the Triple Aim: enhanced results for a
populace, upgraded quiet involvement, and lessened expenses. For
instance, if the pre-conceding medical attendant inaccurately pre-
registers a patient, it can cause noteworthy deferrals upon the arrival

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of medical procedure, signifying 30 minutes of extra work to the
everyday exercises of the pre-medical procedure nurture. This thusly
can bring about a deferral getting the patient to the working room,
squandering specialist time that would some way or another be
gainful. Human services frameworks need to make sense of how to
adjust procedures to convey reliably brilliant to each patient amid
each experience. Understanding the present procedure through
process mapping and perception is a place to begin.
Check Sheet
Check sheet is a simple tool used to collect and analyze the data. It
helps to identify the pattern of events based on the data. It is used to
identify or prioritize the problem based on the number of occurrence,
when a various problems are identified. Once the problem is
identified, we need to decide what events need to be observed or what
data needs to be collected and for how long. This needs to be clearly
communicated. The check is structured based on that decision
(HQSC, 2016 & Health Quality Ontario, 2012).
Pareto Chart

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Pareto chart is a visual representation of the data on a graph in a
descending order. It is mainly used to identify the largest contributing
factor or factors of the problem. It is based on ’80-20 principle’. That
is, 80% of the problems is caused by minority. In another words, one
or two contributing factors have major impact to that problem. Pareto
charts is used along with other problem analysis tools like fishbone
diagram to reiterate the root cause using the pictorial representation of
data (HQSC, 2016 & Health Quality Ontario, 2012).
Problem analysis based on the chosen method
As discussed above, as a analysis on ‘increased workload of nurses in
2 aged care facilities’ using five whys, process mapping, check sheets,
pareto chart and fishbone diagram. As an initial step, we have decided
to get further information on the issue from the RNs using ‘five
whys’. According to Joan (2008), ‘five whys’ is a simple tool for
problem analysis. During the next staff meeting, we have asked the
RNs that, “Why do they think, there is an increase in workload?”
They believe that increased paperwork and workload with the changes
in legal requirements, that is, Health and Disability. But we have

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identified that it is not the real issue, as the standards has not been
changed since 2008 (health and disability services standard, 2008).
We have decided to explore this issue further by using process
mapping. As part of this process, we did a visual representation of the
nurses’ routine during an 8 hour day shift. We have asked the RNs to
explain their daily routine which is shown in the process map below
(Figure. 1)
Figure. 1 Process mapping of nurses’ routine
Then we have reviewed the process mapping with the nurses and
identified that ‘unplanned events’ are main reason for the increased
paperwork. The word ‘unplanned event’ represents accidents or
incidents such as falls, challenging behavior, infections skin tears and
bruises, pressure injury, medication error and other incidents.
We decided to investigate about the unplanned events using the check
sheet. Then we looked at the quarterly data on above mentioned

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incidents by using a check sheet format as shown below (figure. 2.1 &
2.2)
Area Infections Falls
with
injur
y
Falls
without
injury
Other Wandering
&
Challenging
Behaviour
Pressure
Injury
Skin tear
& Bruises
Medication
error
Area 1
(January)
0 3 1 4
Area 1
(February)
2 3 7 1
Area 1
(March)
2 3 3 1 x
Grade 2
Area 2
(January)
2 2 2 3 1
Area 2
(February)
2 1 5 12 1 1
Area 2
(March)
3 2 10 1 3 1 x
Grade 2
Area 3
(January)
2 2 2 4 1 x
Grade 1
1
Area 3
(February)
1 2 3 6
Area 3
(March)
0 2 1 4 6
Area 4
(January)
0 1 1 2
Area 4
(February)
3 4 2
Area 4
(March)
1 2 3 1 1 1 x
Grade 2

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Area 5
(January)
3 7 6 3 1 x
Grade 3
3
Area 5
(February)
0 1 4 6 1 x
Grade 2
2
Area 5
(March)
2 2 1 4 1 x
Grade 2
Total 23 36 49 3 56 3 14 1
Figure. 2.1 Check sheet
Number of incidents
in last quarter
Percentage
Infections 23 12.4%
Falls (with and
without injuries) 85 46%
Other incidents 3 1.6%
Wandering &
Challenging
behaviour
56 30.3%
Pressure Injury 3 1.6%
Skin tear & Bruises 14 7.6%
Medication error 1 0.5%
Figure. 2.2 Check Sheet
Based on the data from check sheet, we have created a bar graph
(figure. 3). According to ’80-20 principle’ or ‘pareto effect’ as
explained in the above literature review, graph and check sheet
indicate that falls (46%) and wandering & challenging behavior

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(30.3%) are major contributing factors of the quarterly data (76.3%),
that is nearly 80% of the incidents in last quarter.
Falls Wandering
and
challenging
behaviour
Infections Skin tear &
bruises Other
incidents Pressure
injury Medication
error
0
10
20
30
40
50
60
70
80
90
Incidents
#REF! Number of incidents in last quarter
Percentage
Figure 3. Graphical representation of quarterly data
By using fishbone diagram (Figure 4), we are now identify how do
falls and challenging behaviors increased the nurses’ workload.

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Figure. 4, Fishbone diagram
The fishbone diagram indicates a significant increase in work load of
nurses as result of a fall or an incident of challenging behavior during
their shift.
Evidence based discussion of the identified problem
According to TAS (2017), 37% of residents in the long term care
facilities (LTCFs) has dementia. It also indicates that the percentage
of residents with cognitive performance issues triggered with
behaviour, communication, mood and delirium Clinical Assessment

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Protocols (CAPs) were significantly higher, compared to the people
without cognitive issues. According to the same report, national data
indicates nearly 35% residents in LTCFs has triggered with
behavioural CAPs and nearly 25% residents were triggered with falls
CAPs. According to Health Quality and Safety Commission (2018),
25% of people at the age of 85 and above had at least one or more
claim with ACC related to fall in 2016.
According to Duffield, Diers, O'Brien-Pallas, Aisbett, Roche, King &
Aisbett (2011), nursing workload has negative impact on patient
outcome such as increased falls, infections, and medication errors. As
part of this assignment, we have read a number of articles which
supports that statement. But based on the root cause analysis of
increased nursing workload in our facilities, we have identified
unplanned events like falls and challenging behaviour are some of the
causes of increased nursing workload. From our personal experience
as nurses, we also agree that those unplanned events increase the
nurses’ workload. Further studies are needed to identify the
effectiveness of measures to reduce or eliminate these root cause on
reducing nursing workload.

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Recommendations for quality improvement
According to Gee, Bergman, Hawkes & Croucher (2016), 30 to 50%
of challenging behaviour related to delirium can be prevented by
implementing simple assessment and management tools. Escalated
endeavors are in progress over the world to enhance the nature of
social insurance. It is essential to utilize assessment techniques to
distinguish change endeavors that function admirably before they are
reproduced over a wide scope of settings. Assessment strategies need
to give a comprehension of why a change activity has or has not
worked and how it can be enhanced later on. In any case, change
activities are perplexing, and assessment are not generally very much
lined up with the purpose and development of the intercession, along
these lines constraining the pertinence of the outcomes. A
multifactorial post fall assessment and interventions based on it can
prevent falls or reoccurrence of falls in older people (Cameron,
Gillespie, Robertson, Murray. Hill, Cumming & Kerse, 2012).

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MEMORANDUM
To: All Registered Nurse From: Anjani Sharma
Date: 20/04/18 Re: Increased Nurses workload

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Dear Staff,
As you have discussed during the RN Forum, regarding the significant increase in
nurses workload. As you have also mentioned it has a huge impact on the quality
of care that is delivered to the residents. We have had various discussions about
it with the management team and quality initiative project group.
As per your feedback the reason for increased workload is due to increased
documentation and legislative requirements. Based on your feedback we have
decided to do a problem analysis using some tools.
The problem analysis has indicated the root cause of the increased workload is
due to unplanned events such as falls and challenging behavior. Data on
unplanned events from January to March shows 76.3% residents with
challenging behavior and falls.
Quality project team will do an action plan on falls prevention and challenging
behavior which will be communicated.
Kind Faithfully,
Anjani Sharma
FACILITY MANAGER

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Conclusion
In conclusion, three of us work in nursing management roles in two
different organisation. The common problem identified is ‘increased
nursing workload’. In this report, we have done a literature review of
various problem analysis methods. Then we used process mapping,
five whys, pareto chart, check sheets and fishbone diagram to do the
root cause analysis of that issue. Based on that we have identified
that, unplanned events such as falls and challenging behaviours are
two main causes for increased nursing workload. Some of the
literatures states that falls and challenging behaviour are significant
issues in older population in New Zealand. As mention in this report,
some studies suggest that falls and challenging behaviour could be
prevented by proactive approach.
Healthcare is a complex system. Most problems identified in this
sector are adaptive challenges which requires innovative solution. “In
order to thrive in tomorrow’s world, quality improvement teams must
develop ‘next practices’ while excelling at today’s best practices.”
(pp. 65, Heifetz et al., 2009). One of the biggest learning from this

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group work is that initial problem identified and the real cause of the
problem may be entirely different. Being solution focussed and trying
to solve the initially identified problem may not be the real long term
solution for it. After doing this root cause analysis, we would like to
explore further: Is nurses’ workload the reason for an increase in
resident incidents or the increase in preventable resident incidents
causes increase in nurses’ workload?

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(2011). Nursing staffing, nursing workload, the work environment and patient
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Appendices
 Identification of a common problem based on feedbacks from
the registered nurses.
 Problem analysis by using five whys
 Problem analysis using process mapping
 Data analysis using check sheets
 Visual representation of check sheets using Pareto chart
 Root cause analysis using fishbone diagram
We agree that all members of this team worked together as a team to
complete this report and we contributed equally.