Running Head: QUALITY IMPROVEMENT 1

Quality Improvement Project

Nicole Habel

Bon Secours Memorial College of Nursing

Dr. Barbara Ellcessor

Professional Role Development: Servant Leadership NUR 4144

March 20, 2018

I Pledge Honor Code

QUALITY IMPROVEMENT PROJECT 2

Quality Improvement

According to the Centers for Disease Control and Prevention (CDC), “one in

three patients who die in the hospital have sepsis” (Centers for Disease Control and

Prevention, 2017). By definition, sepsis is a life-threatening inflammatory response to

infection within the body. Sepsis can lead to multi-organ failure or even death. Early

recognition and treatment of sepsis are hallmark therapies for the disease and as a result,

national organizations such as the Centers for Medicare and Medicaid Services (CMS)

have established core quality measures for hospital adherence in order to reduce mortality

and incentivize evidence-based care. The sepsis core measures designed by CMS require

Joint Commission-accredited hospitals to activate a sepsis bundle when a patient meets

three criterion: one suspected source of infection, two vital sign changes indicative of

systemic inflammatory response, and one or more variable of organ dysfunction (CMS,

2017.) In order to meet CMS guidelines, the time of recognition of sepsis to initiation of a

septic bundle and appropriate treatment should be within a six-hour time frame. While

sepsis is a hospital-wide problem, 80% of sepsis cases begin outside of the hospital,

making emergency room first responders to recognize the warning signs (CDC, 2017).

As a nurse manager in the emergency room, I want to improve my unit’s

recognition and treatment of sepsis and adhere to CMS guidelines. My emergency

department exhibited 57% compliance to the CMS guidelines in 2017. I want to improve

the quality and adherence of our sepsis protocol by encouraging it as a nurse-driven

process. There is a vast amount of evidence in research supporting nurse-driven

protocols. A team of researchers and nurses (Engvall, Padula, Krajewski, Rourke,

QUALITY IMPROVEMENT PROJECT 3

Mcgillivray, Desroches, & Anger, 2014) implemented a research project that empowered

bedside nurses to develop a nurse-driven protocol for a prevalent healthcare condition on

their unit. Results of their research showed that nurses who are empowered by developing

their own protocol have increased job satisfaction and feelings of accountability for care

provided to their patients, stating, “Direct-care nurses, in the role of change agents and

with the necessary supports, have the ability to transform nursing practice to improve

patient outcomes” (Engvall et al., 2014). Following this initiative, I’ll collaborate with

my staff nurses and educate them on the code sepsis criterion and empower them to use

their judgment to activate a code sepsis when initially triaging patients. As I implement

the change for this process as a servant leader, I hope to increase early recognition of

sepsis, decrease sepsis-related mortality, improve our sepsis core measure compliance,

and boost independence of my nursing staff.

Heart Domain

Authors Ken Blanchard and Phil Hodges describe servant leadership using Jesus

as their role model in their book Lead Like Jesus (2005). While the title servant leader

isn’t entirely clear, the authors aptly explain, “We must lead by setting course and

direction, and then we “flip the coin” and serve by empowering and supporting others in

implementation” (Blanchard & Hodges, 2005, p. 84). Further defining servant leadership,

the authors establish four domains that make up a servant leader. The first of these

domains is that of the heart, a form of leadership that starts on the inside of an effective

leader. Blanchard and Hodges define the heart of a servant leader as their motivating

factors. The authors hypothesize that the heart of a leader can distinguish that of a self-

serving leader and that of a servant leader.

QUALITY IMPROVEMENT PROJECT 4

As a nurse manager and hopeful servant leader, the heart of my leadership is the

health of my patients and the happiness of my staff nurses. I’m motivated to employ new

processes within my department that improve its responses to fatal diseases and thus

decrease patient mortality rates. I am also motivated to provide a work environment that

empowers my employees. A practice of exemplary leaders includes enabling others to

act. A more thorough definition of that practice is providing others with the tools

necessary to succeed and grow into leadership roles of their own. By initiating a nurse-

driven sepsis protocol, I am giving staff nurses an opportunity to buy-in to the quality

improvement process and empowering them to think critically and independently. I

believe my initiative creates a more satisfying work environment for nurses and will give

them the opportunity to lead in the process of improvement patient outcomes.

Head Domain

The second domain of servant leadership is the leader’s head, comprised of their

belief system and leadership style. It is essential for leaders to have a clear view of their

beliefs and values in order to recognize any bias or how they may influence others around

them. Leaders with a clear vision of their belief system are better equipped to inspire a

shared vision in their workplace and recruit others to invest in their purpose.

I recognize that I value autonomy, equity of healthcare, and education. I believe

the aforementioned are innate human rights. As a nurse manager, I hope to inspire a

shared vision with my colleagues, which supports these values among many others. I

prefer acting as a democratic leader and am open to the perspectives and values of my

colleagues when implementing new processes in the workplace. If we all share the same
QUALITY IMPROVEMENT PROJECT 5

vision and hope for our place of employment, the more successful we will be at making

positive changes.

Hands Domain

The third domain of servant leadership is the hands, exemplified by your

behaviors and actions. I believe it is important that a leader’s behaviors, or hands, be

congruent with their values, or head and heart. At the root of a servant leader is hard

work and I find it necessary to personally put in the work necessary to meet your goals

and uphold your vision. As a nurse manager in the emergency room, my hands are

represented by the actual implementation of my quality improvement initiative. I am

challenging the process by altering our existing sepsis protocol for one that is nurse-

driven and evidence-based. In addition to challenging the process, I will practice

exemplary leadership by encouraging the heart. A desirable behavior of servant leaders

and nurse managers is supporting your teammates through encouragement and

inspiration. By showing graciousness to my staff nurses, I am encouraging their positive

behaviors and motivating them to continue bringing their top performance to work.

Habits Domain

The final domain of servant leadership are the leader’s habits. Blanchard and

Hodges relay habits to Christ and leadership by stating, “Jesus stayed on track with his

mission by applying five key habits that countered the negative forces in His life.”

Among these habits are a list of activities that provide both solitude and purpose. The

authors hypothesize that without habits, we are unable to lead as servants like Jesus. I

personally find my solitude in nature, books, and through meditation. It would be difficult

to be centered in my workplace if I didn’t take the time necessary to focus on myself

QUALITY IMPROVEMENT PROJECT 6

outside of the workplace. Allowing myself solitude will grant me the time necessary to

reflect on my leadership and how I can improve. I hope being open about my habits will

model the way for my employees to take time to prioritize themselves and reflect in

solitude. Exemplary leaders model the way, in other words, their actions serve as a role

model for their followers’ behaviors.

Professional Practice Implications

A key implication of my pursuits is continued education. In order to implement a

nurse-driven protocol for sepsis recognition and treatment, I need to invest in detailed

education of my staff nurses. An opportune time to educate several nurses at once is at

pre-shift huddles. At that time, I’ll review sepsis and septic shock and how to recognize

early symptoms and warning signs. I’ll also review the CMS criterion for calling a code

sepsis so staff nurses know what parameters must be met to initiate their protocol. In

order to drive this education home, I’ll utilize badge buddies and laminated worksheets

on mobile workstations with a clear-cut list of CMS code sepsis criterion for nurses to

refer to when they are suspicious of infection in their patients. A second implication of

my new nurse-driven protocol requires me and my other nurse leaders such as nurse

educators and clinical care leads to work more hours in evaluate our code sepsis metrics

and measure the success of our new initiative.

Outcomes Evaluation & Conclusion

With the help of the emergency department’s nurse educator and clinical care

lead, I will evaluate the department’s percentage of adherence to the CMS sepsis

guidelines following the initiation of our nurse-driven protocol. We’ll perform a chart

audit of each patient that was called as a code sepsis and evaluate whether the criterion
QUALITY IMPROVEMENT PROJECT 7

used to initiate the protocol was appropriate and if each evidence-based intervention was

completed in the desired time frame established by CMS. I plan to continue encouraging

the heart in this process, and praising the staff nurses that effectively initiated their

protocol and/or met the CMS metrics in huddles or weekly newsletters. With the help of

my nurse educator, we’ll capitalize on any shortcomings in our protocol by educating

nurses on how they could improve their practice or tap into their intuition. The overall

goal in mind is to improve the adherence of my department to CMS guidelines and

empower my nurses to be change agents within the hospital. Much like existing research,

I expect my nurse-driven sepsis protocol to not only improve patient outcomes but also

the satisfaction and investment of my staff nurses. Using the five exemplary behaviors of

servant leaders and honoring the five domains that contribute to my leadership, I hope my

pursuits to a nurse-driven protocol to recognize and treat sepsis will fit in the footsteps of

the original servant leader: Jesus Christ.

QUALITY IMPROVEMENT PROJECT 8

References

Blanchard, K. & Hodges, P. (2005). Lead like Jesus. Nashville, TN: Thomas Nelson,

Inc.

Centers for Disease Control and Prevention. (2017). Sepsis. Retrieved from

https://www.cdc.gov/sepsis/datareports/index.html

Centers for Medicare and Medicaid Services. (2017). Core Measures. Retrieved from

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/QualityMeasures/Core-Measures.html

Engvall, J. C., Padula, C., Krajewski, A., Rourke, J., McGillivray, C. G., Desroches,

S., & Anger, W. (2014). Empowering the development of a nurse-driven

protocol. MEDSURG Nursing Journal, 23(3), 149-154.