SECTION 1 BACKGROUND: IDENTIFYING A PROBLEM
Eleanor is a 52-year-old patient who has had a hip replacement 1 day ago who is on your assigned patient
care team. You complete patient care rounds and assess Eleanor’s vital signs, comfort level, intravenous
(IV) site and wound dressing. Eleanor has an IV for fluid replacement and medication administration. She
also has an indwelling urinary catheter. She tells you that her pain level is a 4 out of 10 and she is
reluctant to move around because of the pain.
You know that the patient’s pain control is a high priority and that the physician ordered the indwelling
urinary catheter until the patient is able to get out of bed easily and tolerate fluids. The urinary catheter is
convenient in that the patient will not experience pain getting up to the bathroom and it provides an
accurate measurement of output. On the other hand, you know that the longer the indwelling urinary
catheter is in place, the higher the risk of an infection.
You ask a trusted senior nurse when is the right time to remove the catheter since Eleanor is now
tolerating ice chips. The senior nurse tells you that the catheter is usually kept until the patient is able to
get up and ambulate independently. You wonder if there are any contraindications or problems with
removing Eleanor’s indwelling catheter now. You decide to follow the senior nurse’s advice, leaving the
indwelling urinary catheter in place and reevaluate for removal in the morning.
SECTION II BACKGROUND: INTERPROFESSIONAL TEAMS AND STAKEHOLDER
This section is focused on the identification of a clinical problem and the steps of forming an interprofessional team
to work on fixing the problem. The intent is to understand who are the stakeholders for this problem and the
importance of engaging stakeholders in the quality improvement (QI) project. Examine the problem of CAUTIs
holistically to identify stakeholders.
You return to work the next day to learn that Eleanor has a low-grade fever of 99.8° F that was reported to
the physician. The physician ordered an immediate urine culture and removal of the catheter the previous
afternoon. The urine culture was positive for Escherichia coli, representing the presence of catheterassociated urinary tract infection (CAUTI). During the bedside report, you find that although Eleanor
states she is tired, she is able to get up to the bathroom with a walker independently. She is also tolerating
oral fluids and foods.
The presence of the CAUTI bothered you enough that you spoke to your Unit Director about looking into
evidence-based interventions to reduce CAUTIs. The Unit Director tells you that the rate of CAUTIs for
the medical–surgical unit has steadily risen over the past year and the monthly total is twice the number
from 2 years ago. You volunteer to convene a committee to work on the problem. Your first step is to
identify others who should be on your team. You know that the stakeholders are individuals who
influence or are influenced by the clinical problem under investigation. Review the discussion on
stakeholders in Chapter 15 for guidance on selecting appropriate stakeholders.
SECTION III BACKGROUND: LEADING A QI TEAM
This section is focused on power gradients and leadership styles within an interprofessional team. Consider how to
lead a team consisting of various healthcare professionals.
You identified a variety of interprofessionals to include on your committee including two direct care
nurses from the medical–surgical unit, one nurse from the operating room, two certified nurse assistants, a
nurse supervisor, a physician, the medical–surgical clinical nurse specialist, a pharmacist, a laboratory
representative, and a dietician. You feel that these individuals clearly represent all aspects of patient care.
Review the information on communicating within a team and with different power gradients in Chapter 8.
By working closely with the clinical nurse specialist (CNS), you are able to convene a meeting of the
SECTION IV BACKGROUND: CLARIFYING THE PROBLEM
The intent of this section is to work through the causative factors to fully understand the clinical problem. The focus
is to use a root cause analysis approach to examine the big picture and pull out the factors that contribute to the
In this section, you will use information provided from previous sections of the case study and your research to
create a root cause analysis. If needed, create scripts from the perspective of the various stakeholders who might be
involved with the process being investigated to illustrate the various perspectives.
Use the Healthcare Quality Improvement Partnership’s Root Cause Analysis for Clinical Audit guide (accessible at
www.hqip.org.uk/resources/using-root-cause-analysis-techniques-in-clinical-audit/) to guide the students through a
root cause analysis. Complete the cause–effect or fishbone diagram. A resource that includes a fillable template for
creating a cause–effect diagram can be accessed through the Institute for Healthcare Improvement (a free account
is required, accessible at www.ihi.org/resources/Pages/Tools/Quality-Improvement-Essentials-Toolkit.aspx).
Chapter 12 Patient Safety includes an example of a root cause analysis.
The clinical nurse specialist (CNS) decides to work through a root cause analysis and use a cause–effect
diagram (fishbone diagram) with the team to identify potential causes for catheter-associated urinary tract
infections (CAUTIs). You work with the CNS to complete this activity with the team.
SECTION V BACKGROUND: PLANNING FOR CHANGE
The intent of this section is to create a preliminary plan for action by using the PLAN-DO-STUDY-ACT model as
outlined in chapter 13.
The team decides to use the Plan-Do-Study-Act model to determine small tests of change that can be undertaken to
improve CAUTI’s in the patients the team cares for. You work with the team to develop a map of the PDSA model.