Influencing Change in Developing Countries Through Mentoring Leaders: A Nursing-Led Quality Improvement Project in Peru

Background: In developing countries, nurses are best positioned to lead large, yet feasible and affordable, organizational-wide quality improvement (QI) projects. Although nursing leaders at a Peruvian hospital recognized the need for QI to better serve their patients, they lacked the knowledge, skills, and resources to effect change. A quality improvement framework with nurse leader mentoring was developed to implement a nursing-led international health facility accreditation program. Accreditation standards are an important QI tool for nurses as the majority of the standards, about 65%, are focused on nursing practices, 10% on physician work, 10% on pharmacy performance, 5% on other therapies, 5% on management and leadership, and 5% others. However, the process of international accreditation begins with organization leaders recognizing the need for system-wide changes and the willingness to work toward realizing improved outcomes. The nurse leaders at a small private hospital in the provinces of Peru recognized the need for quality improvement, accepted mentoring and education, and earned hospital leader empowerment to implement a program to achieve accreditation. The overall project lead to improve quality, safety, and financial outcomes.

Methods: he Nursing Mentorship Resource Guide, published by the Canadian Association of Public Health Nursing Management, supported the development of nurse leader mentoring relationship. The resourse guide is based on the Mertz's Conceptual Model of Mentoring that distinguishes mentoring from other kinds of supportive relationships. The quality improvement work was guided by Roger's diffusion of innovation Theory (changing culture through innovation), King's Systems Interaction Model (interaction of nursing within organizations), and Donabedian's Quality Improvement Triad (structures + processes = outcomes). With this framework, the nurse leaders were mentored to developed a project committee and specific chapter teams, where each team identified projects and sub-projects ranked from lowest to highest resistance to change for each deficiency, SMART goals were established, an iterative PDSA quality improvement process was implemented, and the results for each subproject and project were evaluated.

Key points for discussion: The nurse-leaders successfully implemented a system-wide QI project. The first self-evaluation demonstrated 27% compliance with all accreditation standards. Nurse leaders were guided in formulating strategies to impact the uncompliant areas. In addition, nurse leaders recieve mentoring to manage and overcome obstacles in implementing QI strategies. The subprojects and projects then resulted in an 86% compliance. Importantly, the standards deemed as “critical standards” were assessed at 100%. Furthermore, the operational balanced scorecard demonstrated improvements in financial outcomes and a decreased number of adverse events with harm. The official accreditation evaluation resulted in no chapter deficiencies and a full three-year accreditation was granted.

Conclusion and recommendations: Hospitals in developing countries can substantially increase the quality and decrease the cost for health services by fully engaging nurses. Specifically, international nurse leaders, educators, and clinicians can empower developing country nurse leaders to effect positive change. In addition, empowered nurses can convience hospital leaders to authorize nurse-led quality improvement projects based on accreditation standards. This quality improvement effort resulted in the diffusion of quality innovation organization-wide. In Peru, the importance of nursing practice in hospitals is under appreciated and not recognized as a quality improvement strategy. This nursing-led project clearly demonstrates that simple, structured, and affordable projects can improve hospital quality in developing countries.

References:

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