Magnet Program Directors and Quality Improvement

Sharon A. Cusanza

MSN, RN, NEA-BC, CHCP

Magnet^®, Accreditation^®, Pathway to Excellence^®

Sharon Cusanza brings over 40 years of nursing experience to her consultation practice, including nursing leadership, quality improvement, and Magnet^® experience. She is currently the head of risk management education at LAMMICO.

Sharon Cusanza brings over 40 years of nursing experience to her consultation practice. She has extensive experience as a leader/director including a background in quality improvement, education, and accreditation. Her experience also includes chairing institutional level quality, nursing leadership, and shared decision-making committees. She is currently the lead of risk management education at LAMMICO/Medical Interactive where she oversees ACCME accreditation with commendation and ANCC accreditation with distinction. She was formerly the Magnet Program Director at a large tertiary care hospital, where she successfully wrote two sets of Magnet application documents and coordinated the accompanying site visits. Sharon possesses in-depth understanding and analysis of the ANCC Magnet Recognition Program®, the Pathway to Excellence Program®, and the Accreditation® Program. She is a Fundamentals of Magnet® certificate holder. Fundamentals of Magnet® is a professional credential for consultants who guide hospitals as they apply for Magnet recognition. She also has over 15 years of experience developing local and regional conferences for professional organizations.

In addition to consulting and nursing education, she has presented her own nursing research studies and quality improvement projects at ANCC National Magnet Conferences, AONL, ACCME conferences, and the ANCC NPD Summit.

Summary of Services

Conducts gap analysis and readiness assessments and provides strategies for success.
Develops customized education and training to support organizational needs.
Assists organizations with document development and review.
Assists with electronic document submission.
Conducts comprehensive on-site reviews in preparation for site visits.
Works with all stakeholders to achieve organizational goals.

Education

BSN, Louisiana State University Health Science Center, New Orleans, LA
MSN in executive nursing, University of South Alabama, Mobile, AL

Certifications

American Nurses Credentialing Center–Certificate Holder in Fundamentals of Magnet®
American Nurses Credentialing Center–Nurse Executive, Advanced
Alliance for Continuing Education in the Health Professions-Certified Healthcare CPD Professional

Professional Memberships

Alliance for Continuing Education in the Health Professions
Association for Nursing Professional Development
American Nursing Association
American Organization of Nurse Leaders
American Society for Healthcare Risk Management

Magnet® program directors (MPDs) wear many different hats as they lead, coordinate, and document nursing excellence in their organizations. One of those hats is coordinating quality improvement (QI) projects to document the many needed empirical outcomes (EOs) required in the 2014 Magnet Manual. This manual has 24 EO standards that translate to up to 44 individual sources of evidence. Having a background in QI is an advantage but is not required and not always possible.

The fathers of QI, Shewart and Deming, established a strong framework to help us improve the quality of care that we provide: PDSA—Plan, Do, Study, Act. The steps include planning a change, trying out the plan, studying the results, and then acting on what you learn from the analysis of the test of change. The Toyota Production System/Lean is another model for QI. This framework applies a similar methodology that concentrates on the elimination of waste in processes to achieve the ideal state. Whichever QI model your organization uses should be clearly stated in your organization’s and/or nursing’s QI plan that will be attached to the Organizational Overview documents.

A QI activity should be based on the analysis of data that reveals a gap in the desired state. Some questions to ask before embarking on an improvement project are:

What are we going to improve? Based on data, what needs improvement?
How will we know that a change that we made is an improvement? What are we going to measure, and what is the baseline of that measurement before any changes? Will this be our pre-intervention data point?
What changes can we make that will lead to improvement? What evidence-based interventions can we make?

Here are some tips to navigate the QI aspects of the MPD role:

Consider some additional education in QI. Here are some options:
- The ANA Nursing Knowledge Center offers a one-day workshop on EOs.
- The Institute of Healthcare Improvement (IHI), Centers for Disease Control and Prevention (CDC), and Agency for Healthcare Research and Quality (AHRQ) provide some free resources on QI basics.
- The IHI Open School is also a great resource (fees apply).
Utilize your QI department personnel to facilitate all your EOs. They are the experts in the QI process and can be a strong resource. You should be able to rely on them for the following:
- Project management: QI coordinators’ strength is the oversight of the entire activity using the PDSA/Lean (or other) methodologies.
- Data collection: QI coordinators should ensure that pre-data is collected prior to taking any interventions.
- Data analysis: QI coordinators should utilize tools such as benchmarks, statistical testing, and other analytics to turn the data into information.
- Graphic displays: QI coordinators should be skilled in making visual displays of data to help others understand the meaning.
Develop a process to collect all the QI projects that are being done throughout the organization. This creates a wide variety of projects to select from when documenting sources of evidence (SOE).
Consider utilizing the expertise of a Magnet consultant to assist with strategic planning, QI project management, data analysis, intervention development, and SOE documentation.

As we look toward the future of Magnet, the bar of excellence will be continuously raised. QI activities that result in empirical outcomes will be at the forefront of the movement.

This article was originally published in December 2016.

*Use of ANA Consultation Services does not guarantee you will achieve an ANCC credential. ANA consultants and staff cannot influence the actions of ANCC program staff nor decisions of the Commission on Magnet® Recognition, Commission on Pathway to Excellence®, or Commission on Accreditation in Practice Transition Programs and the Commission for Nursing Continuing Professional Development..