Application of quality control circle in the management of early ambulation after cesarean section: An observational study

Abstract

Background:

The quality control circle (QCC) model has achieved good results in clinical applications in many hospitals in China and has gained popularity. This study aims to explore the application of QCC activities on early ambulation after cesarean section.

Methods:

A QCC management group was established following standardized methods and techniques. The theme of the group was identified as “to enhance the implementation rate of the patient early ambulation after the cesarean section” through a matrix graph. The early ambulation rates after surgery of patients who received cesarean section were compared before and after QCC managements.

Results:

Our data suggested that the early ambulation rates after cesarean section increased from 37.5% to 81.25% after applying QCC management. The biggest factor influencing the ambulation activities 24 ± 4 hours after the surgery was patients and family members do not cooperate. In addition, outstanding improvements in terms of nurses’ sense of responsibility and self-confidence, communication and teamwork capacity in the problem-solving process were observed after the establishment of QCC.

Conclusion:

The application of QCC management had not only increase the early ambulation rates after cesarean section but also improved the quality of nursery care in general.

1. Introduction

The benefits of early ambulation activities after surgery have been recognized by clinic in recent years.^[1] A previous study has reported that early ambulation contributed to the improvement of patients’ blood circulation and promoted the healing of operative lesion as long as reduced the thrombosis formation rates associated with passive congestion of lower limbs. In addition, it also promoted the early recovery of gastrointestinal functions and decreased the chance of pulmonary infection.^[2] On the other hand, delayed ambulation could lead to various complications such as flatulence, pulmonary infection, retention of urine and deep venous thrombosis. However, the early ambulation rate is usually unsatisfactory due to the worry of patients as well as inadequate professional nursery management.

Quality control circle (QCC) is a comprehensive and scientific management model established following the “PDCA” (plan-do-check-act) process.^[3] By the end of 2016, more than 40,000 QCC activities had been successfully carried out in China.^[4] The positive role of QCC in patient management has been repeatedly approved in clinic.^[3,5,6] In order to enhance patient early ambulation after cesarean section, our hospital pulled in QCC activities from May to November 2019 and achieved great success, as introduced below.

2. Methods and materials

2.1. Participants

This study was conducted in the female patients who underwent cesarean section in our hospital from May 1^st to November 30^th 2019. The inclusion criteria were:

The patients were conscious with no postoperative complications; The patients and their families had voluntarily participated in the QCC activity and the follow-up study. The exclusion criteria were: The patients who participated in other clinical trials, Patients with physical disability or psychiatric diseases; Those not cooperate with a certain part of the QCC activity. This study complied with the tenets of the Declaration of Helsinki and was approved by the Ethic Committee of Haining Hospital of Traditional Chinese Medicine (2022-3) and written informed consent were obtained from all patients.

2.2. Formation of QCC

The QCC team was formed from May 1^st under the spontaneous initiative of ten nurses, termed “Care circle,” in order to take special care of pregnant and parturient female patients. The section head nurse was selected as counselor, and the head nurse of gynecology was selected as the chairman of the QCC. All members were required to participate in the discussion and to make a list of problems that required to be solved in work and evaluation method. Based on the 4 aspects including importance, urgency, feasibility and competence of the circle, each item on the list was given a corresponding score.^[7] After discussion, the theme of the group was identified as “to enhance the implementation rate of the patient early ambulation after the cesarean section” through a matrix graph. Each member of the circle had their specific responsibilities and met in designated meeting twice a month.

2.3. QCC process and standardization

A flow diagram of execution of patients’ early ambulation after the cesarean section was depicted through on-site observation and regular conference discussions (Fig. 1). The survey on the implementation situation of patients’ early ambulation after the cesarean section from May 14^th, 2019 to June 17^th was conducted by stratification diagram, checklist and questionnaires. Based on the results of present investigation, multiple hypotheses had been provided to the cause of low implementation rate of early ambulation after cesarean section including personnel, machine, material, method or environment related reasons. Fishbone diagrams were constructed to better understand these hypotheses (Figs. 2 and 3). According to the 80/20 principle in the Pareto diagram, the most important causes were identified as “non-cooperation of patients and family members” and “insufficient health education methods.” The factors of “Non-cooperation of patients and family members” mainly includes 4 major factors: patient, medical staff, surrounding and others (Fig. 2). The factors of “insufficient health education methods” are mainly includes 3 major factors: medical staff, management and surrounding (Fig. 3). The chairman of the QCC summarizes and evaluates the various measures, and then analyzes and modifies the measures through quality management methods.^[8] Specifically, it includes the following points:

Figure 1.

Standardization of work procedures. A flow diagram of execution of patients’ early ambulation after the cesarean section was depicted.

Figure 2.

The fishbone diagram describing the causal factor analysis targeted at “Non-cooperation of patients and family members.” The factors mainly include 4 major factors: patient, medical staff, surrounding and others. For patients, one the one hand, the surgical approach, incision, catheter, physical weakness after surgery and inconvenient infusion all impede patients’ early ambulation; on the other hand, patients psychological factors and lack of early rehabilitation knowledge lead to poor compliance. For medical staff, the medical staff are lack of mission awareness with insufficient health education. For surrounding, the slippery floor and crowded wards also have an impact. For others, the factors include that it is believed that bed rest after surgery is right, over-care of family members and so on.

Figure 3.

The fishbone diagram describing the causal factor analysis targeted at “Insufficient health education methods.” The factors mainly include 4 major factors: medical staff, management and surrounding. For medical staff, the doctors are lack of training in relevant knowledge, inadequate communication with nurses, lack of early rehabilitation knowledge and so on; the nurses are inadequate communication with doctors, lack of doctor assistance, single mission method and so on. For management, it lack of appliance to assist patient activities, poorly training and insufficient supervision. For surrounding, the surrounding is noisy and has no patient education classroom.

2.3.1. Standardizing the training and performance evaluation.

Content of countermeasure: Shifting personnel nursing concept, organizing the whole personnel to have a fast master of the rehabilitation concepts and educating nurses’ early rehabilitation concepts. Offering training about the guidance skills for early ambulation after the surgery in department, asking nurses to master the guidance methods and techniques and evaluated by a relevant examination.^[9] Improving the operating procedure of early ambulation and carrying out standardized training. The head nurse and group leaders were required to conduct a random check and ask questions in morning assembly, department conference, or regular meeting of the circle. Nurses in the QCC were quizzed for patients’ information during morning round.

2.3.2. Additional tools.

The specific content of countermeasures: a walkway for accelerating recovery in the corridor and a pair of special pants to place the drainage pack (Fig. 4). Replacement of all previous packaging tapes with 3M packaging tape to fasten the drainage tube (Fig. 5). Installment hooks for hanging infusion bottles in the toilet of inpatient wards to hold infusion support and guide patients to move at least 5 meters away from the bed.

Figure 4.

Design a pair of special pants. A pair of special pants with a bag right ahead was design to place the drainage pack.

Figure 5.

To replace all previous packaging tapes with 3M packaging tape. The packaging tapes were used 3M packaging tape to fasten the drainage tube.

2.3.3. Combing video and verbal explanations.

The specific content of the countermeasures: Doctors were required to deliberately mention the concept of early rehabilitation and early ambulation in discussions with patients and their families before and after the surgery. Associated articles and educational videos were recommended to patients and their families for learning.^[10] The head nurse also provided patients with specific guidance about early ambulation. Furthermore, nurses were required to offer guidance for patients’ first off-bed activity after the surgery.

2.4. Statistical analysis

Statistical analysis was used SPSS 25.0 software in this study. The categorical data was presented as n(%) and comparison was used chi-squared test. P < .05 indicates a statistically significant.

3. Results

3.1. Survey results of included patients

From May 14th, 2019 to June 17^th 2019, before QCC activities, a total of 32 patients received cesarean section and only 12 (37.5%) patients had early ambulation activities 24 ± 4 hours after the surgery (Fig. 6). According to the target calculation formula, the target value = current value + improvement value = current value + (1-current value) × value of focus × ability of circle = 37.5% + (1–37.5%) × 0.76 × 0.92 = 81%, thus the aim for the QCC team was to enhance the implementation rate of patients’ early ambulation after the cesarean section from 37.5 % to 81% before November 30^th, 2019.

Figure 6.

The early ambulation rate after the abdominal surgery. Before QCC, there were only 12 patients had early ambulation activities 24 ± 4 h after the surgery, while after QCC, 26 (81.25%) patients had early ambulation activities 24 ± 4 h after the surgery. QCC = quality control circle.

3.2. Factors influencing the ambulation activities 24 ± 4 hours after the surgery

The main influencing factors of the ambulation activities 24 ± 4 hours after the surgery were listed in Table 1. The results showed that the biggest factor was patients and family members do not cooperate with 15 (50%) frequency. The second is insufficient health education and method guidance with 8 (26%) frequency. Besides, afraid of slipping of catheters accounted for 10% and both pain at the surgical part and worry about bleeding or spiting incisions accounted for 7% respectively.

Table 1.

Factors influencing the ambulation activities 24 ± 4 h after the surgery.

Influencing factors		Frequency	Composition ratio (%)
Time is too short to get out of bed	Patients and family members do not cooperate	15	50
Family members’ disagree
Inconvenient during infusion
It is not allowed in terms of patient condition
Insufficient health education and method guidance		8	26
Afraid of slipping of catheters		3	10
Pain at the surgical part		2	7
Worry about bleeding or spiting incisions		2	7
Total		30	100

3.3. QCC efficacy

After the implantation of QCC management, from November 1^th to November 30^th, 2019, the same number of patients who received cesarean section were observed and 26 (81.25%) patients had early ambulation activities 24 ± 4 hours after the surgery. The rate of early ambulation after cesarean section was increased from 37.5% to 81.25% (Fig. 6). The rate of early ambulation after cesarean section after QCC was obviously higher than that before QCC (chi-squared value = 12.696, P <.01). Additionally, through the activities required by QCC, the problem-solving ability, evidence-based ability and awareness of quality and safety management of participating members had been greatly improved.

4. Discussion

The early ambulation after cesarean section is critical in patient rehabilitation. As mentioned above, early off-bed activities can promote blood circulation, prevent deep venous thrombosis, contribute to the recovery of peristalsis and reduce abdominal distension as well as increase pulmonary ventilation volume and avoid pulmonary complications.^[1] As a process management and problem-solving technique, QCC was firstly employed in business management and company operation in Japan.^[11–14] With the collective effort from all members and specific procedures, group members can make the most of their advantages and cooperate with other departments and improve the work flow and eventually solve the problems.^[12–15] In the present study, the results showed that the rate of early ambulation after cesarean section was increased though QCC activity.

In this study, the management of early ambulation after cesarean section procedures were established and optimized by the continuous improvement of the QCC activity. For example, nurses should be responsible for the bedside education including video demonstration of off-bed activities, evaluation the condition of patients 24 (±4) after the surgery followed by facilitation of ambulation when possible by fastening the drainage pack (special pants of operation), holding infusion support and guiding patients to move at least 5 meters away from the bed. In additionally, our study suggested that QCC activities also produced some intangible results. Firstly, QCC activities improved the work enthusiasm of team members. QCC activities emphasized the participation of each circle member and empowered them with necessary autonomy. Secondly, QCC activities encouraged collaborations from different departments and cultivated the team spirit.^[4,16]

In this study, QCC activities are oriented for problem-solving, focus on a specific problem, which designed to improve the status quo by exploring and eliminating the causes of the problem. We made a list of problems that required to be solved in work and evaluation method in fishbone diagrams. The fishbone diagram is a visual tool that provides a concise and intuitive way of analyzing and solving a problem. For a problem (as the head of the fish), list the major causes of the problem (fishbone trunk), from the major causes continue to dig deeper, listed in major cause of each major cause (fishbone), layer by layer digging the causes.^[17] Then targeted measures were implemented according to the results of the fishbone diagrams analysis. The use of QCC management tools can detect the key weaknesses in the management system, effectively improve the ability to solve problems in clinical practice, and ultimately lead to improved quality of care, reduced healthcare management costs, and improved efficiency of healthcare services.

Several limitations of this study should also be noted. Firstly, this is a single center retrospective study with limited sample number. A larger and multi-center study is definitively needed to verify the efficacy and accuracy of QCC. In addition, the use of auxiliary equipment was not evaluated in the present study which might obscure the results when interpreting the efficacy of QCC for such patients.

5. Conclusion

In summary, QCC united and enhanced all personnel in the department through various activities.^[4] Our study suggested that QCC was beneficial to achieve early ambulation after cesarean section. Furthermore, it played a positive role in developing high-quality nursing services and improved the quality of nursing in general.

Author contributions

Conceptualization: Yu-Ting Zhu, Yu-Xin Jiang, Lei Pei, Wei-Chao Zhu.

Data curation: Yu-Xin Jiang, Lei Pei, Wei-Chao Zhu.

Formal analysis: Yu-Xin Jiang, Lei Pei, Wei-Chao Zhu, Xiao-Guo Jin.

Supervision: Xiao-Guo Jin.

Writing – original draft: Yu-Ting Zhu.

Writing – review & editing: Xiao-Guo Jin, Yu-Ting Zhu.