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Nursing Quality Improvement

Nursing Quality Improvement

Purpose

The University of Illinois Medical Center strives to deliver patient care which is optimal, customer-focused, and achieves improved patient health outcomes.  The Department of Nursing Services quality improvement program is designed to enhance patient care through systematic assessment and improvement of the quality and appropriateness of care rendered by the department members.  Opportunities to improve patient care through evaluation of clinical and operational performance measures will be integrated into ongoing management processes.

Goals and Objectives

The primary goal of the Quality Improvement program is the ongoing improvement of the delivery, quality, efficiency, and outcome of patient care and services.  This is accomplished through a systematic examination of information provided through ongoing monitoring, evaluation, and improvement activities.  All quality activities are done in accordance with standards of professional health care practices, regulatory, and licensing agencies, and support the overall medical center mission and strategic plans.

Goals and Objectives Based on Medical Center Goals

Goal 1: Employer of Choice Provide ongoing nursing staff education related to departmental QI indicators and results including related internal and external standards.
Goal 2: Provider of Choice
  • Improve patient satisfaction with nurses’ efforts to reduce pain.
  • Improve identification of patients at risk for falls.
  • Reduce patient fall occurrences.
  • Reduce utilization of restraints.
  • Initiate appropriate isolation precautions upon identification of established criteria.
  • Promote patient safety related to medication administration, verbal/telephone orders, critical test results, and clinical alarms.
Goal 3: Productivity & Service Efficiency
  • Increase efficiency of patient data collection and documentation through automation.
  • Provide continuity of care through documentation of patient education  assessment and teaching.
  • Improve nursing documentation ofcomprehensive pain assessment when pain is present upon patient's admission.
  • Improve nursing documentation of pain reassessment and effectiveness of pain relief measures.
  • Indentify factors affecting availability of beds for outside patient transfers.
  • Improve existing and/or develop automated management reports to make data collection process more efficient.
Goal 4: Business Growth & Development
  • Increase outside patient transfers accepted into the hospital.
  • Improve and increase electronic nursing documentation.
Goal 5: Organizational
Compliance
  • Achieve ongoing compliance with internal and regulatory standards related to patient safety (falls, medication administration, verbal/telephone orders,critical test results, and clinical alarms), pain assessment (restraints, pain assessment/management, patient education assessment and documentation, referrals to appropriate services) and infection control practices.
  • Improve provision and documentation of smoking cessation information to patients.

Authority

 The Chief Nursing Officer has the authority and direct responsibility for the continuous assessment and improvement of the quality of services provided based on key indicators which measure customer expectations for critical processes.  The Director will incorporate these quality measures into daily department operations and management decisions and will report significant outcomes or unresolved issues to their Administrative Liaison.

Scope

The Nursing Services quality improvement program encompasses relevant dimensions of performance including those that are high volume, high risk, or problem prone.  The scope of patient care services provided by the department includes:

  • Assessment of patients
  • Planning, implementing, evaluating the nursing plan of care
  • Administration of medications
  • Administration of treatments and therapies
  • Patient and family education

Nursing care is provided on a 24-hour basis to patients from infancy to old age encompassing healthcare needs which span the continuum of care.  Nursing care is provided in  an organized and systematic process under the direction of a registered professional nurse.  This nursing process begins with assessment and recognition of the patient's priority needs, development and implementation of a plan of care to address those needs, and finally the evaluation of the effectiveness of the plan.  Discharge planning, patient teaching, implementation of current nursing standards, and collaboration with the interdisciplinary team are key components of quality nursing care.

Nursing care is provided in various settings including inpatient care units, episodic care areas, and the emergency department.  Providers of nursing care include: Registered Professional Nurses, Licensed Practical Nurses, assistive personnel, and nursing students.

Description of Review Process

The Scientific Method is employed in identifying quality indicators and measuring processes.  The PDCA model of the scientific method is endorsed in the medical center CQI courses.  For example:

  • P - Plan:
    • Identify critical processes
    • Identify customers of these critical processes
    • Identify customer’s requirements
    • Define the quality indicator (operational definition)
    • Devise a data collection plan, including methodology and analysis
  • D - D
    • Collect data on quality indicator
  • C - Check:
    • Analyze results of data collection (benchmarking, internal comparison, etc.)
    • Identify gaps in quality
  • A - Act:
    • Implement CQI tools to improve process outcomes
    • Summarize the indicator’s performance and the implementation/application of QI for making improvements on a regular basis
    • Identify exceptions/barriers
    • Advance unresolvable issues to Administrative Liaison for follow through

Reporting

The Chief Nursing Officer or her designee is responsible for routine reporting to the Administrative Liaison on key quality indicators and their impact on improvement, or potential action plans for unresolved issues.  In turn, reporting advances upward through the management structure until significant quality issues are adequately addressed.  Proposals for formally supported CQI teams can be forwarded based on departmental quality efforts which identify the need for a broader multidisciplinary approach.

On an annual basis, the department will evaluate the effectiveness of the quality program, and will accordingly update the quality plan and indicators based on that evaluation.

Confidentiality

To protect patient and care provider rights, quality improvement information should be accessible to Authorized Personnel Only.

Critical Processes/Quality Indicators (FY - 09 coming soon)

Critical Process Quality Indicator Comparative Standards Standards Source

Pain Management

 

 

 

Restraint Use

 

 

 

Patient Falls

 

 

 

Patient Education

 

 

 

Infection Control Practices

 

 

 

Nursing Referrals to Interdisciplinary Services

 

 

 

Patient Safety: Medication Administration, Critical Test Results, and Clinical Alarms

 

 

 

Staffing Effectiveness

 

 

 

Bed Assignment for Outside Transfers

 

Nursing Quality Improvement Committee

The Nursing QI committee meets every 2nd Thursday of the month. Membership consists of Clinical Practice Specialists/Managers, Patient Care Directors, Associate Directors, Clinical Nurse Educators, and Administrative Nurses.

Comments or Questions

Please email your questions or comments.
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