Nursing Quality and Performance Improvement

Nursing Quality and performance improvement efforts within the Departments of Nursing occur in a unit/service framework. Within this structure, the three domains of quality - structure, process and outcome are evaluated and performance improvement projects are planned.

The parent Quality and Performance Improvement Council serves as the vehicle through which findings are reported and shared. Reports are channeled through the hospital-wide QA & I structure and ultimately to the Board of Trustees.

MISSION

1. Provide a coordinated system that continuously assesses and evaluates quality in patient care and nursing practice through a regular review of NYUHC and benchmark data.

2. Develop, implement, and evaluate service performance improvement efforts, using the Plan-Do-Check-Act (P-D-C-A) model, consistent with NYUHC Performance Improvement program.

3. Promote a forum for the development, discussion, and implementation of Hospitals Center wide, interdepartmental, and intradepartmental performance improvement efforts.

GOALS

1. To foster a commitment to the pursuit of quality at all levels through education of staff regarding the performance improvement process and participation of staff in performance improvement efforts.

2. To develop and test nurse-sensitive outcomes that reflects the direct contribution of the nursing profession to achievement of quality patient outcomes.

3. To identify care issues that benefit from performance improvement efforts, based on high risk, high volume, or problem-prone areas.

4. To educate Council members on a valid and reliable measurement methodology of data collection, analysis, and dissemination of findings.

5. To utilize department and service data sources as the basis for decision making regarding the delivery of nursing care through systematic data collection and reporting on nurse-sensitive outcomes and service-specific indices such as patient satisfaction surveys, patient profiling, clinical pathway and other clinical process improvement data.

6. To promote staff participation in interdisciplinary performance improvement efforts (i.e. Medication Safety, Nursing/Blood Bank, Nursing/Infection Surveillance, and interdisciplinary Clinical Pathway Teams).

Nursing Quality and Performance Improvement Council

This department-level committee provides nursing staff with an opportunity for an active voice in the identification of improvement projects at the unit, service and departmental level. Membership consists of staff and leadership from each clinical service, nursing administration, staff development and nursing research experts. The Nursing Q&PI Council meets every other month throughout the year.

Each clinical nursing service has a service-level Quality and Performance Improvement Council that is comprised of nursing staff and leadership from the specific clinical service. Service-specific projects include improvements in pain management, restraint reduction, pressure ulcer tracking, management of the obstetrical patient in second-stage labor, and management of adolescents on behavioral health.

Core Indicators

The ongoing monitoring of several core indicators establishes compliance with standards of care, and includes the following outcomes:

1. Patient Safety (Falls Prevention and Physical Restraint Reduction)
2. Patient and Family Satisfaction with Nursing Care (Patient and Family Readiness for Discharge / Satisfaction surveys)
3. Timely Notification to Organ Procurement of potential donor
4. Aggregation and trending of resuscitation outcomes
5. Pressure Ulcer Prevention and Treatment
6. Pain Assessment and Management
7. Evaluation of Process Standards
8. Documentation