Hospitals are facing many external pressures to increase quality and performance initiatives, and over the past several years pressures have increased exponentially. Health care reform, The Joint Commission (TJC), insurance reimbursement and patient expectations are some of the driving forces. Hospitals seek to deliver high quality, safe, patient-centered care while decreasing costs by coordinating patient care, increasing access to preventative care services, focusing care on vulnerable populations, and improving the patient and provider care experience. Developing and planning forward-thinking structures, collaboration, and support should eliminate workflow barriers …show more content…
On individual units, staff members use QI vision boards as a way to brainstorm ideas to present to the quality leadership council. Improvement processes are also selected by looking at National Hospital Quality Measures, incorporating TJC national patient safety goals, and focusing on measures defined by the Hospital Value-Based Purchasing Program. All three nursing quality structures manage and monitor improvement processes. At the unit level, the managers monitor and manage initiatives as they work with their Nursing Directors /CNO and staff members to facilitate change and process improvement. Managers share quality data with staff in unit meetings. Staff members are involved in the QI work by reporting medical and health care errors, monitoring activities and processes and participating in efforts to implement and sustain evidence-based practice changes. The departmental structure provides human and technical support, improvement tools, data collections, statistical analysis, and reporting. The committee structure serves as the central resource and interdisciplinary work group for monitoring and evaluating throughout the organization (OneSource, …show more content…
One involves steps to prevent catheter-associated urinary tract infections (CAUTI), and the other examines preventing central line infections with the use of Curos Caps. Quality staff implemented both initiatives using tools from the DMAIC method to develop problem statements with goals and benefits, collect data, identify sources of variation and root causes, develop potential solutions, and validate monitoring and control systems. The CAUTI protocol allows nurses to remove a patient’s urinary catheter when indicated, and nurses are currently auditing results behind the scenes. Several committees are reviewing and evaluating data from this initiative, so it has not resulted in a change of practice. On the other hand, the Curos Cap project is coming to a close right now, and the data from audits show that compliance with the Curos Cap has greatly decreased the incidence of central line catheter infections. The quality department is currently rewriting recommendations for best practice for central line