Nursing Quality Improvement Plan

By Brenda White,2014-04-26 19:50
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Nursing Quality Improvement Plan

    Nursing Quality Improvement Plan



    The Kaiser Permanente Ohio (KPO) Department of Nursing Administration’s quality

    improvement program is designed to enhance patient care through systematic assessment and improvement of quality and safe care delivered by nursing personnel. Through evaluation of clinical and operational performance, the Department will provide evidence-based opportunities to improve patient care practices and integrate them into ongoing nursing processes. This will facilitate and support nursing excellence.


    The goal of the quality improvement program is perpetual improvement in the delivery, quality, efficiency and outcome of patient care and services. This will be accomplished through a methodical analysis of data provided via ongoing monitoring, evaluation and planned improvement activities.


    The Department of Nursing Administration at KPO will develop and deliver a program to standardize and improve patient care and patient safety by elevating nursing standards. The program will:

    1. Develop and maintain a strategic plan to guide nursing quality improvement


    2. Identify and utilize nursing-sensitive indicators to evaluate nursing clinical


    3. Oversee the process for timely and accurate data submission and reporting;

    monitor and analyze data relative to nursing quality and safety practices seeking

    opportunities for continual improvement.

    4. Promote evidence-based nursing quality improvement activities through

    education and communication within the KPO community.

    5. Monitor and ensure compliance in accordance with standards of professional

    health care practices, and regulatory and licensing agencies, and support KPO’s

    overall mission and strategic plan.

    I. Critical Process 1. Patient Safety: Nursing Chart Audit

    A. Objectives

    ; Formalize and standardize chart audits of nursing activities

    ; Set targets/goals for compliance and/or requirements for developing

    corrective action plans

    ; Create, distribute and communicate regular reports based on results of

    nursing audits

    ; Utilize results from nursing audits to create corrective action plans that

    will improve patient care and safety

    ; Communicate quality improvement plans, activities and progress to an

    oversight committee (QCOLT)


    B. Action Items

    1. Convene a work group comprised of a small group of nursing leaders. ; Practice Lead, Nursing Quality and Systems Management ; Manager Medical Specialties

    ; Manager Primary Care

    ; Behavioral Health Specialist

    ; Manager, Call Center/Emergency Services

    2. Create a system to perform chart audits of nursing activities. 2.1 Develop a standard nursing chart audit tool by identifying essential

    elements of an audit for each clinical team.

    2.1.1 Create a template that comprises nursing indicators for all

    clinical teams.

    2.1.2 Enhance the template with team-specific nursing indicators.

    2.1.3 Set goals / targets for each nursing indicator.

    2.2 Identify the number/percentage of charts to audit per clinical team.

    2.2.1 Work with Provider Scheduling to access a report of patient

    visits per physician per quarter. This will be the basis for

    the number of chart audits per nurse. Consider auditing 10% of charts per physician

    per quarterdivided evenly among nursing


    2.3 Identify appropriate auditors. (Teams should not audit their own


    2.3.1 Work with team leads to identify a nursing candidate per

    . This nurse team responsible for chart audits quarterly

    (possibly the team preceptor) will need authorized hours

    designated to perform chart auditsaway from patient care.

    2.4 Develop a system of inter-rater reliability. Teach how to audit

    charts and check for accuracy.

    2.5 Forward results of nursing audits to the Department of Nursing

    Administration for collating results and creating a quarterly report.

    2.5.1 Department of Nursing Administration will create a

    summary report for each clinical team and distribute it back

    to the clinical teams for discussion by team leads/managers

    during team meetings.

    3. Create a system to plan and initiate a corrective action plan for all results that do not meet goal. This will involve the Department of Nursing Administration, the team lead/manager and/or preceptor.

    4. Report quality improvement activities to QCOLT.


    II. Critical Process 2. Unit Readiness: Code 7/Code Assist Response to the

    Need for Medical Assessment/Assistance and/or Life-Threatening


    A. Objectives

    ; Revise the KPO regional policy on Code 7/Code Assist; Determine

    custodian/owner of policy

    ; Ensure that all facilities and relevant clinical personnel are prepared to

    assist members, visitors or colleagues with medical assessments or

    assistance during medical or life-threatening emergencies ; Promote and enforce a system for quality checks on emergency

    equipment to ensure that equipment is always in working order ; Set targets/goals for compliance and/or requirements for developing

    corrective action plans

    ; Identify appropriate credentials (BLS, ACLS, PALS) required as basic

    skills for each clinical unit at KPO

    ; Create a system to monitor credentials of personnel that participate in

    medical emergencies (HR has the responsibility for monitoring

    credentials via LCRC). There is a regional policy to support.

    B. Action Items

    1. Revise the Nursing or Joint Regional policy on Code 7/Code Assist.

    1.1 Convene an interdepartmental committee to review current

    KPO policies and compare them with other regions’


    1.1.1 Involve nursing, physician, quality and biomedical

    engineering representatives.

    1.1.2 Determine whether to create one merged policy or

    two separate policies (Code Assist--Need for

    Medical Assessment/Assistance and Code 7Life-

    threatening Emergencies)

    1.1.3 Identify the custodian or owner of the policy.

    1.2 Rewrite and communicate the creation of a new policy to

    all KPO employees.

    2. Perform facility audits focusing on the presence, location and

    working order of emergency response equipment including first

    responder bags, AEDs, procedure carts/boxes, crash carts, eye

    washes and showers.

    2.1 Identify frequency of checking the working order of all


    2.2 Identify sample checklists/logs for documenting equipment


    2.3 Reconcile all logs and checking intervals to establish a

    uniform documentation tool and a uniform interval for

    checking equipment.


    2.4 Work with pharmacy and biomedical engineering to

    determine responsibilities of each respective department.

    3. Create a system to monitor and report equipment checks, and/or

    develop a corrective action plan.

    4. Once the foundation for training and checking equipment is in

    place, consider holding quarterly or semi-annual mock codes to

    evaluate each facility or department’s preparedness in addressing

    medical emergencies.

    4.1 Create/revise policy for mock codes.

    4.2 Develop/revise documentation tools for QA of mock code.

    5. Determine responsible party for monitoring the status of/renewal

    dates for BLS, ACLS and PALS. (Human Resources vs.

    department managers) HR is the accountable party.

    III. Critical Process 3. Advice Call Monitoring

    A. Objectives

    ; Support the ongoing national initiative on advice call monitoring with

    efforts to standardize advice activities, protocols and documentation

    ; Integrate the activities within the Department of Behavioral Health and

    the Member Service Center into any strategic national initiatives

    ; Set targets/goals for compliance and/or requirements for developing

    corrective action plans

    B. Action Items

    1. Participate with the national advice call monitoring work group.

    2. Support the research of the national consultant on advice call


    2.1 Assist with arrangements for a site visit to KPO.

    2.2 Identify facilities for consultants to visit (Behavioral Health,

    Member Service Center, specialty nurses [heart failure,

    diabetes, HIV] and pediatrics)

    3. Perform chart audits on telephone encounters in Behavioral Health

    and the Member Service Center.

    3.1 Monitor 10 charts per nurse per quarter.

    IV. Critical Process 4. Point of Care Testing (POCT)

    A. Objectives

    ; Ensure that personnel performing POCT are properly credentialed

    (performing within scope of practice) and trained, with competencies

    checked at appropriate intervals

    ; Promote proper documentation of POCT including order entry and

    results reporting; include all documentation required for verbal orders

    ; Set targets/goals for compliance and/or requirements for developing

    corrective action plans

    B. Action Items


1. Write or revise POCT policies as needed. Work

    interdepartmentally as needed.

    2. Provide initial and ongoing training for all POCT for all relevant

    clinical staff. Utilize interdepartmental staff when relevant and

    involve preceptors in training and competency testing. 3. Create a system or process to monitor the status of all required

    competencies and communicate to managers when competencies

    are outdated.


    Kaiser Permanente Ohio

    Nursing Quality Improvement Plan 2008

    Critical Indicator/Monitor Methodology Reporting

    Process Frequency Standard template of indicators for all departments Quarterly Patient Safety: ; Involve all departments but use different audit with several department-specific indicators Chart Audits for templates per department

     Nursing Activities ; Random chart audit

    (focuses on rooming Standard indicators will include: ; 5%-10% of charts per provider per quarter divided activities) ; 2 identifiers checked-.ID evenly among nursing staff

    ; Chaperone offered-.CHAPE (exc. BH) ; Peer review with inter-rater reliability but nurses ; Allergy review cannot audit their own departments

    ; Alcohol/Drug use ; Target: 95% compliance

    ; Medication review ; Action plan required for report rating < 90%

    ; Surgical history ; Report stats, action plans and results of action

    ; Smoking status plans to departments and COLT

    ; Chief complaint

    ; Verbal/Telephone orders entered and cosigned/Note in

    nurses note indicating .VO/’read back’ of verbal orders

    ; T,P, R, BP, Wt, Ht--rooming standards observed

    ; AVS given

    ; Next/ follow-up appointment scheduled

Department-specific indicators will include:

    ; Time out/Side-site verification (GI, AS, ED/CDU, Card,

    any area with conscious sedation)

    ; Audiogram (peds, ENT)

    ; Imm review (peds, prim care)

    ; Last Pap (prim care, OB, peds > 16)

    ; Last Mam (prim care, OB)

    ; LMP recorded (prim care, OB/peds)

    ; Hx varicella (peds, OB)

    ; BCG (urol)

    ; Cryometircs (urol)

    ; Radiology orders (ortho)


; Cast tech order cosigned (ortho)

    ; Nail chart cosign (podiatry)

    ; POCY order and results (OB, urol, neph, ?ED) ; Visual acuity testing (ophth, peds)

    ; Family History

    ; Sexual history

    ; Allergy Skin Test documentation (allergy)


    Critical Indicator/Monitor Methodology Reporting Process Frequency

    First Responder Bags, AED checks and documentation Check all clinical facilities daily and open monthly Quarterly Unit Readiness:

     Code 7/Code Assist

    Emergency Code Carts / Procedure Boxes/Carts Emergency Code Carts Quarterly

     ; ED/CDU, Cardiology, Amb Surgery, GI

     ; Checked daily for integrity

     ; Opened weekly ; Work with pharmacy to determine each department’s responsibilities ; Target: 100% compliance ; Action plan required for report rating < 90% Proc Carts/Boxes ; Amb Infusion Center, OB/GYN (delivery kit), Radiology ; Open monthly ; Target: 100% compliance ; Action plan required for report rating < 90% Code 7/Code Assist Subcommittee> Nursing Policy and Procedure Committee> Nurse Practice Council> COLT Policy(ies) revised and communicated Policy - every 2 yrs. Code 7/Code Assist Subcommittee> Nursing Policy and Procedure Committee> Nurse Practice Council> Mock Codes COLT Policy - every 2 yrs. ; Policy created ; Policy communicated

    Mock codes - ; Documentation tool drafted eventually quarterly ; Mock codes held or bi-annually


    Advice Call Monitoring Quarterly Patient Care ; Involves primarily and initially Member Service

    Annual: Center / Behavioral Health

    INC/MDQC Board ; Ongoing participation in national initiative

    ; Participation via ANGG

    ; Monitor 10 charts per nurse per quarter.

    Point of Care Testing (POCT) - RBS, Rapid Strep Test, RBS: Applicable to clinical areas where glucometers Quarterly Patient Care

    UA, Urine Pregnancy Testing are used

    Rapid Strep Test: ED, Peds, Internal Med (coming ; Inservice education for new hires and yearly for

    soon) those employed in departments where these tests

    UA: ED, OB/GYN, Peds. Requires use of a quality are performed.

    control record ; Annual competency testing is documented

    Urine Pregnancy Testing: OB/GYN

    ; Create a process to reconcile records - Robin

    Petrucelli in the lab and Chris Hanratty in Nursing

    Admin will keep up-to-date data on all employees

    that have completed competencies

    ; 100% competency validation for all personnel who

    perform these tests

    ; Target: 95% compliance

    ; Action plan required for report rating < 90%


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