Dial In for Quality and Safety

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Though nurse-sensitive clinical indicators within a 1,000-bed, two campus Magnet® hospital met benchmark targets, there was lack of continuous improvement for some indicators. This issue included the 20-bed medical-surgical hematology/oncology unit. Analysis revealed opportunities to more narrowly focus and limit competing quality initiatives, understand and comply with evidence-based practice (EBP) protocols and appreciate real-time performance to drive quality and safety. The purpose of this improvement project was to identify key performance indicators (KPIs), standard operational definitions, a template, and standard work for daily quality conference calls between unit managers and their nurse leader. Identified KPIs were urinary catheter, central line and sequential compression device (SCD) utilization; pressure injury and fall numbers and rates; and immunization administration compliance. For each KPI, essential EBP care elements were listed on a standard 1-page template and education regarding each KPI was reinforced to unit managers. Standard work for a daily quality conference call was developed and included: consistent time of day – 12:00 pm or later; identification of participants, to include unit managers and their nurse leader, and a clerical staff member to record data; and, verbal reporting by each manager of their unit’s data according to the template order. To obtain their data, each manager is accountable to make daily patient rounds, including direct care staff in the data gathering and using the interaction as a teachable moment. The daily calls began in Fall, 2016 and continue to present. Four nurse leaders and their managers are involved, covering 36 medical-surgical and critical units. Best practice inhibitors were identified and tactics devised. Manager accountability and staff interactions about quality were enhanced. Organization-wide, catheter utilization decreased and SCD, central line bundle and immunization administration compliance and documentation improved. Pressure injuries and fall improvements were realized by consistent interventions at time of quality call, requiring less coaching. Improvements on the hematology/oncology unit include catheter-associated urinary tract and central line-associated infections, SCD compliance, stage 3 pressure injuries, and falls. This effort confirms that concentrated efforts to increase awareness contributes to outcomes and, “what you measure, you improve.” The hematology/oncology nurse manager and a clinical nurse will detail this pragmatic strategy and share how it promotes evidence translation and drives a culture focused on continuous accountability to impact oncology care delivery and outcomes.


Session: Leadership/Management/Education Poster Session.


Patient Care Services / Nursing, Patient Care Services / Nursing Faculty

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