UNIVERSITY HOSPITAL AND CLINICAL PROGRAMS
PROFESSIONAL NURSING ORGANIZATION
POLICY STANDARDS

ADDENDUM:    L.1
EFFECTIVE:     9/03
REVISION:       6/08
APPROVAL:    7/08

SUBJECT: PERFORMANCE IMPROVEMENT PLAN

SOURCE:

PURPOSE:    The purpose of this plan is to establish and maintain a continuous assessment of nursing care throughout the UAMS Medical Center so that collaboration and accountability are assured for all performance improvement activities.  Additionally, the plan will be utilized to ensure that new and modified nursing processes are well designed and data collection is systematically analyzed resulting in institution-wide nursing care which meets a standard of excellence.

 

POLICY:        The Chief Nursing Officer is responsible for establishing and maintaining standards which ensure that the quality of Nursing Practice within Clinical Programs   throughout the University of Arkansas Medical Center is measured, evaluated and continuously improved.  The Chief Nursing Officer approves the Nursing Performance Improvement Plan annually and receives quarterly reports of improvement activities.

 

REFER TO:   Nursing Quality Assessment and Improvement Process Inpatient and Outpatient

 

PROCEDURE:

ESTABLISHMENT OF PRIORITIES 

 

The Clinical Programs Performance Improvement Plan defines the scope and expectations for all performance improvement activities.  When an interdepartmental process is identified as needing improvement, selected nursing members will be asked to participate on the PI team chartered to address the process.

 

 The Significant/Sentinel Events policy is established to ensure interdepartmental risk-preventions activities.  Nursing members will serve on root cause analysis teams as requested by Hospital Administration. 

 

Risk Management indicators reported through the Patient Safety Net process will be routinely monitored by the Clinical Service Managers, the Nursing Quality Improvement Manager and the Associate Director of Patient Care Services; significant events, trends and patterns will be reported to the Nursing Directors and the Chief Nursing Officer.   A meeting of the Personnel Management Council will be called when nursing peer review is required.  

 

http://www.uams.edu/nursingmanual/Policy/policy-5.htm

 

RESPONSIBILITIES

 

Performance Improvement is the responsibility of every employee throughout Nursing Practice within Clinical Programs.  Oversight of the plan will be the responsibility of the Chief Nursing Officer and the Associate Director of Patient Care will be responsible for executing the plan. 

  1. The Associate Director of Patient Care Services, with the assistance of the Nursing Quality Improvement Manager, carries out the following functions through the Professional Nursing Organization Councils: http://www.uams.edu/nursingmanual/policy-addenda/addendum-e.1.htm

  1. The Nursing Quality Improvement Manager prepares and submits a quarterly analysis of quality improvement reports (both unit and nursing-wide) to the Associate Director of Patient Care Services.

  2. The Inpatient Nursing Operations Committee reviews the quarterly report and recommends additional action as needed.

  3. A quarterly report is also given to the Quality Management Department and the Quality Review Committee.

  1. The Clinical Service Managers assess and improve the care given by staff under their supervision.

  1. Nursing Outcome Indicators are selected to measure and improve nursing practice.

  2. These Nursing Outcome Indicators will be reviewed and revised annually.

  3. Each Clinical Service Manager submits a quarterly report of his/her performance improvement activities to the Nursing Quality Improvement Manager.

THE PROCESS

 

METHODOLOGY:

The methodology used for performance improvement activities for Nursing Practice within Clinical Programs  will be PDCA and all quarterly reports will be submitted in that format.

 

MONITORING AND EVALUATION OF CARE

  1. Based on the patient population and/or the nursing practice provided, important aspects of nursing care will be selected for measurement.

  1. Measurement activities will be selected from the following functions of nursing care:

  1. Assessment of patients

  2. Care/Treatment of patients

  3. Operative/Invasive procedures

  4. Education of patient/family

  5. Patient rights

  6. Continuum of care

  7. Infection Control

  8. Medication Administration

  1. One or more of the following dimensions of performance will be selected for each function measured:

  1. Respect/caring

  2. Efficiency

  3. Appropriateness

  4. Availability

  5. Continuity

  6. Timeliness

  7. Safety

  8. Effectiveness

  1. Indicators will be developed to measure the function.

1.       Indicators will be selected according to the following priorities:

  1. High volume

  2. High risk

  3. Problem prone

  4. Impact on patient outcomes

  5. Impact on nursing care resources

  1. The following types of indicators will be used to monitor nursing practice:

  1. Outcome

  2. Process

  3. Structure

  1. UAMS  will participate in the National Database of Nursing Quality Indicators benchmarking.

  1. The following indicators will be reported quarterly:

  1. Staffing effectiveness

  2. Skin integrity

  3. Falls

  1. Additional indicators will be selected for quarterly monitoring as made available by NDNQI.

  1. Inpatient Staffing Effectiveness will be reported quarterly to Scope of Practice, Executive and Practice and Performance Improvement Councils.

  2. Nurse Recruitment will report the Exit Interview results to the Director quarterly.

  3. Data collection will be systematic and continuous.

  4. Data will be analyzed and reported quarterly.

  5. Opportunities to improve Nursing Practice will be identified and action plans initiated.

SUPPORT

 

  1. Nursing Administration allocates resources for performance improvement to the Associate Director of Patient Care Services through the annual budgetary process.

  2. The Nursing Quality Improvement office serves as a repository for performance improvement and quality information.

 

CONFIDENTIALITY

 

Performance improvement activities are confidential when they are a component of the peer review process, the evaluation of individual staff members, or the treatment of specific patients.  All information or discussion related to individual patients or staff members is designated as “Quality Assurance” and separate records and/or minutes are maintained in accordance with Arkansas statues.

 

Security and confidentiality are maintained for all data and information used in internal and external databases for performance improvement activities.

 

 

 

 

 

 

Back to Policy Standards Table of Contents - Addenda
Home