RN Quality Improvement Program Development

A performance improvement program is an integral part of a hospital. Registered nurses (RNs) are intimate members of the performance improvement, or the quality management team or department. Performance improvement is a series of measurements of a hospital's performance; they range from patient care to the physical environment of the hospital. The Joint Commission's (formerly known as the Joint Commission on Accreditation of Hospitals) manuals are the backbone of any performance improvement program. The manuals cover basic standards of care, with sub-headings for elements of performance; each being measurable with a defined limit for success.

Determine Areas for Improvement

• This is accomplished by gathering data on various areas of patient care. An example is pain management. The Joint Commission Hospital manual (as well as the other four manuals) has several standards that guide the practice of pain management. Gather data on how pain is managed. Data will include initial assessment of pain and reassessment of pain. This is a process that can only be done by the RN. Data on reassessment should include noting how effective pain medications are. Data can be gathered by having staff use a checklist or through chart review.

Analyze the data

• Data collection is an ongoing process but can be analyzed for a given time period, such as a week or a month. Input data into a spreadsheet. Excel is a good program to use to construct graphs from data collected. Analyze the data. The graph will depict any trends, either upward or downward.

Create an Action Plan

• Based on the data collected, an action plan may be necessary. An action plan is a series of steps, with due dates and responsible parties to improve a process. Share the action plan with all the staff involved in and participating in the improvement project and implement the plan. Collect data using the same methods.

Measure Success

• Analyze the data again and create a new graph. After implementation of the action plan, this new data should demonstrate an improvement in the process. Share the improvement and success with the team. Once the process is improved, the next phase is to maintain that improvement. Data collection will be an ongoing process.

Tips

• Performance improvement is a continuing process and data is gathered for many different processes. The Joint Commission manuals outline over 16,000 elements of performance that require measurements. The RN is a primary part of the process and often is the leader of the team that drives performance improvement.