1. To learn how a large teaching hospital developed and standardized the data collection and reporting process for NDNQI.

2. To provide examples of standard methods of data collection, analysis, and reports for use by nursing staff.

The purpose of this educational session is to demonstrate a method of data collection and NDNQI reporting in a large medical center, and to describe the evolution of the process since its inception.

Description: The presentation will provide relevant and current knowledge about techniques employed to involve staff nurses in the tracking of NDNQI data, reporting results to leadership, and implementing changes to current practice.

Summary of Presentation:

A performance improvement (PI) plan was implemented at a large (greater than 600 patient beds) Midwestern Medical Center. The PI plan included indicators to measure nursing and patient satisfaction, NDNQI initiatives, JCAHO patient safety goals, physician partnership, and unit specific initiatives. The plan is evaluated by leadership each year.

In 2003-2004, the goal of the plan was to standardize the PI format at the unit level. This process was resource intensive and supported by manual data collection and collation by unit staff. Using the shared governance model already in place, a staff member on each nursing unit was designated as the PI liaison.  The PI liaison, manager, and advanced practice nurse from each unit attended an educational class “Introduction to Continuous Quality Improvement”. A standardized PI binder was developed and distributed to each nursing unit. PI liaisons are responsible for updating the materials in the binder, in addition to collecting, collating, and reporting data trends. PI liaisons receive support through monthly meetings and individual education from the PI department.

In 2005 the PI plan was restructured to stratify indicators into categories to assist staff in understanding the relationship of data collection and its impact on nursing practice. Nurses began to enter data into excel templates distributed by the PI department. Data submission was expected to follow a standardized computer generated format.

In 2006 the PI indicators were aligned with a new organizational initiative. The process has become less labor intensive for PI liaisons because more data is supplied from other resources. A shared computer drive has been established, resulting in more time for actual data analysis and action plan development.

Reporting:
PI liaisons are responsible for reporting data at staff and unit council meetings, allowing staff to participate in the analysis and solution process. The PI liaison also contributes to discussions with the Unit Manager when an action plan is formulated. The data and plan are reported at the nursing division level, followed by the Hospital Performance Improvement Committee, chaired by the Chief Nurse Executive.

Implications for Practice: The development of a standard PI plan and the use of a PI liaison led to an efficient mechanism to share data trends, develop and monitor action plans leading to improved patient outcomes. It also facilitated greater staff involvement in PI and the dissemination of data to all levels of the organization.