Quality Focus Plan

Purpose:
The quality focus plan was created to support the initiative from the hospital board to improve quality 80% by 2015. The creation and implementation of this model was by the CNO, CMO and the Chair of Quality.

Significance:
The most innovative aspect of the model is the development of the unit level triad and the numerous quality councils for nursing and how they all work together to reduce harm and improve quality. The data is disussed weekly so we are more proactive and less reactive

Strategy and Implementation:
The 4 componets of the quality focus plan are: Unit Triad, Nursing Quality Councils, Quality Improvement Committee and Leadership Quality Council (LQC). Each of the components reports to the Collaborative Practice Council (an interdisciplinary council). The unit triad is composed of the Nursing Manager, a physician and the chair of the Unit Practice Council. Specific areas addressed monthly are: core measures, NSIs, RCAs, infections, regulatory issues and patient satisfaction. The Nursing Quality Council consist of 6 subcouncis: falls prevention, med safety, pain mgnt, HAPU/UAPU, core meas. & restraint. The Quality Improvement Council is a physician council that performs physician case review. If change is needed the appropriate medical department approves the changes.The LQC meets weekly. Membership is: CNO, Risk Manager, Infection Prevention, Chief of Quality and the Program Manager. Topics reviewed: NSIs,quality events, mortality, restraints, RCAs, infections, core meas.

Evaluation:
To meet the 80% reduction in harm by 2015 goals are set for each of the 12 quality indicators annually. There is improvement in 9 of the indicators . Progress is reported bi-monthly at Collaborative Practice Council (purpose is to steer hospital quality improvement initiatives to all disciplines)

Implications for Practice:
With an interdisciplinary and collaborative arpproach harm events can be reduced significantly but it must begin at the unit level and it must be sustained.