NDNQI Clinical Indicatirs Paper

Assignment Purpose: Hospital systems continually engage in a process of quality improvement through critical evaluation of selected indicators. This assignment will provide you experience with the quality improvement (QI) process and strengthen your ability to develop a comprehensive plan to decrease the incidence of a clinical indicators and improve quality.

Instructions:

• Read and understand the scenario below.
• Select one of the following clinical indicators to focus on for your paper:
• Central Line Associated Blood Stream Infections (CLABSI)
• Review all information on the . Use the to course correct the issue. Include the PDCA plans as a 1 page appendix.

Address the following questions in your paper supported by evidence from the literature.

1. What is the problem and why does it matter?
2. What is your plan?
3. What are the proposed interventions?
4. Who are stakeholders involved in the proposed interventions? Why are they selected and why are they important?
5. What data metric(s) will you use for evaluation?
6. What is your data collection method?
7. Why did you choose this data collection versus other data collection method?
8. Do you anticipate any unintended consequences (can be both positive and negative)?
9. How might an improvement in a clinical indicator affect another?
10. Based on your data analysis, how can this intervention be implemented elsewhere?

• Paper should be 2-4 pages (not including title page, references or appendix) and follows APA guidelines.
• Minimum 5 high-quality references related to the selected indicator. The references should not be not more than 5 years old.
• References could either Meta-Analyses, Systematic Reviews, Randomized Control Trials, Cohort/Case-control/Cross sectional studies, Evidence-Based Practice or Quality Improvement papers.

Case Scenario

The CNO of a Level II Trauma Center received the annual hospitals performance report. Looking at the report, the leader knows that urgent attention in some areas is required. To navigate the quality challenges, the CNO sent the following email to all nursing leaders.

Welcome to Mercy General, a prestigious 250-bed, Magnet-designated Level II trauma center! While renowned for its excellent care, some areas require improvement. You, as the Quality Improvement (QI) Nurse Leader, will tackle one of these challenges.

• Emergency Department (ED): (average number pt visits/day- 205)
• Within the organization: 28%
• Voluntary separation: 25.6%
• Involuntary separation: 16.4%
• Hospital-acquired pressure injuries (HAPIs) rate: 1.5%
• ED patient wait times: 105 minutes
• HCAHPS score for emergency care: 75%
• Number of physical restraints utilized per month: 50
• Staff turnover rate: 42%
• Medical-Surgical (Med-Surg) Units: (128 average daily census in all 4 units)
• Number of falls resulting in injury per month: 2
• Within the organization: 18%
• Voluntary separation: 16.8%
• Involuntary separation: 13.2%
• CAUTI rate: 5.0%
• Fall rate: 1.2%
• HCAHPS score for pain management: 88%
• Non-clinical indicator: RN vacancy rate: 12%
• Staff turnover rate: 30%
• RN education and certification rates: 70% with bachelor’s degrees, 30% certified in a relevant specialty
• Critical Care Units: (84 daily census in all 3 units)
• Number of physical restraints per 1,000 patient days: 6.5
• Within the organization: 15%
• Voluntary separation: 12.8%
• Involuntary separation: 7.2%
• NDNQI Indicator: CLABSI rate: 2.0%
• Number of physical restraints utilized per month: 30
• Non-clinical indicator: Staff turnover rates: 35%
• RN education and certification rates: 90% with bachelor’s degrees, 80% certified in critical care

The Challenge: Choose one of these units and its clinical and non-clinical indicators as your focus. Develop a comprehensive QI plan to:

1. Reduce the NDNQI indicator: Implement evidence-based practices and interventions to directly address the chosen clinical issue.
2. Improve the non-clinical indicator: Analyze contributing factors and implement strategies to enhance staff well-being or patient experience, depending on your choice.
3. Consider the interconnections: Explore how improvements in one indicator might positively impact others.

Remember, creativity and a data-driven approach are key to creating a successful PDCA plan. Good luck navigating Mercy General’s challenges!

Please note: This scenario provides a comprehensive framework. Choose the unit and indicators that spark your interest and personalize your plan based on further research and analysis.