2008 NursiNg ANNuAl report - Catholic Health System

Quality in Nursing
The nursing department tracks several nursing-sensitive quality indicators both independently and
through the National Database for Nursing Quality Indicators (NDNQI). Indicators are measured,
reported and tracked at the unit level to be used for practice and process improvements using current
evidence and best practice. Indicators that are monitored and reported on include medication
errors, patient falls, core measures for congestive heart failure and community acquired pneumonia,
restraint use, and pressure ulcer prevalence. For the pressure ulcer prevalence and restraint
use- skin rounds are done on
the same day each month and
Sisters Hospital Pressure Ulcer Prevalence Rate
any patients in restraints are
12.0%
11.0%
documented. The results are
10.2%
10.3%
graphed for reporting to the
10.0%
units and up through the hospital
quality committee. They 8.0%
7.0%
are also reported through the
6.0%
6.0%
5.7%
5.8%
National Database for Nursing
5.1%
5.0%
Quality Indicators (NDNQI)
4.4%
4.2%
3.9%
4.0%
for benchmarking nationally.
These graphs show a trend of
overall improvement for the
use of restraints and pressure
ulcer prevalence for 2008.
2.0%
0.0%
Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08
Rate = Patients with H.A.ulcers /Total
patients surveyed
Total Hospital Rate
Linear (Total Hospital Rate)
The individual Unit Practice
Councils are charged with
analyzing the data and determining
ways to improve
outcomes for their unit. If
successful, they will share their
processes with the other units
in the hospital. When an opportunity
exists for improvement
on all patient care units,
a more global approach to the
problem is developed with all
units implementing the same
improvement plan.
12
10
3
146
# of Restraints
8
6
4
2
0
1
140
10158
Total Restraints
The results from all units are
monitored and shared with the
nurse managers with the expectation
that results are then communicated to the staff for further analysis and idea sharing. The intent is to
continue building our culture of patient safety and nursing excellence.
4
127
130
1 1
133
3
126
2
143
139
1 1
Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08
Pts with Restraints Number of patietnts surveyed Linear (Pts with Restraints)
120
2
127
0
96
180
160
140
120
# of Patients
100
80
60
40
20
0
12