Reason for Action: Act: Status Check · Falls with Injury/1000 PaBent Days, 3rd Med Surg Falls...
Transcript of Reason for Action: Act: Status Check · Falls with Injury/1000 PaBent Days, 3rd Med Surg Falls...
Reason for Action:Nurse Managers cannot alone drive quality goals and strategic alignment. Charge Nurse/Clinical Resource Nurses are 24/7 extension of leadership but need to be mentored with alignment of goals.Mentoring Charge Nurses/Clinical Resource Nurses to be an extension of the Nurse Manager/Director can bring ownership of strategic goals to the bedside of every shift.
Goal:• Create 24/7 directive leadership for bedside caregivers and quality outcomes with mentorship
Plan:• Create standard work to start each shift with mentorship and directive leadership between the Director/Manager and the Charge Nurse for the next 12 hour shift.• Align the standard work to support the strategic mission of the hospital• Provide proactive discussion around potential issues the CRN might be facing for the shift that will identify solutions for prevention
Do:• Meet with each Charge Nurse at the beginning of the shift and review the checklist• Create the expectation and mentor any issues that the Charge Nurse might be facing for the shift• Address any risks to quality, safety or staffing proactively
Check:The Charge nurse leaves the status check aware of his/her focus for the shift and is equipped with solutions to any risks.The Nurse Manager leaves with a better understanding of the unit for the shifts and where he/she may step in to impact the outcomes
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Act: Status Check:
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Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2014 2015
Rate of CAUTI/1000 Foley Days, 3rd Med Surg
CAUTI NDNQI Mean
0 0.2 0.4 0.6 0.8 1
1.2 1.4
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2014 2015
Rate of CLABSI/1000 Central Line Days, 3rd Med Surg
CLABSI NDNQI Mean
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98
2015
Scan Rates of MedicaBons, 3rd Med Surg
Scan Rates of MedicaCons Target
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2014 2015
% of surveyed paBents with Hospital-‐acquired Pressure Ulcers Stage II and above,
3rd Med Surg
Pressure Ulcers NDNQI Mean
0 0.2 0.4 0.6 0.8 1
1.2
2015
Incidence of PotenBally Preventable Post-‐op VTE, 3rd Med Surg
VTE Target
0 1 2 3 4 5 6
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2014 2015
# of Falls with Injury/1000 PaBent Days, 3rd Med Surg
Falls Falls with Injury
NDNQI Mean Total Falls NDNQI Mean Falls with Injury
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4
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8
10
12
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2014 2015
Rate of CAUTI/1000 Foley Days, 3rd Med Surg
CAUTI NDNQI Mean
0 0.2 0.4 0.6 0.8 1
1.2 1.4
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2014 2015
Rate of CLABSI/1000 Central Line Days, 3rd Med Surg
CLABSI NDNQI Mean
86
88
90
92
94
96
98
2015
Scan Rates of MedicaBons, 3rd Med Surg
Scan Rates of MedicaCons Target
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2014 2015
% of surveyed paBents with Hospital-‐acquired Pressure Ulcers Stage II and above,
3rd Med Surg
Pressure Ulcers NDNQI Mean
0 0.2 0.4 0.6 0.8 1
1.2
2015
Incidence of PotenBally Preventable Post-‐op VTE, 3rd Med Surg
VTE Target
0 1 2 3 4 5 6
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2014 2015
# of Falls with Injury/1000 PaBent Days, 3rd Med Surg
Falls Falls with Injury
NDNQI Mean Total Falls NDNQI Mean Falls with Injury
Clinical Resource NurseM T W T F Recognition
Title: Shift Status Checks; Mentoring Shift Leaders to Drive Outcomes Author: Tasha Frisinger RN MSN CNML Hospital: Rapid City Regional Hospital City: Rapid City, SD Email: [email protected]