Choose a Nurse-Sensitive Quality Indicator that needs improvement based on the data presented in the Dashboard
Select one Quality Indicator that needs improvement. Thoroughly review the statistical data provided in the Dashboard and develop a nursing action plan based on best practices. To prepare Choose a Nurse-Sensitive Quality Indicator that needs improvement based on the data presented in the Dashboard. Include information on why this area was chosen. Develop a nursing plan that outlines suggestions on how to improve performance in the chosen area. Provide at least three best practices from evidenced-based literature to support your nursing plan. Assignment Draft a 3- to 4 page paper analyzing areas where there is good performance and areas of opportunity from the sample Dashboard. Analyze the data provided in the Dashboard and select an area of performance that needs improvement. Develop a nursing plan that includes suggestions on how to improve performance on the selected indicator. Each suggestion should be based on at least three best practices. Nurse-Sensitive Quality Indicator Dashboard – Adams 5 (Inpatient Rehab Unit) Time Period Q2FY09 Q3 FY09 Q4 FY09 Q1 FY10 Description Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var NDNQI Data NHPPD^^ 8.15 6.69 6.56 0.13 7.95 6.69 6.59 0.10 8.18 6.69 6.23 0.46 8.27 7.19 7.23 -0.04 RN Care Hrs 54.86 61.86 58.71 3.15 55.49 61.86 55.90 5.96 54.93 61.86 56.59 5.27 54.81 61.86 54.07 7.79 %AGNCYHR 1.99 0.00 0.84 -0.84 2.32 0.00 0.84 -0.84 2.12 0.00 0.08 -0.08 2.8 0.00 0.00 0.00 %PRSSULC 16.47 2.84 20.00 -17.16 14.15 2.84 10.53 -7.69 13.37 2.84 0.00 2.84 12.41 2.84 8.70 -5.86 %AQPRULC 7.73 0.00 0.00 0.00 6.58 0.00 5.26 -5.26 6.58 0.00 0.00 0.00 6.15 0.00 4.35 -4.35 %PRSRSKA 67.77 100.00 100.00 0.00 65.2 100.00 100.00 0.00 68.51 100.00 100.00 0.00 68.79 100.00 60.87 -39.13 TOTFALLS 7.46 3.14 6.96 -3.82 7.68 3.14 0.00 3.14 7.31 3.14 5.97 -2.83 7.38 3.14 9.19 -6.05 %RSK&PROT 88.18 100.00 100.00 0.00 78.86 100.00 100.00 0.00 81.58 100.00 80.00 -20.00 91.09 100.00 100.00 0.00 %BSN 33.42 45.20 46.67 1.47 32.07 45.20 47.00 1.80 33.36 45.20 53.33 8.13 33.19 45.20 62.50 17.30 % CERT 15.3 23.87 20.00 -3.87 14.88 23.87 20.00 -3.87 14.65 23.87 20.00 -3.87 14.86 23.87 31.25 7.38 Nurse-Sensitive Serviceline/Unit -Specific Indicators FIM: Bowel 1.00 1.3 0.30 1.00 1.4 0.40 1.00 1.1 0.10 1.00 1.00 0.00 FIM: Bladder 1.40 1.1 -0.30 1.40 1.3 -0.10 1.40 1.2 -0.20 1.40 1.50 0.10 Nurse-Sensitive General Indicators LOS* 11.80 8.78 3.02 11.80 9.00 2.80 11.80 8.99 2.81 9.80 8.28 1.52 Mislabeled Sp 0 0 0 0 2 2 0 1 1 1 0 1 Nurse-Sensitive Patient Satisfaction Survey Indicators RN Courtesy 88.85 92.70 3.85 88.85 91.40 2.55 88.85 94.6 5.75 88.85 91.2 2.35 Promptness 85.75 84.40 -1.35 85.75 84.10 -1.65 85.75 88.2 2.45 85.75 81.6 -4.15 Attn Spc Needs 87.75 84.70 -3.05 87.75 86.20 -1.55 87.75 90.7 2.95 87.75 84.1 -3.65 Response Pain 88.15 80.00 -8.15 88.15 86.20 -1.95 88.15 89.8 1.65 88.15 85.5 -2.65 Instruct Home 88.55 89.70 1.15 88.55 87.80 -0.75 88.55 91.4 2.85 88.55 86.4 -2.15 Care Well Coord 89.35 88.30 -1.05 89.35 86.50 -2.85 89.35 90.6 1.25 89.35 89.2 -0.15 * Estimated %PRSSULC = % Patients with pressure ulcers %AQPRULC = % Patients with acquired pressure ulcers %PUPRSRSKA = % Patients who were assessed for pressure ulcers within 24 hours of point-prevalence assessment TOTFALLS = Total falls/1,000 days %RSK&PROT = % At risk and on fall protocol ^ With the exception of NHPPD, the target reflects the best quartile performers per NDNQI ^^ NHPPD mean is the NDNQI mean and the target is the Sinai budgeted NHPPD FIM = Functional Independence Measure LOS = Length of Stay NHPPD = Nursing Hours Per Patient Day
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