Chief Quality Officer Rounds: Charting a New Course for Performance Improvement

Vose, Courtney B.

Tuesday, 1 November 2011: 8:30 AM

Courtney B. Vose, RN, MSN, MBA, APRN
Nicole M. Hartman, MSN, RN
Maureen T. Smith, MSN, RN, CNRN
Patient Care Services, Lehigh Valley Health Network, Allentown, PA

Learning Objective 1: Discuss the impact nursing sensitive quality indicators have on reimbursement.

Learning Objective 2: Detail a model developed to create a culture of inquiry and passion for quality improvement.

Reimbursement changes from the Centers for Medicare and Medicaid Services and value based purchasing systems have made performance improvement more crucial then ever. A voluminous amount of data collection is the norm within acute care environments, however, robust analysis of and subsequent action plans that truly enhance quality outcomes is often lacking.

This presentation describes a successful performance improvement model implemented throughout a patient care division, inclusive of medical-surgical and critical care units, in an academic, community Magnet hospital. Root cause analysis and an evidence review prompted development of a quality model inclusive of four key elements: prioritization and exclusivity; staff awareness of data; transparency of outcomes; and, ownership and accountability. A unique aspect of this innovative model is the implementation of daily Chief Quality Officer Rounds (CQOR) by the unit educator to facilitate real-time learning and improve patient care. The educator, focusing on one quality issue, assesses each patient situation, assures appropriate interventions are implemented, and educates the staff regarding opportunities for improvement. The unit staff are held accountable for their ability to improve quality indicators via goals tied to their annual performance appraisal, which focus on data transparency and quality rounds to improve outcomes.

Since implementing CQOR 12-months ago, outcome metrics throughout the division have demonstrated a steady decline in hospital acquired pressure ulcers, restraints, medication errors, catheter associated urinary tract infections, and ventilator associated pneumonia. In the past 6-months, fall rates have slightly declined. Learners attending this session will gain pragmatic strategies to create a culture of inquiry and passion for quality improvement in any patient care organization.

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