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Policies,Administrative,UWHC,Department Specific,Nursing Administrative,Committees, Department of Nursing

Quality Improvement at the Unit and Clinic Level (2.31)

Quality Improvement at the Unit and Clinic Level (2.31) - Policies, Administrative, UWHC, Department Specific, Nursing Administrative, Committees, Department of Nursing

2.31

POLICY & PROCEDURE





Effective Date:
April 1, 2017

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
2.31

Original
 Revision

Page 1
Of 2

Title:
Quality Improvement at the Unit and
Clinic Level


I. PURPOSE:
A. To assure a structure is in place that assures patient care is safe, timely, effective, efficient,
equitable, and patient centered.
II. UNIT/CLINIC RESPONSIBILITIES:
A. Establish priorities for improving performance at the unit/clinic level.
1. Assure areas for improvement are consistent with the UW Health mission, vision, values
and UW Health Department of Nursing strategic plan.
2. The department assures there are performance improvement initiatives related to RN
satisfaction, patient experience and a nurse sensitive outcome measure.
3. A team approach to improving care is utilized and may include other disciplines and/or
units, clinics or programs.
B. The UW Health Improvement Network provides a standard approach, tools and resources for
adding value and improving care.
C. The FOCUS PDCA methodology is utilized for improving performance. This methodology
assures that an evaluation of the improvement plan is completed and that action is taken when
improvements are not achieved or sustained

D. Communicate completed improvement projects by submitting performance improvement work to
the Director, Nursing Quality & Safety for inclusion into the Annual Nursing Quality Report.
E. Review and analyze applicable nurse sensitive outcome measures on a monthly basis, and develop

POLICY & PROCEDURE





Effective Date:
April 1, 2017

Administrative Manual
Nursing Manual
 Other _______________

Policy #:
2.31

Original
 Revision

Page 2
Of 2

Title:
Quality Improvement at the Unit and
Clinic Level


or revise plans for improvement when trends, patterns and variation are identified and/or
underperforming against national benchmarks.

IV.AUTHORED BY
Director, Nursing Quality & Safety

V. REVIEWED BY:
A. Nursing Administrative Policy and Procedure Committee, April 2017
B. Nursing Quality Council, January 2014
C. Nurse Director, Clinical Support, January 2017

SIGNED BY:

Beth Houlahan, DNP, RN, CENP
Senior Vice President,
Chief Nursing Executive