Medical Center Performance Improvement

The Nursing Performance Improvement Committee is part of the medical center quality structure, and reports regularly to the Clinical Performance Improvement Committee. Additionally, there is nursing representation on medical center committees related to clinical quality, medication management, patient safety, risk management and utilization.

Nursing involvement is crucial in the two major performance improvement initiatives being undertaken by the medical center in 2005-2006:

• IHI 5 Million Lives Campaign: UCSF Medical Center and UCSF Children’s Hospital participated in the Institute for Healthcare Improvement’s Campaign to save 100,000 lives in U.S. hospitals by the implementing evidence-based performance projects that will reduced nosocomial infections, prevented adverse drug events, prevented patient deterioration through rapid intervention, and improved care for patients who experience an acute myocardial infarction. We have now adopted additional recommended strategies to
  1. prevent harm from high alert medications;
  2. reduce surgical site infections;
  3. prevent hospital-acquired pressure ulcers;
  4. reduce methicillin resistant staphyloccus aureus (MRSA) infections;
  5. deliver high-quality, evidence-based care for our patients in congestive heart failure;
  6. increase our Board of Trustees’ involvement in the culture of safety at UCSF Medical Center.
• The Joint Commission Core Measures: The medical center is committed to improving performance on the the Joint Commission Core Measures, which include evidence-based performance measures for the following patient populations: acute myocardial infarction, heart failure and community-acquired pneumonia.

The Nursing Performance Improvement Executive Committee

The Nursing Performance Improvement Committee membership includes nursing and quality leaders. Monthly meetings cover the following topic areas:

• Standing reports on ongoing initiatives, clinical quality areas and departmental reports
• Approval of policy, procedure and practice changes
• Development of corrective action plans for gaps in nursing clinical quality
• Nursing-sensitive quality measurement

Staff Nurse Involvement in Performance Improvement

By monitoring performance, we can utilize what we learn from the data to drive improvement processes. All team members play an important part in the monitoring and improvement activities, and involvement in PI at all levels of the organization is crucial to improve care.

Examples of unit-based projects being conducted by unit performance improvement teams include:

• Improving interdisciplinary discharge communication
• Reducing patient fall rates
• Improving pain assessment documentation and compliance
• Revamping the Emergency Department patient flow and discharge process
• Improving and standardizing the medication administration process
• Preventing hospital-acquired pressure ulcers
• Transforming Care at the Bedside (TCAB) project to improve patient satisfaction, staff efficiencies, and patient safety

Staff nurses are also involved in a number of medical center committees with a performance improvement focus:

• Falls Committee
• Pressure Ulcer Prevention Committee
• Pain Resource Nurses
• Patient Safety Fellows