My facility has put an emphasis on quality improvement over the past few months. How can I identify the roles of nurses at every level in the quality improvement initiative?

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The expert this week, Cynthia Barnard, MBA, MSJS, CPHQ, is a research assistant professor at the Institute for Healthcare Studies, where she is also the co-director of the advanced course in quality improvement.

The role of professional nurses in quality improvement (QI) is twofold: to carry out interdisciplinary processes to meet organizational QI goals and to measure, improve, and control nursing-sensitive indicators (NSI) affecting patient outcomes specific to nursing practices. All levels of nurses, from the direct care bedside nurse to the chief nursing officer (CNO), play a part in promoting QI within the healthcare provider organization.

Here is an explanation of the involvement each level of nurse should have in promoting QI:

The CNO: CNOs set the tone for the nursing department's participation in QI. As a member of administrative leadership, the CNO must integrate nursing practices into the organizational goals for excellence in patient outcomes through communication of strategic goals to all levels of staff. The CNO must advocate for and allocate resources to meet nursing QI needs. Although many nurse managers are educated in management principles, QI concepts may be new to them. The CNO must support a culture of education and learning to help the nurse managers integrate QI on their units or divisions and provide them with the skills and resources to collect data and improve and control processes unique to their patient populations.

The nurse manager (NM) or nursing director: The NM or nursing director is responsible for communicating and operationalizing the organization's QI goals and processes to the bedside nurse, identifying specific NSIs that need improvement according to his or her particular patient population, and coordinating QI processes to improve these at the unit level. NMs must implement the organizational QI processes and ensure that their staff members follow those interventions defined for nursing. In addition, NMs must look at specific nursing-sensitive indicators that are unique to the patient population being cared for on their units, and focus on those that can be improved by evidence-based nursing processes.

The direct care nurse: The direct care bedside nurse is the key to quality patient outcomes, carrying out the protocols and standards of care shown by evidence to improve patient care. Without bedside nurses committed to following these QI processes, quality outcomes will not be achieved. Being a QI expert at the bedside may seem like a new role for the bedside nurse, but actually it's what nursing practice has always been about. QI requires that bedside nurses gear nursing care around NSIs unique to the population they care for, and utilize the standards and protocols designed by departmental, unit, or organizational teams from the best evidence available. When the bedside nurse follows the bundles, protocols, and standards of care established through best evidence, these bedside nurses are rewarded with improved patient outcomes.

Cynthia Barnard, MBA, MSJS, CPHQ

(March 2010)