Nursing Quality

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Nursing Quality

The primary goal of the quality improvement program at St. Joseph's Healthcare System is the ongoing assessment and improvement of the delivery, quality, and outcome of patient care. Quality and performance improvement efforts within the Department of Nursing occur in a unit/ service framework. Quality improvement activities are viewed as educational. Staff nurses participate in the quality improvement process and perceive the process as one that improves the quality of care delivered within the organization and supports the overall medical centers mission and strategic plans.



  1. There is a comprehensive plan to assess, analyze, and evaluate clinical and operational processes and outcomes.
  2. Ongoing monitoring, evaluation, and improvement of nurse-sensitive outcomes appropriate to the clinical settings.
  3. Clinical and operational indicators are benchmarked with external entities to modify care processes.
  4. There is involvement of nurses at all levels of the organization in quality improvement planning and improvement processes.

National Database for Nursing Quality Indicators

National Database for Nursing Quality Indicators

St. Joseph's Regional Medical Center participates in the National Database for Nursing Quality Indicators (NDNQI). Membership in NDNQI allows us to compare:

  • Unit-level patient outcomes
  • Nursing care hours
  • Nursing staff skill mix
  • RN education
  • Patient care days
  • Falls/ injury rates
  • Hospital-acquired pressure ulcers


Participation in NDNQI further reinforces St. Joseph's special attention to nursing sensitive measures and indicators that reflect the impact of nursing actions and outcomes. Reports and outcomes of the data are analyzed and used as a tool to replicate successful nursing actions and focus on areas of opportunities for growth or change.


NDNQI quarterly reports are submitted to the CNO, Directors of Nursing, Nurse Managers and staff. Data is reviewed at the Nursing Administrative Council, Nursing Leadership Council, and the Nursing PI Council. Data is also reviewed at the Fall and Pressure Ulcer Committees.


The Department of Nursing also conducts a yearly survey through NDNQI to gather data from staff RNs related to their job satisfaction, perceived quality of care, and their estimates of floating and overtime worked as well as nurse demographic items.

Nursing Quality and Performance Improvement Council

Nursing Quality and Performance Improvement Council

The Nursing Quality Council has the authority to ensure a comprehensive performance improvement program for the Department of Nursing.


  • Nursing Performance Improvement Council provides nursing staff with an opportunity for an active voice in the identification of improvement projects at the departmental, divisional, and unit levels.


  • To create a mechanism by which performance indicators are reviewed and analyzed and improvements are made based on evidence based practice and established benchmarks.
  • To identify, prioritize, and coordinate performance improvement needs and activities with the Department of Nursing.
  • Develop, implement, and evaluate service performance improvement efforts, using the Plan-Do-Study-Act (PDSA) model, consistent with SJRMC Performance Improvement Plan.
  • Provide a forum by which performance improvement process and data is shared and communicated with the Department of Nursing.
  • To foster a commitment to the pursuit of quality at all levels through:
  • Education of staff regarding the performance improvement process
  • Participation of staff in performance improvement efforts
  • To develop and test nurse sensitive outcomes that reflects the direct contributions for quality patient outcomes.
  • To identify care issues that benefit from performance improvement efforts, based on problem prone areas.
  • To educate council members on a valid and reliable measurement methodology data collection, analysis, and dissemination of results.
  • Support nursing staff involvement in collaborative quality initiatives that improve organization performance and patient outcomes.


  • The following quality indicators are hospital-wide goals:
    • Core Measures
    • Patient Identification
    • Patient Satisfaction
  • Nursing performance improvement is influenced by the hospital quality goals. The Nursing Department emphasis is on monitoring six nurse sensitive indicators to assure congruence of the practice with evidence-based policies and procedures.
  • The quality outcomes provide an action-oriented framework toward improving care delivery, organizational performance, and patient outcomes, while assuring a safe environment. The indicators are as follows:
    • Falls per 1,000 patients days
    • Pressure Ulcers per 1,000 census days
    • Documentation of Plan of Care
    • Restraint Use
    • Pain Assessment & Reassessment
    • Medication Reconciliation
    • Our Falls/Pressure Ulcer indicators are benchmarked with the National Database for Nursing Quality Indicators


  • Staff RN representatives from each inpatient nursing unit
  • Nurse Managers
  • Director of Quality and Performance Improvement
  • Quality Manager
  • Administrative Director of Nursing Services
  • Advanced Practice Nurses
  • Nurse Care Managers
  • Nurse representatives from Radiology, Cardiology, Infection Control, and the Center for Education and Development.
  • The Nursing Performance Improvement Council meets during every regularly scheduled Professional Nurse Practice Council (PNPC) meeting

National Database for Nursing Quality Indicators (NDNQI)

NDNQI is part of the American Nurses Association's (ANA) National Center for Nursing Quality. "NDNQI is the only national nursing quality measurement program which provides hospitals with unit-level performance reports with comparisons to national averages, percentile rankings and other important data. All indicator data are collected and reported at the nursing unit level. NDNQI's nursing-sensitive indicators reflect the structure, process, and outcomes of nursing care." For more information click here.



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