Topic 5 DQ 2

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Continuous Quality Improvement (CQI) is a program where by we continually ask ourselves, “How are we doing and what could we be doing better? (NCCHC 2019) CQI was implemented at my institution about 20 years ago and has been continued in multiple different programs, however the general principle remains the same. Health care is changing so rapidly that we must always be monitoring how we are providing our care as related to similar organizations in similar situations across the country. Health care institutions must balance the delivery of health care while promoting advocacy for both patients and staff, all the while following the rules and guidelines of CMS and JCAHO. This requires institutions to be more resourceful and efficient with delivery models for health care and CQI is one way to assess our processes for that delivery.

My organization is currently using the Malcolm Baldridge program for quality improvement. Administration has developed a strategic plan for the institution with five pillars (areas) of need for improvement. These pillars have key success factors under them that cascade down to the front line staff and can be affected by change at the front line level. Each pillar has under it goals for improvement and each manager has to develop a process change that can more the bar if you will in a positive direction. Each nurse manager is responsible for forming committees from front line staff and themselves in order to brainstorm ideas for change that will effect a positive result in how e deliver care to our patients. An example that has been implemented relates to the HCAHPS score related to quietness at night. We have developed a plan that requires turn down service, back rubs, sleeping medication administration, dimming lights in rooms and hallways, silencing IV pump and telemetry alarms as these go automatically to individual phone for nurses and turning phone ringers to vibrate where appropriate. As a result we have seen an improvement in our overall quietness at night HCAHPS scores throughout the organization. The Baldridge program requires continuous monitoring of these types of programs until the need for them is eliminated.


National Commission on Correctional Health Care. Continuous Quality Improvement. Retrieved from: https;//

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