Hospital indicators and rationale

Identify Hospital Indicators with Rationale

For this assignment, you will identify the indicators that a quality director needs to monitor.

1.      Base this assignment upon your hospital or an imagined one.  List at least 10 indicators you believe a quality director would need to monitor.

2.     Blood administration MUST be included. No other laboratory, pharmacy, or radiology indicators or controls will be listed.

Note: There are many, many lab, pharmacy, and radiology indicators that must be monitored. It will be assumed that the department heads in these areas will perform this monitoring. A quality director is, typically, not required to know all of these, but relies upon department directors in these areas for this information. That said, there might be specific indicators related to these areas that you wish to monitor, and that is perfectly OK. For example, you might want to document that patients’ pain levels were assessed prior to narcotic administration, or, that critical labs are called to physicians within a specified time frame. You will note, however, that both examples involve nursing management/documentation.

3.     HCAHPS criteria must be listed as a single item.

4.     Restraint monitoring, or some aspect of restraint monitoring, is explicitly stated.

5.     Unit-specific indicators are to be selected for one identified specialty unit. They are not required to be stated for every hospital unit.

6.     Provide a very brief written rationale for each indicator stated.

Note: These indicators are usually low- frequency, problem prone, or high-risk. You   may use indicators required by TJC, FDA requirement, unit-base initiative, etc. Be sure that something IS required by an agency before you automatically state that it’s required. (Did you know that TJC requires an RN to assess an inpatient within 24 hours of hospital admission, but really has no time-based assessment requirements after that? There is NO requirement by TJC that an RN assess a hospitalized patient at least every 24 hours.)

7.     State how often each item must be measured.

8.     State who will measure the item.

Note: There should be a variety of personnel monitoring items, from staff nurses to department heads. It is important that staff nurses take responsibility (which increases ownership) for those items they can directly control. However, it would not be reasonable to assign a staff RN to monitor hospital-wide fall rates.

9.     State who is ultimately responsible for (and will enforce) item measurement. This must be a person in a position of authority; one who can “tell” the employee to do the monitoring.

10.  This will be submitted electronically in a table format (Excel spreadsheet or Word document).

This assignment will be submitted electronically in a table format (Excel spreadsheet or Word document).

School of Nursing and Health Science

Graduate Nursing Education

NURS 6133: Quality and Regulation Management

HOSPITAL INDICATORS AND RATIONALE RUBRIC