Dashboard Patient satisfaction –AIDET/ PCCM Unit engagement – employee engagement survey results

1. Unit based Quality Committees Overview Purpose- Engage staff in the quality process and to identify opportunities for quality improvement specific to the unit and the division of patient care. In conjunction with the Nursing Quality and Patient Safety Committee, the unit based committees will monitor metrics, identify opportunities for improvement and work on initiatives that will lead to improved patient outcomes. Goal/Benefit: To create a culture of quality and safety at NMH by having a unit based forum to discuss and address quality issues and outcomes. Scope: Nursing and procedural areas. Persons required: Manager, quality chair, co-chair, skin expert nurse, pain expert nurse, fall champion, SLC and safety representatives. Role expectations: Chair and co-chair: • In collaboration with the manager, they will develop and distribute the agenda. • They will keep or delegate a committee member to take minutes for each meeting and will ensure that they are posted and sent to staff. A binder can be kept in the report room with the minutes so that staff have access to them if needed. • They will assign core committee members to projects as needed and will follow- up on progress. • Will assign someone from the committee to report projects and status to the SLC. Manager – Will coach and mentor the chair and co chair. The manager will co-facilitate meetings as needed, mentor staff on the significance behind the metrics and provide updates on quality initiatives from the manager/director meeting. Membership: • Committee membership will include the units skin expert, falls champion, pain expert, SLC representative, pharmacist. It is highly encouraged for the committees to include other members of the multidisciplinary team or ancillary services as needed. Liaison: Will be an adhoc member of the committee and should be included in the meeting minutes distribution list Meetings: • Quality committees will meet monthly • The agenda items will include: Unit/department progress in imbedding the Patient Centered Model of Care and AIDET, Dashboard, updates in the progress of projects the team is working on. In addition, there will be a discussion of current unit and divisional patient care issues, which will be followed by actionable problem solving. • The committee will develop action plans for patient care issues of concern and will monitor progress to goal. • Key Metric(s): Mile Stones: Dashboard Patient satisfaction –AIDET/ PCCM Unit engagement – employee engagement survey results • Description Date (mo/yr) • Every unit has an established In progress • unit based quality committee • Reporting through Department SLCs Executive Sponsor: Sponsor:Process Owner: Michelle Janney Ann Schramm Nursing Quality and Patient Safety Committee and Nursing Excellence Manager