Quality Nurse Champion

1. Quality Nurse Champion • 質の看護婦のチャンピオン

2. Objectives • Infuse quality into the culture of ARMC • Achieve Top Hospital status in the implementation of Best Practice Guidelines • Provide leadership in the education and implementation of Quality projects, to include Core Measure guidelines, 100,000 Lives Campaign initiatives, and identified Performance Improvement activities.

4. Definition • A Quality Nurse Champion is a Registered Nurse from ICU/PCU, Surgical Services, Emergency Department and two medical-surgical floors who will actively participate and engage other associates in accomplishing the goals of Quality projects. Each QNC will commit four hours per month to this role in areas identified by the Quality Outcomes Management Department

5. Justification Physician Champions have been identified and utilized since the beginning of our commitment to the Core Measure initiatives and have proven to be a catalyst to positive change in physician practices.

6. MD Driven Measure

7. Utilizing the Quality Nurse Champion we hope to demonstrate the same positive catalyst effect on nurse-driven quality outcomes.

8. Nurse Driven Measure

9. By 2007, full financial implications will be realized on a per hospital basis. This impact will be based on 2006 compliance percentages; time has become a critical component for implementing change. The Quality Nurse Champion can bridge the knowledge gap between the nurses working at the core of the process and those currently leading the Core Measure Initiatives.

10. The Quality Nurse Champion will have the opportunity to develop a keener understanding and sense of ownership for hospital strategic initiatives while developing leadership skills.

11. Implementation: Opportunities and eligibility requirements of the QNC position will be advertised in the Employee Newsletter and on the elevators. Application process will be similar to that done for the Ambassador Program (actual application to be developed). The QOM staff will review potential candidates with the nurse management prior to the interview process.

12. A special hospital badge identifying them as a 2006 Quality Nurse Champion will recognize selected staff. QOM will provide preceptorship and role orientation in addition to ongoing evaluation of role effectiveness The QNC will maintain this role for a twelve-month period followed by program and participant evaluations

13. QOM will determine the specific assignments for each QNC on a monthly basis and provide individual calendars of scheduled activities QNC may be full or part-time, but total hours should not exceed 40 hours per week. The 4-hour time commitment should be above his/her regular work hours. The time commitment will be scheduled separately from the nurses time on the unit; experience has shown that assigning an additional area of focus while also staffing the unit is unsuccessful.

14. Hours will be attributed to cost centers per administrative direction. Participation as a QNC will become part of employee’s annual evaluation Recognition at Annual Associate Celebration Banquet Timeline : October and November-applications and selection : December-education : January- implementation

15. Assignments and Role Description The QNC will be an active participant in PI teams associated with their individual units related to the Core Measures or 100k Lives campaign. The QNC will assist in the education of staff on Quality Improvement activities. This will include policy and procedure changes, sharing knowledge of the impact that the quality indicators have on the hospital from a quality as well as financial perspective.

16. The QNC will participate in chart audits related to Core Measures and other quality improvement activities. The QNC will act as a liaison between the quality department and the individual nursing units to identify areas of focus to accomplish goals. The QNC will write an article for the employee newsletter related to a quality improvement activity with which they have been involved.

17. The only sustainable process is one that participants believe in…The best way to create vision and understanding is to directly involve participants in improving the process.-IHI Going Lean in Health Care