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DOI
https://doi.org/10.63853/AAEW5305
Description
QUALITY IMPROVEMENT
Background: The Clinical Quality Improvement Consultant (CQIC) role was established in 2023 for Acute Care Services (ACS) and Clinical Resource Teams (CRT). This role was developed to accurately track data and facilitate quality improvement initiatives. ACS includes acute pediatrics, renal, trauma, gastroenterology, pulmonary, neurology, integrated therapy, and observation units. CQICs performed a gap analysis which uncovered a lack of knowledge of current unit state and pro-active hospital acquired condition (HAC) data. In partnership with clinical leaders, a weekly Quality Leader Rounding (QLR) was created to address this, environmental state, and patient family education. The goal of QLR was to decrease the HAC Rate for the included units from 17.2% in 2023 to 15.5% in 2024.
Methodology: The leadership team completes QLR through observations and interventions at point of care while providing real time coaching and feedback with frontline staff. QLR has been refined through multiple PDSA cycles, including changes to the audit tool, lessons learned to add multidisciplinary partners such as Infection Preventionists and Respiratory Therapists and expansion to night shift. After QLR, debrief huddles are held to share immediate findings. In addition, CQIC’s collect and share weekly updates and track monthly progress for ACS/CRT leadership. Action planning meetings are held bi-monthly to address sustained trends and standardize processes.
Outcomes: In 2024, the HAC Rate decreased to 12.5%, exceeding the initial goal and resulting in a 28% rate reduction. This reduction also impacted the system HAC rate which saw a 24% reduction. Additional outcomes included: opportunities to standardize widely valued best practices while also empowering individual units to initiate quality improvement projects; an increase in staff engagement and accountability, fostering an enhanced culture of safety; and an avenue to address patient concerns in real time enabling more effective service recovery. The process of QLR has produced positive outcomes and has spread to other departments within the organization. It is now engrained as standard practice for ACS/CRT leadership. QLR is well supported by the literature as a reproducible intervention that improves the culture of safety and drives positive outcomes.
Publication Date
11-24-2025
Disciplines
Pediatric Nursing
Recommended Citation
Dutton, Hayden; Castro, Jesse; Leal, Maria; and Mysliwiec, Megan, "Walk the Talk: Elevating Quality One Step at a Time" (2025). 2025. 44.
https://scholarlycollection.childrens.com/nursing-anf2025/44
Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-No Derivative Works 4.0 International License.
