EP - Exemplary Professional Practice

EP33EO: Quality Care Monitoring and Improvement-Describe and demonstrate how the allocation and/or reallocation of resources improved the quality of nursing care.

Example of improvement with the reallocation of resources

Kelly Sietsma BSN, RN Stroke Center Manager began her career at Jersey City Medical Center in 2007. Initially she started in the Performance Improvement Department and primarily worked on Surgical Care Improvement Project (SCIP). She also began collecting data for the newly implemented Stroke Program with Michele Lopez MSN, RN, CEN at the helm. Shortly after the initiation of the Stroke Program in 2010, Ms. Sietsma’s services were reallocated to that Department. When Ms. Sietsma first assumed the Stroke Coordinator role, her first endeavor was to insure that all stroke patients received the appropriate educational materials. It is imperative that patients no the signs and symptoms of stroke, because these patients are more likely to have another stroke, and early detection is imperative. Ms. Sietsma’s educational package includes information on:

Much of this material is taken from the American Stoke Association and Ms. Sietsma prepares a stroke packet for the patients. She also includes in the packet a welcome letter as well as an educational flyer of FAST (Face, Arm, Speech, Time) to help patients to identify the signs and symptoms of stroke. She also includes a list of the New Jersey Stroke Support Groups. Ms. Sietsma has been very successful with this educational program as is portrayed on the graphs below.

Example of Allocation of Resources

Rachele Dalalian RNC, CLNC Quality Outcomes Manager was allocated to the Performance Improvement Department to work with clinical personnel to improve quality hospital-wide. She works very closely with the nursing staff on all quality improvement projects. (Please see Reference EP33EO-A for job description). One of the quality measures that she has improved is the administration of the Pneumovax vaccine administration. The parameters and criteria for the administering of this vaccine was recently changed in 2012, and Ms. Dalalian determined to work with the nursing/medical staff to insure a smooth transition.

The Pneumovax vaccine is indicated for vaccination against pneumococcal disease caused by those pneumococcal types included in the vaccine. The effectiveness of the vaccine has been demonstrated in the prevention of pneumococcal pneumonia and pneumococcal bacteremia. Requirements for the administration of the vaccine were updated in January, 2012 by the Center for Medicare and Medicaid Services. The indications for the administration of the pneumococcal vaccine are listed in the table below:

Indications and Contraindications for the Administration of Pneumovax

Upon receipt of the current revisions for the pneumovax immunization, Ms. Dalalian launched a hospital-wide plan to educate all staff. Initially all clinical managers were educated at the monthly Clinical Managers meeting as to the guidelines (specifically age range changes). This forum allowed managers to ask questions and provide instruction and guidance to their frontline nursing staff. Global e-mails were sent providing the current changes and revisions. These e-mails have the ability to reach a large number of people within the organization and is a primary method of communication. Furthermore, Ms. Dalalian insured that all residents were educated on these revisions in the morning rounds. Core Measures, including revisions are included in new hospital orientation programs. Hospital-wide education was further provided by the Safety Summit in March, 2012. Ms. Dalalian has provided all these interventions which proved to have a positive effect on pneumovax administration. See graph below for improvements:

2012 Data