CHA Nursing Quality Improvement Project Critical Lab Value
CHA Nursing Quality Improvement Project: Critical Lab Value Reporting and Documentation
The Plan: • Date of Implementation: March 2018 • QI Measure : Tracking critical lab results and documentation of communication to physician of critical lab results by nursing • Goal: 100% documentation of critical labs
• Participants: Med/Surg Nursing, Lab, House Supervisors, ADON, DON • Plan: To track critical lab results, and track documentation/communication of critical lab results to physician by nursing and any interventions that are a made as a result of reported labs • Barriers: Shift change, time of day reported • Resources: Lab reports, nursing staff
• Target Date of Completion March 2019 • • DO: Steps to Implement Plan/Data Collection Daily critical lab results reports will be pulled for evaluation; corresponding patient charts will be evaluated for documentation of critical labs • CHECK: Evaluate Data/ Process Target Date of Completion March 2019 • Charts will be reviewed and a monthly graph will be presented to show data. • ACT: Remedial Action Plan: This could include Adopt, Abandon, or Redesign: Date: March 2019 • REEVALUATE: Action Plan Continues to Accomplish Goals: Ensure improvements are realized and sustained. Date: March 2019
DO: Steps for Implementation • Beginning in April, lab data was collected and then each critical lab value was looked up in patients chart to see that it had been documented by nursing • STUDY/EVALUATE DATA • Numbers initially started out in the 40 -50% range. A lot of education was done with nursing staff and since we have seen a steady increase to about 80%.
ACT: Remedial Action Plan, this could include abandon, adopt, or redesign • April, May, June initial education began with nursing staff • July-December steady improvement seen with nursing documentation • Staff reminded in monthly meetings about continued documentation
Re-Evaluate: Action plan continues to accomplish goal of 100% documentation Critical Results 2018 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% April May June July August September October November December
Thank you Questions?
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