Assignment: Dashboard Analysis And Nursing Plan

Using the data sheet provided:

 

Assignment

  •  analyzing areas where there is good performance and areas of opportunity from the sample Dashboard.
  • Analyze the data provided in the Dashboard and select an area of performance that needs improvement. Include information on why this area was chosen.
  • Develop a nursing plan that includes suggestions on how to improve performance on the selected indicator. Be sure to provide at least three best practices from the evidenced-based literature to support your suggested nursing plan.

Sheet1

Nurse-Sensitive Quality Indicator Dashboard – Adams 5 (Inpatient Rehab Unit)
Time Period Q3FY05 Q4FY05 Q1FY06 Q2FY06 Q3FY06 Q4FY06 Q1FY07 Q2FY09 Q3 FY09 Q4 FY09 Q1 FY10
Description Mean Target^ Actual Var Mean Target Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var Mean Target^ Actual Var
NDNQI Data
NHPPD^^ 7.65 8.52 6.39 -2.13 7.82 8.78 7.06 -1.72 8.08 9.10 6.41 -2.69 8.13 9.07 6.54 -2.53 7.97 6.51 6.31 -0.20 8.09 6.51 7.03 0.52 8.15 6.69 7.07 0.38 8.15 6.69 6.56 0.13 7.95 6.69 6.59 0.10 8.18 6.69 6.23 0.46 8.27 7.19 7.23 -0.04
RN Care Hrs 53.31 61.47 59.46 -2.01 53.3 61.09 56.96 -4.13 53.48 60.56 59.20 -1.36 53.84 60.89 56.87 -4.02 54.82 62.09 56.01 -6.08 54.05 61.08 59.47 -1.61 54.48 62.42 58.42 -4.00 54.86 61.86 58.71 3.15 55.49 61.86 55.90 5.96 54.93 61.86 56.59 5.27 54.81 61.86 54.07 7.79
%AGNCYHR 1.76 0.00 0.31 0.31 1.8 0.00 0.06 0.06 1.83 0.00 3.05 3.05 1.85 0.00 6.01 6.01 1.85 0.00 6.89 6.89 1.76 0.00 6.58 6.58 1.92 0.00 0.00 0.00 1.99 0.00 0.84 -0.84 2.32 0.00 0.84 -0.84 2.12 0.00 0.08 -0.08 2.8 0.00 0.00 0.00
%PRSSULC 15.28 3.70 23.81 20.11 15.18 5.26 15.00 12.85 12.85 3.23 17.39 14.16 14.39 4.17 44.44 40.27 16.11 4.35 22.22 17.87 15.41 4.17 0.00 -4.17 14.65 0.00 23.53 23.53 16.47 2.84 20.00 -17.16 14.15 2.84 10.53 -7.69 13.37 2.84 0.00 2.84 12.41 2.84 8.70 -5.86
%AQPRULC 7.46 0.00 4.76 4.76 6.68 0.00 15.00 15.00 5.01 0.00 8.70 8.70 6.07 0.00 33.33 33.33 6.65 0.00 5.56 5.56 5.84 0.00 0.00 0.00 5.64 0.00 17.65 17.65 7.73 0.00 0.00 0.00 6.58 0.00 5.26 -5.26 6.58 0.00 0.00 0.00 6.15 0.00 4.35 -4.35
%PRSRSKA 54.74 100.00 100.00 0.00 59.02 100.00 95.00 -5.00 56.68 100.00 78.26 -21.74 63.46 100.00 94.44 -5.56 63.9 100.00 100.00 0.00 61.48 100.00 100.00 0.00 65.72 100.00 100.00 0.00 67.77 100.00 100.00 0.00 65.2 100.00 100.00 0.00 68.51 100.00 100.00 0.00 68.79 100.00 60.87 -39.13
TOTFALLS 7.35 3.00 5.71 2.71 7.71 3.45 10.11 6.66 7.35 2.93 24.37 21.44 7.32 2.86 8.84 5.98 7.56 3.22 8.64 5.42 7.73 3.17 4.28 1.11 7.46 3.03 2.40 -0.63 7.46 3.14 6.96 -3.82 7.68 3.14 0.00 3.14 7.31 3.14 5.97 -2.83 7.38 3.14 9.19 -6.05
%RSK&PROT 91.11 100.00 100.00 0.00 90.35 100.00 90.00 -10.00 90.12 100.00 66.67 -33.33 92.27 100.00 81.82 -18.18 92 100.00 80.00 -20.00 90.91 100.00 80.00 -20.00 92.01 100.00 66.67 -33.33 88.18 100.00 100.00 0.00 78.86 100.00 100.00 0.00 81.58 100.00 80.00 -20.00 91.09 100.00 100.00 0.00
%BSN 31.44 42.86 31.25 -11.61 32.98 44.44 21.43 -23.01 32.97 44.44 23.08 -21.36 34.03 44.64 36.36 -8.28 33.42 46.41 50.00 3.59 32.31 45.45 57.14 11.69 32.11 43.75 53.33 9.58 33.42 45.20 46.67 1.47 32.07 45.20 47.00 1.80 33.36 45.20 53.33 8.13 33.19 45.20 62.50 17.30
% CERT 12.72 20.00 31.25 11.25 14.34 22.73 0.00 -22.73 15.33 24.00 15.38 -8.62 16.02 25.00 18.18 -6.82 14.92 25.00 14.29 -10.71 15.78 23.53 21.43 -2.10 15.05 23.08 20.00 -3.08 15.3 23.87 20.00 -3.87 14.88 23.87 20.00 -3.87 14.65 23.87 20.00 -3.87 14.86 23.87 31.25 7.38
Nurse-Sensitive Serviceline/Unit -Specific Indicators
FIM: Bowel 1.00 1.30 0.30 1.00 1.20 0.20 1.00 1.40 0.40 1.00 1.40 0.40 1.00 1.50 0.50 1.00 1.6 0.60 1.00 1.6 0.60 1.00 1.3 0.30 1.00 1.4 0.40 1.00 1.1 0.10 1.00 1.00 0.00
FIM: Bladder 1.50 1.40 -0.10 1.40 1.50 0.10 1.40 1.40 0.00 1.40 1.60 0.20 1.40 1.50 0.10 1.40 1.4 0.00 1.40 1.4 0.00 1.40 1.1 -0.30 1.40 1.3 -0.10 1.40 1.2 -0.20 1.40 1.50 0.10
Nurse-Sensitive General Indicators
LOS* 4.00 3.79 -0.21 11.80 8.67 -3.13 11.80 8.78 3.02 11.80 9.00 2.80 11.80 8.99 2.81 9.80 8.28 1.52
Mislabeled Sp 0 1 -1 0 3 3 0 1 1 0 2 2 0 1 1 0 1 1 0 0 0 0 0 0 0 2 2 0 1 1 1 0 1
Nurse-Sensitive Patient Satisfaction Survey Indicators
RN Courtesy 87.52 93.80 6.28 87.52 92.70 5.18 87.52 93.10 5.58 87.52 95.10 7.58 87.52 91.80 4.28 83.90 89.30 5.40 93.80 94.00 0.20 88.85 92.70 3.85 88.85 91.40 2.55 88.85 94.6 5.75 88.85 91.2 2.35
Promptness 87.52 86.10 -1.42 87.52 84.00 -3.52 87.52 90.60 3.08 87.52 85.70 -1.82 87.52 83.60 -3.92 84.50 79.50 -5.00 87.00 84.50 -2.50 85.75 84.40 -1.35 85.75 84.10 -1.65 85.75 88.2 2.45 85.75 81.6 -4.15
Attn Spc Needs 87.52 87.00 -0.52 87.52 89.20 1.68 87.52 91.70 4.18 87.52 89.60 2.08 87.52 88.00 0.48 85.30 80.60 -4.70 90.20 87.50 -2.70 87.75 84.70 -3.05 87.75 86.20 -1.55 87.75 90.7 2.95 87.75 84.1 -3.65
Response Pain 87.52 89.50 1.98 87.52 90.30 2.78 87.52 92.50 4.98 87.52 92.40 4.88 87.52 88.60 1.08 86.00 87.00 1.00 90.30 90.30 0.00 88.15 80.00 -8.15 88.15 86.20 -1.95 88.15 89.8 1.65 88.15 85.5 -2.65
Instruct Home 87.52 85.70 -1.82 87.52 84.40 -3.12 87.52 87.20 -0.32 87.52 88.80 1.28 87.52 85.20 -2.32 87.80 81.50 -6.30 89.30 89.60 0.30 88.55 89.70 1.15 88.55 87.80 -0.75 88.55 91.4 2.85 88.55 86.4 -2.15
Care Well Coord 87.52 84.70 -2.82 87.52 87.50 -0.02 87.52 87.90 0.38 87.52 89.20 1.68 87.52 90.20 2.68 88.90 88.00 -0.90 89.80 90.10 0.30 89.35 88.30 -1.05 89.35 86.50 -2.85 89.35 90.6 1.25 89.35 89.2 -0.15
* Estimated Unfavorarble
%PRSSULC = % Patients with pressure ulcers Favorable
%AQPRULC = % Patients with acquired pressure ulcers
%PUPRSRSKA = % Patients who were assessed for pressure ulcers within 24 hours of point-prevalence assessment
TOTFALLS = Total falls/1,000 days
%RSK&PROT = % At risk and on fall protocol
^ With the exception of NHPPD, the target reflects the best quartile performers per NDNQI
^^ NHPPD mean is the NDNQI mean and the target is the Sinai budgeted NHPPD
FIM = Functional Independence Measure
LOS = Length of Stay
NHPPD = Nursing Hours Per Patient Day

Sheet2

Sheet3