Nursing Quality - Nursing Quality and Performance Improvement Council

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Article Index

  1. Nursing Quality
  2. National Database for Nursing Quality Indicators
  3. Nursing Quality and Performance Improvement Council current position

Nursing Quality and Performance Improvement Council

The Nursing Quality Council has the authority to ensure a comprehensive performance improvement program for the Department of Nursing.


  • Nursing Performance Improvement Council provides nursing staff with an opportunity for an active voice in the identification of improvement projects at the departmental, divisional, and unit levels.


  • To create a mechanism by which performance indicators are reviewed and analyzed and improvements are made based on evidence based practice and established benchmarks.
  • To identify, prioritize, and coordinate performance improvement needs and activities with the Department of Nursing.
  • Develop, implement, and evaluate service performance improvement efforts, using the Plan-Do-Study-Act (PDSA) model, consistent with SJRMC Performance Improvement Plan.
  • Provide a forum by which performance improvement process and data is shared and communicated with the Department of Nursing.
  • To foster a commitment to the pursuit of quality at all levels through:
  • Education of staff regarding the performance improvement process
  • Participation of staff in performance improvement efforts
  • To develop and test nurse sensitive outcomes that reflects the direct contributions for quality patient outcomes.
  • To identify care issues that benefit from performance improvement efforts, based on problem prone areas.
  • To educate council members on a valid and reliable measurement methodology data collection, analysis, and dissemination of results.
  • Support nursing staff involvement in collaborative quality initiatives that improve organization performance and patient outcomes.


  • The following quality indicators are hospital-wide goals:
    • Core Measures
    • Patient Identification
    • Patient Satisfaction
  • Nursing performance improvement is influenced by the hospital quality goals. The Nursing Department emphasis is on monitoring six nurse sensitive indicators to assure congruence of the practice with evidence-based policies and procedures.
  • The quality outcomes provide an action-oriented framework toward improving care delivery, organizational performance, and patient outcomes, while assuring a safe environment. The indicators are as follows:
    • Falls per 1,000 patients days
    • Pressure Ulcers per 1,000 census days
    • Documentation of Plan of Care
    • Restraint Use
    • Pain Assessment & Reassessment
    • Medication Reconciliation
    • Our Falls/Pressure Ulcer indicators are benchmarked with the National Database for Nursing Quality Indicators


  • Staff RN representatives from each inpatient nursing unit
  • Nurse Managers
  • Director of Quality and Performance Improvement
  • Quality Manager
  • Administrative Director of Nursing Services
  • Advanced Practice Nurses
  • Nurse Care Managers
  • Nurse representatives from Radiology, Cardiology, Infection Control, and the Center for Education and Development.
  • The Nursing Performance Improvement Council meets during every regularly scheduled Professional Nurse Practice Council (PNPC) meeting

National Database for Nursing Quality Indicators (NDNQI)

NDNQI is part of the American Nurses Association's (ANA) National Center for Nursing Quality. "NDNQI is the only national nursing quality measurement program which provides hospitals with unit-level performance reports with comparisons to national averages, percentile rankings and other important data. All indicator data are collected and reported at the nursing unit level. NDNQI's nursing-sensitive indicators reflect the structure, process, and outcomes of nursing care." For more information click here.


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