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Delivering Quality Care with Performance Improvement - 2 Nursing CEs
Delivering Quality Care with Performance Improvement - 2 Nursing CEs
Author: Kristi Hudson RN MSN CCRN

Course Description
This course is designed to examine the role that performance improvement plays in the clinical setting. Defining performance improvement and understanding the role that “competency” plays in performance improvement will be discussed. Data sources to determine performance improvement ideas and priorities, getting staff buy-in, benchmarking and methods or approaches for getting started will be presented. Answers to frequently asked questions regarding outcomes of performance improvement project will be the final focus of this course.
Course Objectives
Upon completion of this course the student will be able to:
  • Define performance improvement
  • Discuss the role that “competency” plays in performance improvement
  • List 3 sources of data that can be used to determine performance improvement priorities.
  • Explain the role of benchmarking in performance improvement
  • Describe FOCUS PDCA
  • Discuss methods of measuring the success of a performance improvement project
Defining Performance Improvement
Performance improvement is a continuous, ongoing measurement and evaluation process with the intended goal being “improvement in quality care”. The process of performance improvement includes monitoring, analyzing, improving and sustaining performance.
The Role of Competency in Performance Improvement
  • Competency is the basis of effective performance improvement.
  • Competency assumes that a pre-determined level of excellence has been established as a guideline for practice (benchmarking).
  • It is when this standard or established measure is “not” met that a performance improvement action should be taken.
  • Staff competency includes assessing and measuring staff knowledge, behaviors, understanding and psychosocial skills.
  • Knowledge, behavior and skills can be determined via objective tests, essay tests, computer simulation, computer based questionnaires, case studies, actual observation, peer evaluation and nursing audits.
Possible data sources for performance improvement include
  • Nursing audits.
  • Problem focused studies.
  • Patient surveys.
  • Infection rates.
  • Performance appraisal (evaluations).
  • Inservice program evaluations.
  • Continuing education program evaluations.
  • Staff meetings.
  • Committee meetings.
  • Anything collaborative.
Getting Staff “Buy In” for Quality Improvement
The success of a performance improvement projects depends on the nurses’ involvement and understanding of the process.
Nurses fulfill many roles in these projects such as team leaders, educators as well as team members. Getting them to be active members of the project team is the challenge for nurse managers. The following are suggestions for nurse managers to assure that staff members are active participants in the performance improvement process:
  • Staff nurses are involved in the quality improvement and see it as educational while also believing that it helps improve patient care.
  • Make it “about the patient”.
  • Make improving quality an expectation and everyday event in your department (make staff accountable).
  • Show the correlation between quality and autonomy.
  • Involve all team members (physicians, nurses, ancillary, case management).
  • Nurses who believe that they are providing high-quality patient care and who also believe that their organization makes high-quality patient care a priority are more likely to participate.
Implementing a Performance Improvement Project
There are many different approaches to “getting started” with performance improvement. Using the nursing process (assessment, planning, intervention and evaluation) is a simple approach to performance improvement. The FOCUS PDCA is a second and frequently used approach to developing a performance improvement project. The performance improvement method “FOCUS-PDCA” provides a structured approach to problem solving and outcome indicators for measuring specific criteria. FOCUS-PDCA is a nine step process that allows the participants to clarify a process, analyze the problem, choose appropriate strategies, implement proper plans for change and evaluate outcomes.
The process is as follows:
F=Find a Problem – this can be any clinical problem or area that requires improvement (note: beginners should choose a small problem for starters).
O= Organize a Team – a multidisciplinary team is the most valuable for performance improvement (absolutely involve one of the CQI or PI team members at your facility).
C=Clarify knowledge of the Current Problem – determine how the problem was identified (infection rates, patient/physician complaint etc.).
U=Understand the Problem – uncover the root cause of the variation or poor outcome.
S=Solve the Problem – come up with solutions for the problem.
P=Plan – plan the process improvement.
D=Do – implement the process improvement
C=Check – check results by data collection and analysis and adjust the plan as necessary.
A=Act – act to hold gain (once a successful plan has been implemented, make sure it keeps going).
The Role of Benchmarking in Performance Improvement
Benchmarking essentially allows for the measurement or comparison of practices and services against other organizations “best practices”. It provides information on where your organization or department ranks on the quality scale. Before beginning a performance improvement project; knowing your starting point on the quality scale is important in order to measure progress.
Setting Project Priorities
Any deficit that compromises patient safety (falls, skin breakdown, medication errors etc.) is usually a good starting point for a performance improvement project. The National Database of Nosocomial Quality Improvement (NDNQI) is a large national database that many hospitals use to benchmark quality scores. NDNQI takes into consideration hospital/department size and available (as well as “like”) services to assure that comparisons are made accurately.  Other considerations in setting priorities include:
  • High risk and low volume procedures (or processes)
  • Standards, accreditation or regulatory agency compliance requirements
  • Problem prone procedures and processes
  • Customer satisfaction concerns.
Note: In determining priorities, the amount of resources that can be devoted to the problem should be considered.
Measuring Success (Evaluating the Process)
How to determine if performance improvement has actually occurred?
Observation of behavior, clinical competence, surveys, improved documentation, questionnaires, interviews and data collection/analysis are all effective ways to determine improvement in quality and performance. Note: these are usually the same tools that originally were used to determine the extent of the problem.
What is considered to be an acceptable amount of improvement?
100% improvement would be nice, but is not always realistic (it is not likely that customer service scores would show 100% improvement, or that medication errors would be reduced to “zero”). Determining the extent of the problem and what an acceptable, achievable and realistic result is is important “prior” to implanting a performance improvement project.
How often should performance be measured?
New projects should be monitored closely until expected outcomes have been reached (check regulatory and accreditating agencies for guidelines). Once a project has met the pre-set goals, annual monitoring is usually sufficient. Note: initial performance should not be measured until all team members have been trained and have had enough time to actually “improve”.
What is the Role of the Leader or Manager in Performance Improvement?
Nurse Managers are often the people who initially identify a performance deficit (not in all cases however). It must be made clear that the sole responsibility of performance improvement is not that of the nurse managers. Staff nurses should be primarily responsible for monitor and maintain quality care in the performance improvement process. Providing the necessary support and training to staff nurses as well as using the necessary authority to make improvement changes “mandatory” are key role features for nurse managers.
How to get “Staff Buy-In” for Performance Improvement?
Change is a slow process that requires careful planning by the nurse manager. Assessing attitudes, knowledge and skills of those participating in the improvement is the first step to assuring buy-in. Once staff is adequately prepared to participate; dangle the carrot of friendly competition. Post current rankings of your quality score and show comparisons of other similar departments on the unit bulletin board. Set the goals for improvement in small increments and recognize and reward staff members for small improvements. Discuss improvements at staff meetings and continue to encourage progress. As important as it is to recognize those who are positively contributing to the performance improvement, it is important for the nurse manager to take correction action for those who refuse to participate in the process (improving quality cannot be an option, it needs to be an expectation).
Implementation of 3% Sodium Chloride IV Infusion for Patients Diagnosed with Cerebral Salt Wasting.
F=Find an Opportunity to Improve:
There is a need for guidelines to administer 3% Sodium Chloride IV infusion for Neuroscience patients with a diagnosis of; Head Trauma, Stroke (SAH, ICH and ischemic) or status-post resection of malignant tumors who are suffering from Cerebral Salt Wasting Syndrome. Current practice has been to assess the need and administer 3% Sodium Chloride for patients with Hyponatremia due to Cerebral Salt Wasting however; because we have not had standardized titration guidelines, rates have been increased and decreased at the discretion of the physician and/or nurse.
O= Organize a Team:
The performance improvement team will consist of:
  • A Neurologist
  • A Neurosurgeon
  • A Pharmacist & Pharmacy Intern
  • The Nurse Manager of the Neuroscience Department
  • Two clinical bedside nurses
  • One member from the performance improvement team
C=Clarify knowledge of the Current Problem
Currently patients who are suffering from Cerebral Salt Wasting Syndrome with Na+ levels less then 135 are being treated with a continuous IV infusion of 3% Sodium Chloride. Though Na+ levels are drawn q 4-8 hours and the infusion rate is adjusted based on the result, there are currently no specific titration guidelines. There has been nursing education regarding the difference between Cerebral Salt Wasting Syndrome and SIADH, but no formal training as to how to titrate an IV 3% Sodium Chloride infusion has taken place.
U=Understand the Problem:
Cerebral salt wasting syndrome is defined as the renal loss of sodium during intracranial disease leading to hyponatremia and a decreased extracellular fluid volume (i.e. hypovolemic hyponatremia). It is seen with a number of intracranial diseases, especially head injuries, subarachnoid hemorrhage, brain tumors, and infections. Up to 30% of patients with subarachnoid hemorrhage (SAH) will develop cerebral salt wasting syndrome. Hyponatremia results in hypo-osmolality, which can aggravate cerebral edema, and lead to elevated ICP and clinical deterioration. It may also precipitate seizures and decreased level of consciousness. Therefore, cerebral salt wasting syndrome should be treated as soon as possible.
S=Solve the Problem:
To assure that the care and management of the Neuroscience patient with a head injury, stroke (SAH, ICH or ischemic), or status-post resection of malignant tumors with Cerebral Salt Wasting Syndrome, the performance improvement team members will develop and implement the following:
  • P=Plan
  • Physicians and Pharmacist – Develop 3% Sodium Chloride Titration Guidelines
  • Neurologist and Clinical Nurse – To present education on SIADH and Cerebral Salt Wasting to Critical Care Nurses at Critical Care “Hot Topics” seminar.
  • Neurosurgeon – Will work with residents and PA’s to assure that 3% Sodium Chloride is ordered appropriately in the computer.
  • Neurologist and Pharmacist – Submit guidelines to Critical Care Committee
  • Nurse Manager – Submit to Standards Committee
  • Nurse Manager -  Submit to Pharmacy and Therapeutics Committee
  • Physicians to inservice staff on proper use of guidelines
  • Clinical Nurses - inservice staff members on SIADH and Cerebral Salt Wasting.
  • Nurse Manager and Clinical Nurses to educate nursing staff to guidelines.
  • Performance improvement participant - to assure that computer generated data collection of patient outcomes is achievable.
  • Pharmacist and Pharmacy Intern to gather data.
  • D=Do:
Implementation of the above plan is currently in progress. Inservice records will be kept to assure knowledge and expected outcome is clear to all employee’s Progress will be monitored.
  • C=Check:
Implementation is planned for the start of the third quarter; data will be collected by auditing charts of patients who were placed on 3% Sodium Chloride IV infusion for Cerebral Salt Wasting. The audits will assure that sodium levels were within proper parameters with the use of these guidelines. Based on the data collected, if alterations in the titration or weaning parameters are required; this PI group will make those adjustments. If there is evidence of the need for continued staff education, this will be done at this time as well. Thereafter this quarterly audit will be repeated, and if necessary, changes will be made.
  • A=Act:
Continued and frequent monitoring of the process and make necessary changes as required.
Conner, M., H. (1993). Mississippi nurses address quality improvement. Retrieved on June 3, 2006 at:
Medical Risk Management Associates. (2005). The FOCUS PDCA methodology. Retrieved on May 20, 2006 at:
Scally, R. (2004). The magnet recognition program: A decade of seeking nursing excellence and innovation. Retrieved on June 3, 2006 at:
The Advisory Board (Nursing Leadership Academy). (2004). Setting goals and motivating staff: Creating the high performance unit. The Advisory Board Company, Washington D.C.
Webb, D., G. (2002). Performance improvement. In Puetz. B., E. & Aucoin, J., W. (Eds.). Conversations of nursing professional development. (Chap. 28). Pohl Publishing Inc.
Yu, W., M.D. & Baje. M. (2006). 3% sodium chloride guidelines for patients with cerebral salt wasting syndrome. UCI Medical Center, Orange. Ca.

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