Reaching Regulatory Compliance Metrics

Abstract

It can be challenging to meet regulatory compliance measures when there are competing priorities with short staffing and workplace burnout. Finding a way to reach regulatory compliance standards without heavily relying on dispensary actions to enforce compliance can help reengage nursing teams, create a sense of purpose, and establish a leader and staff collaborative approach to nursing excellence. By creating a shared vision for the unit, nurse leaders can collaborate with staff to reach needed standards that support patient care outcomes. Additional methods, such as routine audits, tracking, leader commitment, staff communication, individualized teaching, feedback, and team building, are all efforts that supported two units in reaching compliance standards for the first time in 4 years through a team project. Unit A had a 4-year pain reassessment completion average of 77.6%. Unit A's average after the project was 88.1%, a 10.9% increase. Unit C had a 4-year running average of 78.0%. After the project, unit C's average increased to 90.1%, a 12.4% increase. Unit A's skipped function usage 6 months before the unit project was 21.05%, and postproject intervention use was down to 6.55%. Unit C's skipped function usage 6 months before the project was 22.84%, and postproject intervention use was 6.99%. Overall severity compliance had a remarkable upward trend. Lastly, a 10.2% increase in patient responses to the NRC Health question on staff eased discomfort compared to the results from the previous 6 months.