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Quality Care & Patient Safety

FMH is dedicated to providing outstanding and safe clinical care to its patients. This includes using quality control, quality assessment, peer review, and performance improvement methodologies to assure nursing related processes are continuously improved. Additionally, FMH is committed to meeting or exceeding The Joint Commission (TJC) standards, Maryland state regulations and Center for Medicare and Medicaid Services (CMS) requirements. Nursing makes an essential contribution to patient safety and quality of care. Desirable patient outcomes are an empirical part of a patient's care at FMH. To demonstrate this passion for quality and safety, the nursing department is beginning the journey to excellence with the Magnet Recognition Program. This program was developed more than 25 years ago and hospitals who are awarded this honor demonstrate excellence in nursing practice.

Department of Nursing Professionals and Clinical Development

The primary mission of the Department of Nursing Professional and Clinical Development is to provide for the clinical and professional development of FMH nurses to ensure excellence in nursing practice and patient outcomes.

The department is led by a Director who is a Doctor of Nursing Practice and a Manager who also serves as the hospital’s Magnet Coordinator. The department is comprised of master’s-prepared Clinical Nurse Specialists (CNSs) who serve as expert clinicians in a specialized area of nursing practice. The specialty may be identified in terms of a population (i.e. Pediatrics), a setting (ie. Emergency Dept.), a disease or medical subspecialty (i.e. Stroke), type of care (ie. Surgical), or type of problem (i.e. Pain). The CNS is an Expert in Clinical Practice, Educator, Leader, Researcher and Consultant, who influences the three spheres of practice: Patient Care, Nursing, and Organizations/Systems.

The department focuses on assuring that best practices are in place to achieve the following important goals:

  1. Advance nursing practice by providing inter-professional, system-wide leadership to achieve organizational goals.
  2. Facilitate strong, patient-focused, inter-disciplinary relationships between nurses, physicians, and other members of the healthcare team.
  3. Utilize evidence-based strategies to improve patient safety and patient outcomes.
  4. Create, monitor and evaluate cost-effective, evidence-based policies, procedures, protocols and best practice models.
  5. Support the successful transition of experienced and new nursing staff into practice as members of an interdisciplinary team at FMH.
  6. Promote the integration of patient-centered care into the practice of nurses.
  7. Create systems for ongoing evaluation of nurse competence.
  8. Ensure nurse-sensitive patient outcomes outperform the mean benchmark in the National Database of Nursing Quality Indicators (NDNQI).
  9. Implement improvements in the health care delivery system in areas such as new technology or changes in nursing practice standards.
  10. Provide for professional development of the nursing staff in areas such as specialty certification, advanced degrees, and progression on the clinical ladder. 
  11. Establish an emphasis on clinical inquiry, knowledge development, and innovation so that nursing practice at FMH reflects the current best science.

FMH has seen positive impacts due to the CNS team such as a significant reduction in falls, pressure ulcers and catheter-associated UTI’s, to name a few. Research about CNS practice demonstrates outcomes such as reduced hospital costs and length of stay; improved pain management practices; reduced frequency of emergency room visits; increased patient satisfaction with nursing care; and reduced medical complications in hospitalized patients.

CNSs consistently collaborate with others to lead system-wide improvements and change in this very complex healthcare environment. Their leadership will be essential as we take on the challenges that are presented with improving outcomes and cost-efficiency, healthcare reform, and our journey to ANCC’s Magnet recognition.

Patient Safety ♦ Clinical Quality ♦ Evidence-Based Practice ♦ Professional Development ♦ Education ♦ Innovation

Performance Improvement

To assist with these efforts, the Performance Improvement (PI) Department supports the Nursing Departments in a variety of ways including collecting data, educating staff, identifying opportunities for improvement, identifying root causes, and reporting results.

Core Measures

For many years, the PI department has been collecting data on core measures as required by The Joint Commission. This data is also reported to CMS and the state. These measures include Acute Myocardial Infarction, Heart Failure, Community Acquired Pneumonia, and Surgical Care Improvement Process (which began with hip and knee surgeries). Many of these measures are influenced by the care provided by the nursing staff. Some of the indicators most influenced by nursing include smoking cessation, timing of prophylactic antibiotics, obtaining blood cultures prior to administration of antibiotics, timing of aspirin therapy, and removal of foley catheters. The results of the organization's efforts have paid off! Recently FMH received approximately $150,000 from CMS for achieving a high level of performance and showing dramatic improvement.



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