A Model Clinical Practice Program at Northwestern Memorial Hospital

A Model Clinical Practice Program at Northwestern Memorial Hospital

Sandra E. Gaynor

Nursing staff and the care they give are key strategic resources for health care organizations. Assuring that all nurses deliver a consistent, high level of quality care or “impeccable clinical practice,” is an organizational priority. A challenge for organizations is to determine how to ensure impeccable clinical practice amongst a large nursing staff practicing in a variety of specialty areas. While all health care organizations have a unique set of structured policies and procedures intended to standardize practice, paper guidelines do not stand alone in establishing actual nursing practices. Nursing practice and procedures are ultimately established by the quality of clinical orientation and ongoing education a nurse receives and the role modeling of colleagues in peer practice. To address these issues and supplement existing orientation, education, and quality improvement efforts, Northwestern Memorial Hospital (NMH) developed an innovative Clinical Practice Program (CPP) designed to ensure impeccable clinical practice throughout the nursing organization.

Northwestern Memorial Hospital is a 750-bed academic medical center located in downtown Chicago, with over 1,100 professional nurses in the division of patient care. The CPP was developed in early 1997 as an administratively driven and clinically implemented program throughout the division of patient care. The intent of this program is to provide a framework for assessing nursing practice issues and to promote safe and effective practice across all hospital units, consistent with policies and procedures. The program is designed to complement existing educational and quality programs thus strengthening the foundation of impeccable clinical practice throughout the division.

Program Conception

The genesis of the clinical practice program came from discussions within the nursing administrative leadership group. Ongoing review of quality reports and patient satisfaction data revealed clinical trends and issues that afforded opportunities for improving nursing practice.

Nursing administrative leadership had a high awareness of national and local trends in clinical practice. Further discussions of best practice techniques, strategies, and quality measures helped the group arrive at the concept of the CPP. Causes of sentinel events in patient care were discussed along with the need to ensure a consistently high quality of care. Special thought was given to highly complex procedures involving multiple hospital systems (such as chemotherapy orders) and those where the nursing staff were unclear about new or updated hospital policies and procedures. The goals of nursing administration quickly became clear. There was a need to identify the components of impeccable clinical practice within the organization, communicate these clearly to all staff, and develop a mechanism to ensure consistent execution of this level of practice. The program needed to meet the knowledge and clinical practice needs of the 1,100 nurses practicing at different experience levels and in diverse settings, from neonatal intensive care to acute adult psychiatry.

Program Design

Administrative and clinical leadership reviewed quality management reports and patient satisfaction data to identify four initial priority areas. These were considered part of core nursing practice but additionally as high risk, highly complex, and important from the patient’s perspective. These four initial priorities were: vascular access, pain management, restraint use, and medication administration. It was determined that this program would be refined and implemented by the divisional nursing practice committee. Program design was recommended to be in modules, by topic area, with each module containing an updated policy/procedure, a case study, an audit tool for observation of practice, and a posttest.

Program Development Process

The nursing practice committee (NPC) is a division-wide committee responsible for coordinating all nursing policies, procedures, and standards activities, as well as establishing guidelines for clinical nursing practice at NMH. As with all the divisional committees, this group reports to the vice president of patient care and the divisional quality management committee. The NPC comprises the departmental chair from each clinical departmental practice committee, as well as a nursing director and a coordinator from the department of nursing development. The departmental practice committees are composed of a staff nurse from each individual nursing unit within that department. Over the years, this committee structure has demonstrated a remarkable ability to quickly disseminate information between the administrative and staff nurse levels regarding practice issues. The NPC appointed a task force to further develop the groundwork laid by the nursing administrative group. This task force comprised a nursing director, the NPC chair and vice-chair, the nursing development coordinator, and staff nurses.

Over several meetings, the task force considered a variety of methods to educate and inform staff regarding practice changes, including unit-by-unit inservices, nursing grand rounds, a videotape, case studies with quizzes, and self-study packets. The self-study packet was eventually selected, as this method (a) had proven successful in the past at NMH, (b) was the most cost efficient, and (c) was the most flexible way of presenting information to a large audience.

Concurrently, as the task force developed the Clinical Practice Program components, the NPC was completing major revisions to all of the intravenous therapy-related policies and procedures. Fourteen intravenous-related policies and procedures were consolidated into a single section of the policy manual. Along with the streamlined format, several clinical practice changes were also incorporated. Based on this work, it was determined that the first clinical practice program module to be introduced would be the VADs module.

Program Elements and Implementation

The Clinical Practice Program task force incorporated all of the VADs practice and policy changes into the first CPP self-study packet and presented it to the NPC. The self-study packet included:

1. An introduction to the CPP.

2. A “highlights” page.

3. The revised policies and procedures, with all changes highlighted.

4. A quiz to test learning.

5. A tracking page (sign-in sheet) for managers to ensure that all RNs participated.

6. A resource and reference page for additional learning.

7. Instructions for quality improvement monitoring to demonstrate that clinical practices actually did change.

An implementation timeline was determined, in addition to a deadline of 3 to 4 weeks to ensure all RNs completed the quizzes and that the quality improvement monitoring would begin at the same time across all departments. As other modules were developed, these elements proved to be the foundation for all subsequent CPPs.

The NPC approved the program with some minor revisions and an implementation plan was developed. Since the CPP was a new concept and was intended to become an ongoing program, support from all clinical nurse managers was essential. To underscore the strategic importance of the program it was introduced to the management team by the vice president of patient care in conjunction with the chairs of the nursing practice committee. Complete program packets and timelines were distributed to each manager to support implementation at the unit level.


The program has been received positively by both the clinical nurse managers and staff nurse groups. Managers feel the program allows them a comprehensive vehicle to provide staff education and to monitor important areas of practice. Staff feel that they are kept abreast of important changes in policy and practice in a more focused manner. More significantly, since the program has been implemented there is an improvement in patient perception of nursing care and there are positive outcomes in practice as identified through the quality monitoring process.

Ongoing Program

Since its inception in the spring of 1997, one Clinical Practice Program has been introduced approximately every 6 months. The first three CPPs were entitled “Vascular Access Devices” (key elements of this program are included in this article; see Figures 1-4), “Pain Assessment and Patient Controlled Analgesia,” and “Care of the Restrained Patient.” A fourth entitled “Medication Administration,” is now being developed.

Figure 1.

Clinical Practice Program

RN Study Packet Topic: Vascular

Access Devices (VAD)

* Program highlights

* Nursing care procedures

–Summary of central vascular

access devices (CVAD)

–Administration of fluids

through VAD

–Maintenance of a CVAD

–Obtaining blood specimens

from a VAD

–Maintenance of a CVAD

–Obtaining blood specimens

from a VAD

–Obtaining central venous

pressure from a CVAD

–Management of an occluded

central VAD

–Accessing an implanted


–Initiation and maintenance

of peripheral IV therapy

* Educational Resources for VAD

* Quiz

* Tracking Record

* Audit Tool

* Key Elements for IV Assessment

Figure 2. NMH Clinical Practice Program Vascular Access Device Audit Tool

1. Dressing Change in Compliance 1 2 3 4 5 6 7 8 9 10

* PIV/PIL changed q 24 hrs COMMENTS:–

* CVAD changed q 7 days and

24 hours after insertion

* Dressing labeled with date

and time (Observation)

* Dressing change documented

in the medical record

* Gauze dressing changed q 24 hours

(PIV)/ q 48 hours (CVAD)

2. Tubing Changes in Compliance 1 2 3 4 5 6 7 8 9 10

* IV tubing change q 72 hours COMMENTS:–

except HA/IL tubing changed

(Observation) q 24 hours (including

“Y” connector and extension


* IVPB/intermittent infusion

tubing changed q 24 hours


* All tubings labeled with date

and time to be changed (Observation)

* Medical record documents

tubing changes

3. All IV Fluids Changed Every 24 Hours 1 2 3 4 5 6 7 8 9 10

* Fluid changes documented in COMMENTS:–

the medical record

* IV bags labeled with date/time

hung (Observation)

4. Site Assessment in Compliance 1 2 3 4 5 6 7 8 9 10

* No phlebitis or s/s infection COMMENTS:–

noted at IV sites (Observation)

* Site assessment documented in

the medical record q 8 hours

* PIV/PL site changed q 72 hours

and documented (if not

changed, chart should reflect

rationale) (Observation)

5. Staff Compliance: Ask 80% of Staff … COMMENTS:–

* Query staff members: “Ask the

beginning and throughout your

shift, what are the major elements you

asses in a patient with an IV?”

Unit:– Name of auditor:–

Goal: 90% of compliance for each item

Figure 3. NMH Clinical Practice Program Key Elements for IV Assessment (Standards of Practice)

[right arrow] Verify IV Fluid

* Fluid is as ordered and present on Kardex

[right arrow] Verify Rate

* Rate as ordered

* Recalculate drip rates to verify dosage is as ordered

[right arrow] Verify Site

* Check for s/s/infection, infiltration, phlebitis

* Check for dressing integrity

* Check site expiration date

[right arrow] Verify Expiration Dates

* Check dates for tubings, solutions, and site

Remember the four important elements:

Fluid, Rate, Site, Dates

Editor’s Note: For more information on this program, contact Gary L.C. Reschak, MS, RN, CNAA, Coordinator, Nursing Development, Northwestern Memorial Hospital, 250 East: Superior Street, Suite 1705, Chicago, IL 60611-2950; (312) 908-9652; FAX (312) 908-1741.

Sandra E. Gaynor, DNSc, RN, is Director, Nursing Development, Northwestern Memorial Hospital, Chicago, IL.

Julie L. Creamer, MS, RN, is Vice President, Patient Care, Northwestern Memorial Hospital, Chicago, IL.

Gary L.C. Reschak, MS, RN, CNAA, is Coordinator, Nursing Development, Northwestern Memorial Hospital, Chicago, IL.

Holly A. Clayton, MSN, RN, CCRN, ACNP, is Advanced Practitioner, Ortho/Neuro/Surgical Nursing, Northwestern Memorial Hospital, Chicago, IL.

COPYRIGHT 1999 Jannetti Publications, Inc.

COPYRIGHT 2007 Gale Group