ABSTRACT
OBJECTIVE: To decrease variability in clinical practice and to standardise and develop a systematic care programusing nursing care protocols. MATERIALS AND METHODS: The Directorate of Nursing of the Gregorio Marañón Hospital decided to develop a systematic program to produce nursing care protocols in 2004. It followed 5 phases: preparation, processing, dissemination, evaluation and updating. The program was based on the methodology for continuous improvement cycle (PDCA). Particular attention was paid to the evaluation phase, and to the three types of tools used: evaluation of the process and performance indicators and a survey on the perception of professionals. RESULTS: A total of 30 protocols and 80 procedures were developed. They were evidence based, accessible, available for updating and with evaluation indicators. DISCUSSION: Nursing care protocols decrease the variability of clinical practice. They homogenize care and increase the involvement of professionals. The evaluation of the process, outcomes and adherence of professionals is imperative for continuous improvement.
