ABSTRACT
This article describes the development of a quality improvement program for a clinical nurse specialist department reflecting the 10-step process described by the Joint Commission on Accreditation of Healthcare Organizations. The philosophy of continuous improvement has allowed the department to promote concurrent improvements as well as to measure and monitor selected direct and indirect patient care indicators. The department developed process indicators to verify the processes in place. The department anticipates development of outcome indicators for subsequent programs. Identified opportunities for improvement, and the changes which occurred to address those opportunities, are also described. Information regarding data collection related to resource consumption and increased collaboration with other departments, is also described.
