I hope that this makes sense. I work on only one aspect of QI, but have been exposed to the overall picture and will share my observations. If anyone else in QI has better or more clear interpretations, I welcome your input.
You will need to establish some goals for the new department. The leadership of the hospital, medical staff, and nursing need to be committed to the goals that are established. QI is primarily education focused. Find a problem, evaluate the current practices, and educate the staff as needed regarding appropriate current therapy. Implement changes as needed and them re-evaluate. It is a continual process, much like the nursing process itself.
What type of data are you going to be collecting? Aggregate data is useful in showing the overall success of your facility in treating various health conditions. This data does not look at individual staff members, but is more focused on policies and procedures. Patients with selected health conditions are reviewed to determine if appropriate care was ordered and administered, according to established criteria.
For instance, pneumonia patients need to have cultures obtained prior to antibiotics. The antibiotics need to be administered within a set number of hours, usually within four hours or less from admission. Heart attack patients need to have certain routine treatments or medications administered within a specified time frame. These time frames may be established by the facility, or may be provided by a government agency or another recognized source. Did the patients meet these established criteria? If not, educate the staff and implement new policies as required. Then re-evaluate and monitor the trends.
Patient satisfaction is another tool that many facilities use to determine the quality of care provided. Questionaires are developed and processed. There are organizations that compile this data, compare it to other similar facilities, and return reports to the hospitals.
Another type of focus is on individual patient records according to certain clinical indicators. For instance, all mortality cases are reviewed at my facility. A nurse does the initial review. If all criteria are met, the review ends, but if there are criteria that are not met, such as unexpected death or death within 48 hours of an invasive procedure, the chart is reviewed by a physician with similar training and experience to the physician providing the care. If concerns about care are expressed, the record is forwarded to the department chair for follow up.
This follow up is primarily educational in nature. A copy of the review is kept on file for when the physician applies for credentialling at an interval established by the hospital's medical staff.
Hospitals in the US who receive government funding or Medicare reimbursement are required to participate in QI reviews. These reviews are currently undergoing changes and are in a state of flux. They are related to the aggregate data collection as discussed above, and compared to other similar facilities.
Here are some website links that may be helpful.
There are sure to be many other websites available. Just do a search on a search engine to find additional resources. As with everything else, the people with the information that you seek will probably want your organization to pay a fee for that information, or to pay a fee to participate in any studies that analyze your data, compare it to the data of other facilities, and return a report to your facility. That is only reasonable, but I wanted you to know that most of what you find will not be free.
If I can be of further assistance, please contact me by another post, by a private message, or by e-mail. Good luck in your efforts to establish an effective QI program at your facility.