High Reliability and Sustainability: A Nurse-Driven QI Initiative in the Women’s Health Clinic at an Urban Acute Care Facility

Purpose: The evolution of the use of transvaginal ultrasound (TVUS) probes in gynecological care has been equated with decreasing rates of gynecology-related morbidity and mortality. According to the Centers for Disease Control and Prevention, it is a regulatory requirement to maintain infection prevention best practices related to TVUS probes. Some of these regulatory requirements include pre-cleaning devices as per manufacturers’ instructions, the use of logs for process measurement and improvements, and sterilization processes to prevent infection and communicable diseases.
The nursing team in the women’s health clinic in an urban acute care facility identified a lack of communication between nursing and central sterile processing (CSP). The department of infection control conducted an audit of the electronic medical record which subsequently identified inconsistent documentation of probe serial/inventory numbers in logbooks stored by both nursing and CSP.
Methodology: Using the plan-do-study-act methodology, the following processes were implemented for a quality improvement project: monthly cadence meetings with an interprofessional team composed of staff from nursing, infection control, and CSP; real-time notification of fallouts between nursing and CSP, creating a channel of effective communication between departments to foster transparency and visualization of deficiencies; creation of a comprehensive log sheet with tracking mechanism; development of a comprehensive reference guide to enable prompt recognition and notification of deficiencies to/from CSP; and data trended and reviewed in huddles with front-line staff.
Analysis: Within a 5-month period (November 2023 to April 2024), interprofessional and interdepartmental communication and collaboration related to the probe documentation process increased from 0% to 100%. Accurate documentation of probe serial numbers in the electronic medical record increased from 18.75% in November 2023 to 100% in April 2024. This was an 81% improvement which has been sustained as of November 2024.
Results: Using the integrated and standardized process of real-time notification and communication between the nursing and CSP departments, this quality improvement project showed a 100% increase in communication between departments. Also, EMR documentation improved by 81% and there was a significant improvement in both the clinic’s newly developed probe logbook and the CSP high-level disinfection logs.