Digital Commons Network^™

Improving Nursing Shift Handoff Reports: A Quality Improvement Project, Nathan Mm Secrest

Master's Projects and Capstones

Nursing shift-to-shift handoff report can greatly impact a patient’s quality of care. According to the Joint Commission, “an estimated 80 percent of serious medical errors involve miscommunication between caregivers when patients are transferred or handed-off” (Inadequate handoff communication, 2017). In total, this quality improvement (QI) project worked with three hospital inpatient units on three different floors in an urban California (CA) city. Each unit and even shifts within each unit varied, leading to the conclusion that interventions should be trialed by units with the most buy-in, then adjusted to the unique needs of each unit. For our main intervention we …

Improved Data Communication With Frontline Staff, David Sprecher

Master's Projects and Capstones

Problem: Frequently, communication from the Quality Department (QD) needs to be filtered through several organizational layers without first-hand knowledge of what message was given to frontline staff. Current mechanisms of communication between the QD and front-line microsystem teams have barriers preventing them from being consistent and reliable.

Context: Research has found that collaborating with and supporting frontline staff was key to establishing a culture that supports change and a focus on safety. Establishing open communication and effective teamwork with individuals on the frontline leads to shared values within a team and better collaboration which drives performance improvement.

Interventions: For trended …

Reducing Implicit Bias: Evaluating Cultural Humility And Mindfulness Practices In The Perinatal Microsystem, Charlene Johnson

Master's Projects and Capstones

Problem: In one perinatal microsystem, an assessment revealed 49 reported events that alleged perceived bias occurred over a one-year period. This project aims to address implicit bias and educational solutions to improve communication and create a culture of humility and equity.

Context: The setting was an urban hospital within a large non-profit healthcare organization. The improvement team included registered nurse champions, obstetrical technicians, midwives, physicians, managers, and an educator.

Intervention: A virtual interactive education session for a multidisciplinary volunteer group (n=18) was introduced followed by five weekly follow-up discussions. The education focused on translating the cultural humility …

Aidet And Commit To Sit Implementation In The Outpatient Surgical Setting, Olivia V. Meehan

Master's Projects and Capstones

Problem: This quality improvement project implements AIDET and commit to sit to improve communication and increase the patient satisfaction of an outpatient surgery microsystem. The microsystem’s patient satisfaction is assessed, and it is currently scoring below the reach goal of 85^th percentile. The detractors from their overall score mainly stem from the patient not feeling listened to, informed, or updated on the timeline. AIDET and commit to sit are ideal tools for addressing those deficits.

Context: The microsystem being addressed is an outpatient surgery unit that specialized in general surgery for the pediatric population. The pediatric population that the …

Closing Communication Gaps For Unplanned Surgical Patients: One Pre-Op Checklist At A Time, Seda L. Vash

Master's Projects and Capstones

Problem: Unplanned, inpatient surgical patients were experiencing poor outcomes and dissatisfaction with their overall care. This surgical patient population also lacked communication from their healthcare teams with regard to plans of care throughout their hospital stays.

Context: This was a quality improvement project for the unplanned, inpatient surgical patient population in the Central Valley of California. Approximately 13% of this hospital’s surgical patients required post-surgical care in the inpatient units. These patients, according to unfavorable HCAHPS scores, experienced unsatisfying care and insufficient communication from their healthcare teams, including physicians and nurses.

Intervention: This project implemented an Add-On Communication Tool for …

You're On Mute - How The Shift From In-Person To Virtual Board Meetings Impacts Board Governance And Communication In Nonprofit Associations, Theresa Hurley

Master's Projects and Capstones

Because of the Covid19 pandemic meeting restrictions that started in March 2020, almost all nonprofit boards had to move to virtual board meetings. Through a literature review, expert interviews and a survey of nonprofit association Executive Directors, Chief Executive Officers and board members, this capstone explores the impact of the shift from in-person to virtual board meetings on board governance and board communication and dynamics for nonprofit associations. Some findings were positive - virtual meetings are more cost-effective, are better attended and more convenient and efficient than in-person meetings. Other findings were negative - multiple communication challenges inherent in the …

Standardizing And Documenting Decision-To-Incision Intervals For Unscheduled Cesarean-Section Deliveries, Molly Bloom

Master's Projects and Capstones

The term decision-to-incision interval (DII) refers to the interval between when a laboring patient and their healthcare provider agree to an unscheduled surgical cesarean section (C/S) delivery and when the first incision is made in the operating room. The ideal length for this interval varies with the urgency of each case, and there is no international consensus regarding the timing. In an urban labor and delivery unit in a private hospital, examination of this interval revealed inconsistent documentation of the decision, as well as unclear guidelines on the DII for two of the three unscheduled C/S urgency levels. This quality …

Standardizing The Bedside Shift Report: Improving Nurse-To-Nurse Communication, Deepi Sahota

Master's Projects and Capstones

PROBLEM: The Community Living Center (CLC) reveals an immense concern on shift-to-shift handoff report. Shift-to-shift report is done in the report room, often times unclear information is given and critical information is not appropriately conveyed.

CONTEXT: The project was implemented on a 50-bed unit at the Veterans Affairs. The improvement project was focused on collaborative partnerships, standardized bedside shift report, and utilization of the SBAR tool. in the prevention of communication errors.

INTERVENTIONS: The SBAR tool was utilized to provide a framework for effective communication between nurses. The CNL facilitated an hour in-service on bedside shift report to nurses …

Standardizing The Bedside Shift Report: Improving Communications And Promoting Patient Safety, Chona C. Alforque

Master's Projects and Capstones

PROBLEM: Nursing shift reports are integral to nursing as they allow for the transfer of critical information and responsibility of patient care from one nurse to another. Ineffective communication during shift-to-shift reports can contribute to gaps in patient care and breaches in patient safety, including medication errors, falls, and sentinel events. The greatest risk of communication breakdown is during transitions in care.

CONTEXT: St. Louise Regional Hospital, a small community hospital, consisting of an eight-bed medical-surgical intensive care unit lacked structure in how handoff should occur and had variances in shift handoffs. Observation of the shift handoff at the nurses’ …

Improving Nursing Communication Outcomes Through The Tell-Us Card, Jeffrey Salao, Nina Park, Laura Le, Brittney Pilker, Jillian Cule, Maricarmen Reyes

Master's Projects and Capstones

Abstract

Nursing communication plays a pivotal role in patient-centered care. However, statistics have shown that failures in communication exist in more than 20% of all hospital settings (Sethi & Rani, 2017). Within the explored microsystem, a gap in patient communication was identified through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Reports revealed that the microsystem was performing at 69%, which is 11% below the national average for nursing communication (Centers for Medicare and Medicaid Services [CMS], 2018). After performing a microsystem assessment, there was a measurable communication opportunity between the patients and nurses. It was determined …

Improving Nursing Communication Outcomes Through The Tell-Us Card, Brittney Pilker, Jillian Cule, Laura Le, Nina Park, Jeffrey Salao, Maricarmen Reyes

Master's Projects and Capstones

Nursing communication plays a pivotal role in patient-centered care. However, statistics have shown that failures in communication exist in more than 20% of all hospital settings (Sethi & Rani, 2017). Within the explored microsystem, a gap in patient communication was identified through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Reports revealed that the microsystem was performing at 69%, which is 11% below the national average for nursing communication (Centers for Medicare and Medicaid Services [CMS], 2018). After performing a microsystem assessment, there was a measurable communication opportunity between the patients and nurses. It was determined that …

Improving Nursing Communication Outcomes Through The Tell-Us Card, Nina Park, Laura Le, Brittney Pilker, Jillian Cule, Maricarmen Reyes, Jeffrey Salao

Master's Projects and Capstones

Nursing communication plays a pivotal role in patient-centered care. However, statistics have shown that failures in communication exist in more than 20% of all hospital settings (Sethi & Rani, 2017). Within the explored microsystem, a gap in patient communication was identified through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Reports revealed that the microsystem was performing at 69%, which is 11% below the national average for nursing communication (Centers for Medicare and Medicaid Services [CMS], 2018). After performing a microsystem assessment, there was a measurable communication opportunity between the patients and nurses. It was determined that …

Cnl As Outcomes Manager: Improving Communication During The Er To Icu Handoff, Amy Ho

Master's Projects and Capstones

Emergency room (ER) to Intensive care unit (ICU) handoff reports are often ineffective because the lack of an standardized guideline. The aim of the Clinical Nurse Leader (CNL) improvement project was to improve the nurse satisfaction survey scores in the ER and ICU microsystems within a mid-sized community hospital in northern California. Participates included registered nurses, and ER and ICU managers. The failure mode and effect analysis (FMEA), Strength, weaknesses, opportunities, and threats (SWOT) analysis, and the Plan-Do-Study-Act (PDSA) cycle were used for this project. Literature reviews were conducted to identify effective theories, patterns, and tools for handoff reports. Nurse …

"Improving Nursing Communication Outcomes Through The Tell-Us Card", Jillian Cule, Jeffrey Salao, Nina Park, Laura Le, Brittney Pilker, Maricarmen Reyes

Master's Projects and Capstones

Nursing communication plays a pivotal role in patient-centered care. However, statistics have shown that failures in communication exist in more than 20% of all hospital settings (Sethi & Rani, 2017). Within the explored microsystem, a gap in patient communication was identified through the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Reports revealed that the microsystem was performing at 69%, which is 11% below the national average for nursing communication (Centers for Medicare and Medicaid Services [CMS], 2018). After performing a microsystem assessment, there was a measurable communication opportunity between the patients and nurses. It was determined that …

Introduction Of Communication Strategies To Decrease Patient Falls In An Acute Rehabilitation Setting, Alicia Joachim

Master's Projects and Capstones

Background: Due to the lack of appropriate fall prevention measures in an acute rehabilitation unit, there has been a notable increase of patient fall occurrences within a 6 month period. The purpose of this practice improvement project was to reduce patient falls within a 36-bed unit, using visual aids and effective communication among nursing staff. The multi-disciplinary members involved licensed nurses, nursing assistants, nursing supervisors, director of nursing, and executive administrator. Methods: The method used to implement this project included a literature search, informational interviews and staff surveys, and prioritization of interventions by the team. Project implementation was guided by …

The Interactive Patient Careboard: A Technological Innovation To Improve Patient Safety, Perla Q. Baldugo

Master's Projects and Capstones

Problem: An innovative method to communicate with the patient and between interdisciplinary team members is the use of the interactive patient careboard (IPC) which has declined since its implementation. Concurrently, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores for the med surg unit need improvement. The low HCAHPS scores in communication suggested to nursing leadership that revitalizing use of the IPC could lead to improvements in the scores. The ideal shift handoff includes IPC as a focal point of communication. The RN is expected to display the careboard during handoff and identify for the patient the healthcare …

Improving Communication In A Virtual Team: A Quality Improvement Project, Deepali Addagarla

Master's Projects and Capstones

Problem: Data analysis based on two surveys revealed team communication, interdependence, technology interfaces, and integration as the quality gaps in the Virtual Surveillance Team. When compared with traditional in-person teams, a virtual working team faces different types of communication challenges.

Context: The virtual surveillance team in the regional quality department at Oakland monitors both Advance Alert Monitor (AAM), a statistical model developed by the Kaiser Permanente (KP) Division of Research (DOR) that is used to predict an individual’s likelihood of deterioration, and eHospital care gaps for Kaiser Foundation Hospitals in Northern California (KFH, NCAL). The latest evaluation from DOR of …

Multifarious Interventions To Reduce Falls On The Medical-Surgical Units, Wenjie Ying

Master's Projects and Capstones

The CNL project was conducted on the 56-bed adult medical-surgical units in a trauma center. There were total eight fall incidences from January to February. The SWOT analysis, stakeholder analysis, pre-educational survey, cost-effective analysis and root-cause analysis suggested in-depth training on multifaceted fall prevention. The objectives include reducing falls by 50%, increasing staff’s adherence to fall prevention protocols, boosting staff’s confidence in patient mobility, improving staff responsiveness and communication with meds in HCAHPS, and enhancing knowledge of medications’ side effects by May 14, 2018. The literature reviews indicated that the multicomponent preventative measures to prevent falls along with leadership supports …

Improving The Use Of The Integrative Healing Approach, Kristina Horak

Master's Projects and Capstones

The Integrative Healing Approach (IHA) is an initiative that promotes holistic healing and includes the use of essential oils, deep breathing techniques, and therapeutic touch. Its purpose is to relieve pain, anxiety, insomnia, and depression among patients, and stress among staff. The IHA pilot initiative was implemented on the Acute Rehabilitation Unit (ARU) and faced barriers to implementation after the first round of staff education. By rounding with staff and conducting surveys, it was identified that the staff are not using IHA interventions as often due to time constraints. Additionally, there is an identifiable rift between Registered Nurses (RNs) and …

Improving The Quality Of Bedside Shift Report Behavior: Implementing A Standardized Bedside Report Tool On The Medical-Surgical Floor At Woodland Healthcare, Amanda Waggoner

Master's Projects and Capstones

Abstract

Nursing handoff communication at change-of-shift is a frequent, yet highly essential nursing responsibility that lays the foundation for providing care that is safe and consistent (Grimshaw, Hatch, Willard, & Abraham, 2016). A microsystem assessment conducted on the medical-surgical unit at Woodland Healthcare (WHC) utilizing the 5P’s (Purpose, Patients, Professionals, Processes, Patterns) revealed that only 6% of twelve hour night shift nurses were performing a quality BSR and 40% of twelve hour day shift nurses reported feeling satisfied with shift report. Additionally, three reportable events occurred as a result communication related errors which led to increased spending on behalf of …

Improving Communication And Satisfaction Through Hourly Rounds, Karen E. Sondeno

Master's Projects and Capstones

The focus of this CNL project is quality improvement using high quality hourly rounds to achieve improved patient satisfaction and communication with nurses. It was determined by reviewing survey results that patient satisfaction and nurse communication is below National levels. Data shows that rounds are not being done well on a medical unit before the improvement project. It is proven that patients receive and perceive higher quality care and communication with increased nurse presence at the bedside. The population of the medical unit has high numbers of confused/dementia, and dual-diagnosis patients. It was determined that the unit would benefit from …

Use Of The Patient Whiteboard To Improve Communication Of Pain Medication Schedule, Carmela Gonzalez-Shalaby Msn, Rn

Master's Projects and Capstones

Abstract

Despite advances in treatment, pain remains a significant problem in healthcare today. Sub-optimal pain management results in poor patient outcomes and patient satisfaction, culminating in decreased quality of life and financial loss for the health care facility. An important component of pain management is transparent and timely health care team/ patient communication. This project aims to improve patient satisfaction in pain management by incorporating pain medication last given and next available times on patient whiteboards. The targeted floor was a busy post-op medical floor in a medium sized community hospital. Staff were educated with short educational sessions, educational pamphlets, …

The Use Of Personalized Whiteboards In The Inpatient Acute Care Setting And Their Effect On Patient And Nurses Perception Of Communication, Cheryl Karn

Master's Projects and Capstones

A microsystem assessment of two inpatient medical-surgical wards in a medical facility determined a majority of nurses reported dissatisfaction with the amount and type of communication with the interdisciplinary team. This, along with a review of Press-Ganey scores from the inpatient wards, revealed patients reported decreased satisfaction when asked if “nurses kept me informed”, compared to previous quarterly reports as well as other VA facilities. Multiple studies have shown the benefit of personalized whiteboards (PWs) at the patient bedside in improving not only communication but also safety and patient outcomes. A PW was developed by the Clinical Nurse Leader …

Implementation Of A Debrief “Takeaway” Board, Carly A. Skeath

Master's Projects and Capstones

Abstract

My original focus of my project was to implement Team STEPPS, to help improve the communication and teamwork within our entire perinatal service department. However, as I started I ran into barriers with time and with other projects put out by our management that needed to take president. It is then that I decided to narrow my focus on one aspect of Team STEPPS which we are already implementing, and that is debriefs. As a member of the Perinatal Patient Safety Program (PPSP), I was able to learn about all the takeaway’s we received from debriefs that had occurred, …

Improving Hand Off Communication To Enhance Patient Outcomes And Staff Satisfaction, Karin Weinstock

Master's Projects and Capstones

Abstract

The specific aim statement is: Improving hand off communication to enhance patient outcomes and staff satisfaction 50% by August 6. Staff had 100% participation. Reduction in unnecessary appointments occurred and a structured standardized hand off form with situation, background, assessment, and recommendation (SBAR) was implemented at the start date. The clinic has 2 exam rooms, 1 lab, a reception area, and two small offices. The majority of the clients are Hispanic females ages 15-25. The non-profit clinic provides free medical services to the community. Evaluation methods yielded quantitative and qualitative results through chart audits and direct observations.

In-services, one-to-one …

Understanding Core And Supportive Processes, Cora M. Murphy

Master's Projects and Capstones

This CNL project explored ways to improve communication and workflow, thus, decreasing the “physician referral to kidney transplant list” process by the Kidney Transplant Team. The existing processes takes nearly double the time of the national standard of ninety days. This is a time sensitive issue for those in need of a kidney transplant; therefore, our objectives include improved quality of care, improved patient safety by offering time sensitive lifesaving treatment options, staff satisfaction with clearly defined processes, and increase productivity. Beginning in January of 2015, the Lean Transformation Team began conducting a series of meetings using lean tools to …

Using Video Simulation To Enhance Rn-Pca Communication, Boris Chang

Master's Projects and Capstones

The purpose of this project was to develop a video simulation exercise to enhance communication between Registered Nurses (RNs) and Patient Care Assistants (PCAs). From a general microsystem assessment initially performed on an urban hospital medical-surgical unit, 75% of respondents noted that the most pertinent issue to address was improving communication between RNs and PCAs. Literature review of evidence-based practices found several studies that support the use of human clinical simulation to promote teamwork and interdisciplinary communication. RNs (n = 24) and PCAs (n = 9) were then individually interviewed with surveys and responses scored based on the …

California High Speed Rail - The Broken Tracks Of Communication, Nathalie Nguyen

Master's Projects and Capstones

Proposition 1A, “Safe, Reliable, High –Speed Passenger Train Bond Act” was passed on November 8, 2008. Fifty-two percent of Californians voted to issue $10 billion in bonds to fund the clean, efficient, and safe high-speed train service, which is known today as the California High Speed Rail system (CHSR). The rail system will provide a mass transit system up and down the state of California if constructed, planned, and funded successfully.

This paper analyzes the City and County of Merced’s approach to planning for this highspeed rail while engaging in public discussion with the California High Speed Rail Authorities (CHSRA) …