Enhancing Client Intake Efficiency In The Removal Defense Program: A Nursing-Led Quality Improvement Initiative, Johnny Linares, Julia Tran Ngo, Daniel Orea, Atheana Yadira Lopez

Master's Projects and Capstones

This quality improvement project focuses on optimizing the intake process for the Removal Defense Program at a nonprofit immigration legal office serving asylum-seeking clients. The existing intake relied on unstructured, phone-call-based intake interviews that gathered incomplete information, leading to inconsistent documentation, reduced efficiency, and significant client processing delays. A structured, multilingual, and multiplatform new-client admission protocol coupled with the implementation of a client-facing resource guide for waitlist clients were co-developed and implemented using the Lippitt Change Theory framework. Utilizing a mixed methods approach, the study involved staff interviews and observational assessments with staff members from the program. Baseline intake process …

Pressure Free Care: Empowering Staff With The Hapi Prevention Reference Sheet, A Quality Improvement Project, Harmony Le, Melissa Suthar, Olivia Tubao, David Valdez, Mckenna Wallace

Master's Projects and Capstones

Hospital-acquired pressure injuries (HAPIs) can significantly impact a patient’s quality of care, increase organizational costs, and pose significant risks for patient safety. According to the United Hospital Fund, “Hospital-acquired pressure injuries (HAPIs)—also known as pressure ulcers or bed sores—can pose significant problems for both the patient and hospital. Being an injury to the skin or underlying tissue, HAPIs can be painful, cause infections, hinder recovery, and prolong a patient’s time in the hospital” (United Hospital Fund, 2025). This quality improvement (QI) project took place in a small, urban southern California hospital with a high incidence and prevalence rate of HAPIs …

Kid Power: Mastering Asthma Management To Keep Hospitals Away!, Kriste L. Moret

Master's Projects and Capstones

Problem: Pediatric asthma remains a leading cause of preventable hospitalizations, particularly in California’s Central Valley, where environmental and health disparities worsen symptoms. Many children are discharged without understanding their Asthma Action Plan (AAP) or feeling confident in symptom management.

Context: On a unit in a community hospital in this high-risk region, asthma-related admissions persisted. Gaps in discharge education highlighted the need for a structured intervention. The Institute for Healthcare Improvement (IHI) Model for Improvement (MFI) guided this effort.

Intervention: A nurse-led, developmentally appropriate asthma education bundle was implemented. Teaching began on admission and was reinforced using teach-back, color-coded AAPs, culturally …

Enhancing Patient Safety: Fall Prevention Through Video Education, Fithawit T. Zere

Master's Projects and Capstones

Abstract

Problem: Globally, hospital falls remain a leading cause of injuries, increased costs, short and long-term disability and emotional impact on patients/families. Despite required prevention measures, a local hospital experienced rising fall rates during 2024 (n=71);13 of these occurred in the Med-telemetry microsystem. Although multiple strategies and financial investments occurred, nursing compliance with the fall prevention “bundle” remained suboptimal.

Context: Thirteen falls resulted in $182,000 in 2024. A quality improvement (QI) project was initiated over 12 weeks after routine audits revealed inconsistency in application of several components of the required bundle: particularly, the fall prevention video upon admission.

Interventions: A …

Sos (Save Our Skin)- A Hospital Acquired Pressure Injury Reduction Quality, Nicholas A. La Mar

Master's Projects and Capstones

Problem: Hospital-acquired pressure injuries (HAPIs) are a significant source of preventable harm. Often associated with increased patient morbidity, reduced quality of life, and substantial financial costs. In 2023, a Northern California level II trauma center reported 44 HAPI cases, with 25% occurring in the telemetry units. Despite a hospital-wide reduction in HAPIs in 2024, telemetry units accounted for 33% of the cases in the first quarter of 2025, highlighting a need for targeted intervention.

Context: The project was conducted in four adult inpatient telemetry units of a 241-bed level two trauma center. The units faced challenges with inconsistent adherence to …

The Influence Of Market Pressures On The Discursive Construction Of Dei In Elite Independent Private Schools, Anthony R. Clemons

Doctoral Dissertations

This study examines how elite independent private schools (EIPSs), traditionally associated with privilege, prestige, and exclusivity, articulate their commitments to diversity, equity, and inclusion (DEI) within a highly competitive market. Using Critical Race Theory and Neoinstitutional Theory, this mixed-methods study employs critical discourse analysis (CDA) and corpus linguistics (CL) to explore underlying forces contributing to the observed disjuncture between the ostensive and performative aspects of EIPSs’ DEI efforts. Using the publicly available diversity statements of 31 Bay Area EIPSs, findings reveal that the DEI discourse among these elite schools often reflects market-oriented institutional logics. EIPSs tend to frame DEI as …

Queer Rights Learning Through Transnational, Digital Communities Of Practice, Hayley D’Souza, Brindaalakshmi Kumbakonam, Bren Kutch, Aparna Arora, Vani Bhardwaj

International Journal of Human Rights Education

Traditional human rights education (HRE), and education writ-large, often depends on and reinforces binary hierarchies. The Society of Gender Professionals (SGP) reflects on how its trans-national, digital communities of practice (“Gender Circles”) are actively “queering” traditional HRE. This article shares reflections and learnings from 14 one-on-one interviews with Gender Circle participants, most notably from the Breaking Gender/Sex Binaries Circles. By facilitating spaces that co-create knowledge, build community, and center lived experiences of people with diverse sexual orientations, gender identities and expressions, and sex characteristics (SOGIESC,) SGP disrupts and queers binaries and hierarchies in education and other constructs, such as with …

A Set Of Axioms Providing A Basis For Understanding And Analyzing Work Systems In Organizational Settings, Steven Alter

Business Analytics and Information Systems

This paper proposes 24 axioms that form a basis for understanding and analyzing sociotechnical and totally automated work systems in organizational settings. The introduction identifies reasons for trying to develop axioms of that type. Two background sections compare axioms with other types of “knowledge objects”, illustrate the minimal presence of axioms in the IS discipline, define the domain of relevance for the axioms discussed here, and explain the process of developing those axioms. The axioms are organized in five categories: 1) system in context, 2) system operation, 3) system goals and goal attainment, 4) system uncertainties, and 5) system-related change. …

Can An Llm Use Work System Axioms When Describing Work Systems For Requirements Analysis?, Steven Alter

Business Analytics and Information Systems

This research-in-progress paper presents part of an ongoing project related to using LLMs for describing, analyzing, and designing work systems (including information systems). General axioms that apply to any non-trivial WS or IS might provide a path toward new tools and methods. This paper identifies 24 work system axioms that extend earlier research. They are organized in five categories: 1) system in context, 2) system operation, 3) system goals and goal attainment, 4) system uncertainties, and 5) system-related change. The axioms potentially address the challenge of helping business and IS/IT professionals understand and collaborate around systems in organization. This preliminary …

Journey To Baby-Friendly: Standardizing Patient Breastfeeding Education In The Postpartum Microsystem, Emily Korwin

Master's Projects and Capstones

Problem Low breastfeeding rates remain a global challenge and a cause of adverse infant health outcomes despite the benefits of exclusive breastfeeding. In response, UNICEF and the WHO developed the Baby-Friendly Hospital Initiative (BFHI) to promote, protect, and support breastfeeding for infant growth and development. Context Hospital A is a mid-size hospital in Northern California. It has 24 labor, 13 antepartum, and 33 postpartum beds and serves a diverse population of patients. Intervention After a literature review, microsystem assessment, stakeholder survey, and root cause analysis, a standardized infant feeding nurse patient education checklist was developed and aligned with Baby-Friendly teaching …

Chronic Disease Screening And Detection In Vulnerable Populations, Courtney J. Seman, Hussein Hadid, Tania Jaimes, Robert Walls

Master's Projects and Capstones

This quality improvement project aims to address gaps in chronic disease screening by implementing standardized protocols for diabetes, hypertension, vision impairment, and scoliosis within the University of San Francisco (USF) Nurse-Led Clinic in Orange County. Problem: The clinic identified a lack of screening practices, which limited early detection and intervention for two specific vulnerable populations. Context: The clinic serves two high-risk groups: older adults, including formerly homeless individuals, and children in two local grade schools. These populations face significant healthcare disparities, making early detection of chronic conditions critical. Interventions: Guided by Kotter’s Change Theory, the project developed and implemented evidence-based …

Increasing Access To Fresh Fruits And Vegetables At An Urban Clinic: A Quality Improvement Project, Jordan Michael Leahy

Master's Projects and Capstones

The microsystem setting for this quality improvement project is an adult health unit at one of five safety net clinics housed within a macrosystem in a large urban setting in Northern California serving a low-income, predominantly Hispanic population. Professionals involved in the delivery of the food security program include patient support services, medical assistants, case managers, health promoters, registered nurses, and providers. With enrollment in clinic’s food security program significantly lower than program goals, clinical site stakeholders sought to identify and address gaps in delivery. This quality improvement aimed to improve the screening process to increase the percentage of eligible …

Sleep To Heal: Creating A Quiet At Night Environment, Victor Marie V. Blardony

Master's Projects and Capstones

Problem: Noise in hospitals disrupts patient well-being, recovery, and satisfaction. A 120-bed community hospital in South San Francisco consistently scored below the national average for nighttime quietness (Medicare, 2023).

Context: Over six months, a multidisciplinary committee launched the Quiet at Night (QAN) Program, focusing on the high-acuity telemetry unit. The program utilized Kotter’s 8 Steps Model and the Institute for Healthcare Improvement Model for Improvement (MFI) to tackle nighttime noise issues.

Interventions: Quiet hours were established from 8:30 p.m. to 6:00 a.m. Patients were provided an “Enhanced Sleep Menu” that included a sleep sound machine and “sleep kits” (eye masks …

Improving Documentation Compliance And Patient Mobility Using The Bedside Mobility Assessment Tool, Hayley M. Bernard

Master's Projects and Capstones

Objective: Patient immobility during hospitalization contributes to avoidable complications including increased length of stay, pressure injuries, thromboembolic events, reduced functional capacity, and increased rates of discharge to rehabilitation facilities. The Bedside Mobility Assessment Tool (BMAT) was developed to empower Registered Nurses to safely assess and mobilize patients without a physical therapy evaluation. Aim: This quality improvement projects aims to enhance nurse compliance with BMAT documentation by 10% in three medical-surgical units of a 244-bed Northern California Hospital. Preliminary findings indicate an average daily patient census of 23.7 of which only 31.3% are assessed using the BMAT. Methods: Across a six-week …

Implementing The Donna Wright Competency Model In Pediatric Perioperative Units For Nursing Professional Development, Benjamin Amezcua

Master's Projects and Capstones

Background Each year, preventable adverse events in hospitals lead to numerous deaths. Research consistently indicates a strong correlation between nurse competency and improved patient outcomes, emphasizing the importance of healthcare organizations prioritizing the continuous development of their staff's skills. Bay Area Children’s Hospital A is taking a proactive step by adopting the Donna Wright Competency Model (DWCM), changing from the traditional approach competencies to a collaborative, shared governance model that incorporates the input and perspectives of the nursing staff. Objectives The project aims to utilize the DWCM to enhance the competencies of 90 nurses in the pediatric perioperative units at …

Improving Anesthesia Technician Workflow: Implementation Of A Standardized Checklist And Formal Handoff Communication Tool To Enhance Management Of The Pediatric Portable Anesthesia Lockers Recommendation, Megan Shayna Sosnick Msel, Rn

Master's Projects and Capstones

Objective: The surgical department of a well-known Bay Area medical center faces substantial challenges in supply management. These challenges include inconsistent stocking, disorganized storage, and an inefficient ordering process. These logistical issues impact patient care negatively, increase supply costs, and weaken team morale and communication. U.S. hospitals spend $83 billion annually on medical supplies, with $25.4 billion wasted on preventable material expenses (Balkhi et al., 2022). Aim and Methods: This quality improvement project aims to train 80% of anesthesia technicians in proper stocking procedures for portable pediatric anesthesia lockers within three months. Interventions include the implementation of a standardized …

Prospectus For Expected Discharge Date Accuracy (Edd) – Prepare To Go, Mary Jane D. Esmilla Msn, Bsn, Rn

Master's Projects and Capstones

Problem: Accurate Expected Discharge Date (EDD) estimates are not just numbers on a chart. They are crucial for optimizing operations, reducing readmission risk, creating safe, timely discharge plans, identifying obstacles, providing transitional care, and enhancing patient satisfaction (Piniella et al., 2023). A hospital-based organization conducted a quality improvement project to improve EDD predictions and discharges, significantly improving patient satisfaction and outcomes. The project had shown that a 12% increase in accuracy, achieving 60% from the baseline of 48%, can be achieved through strong collaboration, transparent communication, and commitment to real-time documentation.

Context: A team analysis improved EDD accuracy, patient satisfaction, …

Reducing Same-Day Case Cancellation By Implementing 72 Hours Preop Phone Calls, Debbie Sharon Centeno

Master's Projects and Capstones

Problem: The increased frequency of same-day surgical cancellations affects patient care quality, causes loss of expenses for patients and facilities, and causes non-compliance with block utilization against regional standards.

Context: A collaborative effort was undertaken to reduce same-day case cancellations in the Ambulatory Surgery Unit (ASU). Patients received preoperative instructions 24 hours before surgery through email or phone call. Data collection revealed that the common causes of same-day cancellations were avoidable reasons (not NPO, patient ill, request for another schedule, no ride), indicating the need for improvement in delivering preoperative phone calls.

Interventions: This included educating preoperative nurses, creating a …

Clinical Trial Research Nurse New Employee Onboarding 30- 60 -90 Day Checklist, Arin Alesia Urban

Master's Projects and Capstones

Problem: The clinical trials research management team was plagued with high nurse turnover and poor clinical documentation due to a lack of seasoned clinical research nurses.

Context: A regional clinical trials team serving 22 hospitals within a Northern California not-for-profit health system.

Interventions: Mixed methods were used to inform the development of new employee onboarding for novice clinical trial nurses utilizing a structured 30-60-90-day checklist, improved communication channels, and continuous mentor support.

Measures: Monthly quality queries and quarterly staff turnover rates were tracked. Employee feedback was collected to assess the interventions' impact.

Results: The number of quality queries was reduced …

Improving Stroke Education Scores At A Primary Stroke Center, Jesse J. Young

Master's Projects and Capstones

Abstract

Problem: The COVID-19 pandemic precipitated a significant departure from the nursing profession, leaving healthcare organizations grappling with critical staffing shortages and compromising patient care standards. In 2023, an advanced Primary Stroke Center in a Northern California hospital’s STK-8 scores fluctuated between 80-100%, with an average annual score of 92.8%, putting the facility's primary stroke certification and long-term patient outcomes at risk.

Context: A 24-bed acute stroke and telemetry unit in a Northern California hospital and designated primary stroke center.

Interventions: The following measures were implemented to improve the quality of stroke care and enhance STK-8 compliance, including …

Enhancing Pain Documentation In Medical Surgical Units: Integrating Supportive Tools With Pain Nursing Education, Mariana Arias

Master's Projects and Capstones

Problem: Pain management in in-patient care, particularly involving opioids, is critical due to the associated risks. Proper pain assessment is essential to ensure safe medication administration and mitigate adverse effects.

Context: This quality improvement (QI) project aimed to improve opioid assessment and documentation rate above 90% compliance in two medical-surgical units, focusing on bedside nurses who play a crucial role in patient safety and effective pain management.

Interventions: A baseline survey provided nurses' understanding on compliance criteria and assessment timing. Interventions included visual reminders, informational posters, and instructions on how to access individual compliance reports.

Measures: A post intervention survey …

Increasing Awareness And Communication To Decrease Catheter Days In The Surgical Intensive Care Unit, Kamila Fortney

Master's Projects and Capstones

Problem Nurse-driven removal protocols (NRDPs) have been shown to reduce indwelling urinary catheter (IUC) days and prevent catheter-associated urinary tract infections (CAUTIs). Communication barriers prevent consistent implementation of the NDRP, leading to delayed IUC removal and increased risk of CAUTIs. Context The project was conducted in a 16-bed adult surgical intensive care unit (ICU) at a teaching hospital in a major metropolitan area. Interventions Urinary catheter reminder posters displaying IUC days were posted at each bedside to prompt discussion of IUC indication and removal. An email describing the project background was sent to all nurses and physicians by the unit …

Early Career Women Of Color As Social Justice Change Leaders, Amy Anh Hoang Dinh

Master's Theses

The student affairs profession is predominantly female, but women, especially women of color (WOC), are disproportionately in entry-level positions. The majority of student affairs professionals also believe social justice is important but desire more support for their social justice work. This study examined how early career WOC perceived the power dynamics that they encountered in their social justice-oriented organizational change efforts, the strategies and tactics they utilized to lead change efforts, and the aspects of their identities that were the most salient to them during their change efforts. The study design used a phenomenology methodology and an intersectionality theoretical framework. …

Shattering Ceilings: Women Of Color, Mentorship, And Corporate Oppression, Raminder Kaur Attwal

Doctoral Dissertations

In the Fortune 500 organizations, a robust survey illuminates the diverse experiences of women of color, framed within theoretical frameworks such as Critical Feminist Theory (CFT), Social Capital Theory, and Community Cultural Wealth. Of 141 responses, 102 participants, representing various racial backgrounds, provide insights into corporate landscapes. Their positions range from mid-level to executive roles, showcasing a holistic view of organizational hierarchies. Remarkably, approximately 70.59% engage in formal mentorship programs, highlighting its profound impact on career development.

Assessing the effectiveness of tailored mentorship initiatives, the research emphasizes their transformative power in confronting oppressive corporate norms, drawing from insights provided by …

Emergence: Social Movements, Law Enforcement, And Defending The Sanctity Of Life, Diana Elizabeth Aroche

Doctoral Dissertations

This study examines the aftermath of national social movements advocating for police reforms and accountability, with San Francisco emerging as a pivotal city at the forefront of criminal justice and policing transformations. Rebuilding community trust and implementing substantive police reforms aimed at preserving lives has proven to be a formidable challenge. The convergence of interests among all stakeholders, driven by a shared commitment to dismantling institutional racism and implementing reforms that fostered trust with communities of color and law enforcement, played a pivotal role.

A significant aspect of this reform process has been the development of social movement convergence, where …

The Experience Of Caregiver Burden And Burnout Among Resident Directors, Tanya Koroyan

Doctoral Dissertations

The goal of this study was to understand the experiences of caregiver burden and burnout for Resident Directors (RDs). RDs live on campus and support students through traumatic experiences by serving in an “on-call” capacity. Student emergencies that RDs respond to include mental health concerns, sexual violence and sexual harassment, suicidal ideation, self-harm, grief, physical assault, etc. There is little research on understanding this work's experience and potential long-term implications.

Through a constructivist-interpretivist research paradigm and phenomenological qualitative methodology, nine interviews took place with individuals who had previously been RDs at Bay Area University, a large public institution in the …

Mentoring Nurses After Specialty Training Or Orientation In Labor And Delivery, Benjamin Jlopleh Worji

Master's Projects and Capstones

Mentoring Nurses After Specialty Training or Orientation in Labor and Delivery

Abstract

Background: The setting for this project was a northern California hospital-based healthcare system referred to as “Hospital KV.” Hospital KV is a non-profit, integrated hospital that operates to improve the community’s health. Hospital KV’s maternal child health (MCH) department comprises a labor and delivery(L&D) unit, a mother and baby unit (MBU), also referred to as a postpartum unit, and an intermediate nursery (IMN).

Problem: The hospital KV MCH department faced the challenge of a nursing shortage. The nursing shortage was associated with substantial challenges to Hospital KV, its …

The Effect Of A Patient-Centered Fall Prevention Tool On Reducing Falls, Maria Gracia Skallet

Master's Projects and Capstones

Problem: Maintaining patient safety is of utmost importance in healthcare. Healthcare organizations develop policies and protocols to minimize preventable harm and deliver care safely. However, hospital falls continue to occur, and preventing falls remains challenging. Falls and fall-related injuries can significantly impact the patient’s quality of life, cause prolonged hospital stays, and higher hospital expenses. Implementing an effective fall prevention program is imperative.

Context: There has been an increased incidence of falls within two medical-surgical units (5C and 5D) at Hospital J in Northern California despite using fall prevention measures such as hourly rounding, wearing yellow skid socks and yellow …

Innovations In Health-Care Service Delivery During The Pandemic, Taryn Vian, Ankita Meghani Phd

Nursing and Health Professions Faculty Research and Publications

The COVID-19 pandemic disrupted health service delivery as countries implemented lockdowns and issued stay-at-home orders. Despite attempts to make essential health services available throughout, the pandemic strained health systems and resulted in rampant shortages of health commodities, beds and health-care staff. There were concomitant declines in tuberculosis screening, HIV testing, and maternal and child health services.2 However, the global pandemic also accelerated the pace of innovation. Some initiatives served as stopgap measures implemented to maintain health services, whereas others helped leapfrog progress in the areas of health information systems, telemedicine, and regulatory policy, bringing efficiencies that could be applied even …

Implementation Of Feeding Education To Increase Hospice Volunteer Knowledge, Hannah Franzwa

Master's Projects and Capstones

Problem: Hospice volunteers have no formal training on end-of-life nutrition and how to feed patients. Insufficient knowledge of feeding patients presents safety issues, leading to decreased patient satisfaction and diminished volunteer role fulfillment.

Context: The setting was an independent non-profit hospice organization that serves around 1,000 patients within the San Francisco Peninsula and South Bay communities. The project was a collaboration between hospice leadership and the quality and education department.

Intervention: Volunteer education was implemented to increase volunteer knowledge about end-of-life nutrition and feeding patients. The educational session included a PowerPoint lecture, a small group discussion portion, and hands-on skills …