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 …

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 …

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 …

An Implementation Of Combined Fecal/Gastric Occult Blood Testing In The Emergency Department, Desiree Long

Master's Projects and Capstones

Problem: The gastrointestinal occult blood test is a point-of-care (POC) test used to detect the presence of occult (hidden) gastrointestinal bleeding via stool or gastric contents. Existing fecal and gastric occult blood point-of-care (POC) testing requires separate and unique sampling cards and developer, respectively. Separate fecal/gastric tests are less definitive and take longer than a combined test. Fecal/gastric testing can be improved and more effective using a combined testing mechanism.

Context: This project includes the microsystem of the emergency department, which involves groups of medical professionals, such as groups of clinicians and staff working together with a shared clinical goal …

Enhancing Compliance Rates: The Impact Of Implementing A Bed Bath Bundle, Lizeth Rosales, Destinee Unabia, Dennisse Espinoza, Nicole Razi, Russell Hall

Master's Projects and Capstones

Abstract Problem: Bed baths are routine bedside procedures offered in hospitals to support patients'

cleanliness and promote comfort and overall well-being. This bedside procedure represents fundamental care provided by healthcare professionals. Ensuring proper bed bathing compliance in the healthcare setting of a medical-surgical observation and telemetry unit has been significantly challenging. After thorough monitoring of the unit, key factors contributing to low bed bath compliance include time constraints, staffing shortage, and barriers specific to patients and staff. The evidence-based interventions to improve bed bath compliance include a bed bath bundle emphasizing teamwork and effective communication, as identified through an extensive …

Fall Risk Identification And Reduction Among The Gerontological Population At A Long-Term Care Facility, Esther A. Lowe, Breanna Cates, Lisa James, Ashley Samson, Jowel Ochoa, Matthew Ng

Master's Projects and Capstones

Abstract

Problem: Data obtained from the facility from February 2022 to July 2023 showed that there were a total of 110 falls at the facility with 51% resulting in injury. The facility also lacked a standardized fall assessment tool with minimal follow up after fall incidents.

Context: A microsystem assessment of the geriatric population at the long-term care facility indicated the need for a standardized fall risk screening tool to accurately assess patients.

Interventions: A staff presentation was created highlighting the high rate of falls at the facility as well as to educate on the implementation of the Morse Fall …

Improving Timely Sepsis Care Through Staff Education Within The Emergency Department, Shirley Chen

Master's Projects and Capstones

Problem: This project was implemented to decrease patient fallout rates through timely compliance with sepsis management according to the SEP-1 bundle. The SEP-1 bundle is already implemented in the emergency department. However, a microsystem assessment indicated barriers are preventing the achievement of the SEP-1 bundle milestones.

Context: This 16-bed emergency department (ED) at an urban Bay Area hospital provides 24-hour emergency services to individuals who suffer from medical injuries, accidents, and other serious health conditions. A random audit of the electronic health system (EHS) revealed that this emergency department consistently fails to meet the sepsis management time goals by 90%. …

Improving Timely Sepsis Care Through Staff Education Within The Emergency Department, Gregory James Trevino

Master's Projects and Capstones

Problem: Providing high-quality sepsis care in a San Francisco Bay Area emergency department (ED) is an organizational priority, however Centers for Medicare & Medicaid Service (CMS) SEP-1 sepsis bundle compliance has decreased to an average of 79% compliance since October of 2022. It was revealed that CMS SEP-1 sepsis bundle compliance issues have resulted in increased patient fallouts.

Context: A microsystem assessment was conducted by the quality improvement team to help identify gaps in practice. After an assessment survey of nursing staff, it was revealed that barriers such as physician order sets, lack of communication, lack of staffing during peak …

Educating Labor And Delivery Nurses On Evidence-Based Birthing Positions To Promote Fetal Descent During First And Second Stage Labor, Sophia Nguyen

Master's Projects and Capstones

The goal of this project was to increase confidence of labor and delivery nurses in utilizing evidence-supported birth positions during the first and second stages of labor in order to aid in fetal descent and labor progression. Current statistics demonstrate climbing trends in cesarean deliveries, which have been associated with increased maternal morbidity and mortality. One nurse intervention that can reduce failure to progress, a main contributor to cesarean sections, is the use of various evidence-supported maternal birth positions such as ambulation, assisted squat, sitting, backwards sitting, lunging, throne, side-lying with peanut ball, hands-and-knees, and throne position. This evidence-based practice …

Increasing Compliance Through Nurse Education On The Bundle, Zachary Harrison-Evans

Master's Projects and Capstones

In an effort to decrease complications and events connected to sepsis in the ED, there is room for improvement with relation to sepsis care and compliance rates. Timely sepsis management and gains in compliance/adherence rates are hindered by SEP-1 fallouts and requirements related to knowledge gaps concerning sepsis bundle procedures, nurses' attitudes about implementing the protocols, and disparities in nurse/physician order sets. It has been determined that the use of standardized protocols and order sets are not being utilized. This is a process gap and a critical area for improvement. Inadequate fluid and lactate documentation, a lack of education, and …

United States Pharmacopeia (Usp) <800> Standards: Increasing Compliance Of Safe Handling And Proper Administration Of Usp General Chapter <800> Drugs, Katelyn N. Sinclair

Master's Projects and Capstones

Problem: United States Pharmacopeia (USP) developed a set of standards to minimize exposure risks to patients, healthcare workers, and the environment when preparing, handling, and administering hazardous drugs (HDs) known as USP <800> HDs. The guidelines became effective December 1, 2019, but additional information is needed to ensure healthcare personnel are complying with the standards.

Context: Two medical surgical units from Hospital A were included in this project. Currently mandatory online modules about USP <800> standards are provided annually to every healthcare worker, but it is unknown if the policies and procedures are being followed appropriately.

Interventions: Active and passive observations as …

Reducing The Risk Of Central Line Associated Blood Stream Infection With Chlorhexidine Gluconate Education, Scarlett Ocon

Master's Projects and Capstones

Problem: A nosocomial central line-associated bloodstream infection is a preventable infection that is costly and potentially fatal. In order to combat bloodstream infections chlorhexidine gluconate wipes have been used as antiseptic. Medical surgical units do not have accessible CHG for bathing purposes. In addition, the staff lacks knowledge of how to use CHG wipes. The current standard bathing practice on this unit consists of using soap and water or disposable washcloths spontaneously without a predetermined time. The aim of this quality improvement project is to educate the registered nurses (RNs) and certified nurse assistants (CNAs) on the benefits of daily …

Improving Nursing Staff Knowledge For Management Of Geriatric Patients With Confusion In The Emergency Department, Kareem G. Carter

Master's Projects and Capstones

Problem: Staff knowledge of effective management of confusion in geriatric patients (>65yo) may be limited and inconsistent with the current goal of establishing a geriatric-friendly Emergency Department (ED) Model of Care. Suboptimal management of this patient population can result in prolonged ED stays, which increases the cost to the hospital and the patient (Han & Wilber, 2013).

Context: An Emergency Department at a large Bay Area urban hospital hopes to obtain Geriatric Emergency Department Accreditation (GEDA) through the American College of Emergency Physicians (ACEP).

Interventions: Create a simplified checklist for nursing staff using mnemonic devices to …

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 …

Instituting A Preceptor Program In Home Health, Abbi Arnold

Master's Projects and Capstones

Problem: Staff being unfamiliar with the role of being a preceptor impacts their ability to perform the job well. Insufficient understanding of a new role creates stress and uncertainty which can lead to poor employee retention or high job dissatisfaction.

Context: The setting for this project is a large hospital-based home health agency that has an average daily census of 375 patients. The project was a collaboration between home health management and the quality department.

Measures: A measurement strategy was developed to meet the outcome measure, process measure, and balancing measure. The outcome measure was increasing the nurses’ understanding of …

Improving The Delivery Of Discharge Instructions On The Postpartum Unit By Increasing The Nurses' Knowledge, Judy Anne Settles

Master's Projects and Capstones

Abstract

The field of nursing prides itself on two critical functions: safety and patient education. One of the mechanisms for both education and safety is the discharge process. Improvements in the discharge process have been shown to increase patient comprehension and safety. This study is grounded in the (Barach & Johnson, 2006) healthcare organizational framework called the 5 Ps microsystems assessment to explore the impacts and improvements in the discharge instruction process on a postpartum unit in a large organization. It was found that HCAHPS scores regarding discharge instructions were 55-60%, which is below what is considered satisfactory. Utilizing the …

Stop The Bleed And Seize Control: Educating Emergency Department Staff On Maternal Hypertension And Hemorrhage, Mayra A. Portillo-Guerra

Master's Projects and Capstones

Problem: A Not-for-Profit Hospital accredited by the Joint Commission was fined for not having a current policy or procedure set in place for the treatment of obstetric emergencies. This quality improvement project implemented a simulation and a training video to prepare Emergency Department (ED) nurses and clinical staff for the awareness of preeclampsia and postpartum hemorrhage (PPH).

Context: This quality improvement project was implemented in two different Emergency Room locations for this Not-for-Profit Hospital. One of the campuses does not have a Labor and Delivery (L&D) unit while the other one does. The overarching goal is to increase awareness of …