Quality Improvement Commons^™

The Impact Of A Mindfulness Meditation Program On Phq-9 Scores In Eskd Clients At The Dialysis Center, Christi Collins Weaver

Student Scholarly Projects

Practice Problem: Patients undergoing hemodialysis for end-stage kidney disease (ESKD) experience high rates of untreated depressive symptoms, which negatively impact quality of life, treatment adherence, and therefore increased hospitalization and higher mortality rates.

PICOT: In adult patients receiving in-center hemodialysis (P), how does the implementation of a structured mindfulness meditation program (I), compared to usual care (C), affect depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9) (O) over an eight-week period (T)?

Evidence: Current literature demonstrates that depression is highly prevalent among individuals with ESKD and is associated with increased morbidity and decreased treatment adherence. Evidence supports mindfulness …

Utilizing Proactive Rounding With Nursing Leadership To Improve Patient Satisfaction Scores In An Adult Medical-Surgical Unit, Lily A. Bogyah

Student Scholarly Projects

Practice Problem: Patient satisfaction is a key quality indicator that reflects patients’ perceptions of care and the healthcare system’s performance. Patient satisfaction scores at the project site were significantly lower than the national benchmark, particularly on the adult medical-surgical unit.

PICOT: The PICOT question that guided this project was: In patients on an adult medical-surgical unit (P), how does the use of proactive patient rounding conducted by nurse leaders (I) versus current practices alone without such rounding (C) affect patient satisfaction scores over an eight-week period (T)?

Evidence: A literature review of multiple studies found that implementing daily nurse leader …

Hybrid Diabetes Coaching Model: Integrating In-Person And Telemedicine Strategies To Improve Glycemic Outcomes, Sandis A. Mundackal

Student Scholarly Projects

Practice Problem: In patients with type 2 diabetes, poor glycemic control among adults remains a significant challenge in primary care settings, particularly within federally qualified health centers (FQHCs) that serve underserved populations. At the FQHC practice site, patients were managed using standard care with quarterly follow- up visits, without a structured hybrid coaching approach. This inconsistency contributed to a high number of patients with hemoglobin A1c (HgbA1c) levels ≥ 9%, placing them at increased risk for diabetes-related complications.

PICOT Question: In adults with poorly controlled type 2 diabetes (HgbA1c ≥ 9%) (P), does monthly hybrid coaching delivered through in-person and/or …

Enhancing Sepsis Prevention In Long-Term Care Facilities: Development Of An Infection Prevention Sepsis Toolkit, Emmalyn A. Tuhin

Student Scholarly Projects

Objectives: The purpose of this Doctor of Nursing Practice (DNP) project was to create, validate, and refine an Evidence-Based Sepsis Prevention Toolkit to enhanced early sepsis recognition and interprofessional coordination of care within long-term care facilities (LTCFs).

Background: Sepsis remains a leading cause of mortality and preventable transfer to the hospital for the elderly residents within the LTCFs. A significant practice gap persists because sepsis in this population often presents atypically, resulting in delayed or inaccurate diagnosis and treatment.

Methods: This project was guided by the following PICOT question: For healthcare professionals caring for patients aged 65 years and older …

Assistive Technology For Proper Seating And Positioning For Geriatrics, Jacee Lyons, Rebecca King

Fall 2025 OTD Capstone Symposium

The lack of staff education on pressure injury prevention places older adults at a higher risk of developing pressure injuries in a skilled nursing facility.

Empowering Independence: Strategies For Safe Aging In The Home And Community For The Older Adult Population, Madelyn Rashford, Becky King, Keegan Mckay

Summer 2025 OTD Capstone Symposium

This capstone project created an occupational therapy–based guidebook to promote safe aging in place for community-dwelling older adults. The guidebook includes fall prevention exercises, home safety strategies, and community resources to support independence in daily activities. Implementation showed increased safety awareness and confidence, reinforcing occupational therapy’s role in fostering independence and quality of life.

Enhancing Medication Communication In The Acute Care Setting To Strengthen Patient Comprehension And Retention, Ashleigh C. Christensen

Student Scholarly Projects

Practice Problem: Research has shown that breakdowns in communication, especially in the context of medication education, play a critical role in the delivery of safe and effective patient care. These findings underscore the need to prioritize effective communication in medication education. In the acute care setting, effective communication is essential for ensuring patient safety, adherence, and improved patient-centered outcomes.

PICOT: In clinical staff providing direct patient care in the acute care setting (P), does the implementation of the evidence-based teach-back method (I), as compared to current practice (C), improve patient knowledge, understanding, and self-management upon discharge (O), over ten weeks …

Implementation Of Artificial Intelligence For Scribing In An Outpatient Mental Health Clinic, Elissa A. Moore

Student Scholarly Projects

Practice Problem: Traditional documentation practices place a significant burden on psychiatric mental health nurse practitioners (PMHNP) in outpatient mental health clinics (MHC), contributing to provider burnout and negatively impacting the patient-provider relationship. Preserving practicing PMHNPs is essential across the United States, but imperative in medically underserved areas where mental health services are limited.

PICOT: In PMHNPs (Population), does the use of AI scribing software (Intervention) compared to traditional documentation methods (Comparison) reduce documentation time and increase provider satisfaction (Outcome) over a ten-week period (Time)?

Evidence: This Doctor of Nursing Practice (DNP) scholarly project was informed by evidence obtained from 15 …

The Importance Of Well-Being For College Students, Benjamin Williamson, Dr. Mary Jan Greer, Phd, Otr

Spring 2025 OTD Capstone Symposium

Provided education on well-being, enabled independence, and improved quality of life, specifically for college students in this setting.

Advocate for Sustainable Programs:

Advocated for more programs to address the needs of college students and integrated all 8 dimensions of wellness into their current lifestyle

Support Academic Advancement:

Addressed college students' needs for overcoming occupational adversities which affects the longevity and academic success of college students

Motivate College Students:

Provided accessible and occupation-based resources that supported participating college students in independently improving their occupational roles

Advance Holistic Based Strategies:

Incorporated holistic based strategies that apply to each occupational role affecting participating …

Evaluating The Perceived Benefits Of Education In Revenue Cycle Management And The Impact On Medical Claims Reimbursement, Jessica L. Miller

Student Dissertations

Efficient Revenue Cycle Management (RCM) is essential for healthcare organizations to ensure timely and accurate reimbursement for medical claims. The research problem was the significant inadequacies in RCM process in medical billing that has resulted in financial burdens imposed on providers, patients, and the organizations that provide medical services. There are clearly identified educational gaps in RCM that contribute to claim denials, delays, and revenue loss, underscoring the need for robust training programs. The purpose of this study was to explore the perceived impact of education in RCM on medical claim reimbursement outcomes within the U.S. healthcare system. The study …

Enhancing Emergency Department Efficiency: Utilization Of Streamlined Triage System To Reduce Waiting Times, Sunah Kim

Student Scholarly Projects

Emergency departments (EDs) often experience prolonged waiting times, leading to patient dissatisfaction and potential negative health outcomes. This project addresses the need for improved triage processes to enhance patient flow and reduce delays in care.

PICOT

In adult patients presenting to the emergency department (P), how does the implementation of a streamlined triage process (I) compared to standard emergency department protocols (C) lead to a reduction in waiting times (O) within a twelve-week period (T)?

Evidence

A review of current literature indicated that streamlined triage systems can significantly decrease patient wait times and improve overall ED efficiency by incorporating colors …

Reducing Rates Of Blood Culture Contamination In The Emergency Room, Erika Goldberg

Student Scholarly Projects

Practice Problem: In one emergency room (ER) blood cultures (BC) drawn by nurses had a high contamination rate due to lack of collection standards, which lead to poor patient outcomes.

PICOT: The PICOT question that guided this project was; In adult emergency room patients where blood cultures are drawn (P), how does implementation of an evidence-based practice method (I), compared to the standard method of obtaining blood cultures (C), affect blood culture contamination rates (O), within ten weeks. (T)?

Evidence: Based on multiple sources within the literature; best evidence for lowering blood culture contamination rates (BCC) is done using EBP …

Transitions Of Care And The Prevention Of Readmissions, Beatriz Granado

Student Scholarly Projects

Unplanned hospital readmissions often result from poor discharge planning and challenges during the transition from hospital to home, including medication errors and weak communication with primary care providers. A well-organized and personalized discharge plan can significantly reduce hospital stays, lower readmission rates, minimize medication errors, and improve patient outcomes, all while decreasing healthcare costs. In post-discharge Medicare-eligible patients (P), how does transitional care coordination through organized, personalized, and patient-focused discharge planning (I), compared with standard or no transitional care coordination provided (C), affect readmissions (O) within the 30-day post-discharge phase monitored over a 10–12-week period (T)? A search was conducted …

Measures Of Function In Physical Therapy Assessment Of Children With Cerebral Palsy: A Clinical Audit, Marvin D. Zotomayor

Philippine Journal of Physical Therapy

Introduction: The assessment of outcomes in children with cerebral palsy (CP) is important for monitoring their progress, evaluating interventions, and guiding health policies. This study aimed to (1) identify the most common outcome measures used in the clinics to assess function in children with CP, and (2) determine whether the outcome measures used in the clinics meet the current standards of assessment for the purpose of improving patient care decisions, research, and quality assurance.

Methodology: A retrospective record audit study design was used to determine if the current practice in the clinics on the assessment of function in children with …

Clinical Practice Implementation To Address Ascvd Risk: A Practice Change In Primary Care, Elizabeth Wooten

Student Scholarly Projects

Practice Problem: Heart disease stands as the leading cause of mortality in the United States. While healthcare providers strive to identify and optimize prevention strategies, particularly in high-risk patient populations, notable gaps in care persist, notably in the management of modifiable risk factors such as low-density lipoprotein cholesterol (LDL). By harnessing the power of artificial intelligence (AI) integrated software within clinical settings, we can revolutionize the landscape of this devastating chronic disease.

PICOT: The PICOT question that guided this project was: In Primary Care Advanced Practice Providers (APP) caring for high-risk and/or very high-risk patients with atherosclerotic cardiovascular disease (ASCVD) …

Early Discharge Planning To Improve Throughput, Alan Chhith

Student Scholarly Projects

Early discharge planning can improve the safety and outcomes of hospitalized patients. The aim of the multidisciplinary team early discharge rounds was to manage patient flow by removing discharge barriers to reduce the length of stay in the medical/surgical unit. The overall goal of the process improvement project was to make inpatient beds available to admit patients from the emergency department, reducing long ED boarding, and decrease the hours of diversion. The PICOT question for this project was: in the Veteran population (P) in the VA medical/surgical unit, early discharge planning with an interdisciplinary team (I) compared to regular discharge …

Improving Access To Cardiac Catheterization, Sunitha Dharman

Student Scholarly Projects

The American Heart Association lists cardiovascular disease as the underlying cause of death for 874,613 people who lost their lives in 2019 (Tsao et al., 2022). On average, someone in the United States has a myocardial infarction every 40 seconds, and someone dies of a stroke every 3 minutes and 30 seconds. Studies support coronary artery disease as a significant contributor to cardiac arrest in a non-hospital setting (Yannopoulos et al., 2019). The authors provide evidence supporting the importance of early cardiac catheterization. There is a 10-15% survival rate with a higher level of functioning compared to delayed or no …

Hypertension: Care Management Program And Medication Adherence, Courtney Montgomery

Student Scholarly Projects

Practice Problem: Medication adherence is a major concern in healthcare as it is a contributing factor to uncontrolled hypertension and resistant hypertension. Uncontrolled hypertension can lead to strokes, heart attacks, kidney failure, and even death.

PICOT: The PICOT question that guided this project was in Medicare Advantage members with hypertension located in Kansas, who were admitted to the hospital or emergency room identified by stratification (P), does care management utilization using hypertension clinical guidelines (I), compared to the stand-alone hypertension clinical practice guideline (C), improve medication adherence (O) over 10 weeks (T)?

Evidence: Hypertension is one of the leading preventable …

Improving Nurses Wound Care Knowledge Utilizing An App, Monica Amador

Student Scholarly Projects

Practice Problem: Nurses needed additional wound care support, but formal training was not in the budget at this time. Nurses needed a quick reference guide to help them assess, document, and treat wounds correctly until the hospital could provide adequate training.

PICOT: The PICOT question that guided this project is; “When treating wound care patients within a hospital setting (P), how does the implementation of a wound software app. (I) as compared to pre-existing nursing knowledge (C) increase a nurse’s self-reported ability to accurately assess and treat wounds (O) during a 10-week period? (T)”

Evidence: Based on a thorough and …

Increasing Equitable Access To Care: Implementation Of Universal Palliative Care Screening In The Intensive Care Unit, Sarah Weaver

Student Scholarly Projects

Practice Problem: At a small community hospital in Virginia, there is an absence of standardized screening processes for identifying intensive care unit (ICU) patients with unmet palliative care needs, contributing to delayed and unequitable access to palliative care consultations.

PICOT: The PICOT question that guided this project was “In adult ICU patients, how does implementing a palliative care screening tool upon ICU admission, as compared to standard ICU admission protocol, affect palliative care consultations within an 8-week time frame?"

Evidence: This project was guided by consensus reports from the World Health Organization and the Centers to Advance …

From The First Encounter: A Communication Program For High Volume, High Acuity Patient Care Locations, Shazam Bacchus

Student Scholarly Projects

Effective communication is a true value to healthcare organizations. Far too many communication sessions are detrimental to patient health outcomes. National data and hospital records are proven information to suggest communication is a major barrier to overall patient satisfaction. Organizations struggle to increase market share and patient satisfaction with a likelihood to recommend because of poor communication by physician and nurses. The use of a strategic communication tool like AIDET plus the Promise can influence the improvement of an organization’s quality of care.

This paper examines the use of AIDET plus the Promise as a strategic communication tool. High volume, …

Establishing A Sustainable Occupational Therapy Student-Led Pro Bono Clinic At The University Of Saint Augustine In Austin, Texas, Daija Chumley

Student Capstone Papers

Under-resourced and underserved communities across the United States experience significant health disparities. These communities lack access to valuable services resulting in health inequities that impinge on their health, quality of life, and engagement in meaningful occupations. There is a need for occupational therapy to provide valuable services to the under-resourced and underserved community to address the historical inequity that impacts their overall quality of life. Universities have the potential to fulfill the gaps within these communities by establishing a pro bono clinic. The purpose of this capstone project is to establish a sustainable occupational therapy pro bono clinic at the …

Implementation Of Daily Nhppd Calculator In The Acute Care Setting, Spencer Y. Cho

Student Scholarly Projects

Practice Problem: In the United States, it is estimated that hospitalized patients experience an adverse event that require a rapid response and/or code blue event in 3% to 18% of hospitalizations.

PICOT: In the adult medical-surgical inpatient (P), does the implementation of a daily NHPPD calculator (DNC) (I) compared to an annual staffing methodology for calculating NHPPD (C) reduce rapid response calls, code blue episodes, and unplanned admission to critical care (O) over 8 weeks (T).

Evidence: Seven studies provided evidence that implementation of staffing methodology, nursing surveillance, and nurse staffing that supports meeting targeted nursing hours per patient …

Oral Care Bundle Impact On Staff Assisted Oral Care, Sabrina Oliver

Student Scholarly Projects

Practice Problem: Non-ventilator hospital acquired pneumonia (NV-HAP) is more common than ventilator acquired pneumonia. Oral care is the only modifiable risk factor for all patient populations.

PICOT: The PICOT question that guided this project was: In non-ventilated patients in a tertiary care setting (P), how does implementing an oral care bundle (I) compared to the current practice of individual tasks without a bundle (C) affect adherence to facility oral care standard of patients receiving oral care at least once a day (O) over six weeks (T)?

Evidence: Lack of an oral bundle that has been proven to decrease …

Perception Is Everything: Implementation Of A Peer Evaluation Program For Nurse Leaders In A Hospital Setting, Teruko Williams

Student Scholarly Projects

Practice Problem: A hospital in the Sacramento County area seeking the ANCC Pathway to Excellence Program^® designation determined upon performing a gap analysis that Element of Performance 2.8, a peer evaluation program, was absent, thus creating a deficiency in the fulfillment of the requirements for the designation.

PICOT: The PICOT question that guided this project was: In nurse leaders (P) how does the development of a formal peer evaluation process (I) compared to no formal process (C), influence the performance outcome score of self-efficacy (O) over 8 weeks (T)?

Evidence: The evidence demonstrated that if a …

Change Project Using A Fall Prevention Action Program To Decrease Falls On A Behavioral Health Unit, Amy Shuptrine

Student Scholarly Projects

Practice Problem: Fall rates are increasing in the behavioral health units of the East Texas hospital. Due to the worldwide COVID-19 pandemic, the units are short-staffed, which further supports the urgent need for a targeted intervention to reduce fall risk.

PICOT: The PICOT question that guided this project was: “In adult behavioral health patients (P), what is the effect of the Edmonson Psychiatric Fall Risk Assessment Tool (I), compared with previous use of the Morse Fall Risk tool (C), on the fall rate (O), in 8 weeks (T)?”

Evidence: Falls are the most reported incidents in acute care hospitals and …

Leadership Rounding To Improve Patient Satisfaction In Pediatric Ambulatory Care, Tara J. Haskell

Student Scholarly Projects

Practice Problem: Low patient satisfaction has been linked to poor treatment compliance, patients leaving the practice, staff decreased job satisfaction, and high staff turnover (Haskard Zolnierek & DiMatteo, 2009; Prakash, 2010). Magnet reporting has identified wide discrepancies in ambulatory clinics, with some clinics reporting below benchmark patient satisfaction ratings.

PICOT: In pediatric ambulatory and primary care services, how will the implementation of leader-led customer service rounding, compared to current practice, increase family and/or patient satisfaction over 4 weeks?

Evidence: Key findings are that the rounding needs to be population-specific, intentional, and swiftly followed up when problems are identified. The body …

Improving Patient Flow In The Urgent Care Setting, Stephanie Carpenter

Student Scholarly Projects

Practice Problem: Urgent care clinics provide care to patients with non-life-threatening illnesses or injuries and are found to be less expensive and more convenient than emergency departments. As urgent care clinics are growing in popularity so are the patient wait times and overall length of stay times.

PICOT: The PICOT question that guided this project was in urgent care clinic patients (P), how does utilizing the Emergency Severity Index (ESI) as a patient triage tool (I) compared to using no patient triage tool (C) affect the patient flow and patient wait times (O) within 13 weeks.

Evidence: Evidence search with …

Implementation Of The National Early Warning Score Tool In The Acute Care Setting, Amanda Reyes

Student Scholarly Projects

Practice Problem: The organization arbitrarily called a rapid response or code blue call based on abnormal vital signs or intuition and needed a new process to identify early recognition of patient deterioration.

PICOT: For adult inpatients in an acute care setting in a large healthcare system (P), will implementation of the National Early Warning Score (NEWS) across the organization (I) compared to data from the last fiscal year where NEWS was not used (C) decrease code blue calls (O) within 8-weeks (T)?

Evidence: Eleven high quality studies met the inclusion criteria and found that the NEWS is a validated …

A Safety Program In A Tertiary Care Center Emergency Department: An Evidence-Based Project To Increase Safety Event Reporting And Improve Frontline Staff Perceptions Of Hospital Management’S Response To Safety Events, Elizabeth Anne Mcmaster

Student Scholarly Projects

Practice Problem: The lack of a non-punitive safety culture with a healthcare organization is associated with decreased safety event reporting, reimbursement rates, and staff satisfaction.

PICOT: The PICOT question that guided this project was: In emergency department frontline staff, does hospital management involvement in a safety event program, contrasted with no safety event program, improve frontline staff’s reporting of safety events and perceptions of hospital management’s response to safety events management involvement over four weeks?

Evidence: Three overlapping themes that guided this project included: improving organizational culture, open communication, and leadership support in promoting patient safety.

Intervention: A safety event …