Sustaining Clabsi Prevention Through Central Line Bundle Compliance: A Focus On Iv Tubing Labeling, Visual Cues And Peer Support, See Elizabeth Vang

Master's Projects and Capstones

Abstract  

Problem: Inconsistent IV tubing labeling compliance on a telemetry unit was identified as a gap in central line maintenance practices that could affect adherence to the CLABSI prevention bundle.

Intervention: A quality improvement project reinforced existing IV tubing labeling practices through a visual job aid, staff education, and peer verification during Nursing Knowledge Exchange (NKE) bedside handoff.

Outcome Measure: The primary outcome measure was IV tubing labeling compliance, with a goal of increasing compliance from 86.5% to at least 95% on 24 bed Telemetry unit.

Results: The project did not achieve the desired improvement in compliance. Multiple concurrent quality …

Reduction Of Length Of Stay For Total Joint Replacement Patients, Melody C. Golden

Master's Projects and Capstones

Abstract

Problem: Prolonged LOS in the PACU for patients undergoing total joint replacement surgery contributes to inefficiencies in patient flow, delayed throughput, and increased resource utilization. At Hospital A, recent LOS averages exceed internal and regional benchmarks, indicating a need for process improvement.

Context: The PACU is a high-volume, fast-paced environment requiring coordination among nursing, physical therapy, anesthesia, and discharge planning teams. Variability in workflow, communication gaps, and inconsistent timing of key processes contribute to delays in discharge readiness.

Interventions: From May through July 31^st, 2026, a quality improvement project was implemented using the Baldrige Excellence …

Integrating Matrescence Into Birth Worker Practice: A Practice Improvement Project, Kelsey B. Green

Doctor of Nursing Practice (DNP) Projects

Background: Perinatal mood and anxiety disorders (PMADs) affect 20–25% of mothers worldwide and are a leading cause of maternal complications. Stigma, fragmented care, and limited provider training leave families vulnerable, while birth workers offer trusted, continuous support.

Problem: Birth workers' maternal mental health (MMH) training is minimal and often excludes matrescence, the developmental transition to motherhood, limiting their ability to distinguish normal adjustment from clinical PMADs and delaying intervention.

Methods: A single-group, pre-/post-test design evaluated a matrescence-informed workshop at Roots Community Health's 2nd Annual Symposium. Anonymous surveys measured knowledge, attitudes, and confidence, analyzed with Mann–Whitney U, Wilcoxon signed-rank tests, and …

Same-Day Cancellation Reduction In An Ambulatory Surgery Unit, Anthone Dalit Vengersammy

Master's Projects and Capstones

Problem: Same-day surgical cancellations in the outpatient surgery setting remain a significant operational and patient care challenge. Preventable cancellations negatively affect patient experience, operating room efficiency, staff productivity, and healthcare costs. 

Context: A microsystem and organizational culture assessment identified several factors contributing to same-day cancellations, including unclear preoperative instructions, incomplete medical clearance, inconsistent patient education, lack of standardized workflows, unclear staff responsibilities, and communication gaps among interdisciplinary teams. SWOT and gap analyses were used to identify opportunities for improvement and guide intervention planning.

Interventions: Quality improvement interventions were implemented through iterative Plan-Do-Study-Act (PDSA) cycles. Strategies included revising preoperative patient instructions, …

Improving Fluoride Varnish Application Rates In A Pediatric Primary Care Microsystem, Roman G. Roxas

Master's Projects and Capstones

Problem

Childhood caries is a preventable public health issue disproportionately affecting the underserved. National guidelines recommend fluoride varnish (FV) application during well‑child visits. In California, fewer than 15% of children under age six received FV. In a pediatric primary care clinic, baseline performance was 11% in 2025.

Context

A six‑month quality improvement project was implemented. Key barriers included reduced team cohesion, workflow variability, unclear roles, and underutilized electronic health record (EHR) prompts.

Interventions

The change package standardized medical assistant–led workflows, activated EHR prompts, and provided targeted education. Leadership reinforcement through regular huddles supported adoption, consistency, and team engagement.

Measures

Outcome …

Optimizing Life Care Planning For Palliative Home Health Care Patients, Lilian Muraya

Master's Projects and Capstones

Problem: In this home health palliative microsystem, many seriously ill patients begin care without timely goals‑of‑care conversations or documented advance directives, leading to fragmented communication and potentially avoidable emergency visits and rehospitalizations.

Context: This quality improvement project took place in a hospital-based home health palliative care program in Northern California, where an interdisciplinary team identified inconsistent Life Care Planning (LCP) practices and variable staff comfort with conducting goals‑of‑care discussions.

Intervention: A structured LCP workflow was developed so that newly admitted palliative home health patients receive a goals‑of‑care discussion and advance directive review within 7 days of start …

Reducing Primary Cesarean Births Among Nulliparous, Term, Singleton, Vertex (Ntsv) Patients Through Structured Multidisciplinary Communication, Toyin Ajani

Master's Projects and Capstones

Background: Primary cesarean birth among nulliparous, term, singleton, vertex (NTSV) patients remained a persistent quality and safety concern in obstetric care. Unnecessary cesarean birth was associated with increased maternal morbidity, neonatal complications, prolonged recovery, higher healthcare costs, and adverse outcomes in subsequent pregnancies. Problem: A Northern California labor and delivery unit identified an elevated NTSV cesarean birth rate of 26.8%, exceeding the national benchmark of approximately 23%. Variability in provider communication, inconsistent labor management practices, and lack of standardized interdisciplinary collaboration contributed to this quality gap. Context: The project was conducted in a high-volume labor and delivery microsystem serving a …

Improving Peer Feedback Participation Through Psychological Safety Interventions In Labor & Delivery Nurses, Lindsey C. Hora

Master's Projects and Capstones

Abstract 

Background: Labor and Delivery (L&D) units require effective communication, speaking up, and team learning to support safe care. Psychological safety informed this quality improvement project as a contextual strategy to strengthen peer feedback engagement.  

Problem: Peer feedback participation among eligible L&D registered nurses at a large acute care hospital in Santa Clara, California, was 14.29% (N = 112) below the 30% project target and 80% organizational target. Low participation limited routine feedback for professional development, recognition, and team learning.

Interventions: Interventions included psychological safety education, peer feedback reinforcement, workflow integration, platform navigation support, dedicated completion time, and unit champions. …

Implementation Of Visual Bed Indicator Lights To Improve Fall Prevention Processes, Andrea Leffew

Master's Projects and Capstones

Problem: Inpatient falls remain a significant patient safety concern associated with preventable patient harm, prolonged hospitalization, and increased healthcare costs. Routine fall bundle validations identified inconsistent adherence to safe bed configuration practices, such as beds left raised and bed alarms turned off.

Context: A 3-month quality improvement project was implemented on a 20-bed medical-surgical telemetry unit within an integrated healthcare delivery system at a 130-bed community hospital in Northern California, which was experiencing an increase in inpatient falls and fall-related sentinel events.

Interventions: Implementation of bed-monitoring technology with visual indicator lights that provided real-time feedback on bed configuration.

Measures: The …

Clinician Perspectives On Fistula Mental Health, Victoria K. Leonard

Doctoral Dissertations

Background – Obstetric fistula is a childbirth injury caused by prolonged labor that leads to stillbirth and incontinence, spurring social exclusion and isolation. These layers of trauma put women with fistula at great risk for psychological suffering, which has profound negative socioeconomic impacts on them, their families, and communities. This study captured treatment as usual at Comprehensive Community Based Rehabilitation in Tanzania (CCBRT), the country’s largest provider of fistula care.

Method – Improving holistic fistula treatment requires engaging the clinicians who care for women with fistula. This study aimed to investigate the training, beliefs, and treatment approaches of nurses and …

Intimate Partner Violence Screening And Awareness Pilot Project, Eleasha P. Partner

Doctor of Nursing Practice (DNP) Projects

Background: In the United States, one in four women experiences intimate partner violence (IPV), highlighting the critical need for improved screening and intervention within the healthcare system. Routine visits in healthcare settings present a significant opportunity for healthcare providers to identify and address IPV.

Local Problem: A primary care family practice clinic in San Leandro, California , currently lacks a standardized evidence-based screening toolkit for IPV.  The absence of such a toolkit creates a gap in practice, leaving patients at risk of undiagnosed IPV and its related consequences.  To address this gap, there is a pressing need for the development …

Advancing School-Based Sexual Reproductive Health Education Through A Fifth-Grade Educator Toolkit, Emira Romero

Doctor of Nursing Practice (DNP) Projects

Background: Although sexual and reproductive health (SRH) education is a critical component of early health literacy and health promotion, educators remain underprepared to deliver this education. Local Problem: A gap analysis conducted at School A, a public elementary school in the San Francisco Bay Area, revealed the absence of a SRH curriculum for their fifth graders. Methods: A Doctor of Nursing Practice (DNP) student-led quality improvement project to introduce a SRH educator toolkit to increase educator confidence and self-efficacy was conducted at School A among fifth grade teachers. Pre- and post-intervention data were collected on implementation day to evaluate the …

Standardizing Preoperative Screening: A Color-Coded Triage Tool Quality Improvement Project, Lyn Green

Doctor of Nursing Practice (DNP) Projects

Abstract

Background: Ambulatory surgery centers (ASCs) require effective preoperative screening to ensure appropriate patient selection and minimize day-of-surgery (DOS) cancellations, which affect patient safety, operational efficiency, and financial performance.

Local Problem: In a Northern California ASC serving a racially diverse, predominantly older-adult population with a high burden of chronic diseases, the DOS cancellation rate was 3.84%, exceeding the 2.3% institutional benchmark. Inconsistent preoperative screening contributed to avoidable cancellations.

Methods: A pre- and post-intervention quality improvement design evaluated the effect of a standardized screening tool and staff education on DOS cancellations.

Interventions: The Preoperative Stoplight Tool, a color-coded triage system classifying …

Treatment Manual For Nonsequential Format Two Part Program For Symptom Self-Management (12 Session Course & Support Group For Booster Dose Of Course), Robin Kay Buccheri, Louise Nigh Trygstad, Martha D. Buffum

Nursing and Health Professions Faculty Research and Publications

This is the Treatment Manual and 5 Appendices for NonSequential Format.  Two-Part Program for Symptom Self-Management of Auditory Hallucinations: 12 Session Course & Support Group for Booster Dose of Course

Treatment Manual For Sequential Format. Two Part Program For Symptom Self-Management (12 Session Course & Support Group For Booster Dose Of Course)., Robin Buccheri, Louise Nigh Trygstad, Martha D. Buffum

Nursing and Health Professions Faculty Research and Publications

This is the Treatment for Sequential Format Two Part Program for Symptom Self Management of Auditory Hallucinations (12-Session Course & Support for Booster Dose of Course).

Treatment Manual For Nonsequential Format. Two Part Program For Symptom Self-Management (12 Session Course & Support Group For Booster Dose Of Course)., Robin Kay Buccheri, Louise Nigh Trygstad, Martha D. Buffum

Nursing and Health Professions Faculty Research and Publications

This is the Treatment Manual for NonSequential Format: Two-Part Program for Symptom Self-Management of Auditory Hallucinations: 12 Session Course & Support Group for Booster Dose of Course

Misconceptions About Nursing In High School Students Of Color: Promoting Diversity In Nursing, Veronnica D. Pham

Doctor of Nursing Practice (DNP) Projects

Background: Equitable and culturally competent care can reduce health disparities among underserved populations; yet the nursing shortage the US faces does not allow for better patient outcomes. One barrier is how the profession can be negatively viewed among high school students of color.

Methods: A comprehensive literature search was performed to identify how perception of nursing affects a student’s career choice and what influences these perspectives. Three databases were utilized for this search: The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and Scopus. Six articles were selected for this review. The following themes have been identified: misconceptions, …

From Fear To Familiar: Decreasing Technology Anxiety Among Older Adults In A Senior Community, Regina Rayz

Master's Projects and Capstones

Objective: Older adults (defined by the WHO as those 65 and older in developed countries) are more susceptible to technophobia than younger adults (Song et al., 2025). The fear and anxiety occurs with use of smartphones, tablets, social media, and telehealth and is associated with higher rates of social isolation and reduced autonomy. Technology-use anxiety is a preventative obstacle that inhibits both technology acceptance as well as overall health (Kim et al., 2023). Aim: To reduce technology-related anxiety among older low-income adults living in a senior residential facility in Richmond, CA by at least 25% using a brief, individualized technology …

Effects Of Communication Boards On Improving Communication In Assisted Living Care Facilities, Koleen Beatrice Arribas

Master's Projects and Capstones

Problem: A Residential Care facility utilizes paper charting causing limited access to vital information such as code status, allergies, and/or diet for those caring for the resident.

Context: Exceptional charting only when a resident’s condition changes may not provide enough vital information for the caregiver to administer medication or provide proper support during an emergency, such as the resident’s DNR status.

Interventions: A communication board was placed in a secure space near the nurses’ station with key resident information. Nurses would huddle at the board at before the change of shift and make updates as necessary.

Measures: Staff input in …

Improving Staff Satisfaction And Flu Vaccine Uptake Through Standardized Workflow Tools, Salma Adriana Blanco

Master's Projects and Capstones

Objective: Insufficient workflows can cause documentation to be confusing, which ultimately

limits staff engagement. This has led to staff dissatisfaction and a low vaccination uptake in

outpatient clinics. The implementation of a standardized workflow tool and proper staff

education and training can improve staff satisfaction and vaccination adherence, as indicated by

a review of literature. Aim: The purpose of this quality improvement project is to implement a

change in workflow in the electronic health record and staff training in an urban community

health clinic primarily serving low income and Latino patients. This intervention seeks to

increase medical assistant user satisfaction …

The Pressure Is On: A Quality Improvement Project To Educate Nurses On Hospital Acquired Pressure Injuries, Lance Ward

Master's Projects and Capstones

Objective Hospital acquired pressure injuries (HAPIs) are injuries developed by admitted patients, from treatment interventions that they encounter during their hospital stay. If a patient acquires a HAPI during their stay, the hospital is required to cover all expenses related to the injury. An in-patient trauma unit at a large medical center wishes to improve patient care by educating nursing staff on preventive measures of HAPIs. A review of relevant literature on HAPIs from the past five years was conducted to identify HAPI preventions tools, such as the Braden Scale and SKINS bundle, as well as the best methods to …

Bridging Gaps In Safety: A Team-Based Approach To Reducing Falls Among Older Adults, Enzali Min

Master's Projects and Capstones

A skilled nursing facility in the San Francisco Bay Area is experiencing fall rates surpassing the national average throughout the year. Falls among elderly residents lead to multi-level complications, from minor bruising to major injuries such as fractures, head injuries and hospital transfer, and in the most severe cases, higher mortality rates. To address the issue of high fall rates at the nursing facility, the post-fall huddle protocol was developed on the unit. The team intends to reduce the facility's fall rate by 25% over the next five weeks, from October 1 through November 5, 2025, along with improving the …

Promoting Interprofessional Collaboration By Increasing Visibility Of Volunteer Doula Services, Ciera Rose Zelie

Master's Projects and Capstones

Objective: The 22-bed Labor and Delivery (L&D) unit lacks a standardized model to introduce doulas, clarify their scope of practice, or communicate the value of the services they provide. To address this gap, the team developed a standardized doula awareness poster featuring each doula's name, photo, years of experience, and personal interests. Aim: Enhance visibility and promote the integration of doula support to strengthen team collaboration and patient engagement. Methods: A pre- and post-implementation survey was distributed exclusively to the volunteer doulas. After the doula awareness poster was displayed for four weeks, a post-survey assessed these same domains to determine …

From Fear To Familiar: Reducing Technology-Induced Anxiety In Seniors, Justin Kyle V. Manalang

Master's Projects and Capstones

Abstract

This quality improvement project focuses on reducing the average technology-induced anxiety score among senior community members through 1:1 mentorship sessions. Aim During an eight-week period from September 10, 2025, to November 5, 2025, this project will reduce the severity of technology-induced anxiety by 25% from the established baseline. Methods: A 5P Microsystem assessment was conducted alongside an initial questionnaire to gauge the residents’ interests and concerns regarding technology use. From the results, focused mentorship sessions were conducted once a week and pertained to the chief complaint the resident had for eight weeks. The mentorship sessions were one-to-one and individualised …

Implementing A Standardized Doula Awareness Tool To Improve Team Collaboration And Patient Understanding, Stephanie Wong

Master's Projects and Capstones

Setting: 22-bed, Labor and Delivery (L&D) unit in the Bay Area serving diverse birthing patients. Problem & Context: The unit lacks a standardized model to introduce doulas, clarify their roles, or communicate their value. Evidence shows that doulas feel unseen by other hospital staff (Kett et al., 2022) and report that their role can be misunderstood, undervalued, or unrecognized, creating barriers to effective partnership (Louis-Jacques et al., 2024). Pre-survey: Only 19.2% of the participating volunteer doulas felt patients understood their role as a doula, and 11.5% felt patients were only slightly knowledgeable. In terms of collaboration, just 15.4% felt consistently …

Improving Interdisciplinary Communication And Collaboration With The Standardization Of Doula Care Through An Informatics Tool, Shela Le

Master's Projects and Capstones

Objective: The 22-bed Labor and Delivery (L&D) unit lacks a standardized model to introduce doulas, clarify their scope of practice, or communicate the value of the services they provide. To address this gap, the team implemented a standardized doula awareness poster that included each doula’s name, photo, years of experience, and personal interests. Aim: The goal is to enhance visibility and promote integration of doula support to strengthen team collaboration and patient engagement. Methods: A pre- and post-implementation survey was distributed exclusively to the volunteer doulas. After the doula awareness poster was displayed for a month, a post-survey assessed these …

Enhancing Flu Vaccination Rates Through Improved Electronic Health Record User Workflow Training, Grace Sayre

Master's Projects and Capstones

A quality improvement project was implemented at an urban community health clinic primarily serving low-income, underinsured, and Latinx individuals. The site had a history of poorly organized flu vaccine rollout and low vaccination rates among the patient population. Seasonal influenza infects millions of people across the US each year, resulting in hundreds of thousands of deaths (Garza et al., 2023), and vaccination is the best prevention. Electronic health record training has been shown to reduce user burnout and improve efficiency (Gordon et al., 2022). The QI project aims to increase medical assistant satisfaction with the flu vaccine rollout by 15%, …

Charting The Course: Improving Psychotropic Medication Documentation Through Staff Education To Promote Patient Safety And Cms Compliance, Anne J. Bertram Rn

Master's Projects and Capstones

The University of San Francisco master’s level nursing program culminates with a clinical nurse leader (CNL) quality improvement project. The objective of this project is to reinforce the program’s didactic CNL classes by allowing students the opportunity to design, implement, and analyze a quality improvement project in a microsystem. SETTING: Skilled nursing facilities often prescribe psychotropic medications to help manage residents’ behavioral and psychological symptoms. Due to the possibility of side effects and increased sedation, there are concerns for patient safety and quality of life. Inadequate management of these patients and symptoms compromises patient safety and breaches state and federal …

A Quality Improvement Initiative To Streamline Flu Vaccine Documentation And Increase Staff Engagement, Carla E. Giron

Master's Projects and Capstones

Objective: This quality improvement project was implemented in an urban community health clinic primarily serving low-income and Latinx patients. Factors such as demographics, socioeconomic status, health, and transportation contribute to low U.S. influenza vaccination rates (Chen et al., 2020), while EHR training can improve provider satisfaction and efficiency (DiAngi et al., 2019). This microsystem faced inconsistent workflow processes, limited EHR training, and documentation errors that contributed to low staff satisfaction rates and influenza vaccination rates. An average of 11.4% of patients received a flu vaccine in October 2023 and 2024. Medical assistants (MAs) completed a pre-intervention survey indicating that 35% …

Improving Chemotherapy Patients' Confidence And Preparedness Through Dual-Format Teaching, Jasmine Esther Aminpour, Harshpreet Kaur, Ana Ruvalcaba, Sarah Muwanas

Master's Projects and Capstones

Section I: Abstract

Objective

Chemotherapy initiation is widely recognized as a period of heightened anxiety and cognitive overload for oncology patients, often limiting their ability to retain essential information during traditional one-time, nurse-led education sessions (Gucuyener & Karabacak, 2025; Howell et al., 2020). This quality improvement (QI) project sought to address gaps in comprehension, preparedness, and digital engagement within an outpatient oncology infusion microsystem by integrating evidence-based digital chemotherapy education with structured follow-up support.

Aim

The project aimed to determine whether a nurse-guided walkthrough of a digital chemotherapy education platform, paired with standardized follow-up calls, would improve patient comprehension, confidence …