Quality Care Improvement Project 4D Trauma Unit
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Transcript Quality Care Improvement Project 4D Trauma Unit
Quality Care
Improvement Project
4D Trauma Unit
Kelly Quinn RN, MS, CNS
Allison Morton, RN, BSN
Jignasa Pancholy, RN
Holland Stephens, RN, MSN, CNL
HCAHPS
(Hospital Consumer Assessment of Healthcare Providers and Systems
Designed to elicit comparable &
measurable data based on
perceptions of patients’ experience
of hospitals nationally.
Results are ranked & hospital
reimbursements can be affected
based on our performance
SFGH lags just 4 percentage points
behind the national average when
patients are asked to rank hospitals
worst to best.
HCAHPS 10 Composites
Communication about
medication
Communication with
doctors
Communication with
nurses
Discharge information
Pain control
Rate hospital
Responsiveness
of hospital staff
Room kept clean
Room quiet at
night
Would
recommend the
hospital
HCAHPS RESULTS
4D Patient Survey
Questions
I am receiving sufficient teaching about my
condition.
I feel confident I'll be able to manage my condition
at home.
My nurses always explain things clearly to me.
My nurses always tell me about side effects of
new medications.
My doctors always explain things clearly to me.
I always receive help when I need it.
My pain is always well-controlled.
My room is always clean.
It's always quiet at night so that I can rest.
Overall I've had a good experience at this
hospital.
Project to Improve Noise at
Night on 4D
Based on the HCAHPS: the
lowest score was patients'
perceptions of noise at night
Aim Statement: Goal is to
reduce noise at night by 10% by
April 20th 2012
Baseline: Patient survey done
January 2012 on 4D
Interventions
SILENT campaign to remind
nurses to be noise conscience
after 11p
Shhhh in the hallway
It's nighttime
Low TV volume ( TV Signs)
Earplugs can be offered!
No loud voices
Turn down nursing station
phone ringers
Supportive Interventions
Volunteers educate
patients on what to
expect at night (e.g.
VSQ4H, AMLs, early MD
rounds)
Other
3%
Nurses Station
phone
15%
Equipment
19%
Call Light
18%
Patient TV
16%
Hallway 1
10%
Nurses Talk
7%
Bi-weekly patient
survey conducted
Hallway2
7%
Break Room
5%
Noise audits performed
to identify noise-prone
areas of the unit
Dates
4/18/2012
3/12-3/19
2/27-3/9
1.5
2/13-2/24
2/6-2/10
1/30-2/4
1/23-1/27
1/12-1/20
1/5-1/11/12
1=Strongly Disagree, 2=Disagree, 3=Agree, 4=Strongly Agree
Noise Data Graph
4.0
3.5
3.0
2.5
2.0
It's always quiet at night so that I can rest.
1.0
Future Projects Impacting
Patient Experience
Nurse to patient communication regarding side
effects of medications
Cheat sheet on COWs
Signs (e.g. pt
rooms/hallways/med room)
CALNOC med pass audit
"Med of the week"
M/S AIM: Increase
“communication about
medicine” score by 10%
(from 55-65%)
3/12-3/19
2/27-3/9
2.50
2/13-2/24
2/6-2/10
1/30-2/4
1/23-1/27
1/12-1/20
/5-1/11/12
1=Strongly Disagree, 2=Disagree, 3=Agree, 4=Strongly Agree
Graph
4.00
3.50
3.00
My nurses always tell me about side effects of new
medications.
2.00
1.50
1.00
Future Projects Impacting
Patient Experience (cont):
Organizing education material
and accessibility
Music therapy available for
patients to decrease pain
Increasing responsiveness to
patient needs
Increasing communication with
MDs/NPs
Staff Communication
Focus placed on increasing staff communication
and disseminating knowledge about unit changes
Emails
Monthly meetings
Communication binder
Open forum board for
suggestions/feedback
Positive Recognition
Board
Roles and Responsibility
Of Quality Care Coordinator
Nurse
Provides patient centered care.
Educates patients and professionals.
Enhances care and work environs.
Develops systems to support quality nursing
and quality care.
Provides assistance to patients throughout care
transitions.
However, this is a nurse among nurses. Our goal
is to support you in your role as med-surg
Sustainability
Continue to create immediate,
visible, flexible and unit-specific
changes that address the unique
needs of the unit
Unit shared governance based
project
Continue to promote nursing
excellence
Continue to improve patient
experience by providing support
and voice for the nurses
Spreading Change through
the SG Structure