Quality Care Improvement Project4D Trauma Unit

Kelly Quinn RN, MS, CNSAllison Morton, RN, BSNJignasa Pancholy, RNHolland 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)

Bi-weekly patient survey conducted

Noise audits performed to identify noise-prone areas of the unit

Nurses Station phone

14%

Call Light18%

Hallway 110%

Hallway27%

Break Room5%

Nurses Talk7%

Patient TV16%

Equipment19%

Other3%

Noise Data Graph

1/5-

1/11

/12

1/12

-1/2

0

1/23

-1/2

7

1/30

-2/4

2/6-

2/10

2/13

-2/2

4

2/27

-3/9

3/12

-3/1

9

4/18

/201

2

1.0

1.5

2.0

2.5

3.0

3.5

4.0

It's always quiet at night so that I can rest.

Dates

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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%)

Medication Communication Graph

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3.50

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My nurses always tell me about side effects of new medications.

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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 ResponsibilityOf 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 nurses.

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