Employing Technology to Make Care Transitions Safer No abstract available

Avoiding Nursing Home to Hospital Transfers: Rethinking Avoidability No abstract available

Shared Governance Approach to Implementing Change of Shift Huddle No abstract available

Quiet Time Improves the Patient Experience Background: A quiet environment promotes rest and healing but is often challenging to provide in a busy acute care setting. Improving quiet in the hospital for designated hours improves patient satisfaction. Such efforts have typically been the primary responsibility of the nursing staff. Local Problem: Two medical units with consistently low Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) “always quiet” scores were chosen for this study. Methods: A multidisciplinary team used Lean methods and the Model for Improvement to test interventions for quiet time (QT) and used HCAHPS “always quiet” scores as the primary outcome measure. Interventions: The team instituted nighttime and afternoon QT supported by rounding and scripting, dimming lights, lowering staff voices, offering a sleep menu at night, and replacing noisy wheels. Results: Quiet scores improved on both units after 11 months. Conclusions: Noise in hospitals is often beyond the scope of nurse-driven improvement; however, a QT protocol led by nurses, developed by multiple stakeholders, and focused on changing expectations for quiet can lead to measurable improvements in patient perception of quiet.

Impact of a Nutrition-Focused Quality Improvement Intervention on Hospital Length of Stay Background: Despite its high prevalence, malnutrition in hospitalized patients often goes unrecognized and undertreated. Local Problem: A hospital system sought to improve nutrition care by implementing a quality improvement initiative. Nurses screened patients upon admission using the Malnutrition Screening Tool and initiated oral nutrition supplements for patients at risk. Methods: We retrospectively reviewed the medical records of 20 697 adult patients to determine whether early initiation of nutrition therapy had reduced hospital length of stay and 30-day readmission rates. Results: We found the average time from hospital admission to oral nutrition supplement initiation was reduced by 20 hours (20.8%) after the quality improvement initiative was introduced (P < .01). Length of stay decreased 0.88 days (P < .05) more for patients at nutritional risk than patients not at nutritional risk; the probability of 30-day hospital readmission did not differ between groups. Conclusion: These results highlight the importance of adequate nutrition screening, diagnosis, and treatment for hospitalized patients.

Blended Facilitation as an Effective Implementation Strategy for Quality Improvement and Research in Nursing Homes Background: Blended facilitation, which leverages the complementary skills and expertise of external and internal facilitators, is a powerful strategy that nursing stakeholders and researchers may use to improve implementation of quality improvement (QI) innovations and research performed in nursing homes. Problem: Nursing homes present myriad challenges (eg, time constraints, top-down flow of communication, high staff turnover) to QI implementation and research. Approach: This methods article describes the theory and practical application of blended facilitation and its components (external facilitation, internal facilitation, relationship building, and skill building), using examples from a mixed QI and research intervention in Veterans Health Administration nursing homes. Conclusions: Blended facilitation invites nursing home stakeholders to be equal partners in QI and research processes. Its intentional use may overcome many existing barriers to QI and research performed in nursing homes and, by strengthening relationships between researchers and stakeholders, may accelerate implementation of innovative care practices.

Health Optimization Program for Elders: Improving the Transition From Hospital to Skilled Nursing Facility Background: Individuals discharged from the hospital to skilled nursing facilities (SNFs) experience high rates of unplanned hospital readmission, indicating opportunity for improvement in transitional care. Local Problem: Local physicians providing care in SNFs were not associated with the discharging hospital health care system. As a result, substantive real-time communication between hospital and SNF physicians was not occurring. Methods: A multidisciplinary team developed and monitored implementation of the Health Optimization Program for Elders (HOPE) to improve patient transitions from acute hospital stay to SNFs. Interventions: The HOPE used a nurse practitioner (NP) to identify geriatric syndromes, set patient/caregiver expectations, assess rehabilitation potential, clarify goals of care, and communicate information directly to SNF providers. Results: The intervention was feasible, addressed unmet needs and errors in the SNF transition process, and was associated with lower 30-day readmission rates compared with concurrent patients not enrolled in the HOPE. Conclusions: An NP-led hospital to SNF transitional care program is a promising means of improving hospital to SNF transitions.

Sustaining Quality Improvement: Long-Term Reduction of Nonventilator Hospital-Acquired Pneumonia Background: Hospital-acquired pneumonia is now the number one hospital-acquired infection. Hospitals have addressed ventilator-associated pneumonia; however, patients not on a ventilator acquire more pneumonia with significant associated mortality rates. Local Problem: In our hospital, non-ventilator-associated pneumonia was occurring on all types of units. Methods: The Influencer Model was used to reduce nonventilator hospital-acquired pneumonia rates. Statistical process control R and X-bar-charts were monitored monthly. Interventions: After a gap analysis, an interdisciplinary team implemented enhanced oral care before surgery and on the units, changed tube management, and monitored stress ulcer medication. Results: We achieved a statistically significantly reduction (P = .01) in pneumonia rates that have been sustained over 4 years. Conclusions: Sustaining change requires (a) a continued team-based, collaborative approach, (b) ongoing stakeholder and executive leadership engagement, (c) monitoring that easy-to-use protocols and required equipment remain in place, and (d) embedded analytics to monitor results over a prolonged period.

Manifestations of High-Reliability Principles on Hospital Units With Varying Safety Profiles: A Qualitative Analysis Background: To prevent patient harm, health care organizations are adopting practices from other complex work environments known as high-reliability organizations (HRO). Purpose: The purpose was to explore differences in manifestations of HRO principles on hospital units with high and low safety performance. Methods: Focus groups were conducted on units scoring high or low on safety measures. Themes were identified using a grounded theory approach, and responses were compared using qualitative thematic analysis. Results: High performers indicated proactive responses to safety issues and expressed understanding of systems-based errors, while low performers were more reactive and often focused on individual education to address issues. Both groups experienced communication challenges, although they employed different methods of speaking up. Conclusion: Some HRO principles were present in the language used by our participants. High performers exhibited greater manifestations of HRO, although HRO alone was insufficient to describe our results. Mindful organizing, which expands on HRO, was a better fit.

Using Lean Six Sigma to Improve Controlled Drug Processes and Release Nursing Time Background: Hospital controlled drug processes are established to adhere to legislation, with little consideration of efficiency of processes. Local Problem: A controlled drug process existed, where nurses requested a porter to collect a hand-written order; however, only 19% of drug orders were processed this way. Instead, an unscheduled, ad hoc process led to an average of 17 nurse journeys to pharmacy daily. We aimed to reduce nurse journeys to the pharmacy by 25% to release nursing time. Methods: A pre-/postintervention design was used with Lean Six Sigma methods. Interventions: A multifaceted intervention involved process redesign, increasing the frequency of a porter-led delivery service, amending delivery times to reflect times of greatest need, and streamlining checking requirements. Results: Following implementation, there was a statistically significant 44% decrease in nurse journeys to pharmacy for drug collections, which was maintained after 18 months. Conclusions: Interprofessional collaboration improving hospital-wide processes can have significant benefits for the release of nursing time.