Running head: IMPROVEMENT AND EFFICIENCY IN PATIENT CARE 1

Improvement and Efficiency in Patient Care

Kelley Schlosshan

Bon Secours Memorial College of Nursing

Synthesis of Nursing Practice

NUR 4242

Wendi Liverman, MSN, CEN, RN

October 26, 2019

Honor Code: I Pledge…

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Improvement and Efficiency in Patient Care

Introduction

Over the last several months, there has been an increasing number of joint replacement

patients arriving 10-15 minutes late to the class which can cause the patient to miss vital

information related to their post-surgical care. Additionally, there has been patients left in the

surgical waiting area who miss the entire class because nurses forget to take them. Other factors

include time management challenges including; interruptions, distractions, phone calls, and

unforeseen variables contributing to the patient being late to class. Surgery center registration has

only one registrar who is responsible for registering surgery and preadmission testing patients.

Surgery patients take priority. As part of the quality improvement project for the preadmission

testing department, I decided to focus on increasing patients on-time arrival to class to ensure

patient learning, improve patient outcomes and staff efficiency.

Background

Healthcare organizations face many challenges to delivering safe, effective and quality

patient care. The Institute of Medicine, the Joint Commission, and the Centers for Medicare &

Medicaid Services necessitate improved patient quality and safe care. In healthcare today, nurses

are expected and required to use evidenced-based clinical practice guidelines and contribute to

ongoing quality improvement efforts, ensuring a safer healthcare environment and providing

excellent patient care (Balakas & Smith, 2016). Prevention of medical errors and omissions in

patient care are essential. Hospitals have reported reduced patient harm after investing in a

quality improvement program with lower hospital readmission rates, decreased hospital acquired

conditions, improved patient mobility and decreased falls, and improved hand hygiene and

access to care (Sarff & O’Brien, 2019).

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During my quality improvement project, I carried out a model of improvement suggested

by the Institute of Health Improvement (IHI) called the PDSA (Plan, Do, Study, Act) cycles. For

implementation of the project, I monitored pre-data starting from August 12th through

September 10th, 2019. With this data, I tracked the number of patients scheduled for class,

patient’s tardy, patient omissions, patients requiring wheelchairs, patients registered late, and

time management challenges. During this time, 25% of patients were tardy to class. This made it

essential to come up with some process improvement measures.

In an effort to increase on-time arrival to the joint replacement class and prevent

omissions in patient care, I worked with the charge nurse to improve communication and

efficiency. In the first cycle of the planning phase, I worked directly with the charge nurse to

have patient’s arrive for registration 30 minutes before their appointment time. In an effort to

prevent the patient from going to the wrong location for their appointment the charge nurse was

very specific in communicating directions to the preadmission testing department communicated

to the patient. Additionally, she committed to making nurse/patient assignments the day prior to

the appointment by 4:30 pm to allow nurses time to review patient charts. In the Do cycle, I used

the period from September 16th through September 24th, 2019 to observe and listen to the

charge nurse make patient reminder calls and making out the assignment by 4:30 pm the day

before. After the two week period, I studied my data to see the percentage of patients tardy to

class; 22% and this was only a 3% improvement. Then I designed the next cycle to work with

nurses in the preadmission testing department to develop tools to assist with time management.

In the second PDSA cycle of the planning phase, I planned in advance for equipment

needs. During this cycle a joint replacement class checklist was implemented to help nurses

ensure the required tests, responsibilities, and equipment needs such as wheelchairs, EKG
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machines are available. For patients who are late to class, there is a space on the joint checklist

tool to write the reason patient was late and to state the day the nurse was able to review the

patients chart. Additionally, I assigned a nurse to be responsible for getting two wheelchairs the

day before and have the EKG machine ready and available between 8:00 am and 9:30 am on

Mondays and Tuesdays as other departments borrow our EKG machine. I carried out a two week

trial from September 30th through October 8th, 2019, to monitor for compliance of completing

the joint replacement class checklist. This was used as a guide to ensure all patient tasks are

completed and to help staff become more time efficient. I studied my observations which

resulted in an 11% increase of on-time arrival to class and 50% compliance in completing the

joint replacement class checklist. In reviewing the data, I noticed the percent of patients late to

class was the same as the percent of patients registered late for their appointment, 14.3%.

Following the first two PDSA cycles, I realized there was still room for improvement

within our process. I designed the next cycle of planning to work with the registrar to track how

much time it is taking to register patients since the percent of patients late to class is the same

percent of patients who are registered late. As part of this process I will need to become more

familiar with the registration process in order to more effectively work with the registrar, but

patients being registered late will fall into two categories; patients who did not arrive on time for

their appointment and those who did arrive on time but are still late to the joint replacement

class.

Method

Throughout this quality improvement project, there were several interventions I

implemented. In order to help make this project successful, I talked with our charge nurse and

the nurses in our department to work and be actively involved in trying to increase patient’s on-
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time arrival to the joint replacement class. These interventions are essential in patient learning

and their recovery process. Communication played a huge factor in this project starting with the

charge nurse giving patients specific detailed instructions about their preadmission testing

appointment and joint replacement class in their reminder call. These details included location of

appointment and time of arrival. Our charge nurse made out the assignment by 4:30 pm on

Fridays and Mondays to allow nurses to review their assigned patient’s chart. Nurses were able

to review patient’s charts the day before a majority of the time and this did allow an opportunity

to increase time efficiency. The only changes implemented from the first cycle to the second

were adding a joint replacement class checklist and focusing on equipment needs. A

departmental nurse was assigned to ensuring wheelchairs and an EKG machine was accessible

on class days to improve time efficiency. Communication through the joint replacement class

checklist tool was implemented and used as a reminder of essential tasks to help prevent

omission in care. Throughout this project, there were not any unusual findings noted.

Results

Although our department did not meet our goal of 20% improvement in on-time arrival to

the joint replacement class, the changes implemented did results in beneficial improvements.

From reviewing pre-data to post-data, our on-time patient arrival increased from 3% to 11%.

Through initiating several changes throughout the project, there were many factors that

contributed to an increase in on-time patient arrival to the joint replacement class. The charge

nurse made out the assignment a majority of the time by 4:30 pm. Their role with the patients

was vital in the reminder phone calls to increase patient on-time arrival. Other factors include

having an EKG available during from 8:00 to 9:30 am on Mondays and Tuesdays every week
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and at least two wheelchairs available to increase time efficiency. In the second cycle, there

were two patients tardy to class as a result of being registered late, 14.3%

There are several things I learned through doing this quality improvement project. In a

quality improvement project, I learned it takes small steps to make a difference and to make an

impact. I learned how being an engaged employee is important and effective communication

makes a difference to contribute to better outcomes. My mentor played an essential role in this

process of supporting my ideas, being available by phone, work, email, and lunch conversation

to update on progress. She also encouraged me to step out of my comfort zone and challenge

myself to help me grow as a nurse.

Conclusion

In summary, patients tardiness to the joint replacement class can affect patients learning

and outcomes because they can miss vital information. Nurses are expected to give high quality

and safe care. In an effort to improve on-time arrival, it is necessary to review and implement

new process measures. Two PDSA cycles were completed and the results did show continued

improvement. Clear and consistent communication can make a huge impact in patient care and

learning to implement other avenues to search for continued process improvement. It takes all

members on the team to make a difference.

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References

Balakas, K., & Smith, J. R. (2016). Evidence-Based Practice and Quality Improvement in

Nursing Education. The Journal of Perinatal & Neonatal Nursing, 30(3), 191-194.

https://doi.org/10.1097/JPN.0000000000000197

Sarff, L., & O’Brien, R. (2019). Evidence-Based Quality Improvement Training Programs:

Building Staff Capability and Organizational Capacity. Journal of Nursing Care Quality,

00(00), 1-7. https://doi.org/ 10.1097/NCQ.0000000000000416