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University of Colorado Hospital

Performance Improvement Team Worksheet

Department BMT/OMG Date July 26, 2014
Primary Contact Person Aurora Davis Extension 84275

(F) Find a Process to Improve (name the process, describe the beginning and ending steps in
the process, name the customers served; state why it is important to work on this now).

Opportunity Statement

The BMT/OMG HCAHPS are not at the desired benchmark in the area of Pain Management.
Specifically, the questions Was your pain always well controlled? and Did staff do everything to
help with your pain? did not receive a response of Always 77% or more of the time.

Circle all that apply:
Dimension of Performance: Dimensions of health care performance are those definable,
preferably measurable, attributes of the system that are related to its functioning to maintain,
restore, or improve health care.
- Efficiency - Safety
- Staff Satisfaction - Effectiveness
- Patient Centeredness - Continuity

- High Risk - High Impact on Performance
- High Volume - High Potential for Improvement
- Problem Prone - Supports Critical Success Factors
- Low Volume - Patient Safety


(O) Organize a team that knows the process:
List Team Members:

Aurora Davis, Clinical RN, Oncology/BMT Units
Regina Fink, Research Nurse Scientist
Barb Wenger, CNS, Oncology/BMT Units
Barb Krumbach, Peri-Op Nurse Educator (Retired)
Max Swedhin, Med/Surg Progressive Care Unit Nurse Educator

(C) Clarify the current knowledge
What do we know about the process?

A literature search was performed to indicate potential targets to improve patient satisfaction.
Evidence shows that patient education about pain management is critical. Lack of education can
be a barrier to proper pain management. Proper patient education significantly increases overall
patient satisfaction regarding pain management. Patient education reduces barriers to
adherence, which improves outcomes. While it is expected that education on pain management is
performed each shift by the patients RN, there is no formal teaching on pain being given to

(U) Understand sources of variation:
Why are we looking at this process? Why is the process not going the way planned?

It is an expectation that the patients RN will provide education on pain management each shift.
However, the preliminary results of a pain study being performed at UCH show that 43% of study
participants reported receiving no information about pain treatment options. Furthermore,
appropriate documentation in the EHR regarding pain education is sporadic, giving no way to
accurately verify the true frequency of pain education.

(S) Select the improvement:

A formal education tool will be developed. The tool will be used to educate patients about pain

(P) Plan the improvement:

The tool will include information regarding pain management, the WILDA scale, alternative
therapies, and the comfort-function goal. It will be used to educate patients and create a team-
centered approach to pain management (with the patient an active member of the team). The tool
will be a single page teaching sheet on brightly colored paper, available in DOD. The tool will be
translated into Spanish.

(D) Implement the improvement:

The tool was designed and vetted through the units Leadership Team, the physician based Acute
Pain Service, the hospital wide Pain Champions of Change Committee, and the hospital wide
Patient Education Committee. As the design of the tool came to completion, the Pain Champions
decided the distribution and implementation of the tool should be hospital-wide, as opposed to
only unit based. The tool was presented to the Nurse Educators Committee, which agreed upon
a hospital-wide, Level 2 roll out. The tool was rolled out throughout UCH on 5/1/14.

(C) Check the results:

Initial HCAHPS data after implementation of the education tool shows mixed results. The data for
the BMT unit decreased in May to 54% and was a mere 66% in June. The data for OMG has
increased to 70% in May and 78% in June. These numbers are also based on incomplete data for
June, as the number of returned surveys is still small. More data is needed.

(A) Act to hold the gain:

More data will be needed to draw conclusions. However, planning has begun to implement
solutions if the data continues to be mixed or decreases further. Additional data may be gathered
from alternative sources, as well (specifically, Regina Finks UCH Pain Study). Suggested
interventions include: auditing to determine if the tool is being used, reeducation regarding the
pain tool, further education regarding effective pain management, surveys of RNs and patients
regarding the tools use, and additional pain management interventions through alternative
venues (such as the Pain Champions initiatives).

Repeat PDCA as needed and maintain documentation in your department.