University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet
Department __11th floor BMT/OMG
Date__7/1/15__
Primary Contact Person Mary Hendrickson Extension________
(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

HCAHPS scores have been low in a number of areas on the BMT/OMG unit, and
responsiveness is one of the lowest scoring categories. The BMT/OMG unit goal is 70%
in responsiveness but our scores are well below this goal.
Underline 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
Prioritization:
- High Risk
- High Volume
- Problem Prone
- Low Volume

High Impact on Performance

High Potential for Improvement
Supports Critical Success Factors
Patient Safety

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

Mary Hendrickson, BMT/OMG Permanent Charge Nurse

Jamie Nordhagen, BMT/OMG Nurse Manager
Mandy Johnson, BMT/OMG Assistant Nurse Manager
Elizabeth Klatt, BMT/OMG Assistant Nurse Manager
Kyle Hammond, BMT/OMG Nurse Educator
Annsley Buffington, BMT/OMG Nurse Educator
(C) Clarify the current knowledge
What do we know about the process?

Currently, the patient presses their red call button on the bed or call light to request help,
whether it be for pain medication, help to the bathroom, water, positioning, etc. On the
BMT and OMG units, the call rings to the nurse first and the nursing assistant second. It
can take up to 2 minutes before the nurse or nursing assistant answers the call. If it is
not answered within those 2 minutes, then it will begin to ring overhead for all staff.

(U) Understand sources of variation:

Why are we looking at this process? Why is the process not going the way planned?

HCAHPS scores currently show that the BMT/OMG unit responsiveness scores are very
low. Only 62% of the time on BMT and 55% on OMG, do patients feel they are receiving
help within a reasonable time. The literature indicates that implementing specific
scripting into LOOK report can help set the patients expectations ahead of time.
(S) Select the improvement:

A new patient assistance request call system process will be implemented, as well as
education for staffing regarding scripting and setting expectations for the patient.
(P) Plan the improvement:

I will create a new patient assistance request call system process. The patient will call
their nurse or nursing assistant directly on the cisco phones from their room phone. This
will potentially decrease the time it take for their call to be answered, as well as
streamlining accommodating their needs in a more timely manner. The nurse and
nursing assistant will write their names and phone numbers on the white board at the
start of every shift. I will also create large signs for every patient room on our unit. These
signs will include information on what they can call their nurse for (pain, beeping pumps,
nausea, etc.) and what they can call their nursing assistant for (linens changed, water,
positioning, etc.).
(D) Implement the improvement:

I created educational flyers for all staff. These flyers included information on the new call
system, scripting during LOOK report, and phone etiquette. This information was sent to
all staff prior to implementation. Reminders about the new call system were
communicated through Shift Huddles and ongoing email communication. Staff began
implementing this change the end of August 2014 and patients were educated on the
new call system at the start of every shift in LOOK report. I printed out 72 17x11 signs
for every patient room. These were placed in an obvious, easy to read spot for the
patient in February 2015.
(C) Check the results:

Through random audits, nurses and nursing assistants are writing their names with their
cisco phone numbers on the white board 100% of the time. It is unclear how often they
are educating patients on using the new call system during LOOK report, though. Our
HCAHPS scores show a dramatic increase in scores for responsiveness on the OMG
unit from 55% in June 2014 to 66% in June 2015. The BMT unit, however, had a
decrease in overall responsiveness rates from 62% in June 2014 to 56% in June 2015.
(A) Act to hold the gain:

More education on scripting is necessary to remind staff to inform patients of this new
call system process, as well as setting expectations for the patient to know an exact
timeframe for when a staff member will be able to help them. There has been a large
turnover of staff on our unit in the last few months; therefore, new staff will continue to
receive education/orientation on the importance of this new call system. In order to
improve the BMT unit, I plan to research ways to implement the Beacon call system that
is in place on the OMG unit. Due to the call system infrastructure on BMT, there is a
longer delay (approx. 2 minutes) in transmitting patients phone calls. I intend to

collaborate with leadership and management to implement the new Beacon call system
on the BMT unit. Further interventions to improve this response process could include
performing LOOK report audits as well as harnessing the support of our unit service
excellence committee to brainstorm ideas.
Repeat PDCA as needed and maintain documentation in your department.