Running head: FINAL SUMMARY REPORT

Final Summary Report

Jessica Organt
Bon Secours Memorial College of Nursing
Synthesis of Nursing Practice
Nur 4242
Wendi Liverman
November 1, 2015
Final Summary Report
Introduction
The purpose of this paper is to go over the final summary report of a quality improvement
project that has recently been implemented. The author chose to focus on a general
Medicine/Surgical/Oncology floor at the Veterans Administration (VA) Hospital. It had been
noted in recent months prior to this studys implementation, that overall patient falls had
increased and patient satisfaction had decreased significantly. The purpose of this project was to
implement hourly rounding with a purpose. That is, to ensure that during hourly rounds the four
Ps are being addressed; pain, positioning, possessions and potty. In addition, to help reduce falls,
the author added in a section for bed alarms as well. The hope for this project was to not only

increase patient satisfaction and decrease patient falls, but to also hold all the nurses accountable
for hourly rounding on their patients.
Prior to the implementation of this project, there had been no such protocol in place for
documenting hourly rounds. Although it was something that was implied should be carried
through; there was nothing at the bedside to denote so. Before this project could be implemented,
an in-service needed to be done for all staff: the Registered Nurses (RNs), Licensed Practical
Nurses (LPNs), and Nursing Assistants (NAs). In this in-service, the purpose of this project was
discussed, as well as proper documentation. It was noted during the in-service that there was
much confusion about proper settings for bed alarms on the unit. It turns out, much of the staff
was misinformed about the proper way to set the alarm, and in doing so, the alarm was not set to
the proper sensitivity level and the alarms were not going off until the patient had gotten fully out
of the bed.

Implementation
To begin the project, as previously stated, an in-service was held for the entire unit.
During the in-service, the author discussed the changes to hourly rounding protocols, and the
reasoning behind it. The author explained that recent studies where hourly rounding with a
purpose had been implemented, that overall patient satisfaction rose, patient falls declined and
the number of pressure ulcers hospital-wide decreased (Brosey & March, 2015). As previously
stated, during this in-service it was noted that there was a large percentage of staff that had not
been properly trained and educated on the bed alarms. The bed alarms have a scale to set
sensitivity levels; one side of the scale is very sensitive, alarming when the patient puts any
weight on even the side rails while the reverse side of the scale is less sensitive, only alarming

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once the patient is fully out of the bed. Because many of the nurses were setting the alarms
improperly, an in-service on bed alarms alone was also conducted to properly educate all staff.
Prior to the project starting, the author pulled up the last six months of Press Ganey
surveys in regards to patient satisfaction, as well as patient falls. This was used as the baseline
for the project model.
The project began on September 7, 2015, by dispersing hourly rounding sheets to every
bedside. On each sheet, there was a box to check every hour in regards to pain, positioning
(turning or assistance with getting comfortable), potty (assisting with bathroom privileges or
changing the patient as needed), possessions (making sure the patient had all their belongings
they wanted within reach, including call bell), and lastly bed alarms (ensuring that all high fall
risk patients had a bed alarm on and engaged to proper settings).
Aside from noticing that not all staff had been properly educated and trained on the bed
alarm systems, the author also found that many of the bed alarms were faulty. Either an electrical
problem with the bed not working with the call bell system, or the bed alarm just not working at
all, the author had to place engineering work orders for every bed that wouldnt properly alarm.
Once the project had been implemented, it took a week or so for the staff to get truly
involved; ensuring that they were documenting every hour as they should and checking all bed
alarms. As charge nurse, the author also went behind each nurse and made rounds on the floor to
ensure proper documentation and rounding had been done. The author also included overall
patient satisfaction as a question in daily rounds, asking if there was anything else the unit could
be doing better for the patient.
Conclusion

FINAL SUMMARY REPORT

After the first round of the project was completed, data was retrieved from the nurse
manager regarding patient satisfaction scores and falls. It was noted during daily rounding as
charge nurse, that overall pain control was reported higher, patient satisfaction was greatly
improved, and the only suggestions for improvement were non-nursing related (such as food and
room setup). Patients also stated that they felt they saw the nurses more frequently, and felt their
needs were being met in a more timely manner. Past research supported this finding, that when
hourly rounding is implemented, patients feel their nurse presence had increased as well
(Rondinelli, Ecker, Crawford, Seelinger, & Omery, 2012).
At the start of this project, patient satisfaction had been at a very low point (78.4). The
goal for the unit in the facility is to maintain at least 81 percent patient satisfaction. After one
cycle had been completed, by October 9, 2015 patient satisfaction had rose to 93.2 percent, the
highest it had been in quite some time. Patient falls have also decreased after the in-services and
implementation of hourly rounding, and compliance with bed alarms is at 100 percent. All
patients who have been noted as a high fall risk from the Morse Fall Scale has a bed alarm
engaged.
It should be noted that throughout the cycle of this project that many of the bed alarms
continued to go out of commission. This is an ongoing problem that has been addressed by
engineering, and new beds have been ordered to replace the faulty beds that continue to not work
properly at all times. Because of this, until the new beds arrive in December, it is essential that
all employees continue to check the bed alarms to ensure they are in proper working condition.
Since the implementation of this project, it is clear that patients and staff have responded
very well, and the project was a success. As a unit, it has been decided that this will no longer be
a project to run cycles on, rather this will now be the new standard for the unit. After seeing the

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results from the first cycle, it has been noted that other units in the hospital have also
implemented the same rounding protocols. The unit and facility hope that the rise in patient
satisfaction and decrease in the number of patient falls continues on the trend that has been set.

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6
References

Brosey, L. A., & March, K. S. (2015). Effectiveness of structured hourly nurse rounding on
patient satisfaction and clinical outcomes. Journal of Nursing Care Quality, 30(2), 153159. http://dx.doi.org/10.1097/NCQ.0000000000000086
Rondinelli, J., Ecker, M., Crawford, C., Seelinger, C., & Omery, A. (2012). Hourly rounding
implementation: A multisite description of structures, processes and outcomes. Journal of
Nursing Administration, 42(6), 326-332.
http://dx.doi.org/10.1097/NNA.0b013e31824ccd43