Running head: NO PASS ZONE

Online Project: No Pass Zone

Melinda L. Swander
University of Central Florida

NO PASS ZONE

No Pass Zone: Cardiology Unit at Munroe Regional Medical Center

Module One-1: Introduction
This module will serve as a make-up session for both registered nurses and
certified nursing assistants on the cardiology unit, who were unable to attend one of the
mandatory skills lab sessions for implementation of the clinical and non-clinical No Pass Zone
Initiative. The No Pass Zone Initiative, is designed to help assist patients in a timelier manner
and improve their perception of staff responsiveness (Colancecco, Moriarty, & Litak, 2014).
Currently, according to the most recent Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) survey results, Munroe Regional ranks in the 1% percentile for
responsiveness compared to other hospitals within the HealthStream database (HealthStream,
2015). This is by far the facilities lowest ranking score and needs the attention and support of
both clinical and non-clinical staff house wide. Together, the staff can significantly impact the
perception of our patients! Learning objectives for this module focus on the cognitive domain
and are listed below (Bastable, 2014).
Objectives
At the completion of this module, the associate will be able to
1. Identify at least three tactics in which patients and/or their families use to indicate to the
staff that they need attention. (Cognitive domain, knowledge)
2. List four methods all associates can use to improve the way their responsiveness is
perceived (Cognitive domain, application)
3. Discuss the five steps for responding to a call light of a patient that is not directly
assigned to the staff member (Cognitive domain, comprehension)

NO PASS ZONE

4. Evaluate two key phrases that work to improve patients perception when responding to a
call light (Cognitive domain, analysis)
Required Readings and Resources

California Hospital Patient Safety Organization. (2015). Lessons learned: the no pass
zone for patient safety. Retrieved from http://www.chpso.org/lessons-learned/nopass-zone-patient-safety

Colancecco, E., Moriarty, S., & Litak, L. (2014). None shall pass...Without answering
the call bell. Nursing, 44(1), 16-17.

Press Ganey. (2010). CAHPS Hospital Survey (HCAHPS): Solution starter. Retrieved
from
http://mrhswss02/HCAHPS/Understanding%20HCAHPS/HCAHPS%20Solution%20
Starter.pdf (Link available on hospital intranet)

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Module One-2: Patient Survey Results
What are the patients saying about the staffs responsiveness to their needs? At Munroe
Regional Medical Center, the Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) survey is utilized to hear the voice of the patient. The full survey is
twenty-seven questions regarding their hospitalization that is given to a random sample of
patients forty-eight hours to six weeks following their discharge (Center for Medicare &
Medicaid Services, 2014). At Munroe Regional, the nursing staff is specifically focused on
the percentage of patients that responded always or very satisfied in question domains
that address: Communication, pain, and responsiveness. The HCAHPS survey results are
reported by HealthStream and the results for 2015 are as follows:

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The responsiveness domain is the lowest scored area of focus. Listed below are Munroe
Regional Medical Centers specific results to the questions within this domain:

(Charts created using HealthStream 2015 Data for Munroe Regional by M.Swander)

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Module One-3: Assessment & Strategies
Assessment
Patients and their families can communicate to staff that they need assistance with both
verbal and non-verbal cues (Studer, Robinson, & Cook, 2010). While some patients may utilize
their call light, others will stand in the hallway, call out, follow the staff member down the hall,
call the nursing station, or wave the staff member down as they pass the room. Patients are also
located beyond the nursing units in the hallways and elevators. How many of you have been
walking down the hall and spot that patient or visitor that looks lost? Do they have to tell you
that they need directions? Interactions with patients and or their visitors occur countless times
throughout shift.
Strategies
In addition to responding timely to a patients call light, there are other ways staff can
improve a patients perception of responsiveness. When staff see a lost patient or visitor in the
hallway, they can use way-finding, ask them where they are going and take them to their
destination (Press Ganey, 2010). This shows compassion and allows them to see that we are
responding to their needs before they even ask. Using elevator etiquette and acknowledging
people within five feet is also a great way to show responsiveness.

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Module One-4: The No Pass Zone
In efforts to improve our responsiveness to call lights, Munroe Regional is introducing
the No Pass Zone Initiative for both clinical and non-clinical staff (Community Cares, 2015).
Nursing is certainly not the only staff members that can impact the patients perception of staff
responsiveness (Studer, Robinson, & Cook, 2010).
Please click on the link below to watch the narrated PowerPoint:
No Pass Zone Narrated PowerPoint (approximately 5 minutes)

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Module One-5: Learning Activities & Evaluation
1. Watch the following YouTube clip created by the University of Cincinnati:
HealthNutsMedia. (2015, November 12). The no pass zone: UC Health [Video file].
Retrieved from https://www.youtube.com/watch?v=4QDfE-aMt9c
(approximately 2.5 minutes)
2. Log on to Adobe Connect on December 10th at 1400-1500 to discuss your thoughts
regarding the video. https://meet16194701.adobeconnect.com/no_pass_zone/ Be prepared
to discuss: What the associate did well and what he could have done better when
responding to the patients call light. Please share your thoughts with using these tactics.
Active participation in the discussion is expected and points will be deducted for
inactivity. (Must be present for full hour to receive credit and contribute at least two
times to the discussion). Please ensure to create username and check connectivity prior to
scheduled discussion time. If you have questions regarding set up, please contact the help
desk at 555-5555.
3. Complete the on-line quiz (5 questions) by December 11th at 2359. You will have 15
minutes to complete the quiz. See rubric below for content.
4. Evaluate this learning activity on SurveyMonkey by December 11th at 2359. (5 questions)
https://www.surveymonkey.com/r/XJ79CHD

If you should have any questions or concerns while completing this module,
please contact Melinda Swander at 352-427-5225 for assistance.

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Module One Grading Rubric

Adobe Connect Discussion

On-Line Quiz

Learning evaluation on
SurveyMonkey

Total Points

Module One Grading Rubric: No Pass Zone

Active participation in online discussion that
demonstrates knowledge of the module content.
You must contribute two times to receive full credit
and be present for the full hour.
There will be a total of 5 quiz questions: Content
will include: Tactics used by patients/families to get
our attention, methods to improve responsiveness,
steps in responding to call lights, and using words
that work when communicating responsiveness to
patients. You will have 15 minutes to complete
quiz. Quizzes completed after due date will not
receive any credit.
Completion of learning evaluation- Total of 5
questions. Print and submit confirmation page that
you have completed evaluation on SurveyMonkey.
Confirmation pages received after due date will not
receive any credit.

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References
Bastable, S. B. (2014). Nurse as educator: Principles of teaching and learning for nursing
practice (4th ed.). Burlington, MA: Jones & Bartlett .
California Hospital Patient Safety Organization. (2015). Lessons learned: the no pass zone for
patient safety. Retrieved from http://www.chpso.org/lessons-learned/no-pass-zonepatient-safety
Colancecco, E., Moriarty, S., & Litak, L. (2014). None shall pass...Without answering the call
bell. Nursing, 44(1), 16-17.
Community Cares. (2015). No pass zone algorithm. Retrieved from
http://mrhswss02/The%20Munroe%20Way%20Toolkit/No%20Pass%20Zone%20Resour
ces/No%20Pass%20Zone%20Algorithm.pdf (Available on hospital intranet)
HealthStream. (2015). Insights online. Retrieved from
https://www.healthstreamresearch.com/InsightsOnline/Pages/ReportBuilder.aspx
(Available on hospital intranet)
HealthNutsMedia. (2015, November 12). The no pass zone: UC Health [Video file]. Retrieved
from https://www.youtube.com/watch?v=4QDfE-aMt9c
Press Ganey. (2010). CAHPS Hospital Survey (HCAHPS): Solution starter. Retrieved from
http://mrhswss02/HCAHPS/Understanding%20HCAHPS/HCAHPS%20Solution%20Star
ter.pdf (Available on hospital intranet)
Studer, Q., Robinson, B., & Cook, K. (2010). The HCAHPS Handbook. Gulf Breeze, FL: Fire
Starter Publishing.
SurveyMonkey. (2015). No pass zone. Retrieved from
https://www.surveymonkey.com/r/XJ79CHD