J Bunch D221 Practice Improvement Plan Proposal

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Western Governors University *

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D221

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Health Science

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Jun 2, 2024

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1 Practice Improvement Plan Proposal Jessica Bunch College of Health Professions, Western Governors University D221: Organizational Systems and Healthcare Transformation Leslie Ferrygood November 25, 2023

2 Implementation of Bedside Shift Report A1. (S)ituation Hand off communication or shift report between registered nurses and the way it is delivered plays a vital role in patient safety, patient satisfaction, and effective communication not only between healthcare professionals but patients’ and families as well. Several organizations including The Joint Commission who has created a national patient safety goal regarding hand off communication, have stressed the importance of having and utilizing a standardized approach to shift report. There are two predominant types of shift report that occur; traditional, in which report is given at the nurses’ station between the oncoming and off going nurse, and the more modern approach of bedside shift report, in which report takes place at patient bedside between the oncoming and off going nurse. There have been several studies showing bedside shift report (BSR) to be effective in reducing sentinel events, and medication errors along with improving patient satisfaction, patient safety, and overall communication between patient and healthcare professional along with healthcare professional to healthcare professional. A2. (B)ackground A2a. The Joint Commission (2017) estimates failed or inadequate hand off communication or shift report contributed to one thousand seven hundred and forty-four (1,744) deaths, and (30%) of all malpractice claims over five years. While the research conducted by Gregory, Tan, Tilrico, Edwardson, and Gamm (2014) after conducting an analysis of twenty-five (25) different studies on the effects and outcomes of BSR there was not only an overall increase in patient satisfaction, but improved care coordination, patient safety, nurse satisfaction, overall reduction in time spent giving shift report, and increased communication between nurse and patient. Out of the twenty-

3 five articles reviewed almost (44.8%) mentioned increased patient satisfaction, (34.5%) noted a patients’ increased understanding of care, (34.5%) showed increased patient safety and communication with nurses, (20.7%) indicated increased nurse involvement with care, and (31%) mentioned both improved nurse satisfaction and a reduction in overall time spent on shift report (Gregory et al., 2014). A2b. The Joint Commissions Sentinel Event Alert: 58 (2017) states in 2006 that failed hand- offs or shift report was identified as a longstanding and common problem in health care requiring the establishment of a National Patient Safety Goal (NPSG) that specifically addressed hand-off communication. Following the creation of the 2006 NPSG for hand-off communication the provision of care standard PC.02.02.01, element of performance (EP) 2 was made effective in 2010. According to The Joint Commissions Sentinel Event Alert: 58 (2017), this particular provision of care standard requires that: “The organization’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information.” Bedside shift report has been shown to allow nurses and/or healthcare professionals to improve patient safety and satisfaction, while simultaneously reducing medication and communication errors. With BSR it allows both on-coming and off-going nurse to be present at the patient’s bedside to not only be able to visualize the patient, but to confirm medication dosages and or rates on IV pumps, inspect and ensure proper patient alarms are in place, turn or reposition patient’s helping to potentially mitigate skin breakdown, and allows for the patient to participate and engage in his or her own care. As stated, before there are a multitude of studies showing the effectiveness of BSR and it addresses the problems and issues

4 of inadequate shift report or hand-off communication that can be seen with traditional shift report that is conducted at the nurse’s station. A3. (A)ssess Traditional shift report conducted at the nurses’ station impacts patients, staff, and the organization as whole by leaving the door open for failed hand-off communication through, inconsistencies in the amount of information exchanged in report, non-standardized organization of information, lack of cleanliness of patient's rooms, and increased time away from the patients’ room. All of which could potentially lead to missing an incorrectly programed IV pump, missed alarms, missed drain malfunctions, and many other avoidable adverse patient safety events. Bedside shift report can avoid or mitigate many missed alarms or potential safety events ultimately reducing patient harm, the risk for medical claims and lawsuits, and legal issues that may arise from an adverse or sentinel event. A3a. According to Martini and Reset (2021) shift report is defined as a critical transition of care and is a time when essential information about the care of the patient and about the patient is exchanged. A nurse’s role is preventing harm and care for patients by providing safe, effective, quality care to every patient. Traditional shift report away from the patient’s bedside can reduce the overall value of patient care given to a patient. In general, traditional shift report leads to reduced patient satisfaction and understanding of care along with the chances of adverse or safety events occurring while in report away from patient bedside. Patient harm or adverse safety events such as a fall or medication error can increase healthcare cost for both the patient and hospital along with increasing length of stay leading to potentially more adverse events or

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