NATIVIDAD MEDICAL CENTER Developing a Test of Change (PDSA Cycle)
Project Title:ICU “getting to know you” IHI Patient Preferred Name Project / Date:1/27/17
Idea to be tested:
Adding field to white board to increase patient-centered care through identification and communication of patients preferred name / PDSA Cycle #1, #2
To test an idea, it will usually require multiple PDSA cycles.
Describe your first (or next) test of change:
ICU will begin staff education and two week test of change / Responsible
Parties;
ICU Leadership and RN staff / When to be done:
Monday 1/30/17 / Where to be done:
ICU
Plan / List the tasks needed to set up this test of change. / Person Responsible / When to be done / Where to be done
1.ICU room review for ideal location of patient name information
2. MSU field trip to review white board pen storage
3. Team identification of anticipated process
4. Staff education of new process/ Huddle Board and 1:1 by Charge RN
5. Organizational informational note of current test of change
6. Creation of simple paper audit tool
7. Review Aim statement with team
8.ICU leadership to use huddle time to discuss visibility of plan with staff (size, color etc.) / 1. Siri, Elena, Susan, Lynette, & Geni
2.. Siri and Elena
3.. Siri, Elena, Susan, Lynette, Geni
4. Elena and Uly
5. Susan
6. Lynette & Siri
7. Team
8. Siri and Susan / 1. 1/27/17 Met
2. 1/30/17 Met
3. 1/27/17 Met
4. 1/30/17 Met
5. 2/3/17 Deferred
6. 1/30/17 Met
7. 2/22/17 Met
8.2/28/17 /
- ICU
- MSU
- Susan’s office
- ICU
- ICU
- ICU
- ICU
- ICU
Predict what will happen when the test is carried out / Measures to determine if prediction is correct
1. ICU nurses will generally be agreeable to new admission step
2. There may be inconsistent application of process to start
3. Team may discover unrecognized staff concerns/ work flow issues / 1. Feedback from staff education – Occurred as expected
2. Audit tool to measure consistency- Occurred as expected, but acceptable to audit results and reinforced as needed
3. Refinement of process as needed-
Do /
- Share project with staff/educate toward expectations and monitoring
- Carry out the change or test and collect data. Document date completed.
- Have mid-point meeting to review data and processes- refine Aim statement as needed. Discuss barriers/ revise plan
- Take team discussion back to daily huddle for front line staff input toward cyclical process improvement.
- Add follow-up patient satisfaction questions for Administrative walking rounds to be ask of patients in MSU that transferred from ICU.
- 1/27/17
- Please see audit results
- 2/22/17
- Through 2/28/17
- Email request sent to team for approval 2/23/17 prior to sending to to Jeanne , Maria and Nancy
Study / Analyze the data. Describe the measured results and how they compared to the predictions. Summarize what was learned.
In studying the results of this initiative we’ve noted movement toward peripheralparticipation by our providers. Nursing is committed to moving Patient-Centered team communication forward but is limited by scope constraints to propel project to a deeper unit culture level without further provider buy-in. / 2/22/17
Act / Describe what modifications to the plan will be made for the next PDSA cycle from what you learned. Are we ready to implement this change?
- Current modifications involve reducing our expansive Aim statement from the expectation that staff will accomplish 100% preferred patient name identification toAs a standard ofICU care,the assigned nurse will assess the patient at each shift assessment for patients/family’s ability to provide Patient Preferred name, then place information on common white board in patient’s room as information is provided 100% of the time by end of this learning series.
- Improve visibility of preferred name information with staff input
- Share study findings from team with providers and administrative leaders, not to force change, but for transparency and support toward future patient-centered goals as determined by ICU leadership.
- 2/22/17
- By 2/28/17
- By 2/28/17