University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet
Department !ncolo"y#$one %arro& Transplant Inpatient Unit
Date Au"ust '()*-Au"ust '()+
Primary Contact Person Pamela Heinke, -., $/., !C.
01tension 2'(-3+3-+'24
(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).
!pportunity /tatement
On our unit a lack of communication, recognition, and education amongst the C!"!C# group had
been an issue since $ began as an !C# in %&&'. $ performed a few literature searches and found that
continuously educating C!"!C#s led to better patient outcomes and overall (ob satisfaction. $ therefore
wanted to start a C!"!C# council that would allow them to e)press their concerns, provide education to
them, and also recogni*e all of their hard work. $ met with our unit leaders and they agreed this would be a
useful pro(ect for our unit. $ feel it is e)tremely important to work on this now because C!"!C#s are
such a critical part of patient satisfaction and + satisfaction scores. $ wanted them to feel valued, which
would help staff retention, burnout rates, and provide better patient outcomes.
Circle all that apply
Dimension of Performance ,imensions 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.
- .fficiency - /afety
- /taff /atisfaction - .ffectiveness
- #atient Centeredness - Continuity
Prioriti5ation
- 0igh +isk - 0igh $mpact on #erformance
- 0igh 1olume - 0igh #otential for $mprovement
- #roblem #rone - /upports Critical /uccess 2actors
- 3ow 1olume - #atient /afety

(O) Organize a team that knows the process:
List Team Members:
4he team for this pro(ect included5 6ennifer 7wink, +, 8/, OC (urse 8anager); 6amie
ordhagen, +, 9/, OC (!ssociate urse 8anager); 8andy 6ohnson, +, 80#, CC+ (!ssociate
urse 8anager); :yle 0ammond, +, 9/, OC (Clinical urse .ducator); !nnsley 9uffington, +,
9/, OC (Clinical urse .ducator); 9arbara ;enger, 8/, +, !OC/, C+$ (Clinical urse
/pecialist).
(C) Clarify the current knowledge
What do we know about the process?
;hen $ started this pro(ect there was an opportunity to increase communication among
C!"!C#s. 4here was a lack of communication among this group, recognition, and continuing education.
$ conducted a comprehensive literature search and confirmed that all of the above mentioned are critical to
staff retention, staff satisfaction, and positive patient outcomes. +etaining C!s is important as it is linked
to better <uality of patient care. 4he literature also shows that lack of appreciation and respect from
supervisors and employers has been cited as one of the most common reasons C!s leave their (obs (Choi
et al, %&=%).
(U) nderstand sources of !ariation:
Why are we looking at this process? Why is the process not going the way planned?
2rom the literature it is noted that other institutions may not have a formal council for C!"!C#s,
but they do touch base with them more consistently for training and for support. 2ederal law mandates =%
hours of continuing education every year. 4his level of training and continuing educations is considered
inade<uate in preparing direct care workers for providing <uality care (/engupta et al, %&=%). 9urnout
rates, turnover, poor attitudes, lack of empowerment, and relationship to C! performance are related to
perceived training availability. /tudies suggest that when training is amply provided, attitudes improve,
turnover reduces, and performance increases (>eatts et al, %&=&). 4his council was designed to help with
staff recognition, training, and staff satisfaction. Currently the only ongoing training for C!"!C#s is an
annual ;.33/ center training. ;e also only touch base with them on an annual basis for their reviews
(unless disciplinary action is re<uired). $t is important to provide positive feedback and an environment full
of enrichment in order to improve staff satisfaction and better patient outcomes.
(S) "elect the impro!ement:
8y pro(ect?s goal was to develop a unit based C!"!C# council to help with recognition, (ob
satisfaction, staff retention, and communication. $n order to do this $ needed to improve communication
among C!"!C#s (currently there is very minimal communication other than the annual competency).
$ also needed to recogni*e staff through email, in person, and at shift huddles to increase (ob satisfaction.
2inally, $ needed to provide monthly educational emails to C!"!C#s. #rior to starting this pro(ect $ felt it
would help to gain input from this group so $ sent out a #re-/urvey to all C!"!C#s to find out how they
were feeling in their (ob duties, educational needs, and work environment. $ designed my own surveys as $
could not find a good survey tool for a C!"!C# council.
(P) #lan the impro!ement:
!fter the input from the pre survey, my plans for the pro(ect included5
=) #lan monthly meetings agenda.
%) #lan mandatory meetings in !pril to discuss the new e)pectations of this group. 4his includes
logging into /hare#oint two times a month in place of staff meetings.
@) #lan <uarterly in person meetings with C!"!C#s to allow more face time with management.
A) 8eet with 6amie ordhagen to gain access to /hare#oint and approve meetings. Bet a budget
for C!"!C# council to give out gift cards for e)cellent service.
(D) $mplement the impro!ement:
/tarting in 6anuary of %&=A $ began sending emails to the C!"!C# group to advertise the new
council. $ also put up posters and flyers. $ then did the following5
=) /tarted a C!"!C# council and implemented monthly meetings for support"teaching
opportunities.
%) 8andatory training for C!"!C#s in !pril in addition to the mandatory ;.33/ center
training in 8ay.
@) /tarted posting online (/hare#oint) to deliver information and allow for discussions in a safe
environment. 4his online option will allowed a way for C!"!C#s to participate and obtain valuable
information. !ttendance at staff meetings has been notoriously low for this group and this now give a way
for them to participate without having to physically come in to work.
A) +ecognition emails to staff, in person, and at shift huddles.
C) Obtained a budget from 6en 7wink in 6une %&=A of D=%C per year in gift cards. /tarted giving
them out. 0elped to plan annual C!"!C# party in 6une %&=A and passed out more gift cards and thank-
you cards.
E) #ost-surveys sent out to see if (ob duties, educational needs, and work environment improved.
(C) Check the results:
$n 6une of %&=A after E months of meetings and posting on /hare#oint $ sent a post survey to
evaluate the outcomes from this pro(ect. !s $ could not find a good survey tool for a C!"!C# council
through my literature searches, $ designed my own survey. $ asked a series of =% <uestions and had the
C!"!C#s rate their answers as =FCompletely disagree, %F,isagree, @F !gree, and AF Completely
,isagree. $ then took all of my scores and determined the mean and standard deviation of the scores.
!fter waiting % weeks from sending out my post surveys, $ received a total of %% surveys. 2irst $
separated all of my survey results into all received (%%) and matched post surveys with my pre surveys
(E"%%). /ince my matched surveys were such a small sample, $ decided to analy*e the matched and
unmatched surveys separately.
2or my matched surveys, $ found that there was a large improvement in satisfaction of (ob duties,
with the e)ception of acuities and bathing patients. 4his is not surprising, as $ did not have an intervention
in place at the time of the post survey for C!"!C# acuities. $ am currently in the process of finali*ing an
acuity tool for C!"!C#s. 2or bathing of patients $ did not apply any interventions so am not surprised
that the scores went down. 0opefully with the acuity tool these scores will also improve.
2or the educational needs it was accessed during the pre survey that there was not a lot of need for
more education on transferring, toileting high fall risk patients, or identifying high fall risk patients. 8ost
disagreed that they needed further information during the pre survey and the post survey found that most
agreed or completely agreed that they were educated on these values. 2or the work environment there was
an improvement in (ob satisfaction among the matched post survey in all three <uestions asked.
2or the unmatched post surveys, the results were very similar to the matched surveys. 4he main
difference was that the unmatched surveys did feel that they had ade<uate time to bath patients. !ll other
results were consistent with what was found in the matched surveys.
#ost 8atched /urvey +espondent ,emographics (FE)
Demographics
Post Matched
Gender 8ale &"E 2emale E"E (=&&G)
Job Description:
CNA or ACP
C!s @"E (C&G) !C#s @"E (C&G)
Shift most often
worked
,ay shift @"E (C&G) ight shift %"E (@@G) +otating shifts ="E (=HG)
Weekend/Weekda
/ or both
;eekend &"E ;eekday ="E (=HG) 9oth C"E (I@G)
!ears of
e"perience as
CNA/ACP
=-C years E"E (=&&G) C-=& years E"E (=&&G)
!ears of
e"perience as
CNA/ACP at #C$
=-C years E"E (=&&G) C-=& years E"E (=&&G)
#ost /urvey +esults (FE)
Juestions #re /urvey
8ean (/,)
#ost
/urvey
8ean
(/,)
=. $ know how to access KC0?s #olicies and #rocedures @ (=.&') @.C (&.IA)
%. $ feel $ have ade<uate time to toilet patients during hourly
rounding
%.C (&.CC) @ (&.E@)
@. $ feel $ have ade<uate time to turn patients during hourly
rounding
%.C (&.CC) @.% (&.HC)
A. $ feel $ have ade<uate time to bath all of patients during my shift %.% (&.A=) %.H (=.&@)
C. $ am given a short report on patients from +s at the beginning
of my shift
% (&.E@) %.@(&.I%)
E. $ would like my assignment to be acuity based like +
assignments LL#ost survey <uestion 8y assignment is acuity
based like + assignments. LL
@.@ (&.I%) % (&.I')
H. $ feel $ need more education on how to safely transfer a patient
from the bed to a chair and from a chair to the bed LL#ost
%.% (&.A=) @.C (&.IA)
survey <uestion- $ feel educated on how to safely transfer a
patient from the bed to a chair and from a chair to the bedLL
I. $ feel $ need more education on how to identify a high fall risk
patient LL#ost survey <uestion- $ feel educated on how to
identify high fall risk patientsLL
%.@ (&.C%) @.H (&.C%)
'. $ feel $ need more education on how to toilet a high fall risk
patient LL#ost survey <uestion- $ feel educated on how to
toilet high fall risk patientsLL
%.C (&.CC) @.C (&.CC)
=&. $ feel that $ am treated fairly at work %.H (&.C%) @.C (&.CC)
==. $ feel $ am told when $ do a good (ob at work %.H (&.C%) @.% (&.A=)
=%. $ feel my workload is manageable in order to do a good (ob %.% (&.HC) %.I (&.A=)
=F Completely ,isagree %F ,isagree @F !gree AF Completely !gree
LLL.)ample5 ! mean of @ F out of E people the average score agree with <uestion.LLL
#ost /urvey +espondent ,emographics Knmatched (F%%)
Demographics%
Post
#nmatched&
Gender 8ale ="%% (CG) 2emale %="%% ('CG)
Job Description:
CNA or ACP
C!s =%"%% (CAG) !C#s =&"%% (ACG)
Shift most often
worked
,ay shift =@"%% (C'G) ight shift C"%% (%%G) +otating shifts A"%% (=IG)
Weekend/Weekda
/ or both
;eekend %"%% ('G) ;eekday @"%% (=AG) 9oth =H"%% (HHG)
!ears of
e"perience as
CNA/ACP
=-C years %="%% ('CG) C-=& years &"%% M=& years ="%% (CG)
!ears of
e"perience as
CNA/ACP at #C$
=-C years %="%% ('CG) C-=& years &"%% M=& years ="%% (CG)
/urvey +esults (F%%)
Juestions #re
8ean (/,)
#ost
8ean (/,)
=. $ know how to access KC0?s #olicies and #rocedures @.=I (&.'C) @.AC (&.H@)
%. $ feel $ have ade<uate time to toilet patients during hourly
rounding
%.CC (&.I&) %.'= (&.C@)
@. $ feel $ have ade<uate time to turn patients during hourly
rounding
%.'C (&.A') @.&' (&.E=)
A. $ feel $ have ade<uate time to bath all of patients during my shift %.AC (&.I&) %.%H (&.HH)
C. $ am given a short report on patients from +s at the beginning
of my shift
%.&' (&.HC) %.@% (&.HI)
E. $ would like my assignment to be acuity based like +
assignments LL#ost survey <uestion 8y assignment is acuity
based like + assignments. LL
@.%@ (&.E') %.= (&.E')
H. $ feel $ need more education on how to safely transfer a patient
from the bed to a chair and from a chair to the bed LL#ost
survey <uestion- $ feel educated on how to safely transfer a
patient from the bed to a chair and from a chair to the bedLL
=.'C (&.H') @.CC(&.I&)
I. $ feel $ need more education on how to identify a high fall risk
patient LL#ost survey <uestion- $ feel educated on how to
%.=I (&.H') @.CA(&.C=)
identify high fall risk patientsLL
'. $ feel $ need more education on how to toilet a high fall risk
patient LL#ost survey <uestion- $ feel educated on how to
toilet high fall risk patientsLL
%.=I (&.IC) @.C (&.E&)
=&. $ feel that $ am treated fairly at work @.@ (&.H&) @.C (&.C=)
==. $ feel $ am told when $ do a good (ob at work @.&C (&.H%) @.%H (&.E@)
=%. $ feel my workload is manageable in order to do a good (ob %.EA (&.H') @.& (&.AA)
=F Completely ,isagree %F ,isagree @F !gree AF Completely !gree
LLL.)ample5 ! mean of @ F out of %% people the average score agree with <uestionLLL
(A) %ct to hold the gain:
$ plan to continue posting discussions to /hare#oint bi-weekly. $ also plan to send out an
education email once a month with important tips. Juarterly $ will plan meetings for C!"!C# council
for them to attend in person if they desire (possibly making mandatory). 4his will allow them to have some
time with management too. 6amie ordhagen and"or 8andy 6ohnson have agreed to attend these meetings.
$ also plan to bring in guest speakers for these meetings. $ have successfully obtained an annual budget
from management and will continue to reward C!"!C#s for their service e)cellence. 2inally, $ will work
with my nurse educators to develop a continuing educational program for our C!"!C#s <uarterly.
Repeat PDCA as needed and maintain documentation in your department.
-eferences
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(3O. I).
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.ffects of an advanced nursing (ob satisfaction, turnover rate, assistant education
program on and clinical outcomes. 6ournal of Berontological ursing, @'(=&), @A-C&.
doi5=&.@'%I"&&'I'=@A-%&=@&E=%-&% (3O. H)
@. Choi, 6., N 6ohantgen, 8. (%&=%). 4he importance of supervision in retention of C!s.
+esearch in ursing N 0ealth, @C(%), =IH-=''. doi5=&.=&&%"nur.%=AE= (3O. I)
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@A(@), %E-@C. (3O. H)
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=E%-=H&. (3O. I)
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ews (3O. I)
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A%(@), =AA-=AH. doi5=&.=&'H"!.&b&=@e@=I%AIAefd (3O. H)
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@@(A), @I@-@'C (3O. %).
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==. ;est, #., /culli, B., 2ore, !., Okam, ., ,unlap, C., eily, 6., N 8ills, #. (%&=%).
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doi5=&.=&'H"!.&b&=@e@=I%@c=HcH (3O. =)
=%. >eatts, ,. .., Cready, C., /wan, 6., N /hen, >. (%&=&). 4he perception of Otraining
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