Poster - #2022UCDH-5 - Keywords: Call-light Westcom nursing-responsiveness No-Pass-Zone

No Pass Zone: Promoting Nursing Responsiveness

Sandy Burlando, MSN, RN, PCCN, Chair Maria Martinez, BSN, RN, Co-Chair Barbara Gumnor, MSN, RN, CCRN-k, CNRI, NEA-BC Susan Lee, BSN, RN, PCCN Annie Leung, MSN, RN Jackie Rodman, MSN, RN, PCCN Samantha Streepy, MSN, RN, CMSRN, Quality & Safety Champion Hillary Tucker, MSN, RN, CCRN
UCDavis Health

ABSTRACT:
No Pass Zone: Promoting Nursing Responsiveness Background: Patients must feel safe and cared for while in the hospital. One way to achieve this is to ensure nursing response is prompt and efficient. In the fiscal year 2020-2021, the UC Davis Health Systems benchmark for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores regarding nursing responsiveness was 67.7%. In the Cardiothoracic PCU (CTPCU), HCAHPS responsiveness was lacking at 53.5%. In effort to better serve our patients and increase the RN responsiveness HCAHPS scores, the CTPCU Unit Based Practice Counsel implemented The No Pass Zone initiative. Purpose: The No Pass Zone encourages all staff members to acknowledge patient needs, alarming pumps, and safety issues. The goal of this project was to meet or exceed the hospital’s benchmark of 67.7% for patient satisfaction HCAPS score for nursing responsiveness. The purpose of The No Pass Zone was to increase patient satisfaction, address patients’ needs in a timely manner, and to work collaboratively with all nursing staff to ensure safe, satisfied patients. The PDSA (Plan-Do-Study-Act) framework was used for this quality improvement project. Methods: An A-3 was completed to identify causes preventing us from meeting our target. A pre-survey was done with questions that focused on nurses’ abilities to answer their assigned patients’ call lights in a timely manner, as well as their comfort in answering call lights for other nurses’ patients. A four-question Likert-scale survey was developed by the East 6 Unit Based Practice Council. This was sent to RN nursing staff via email and a QR code was posted on the huddle board in September, 2021. Patient satisfaction with responsiveness was based on HCAHPS scores. Additionally, the West-Com call-light system was updated with pre-programmed messages to reflect the top patient needs. The updated call-light system assists the Hospital Unit Service Coordinator (HUSC) in notifying the assigned nurse of exact needs, saving time and allowing the nurse to adequately address the patients needs. The No Pass Zone was presented to all staff during our August 2021 staff meetings. A “go-live” date was set for October 1, 2021. Flyers were designed and posted in staff areas at the beginning of October as a reminder and it was also discussed in daily huddles. A post survey was conducted in December 2021. Results: Out of fifty-three RN staff members, thirty-three completed surveys were received (62%). Only 24.2% of nurses strongly agreed they were confident in answering their call-lights in a timely manner. However, 66.7% of nurses strongly agreed to feeling comfortable in answering call-lights for other staff members. The post-survey was conducted in December 2021 with twenty-six nurses responding (49%). 53.85% of the nurses strongly agreed they were confident in answering their call-lights in a timely manner and 65.38% of nurses strongly agreed they were confident in answering call-lights for their peers. Additionally, CTPCU’s HCAHPS nursing responsiveness scores showed an increase from 48.3% in September, 2021 before the intervention to 70.8% in November 2021 after the intervention. Discussion/Conclusion: Both patient satisfaction with nursing responsiveness, and nurses’ confidence in their ability to answer call-lights in a timely manner showed positive outcomes after implementation of The No Pass Zone. The hospital benchmark of 67.7% was met. To improve RN staff adherence to The No Pass Zone, staff audits and just-in-time coaching could be utilized in the future. Continued education to both nurses and HUSC’s regarding the importance of answering call-lights would be beneficial to ensure that nursing responsiveness stays at, or above the hospital’s benchmark. Limitations to this project were that only East 6 RN’s and HUSC’s were included. For The No Pass Zone to be fully implemented, all disciplines need to be included. Next steps will include providing education and increasing inter-disciplinary collaboration on The No Pass Zone.