2013 11

th
Floor Oncology/BMT RN Action Plan

We are an amazing team that takes pride in the excellent care we provide our patients. However,
recent patient surveys have identified areas we must improve upon. With these small procedural
improvements, we can excel in customer and staff satisfaction too!

1. PAIN MANAGEMENT: GOAL: 74.3% (Percent of patients who feel their pain is adequately controlledreport their pain is
ALWAYS well controlled and staff ALWAYS does everything to help with pain.)
o Current Score: BMT 67.950.0%, ONC 71.068.7%
o Areas that need the greatest improvement: COMMUNICATION and EDUCATION
o Communication with PATIENTS: RN will discuss pain management with patients.
EDUCATE patients about their pain options using the Patient Pain Education Tool, both
upon admission and as needed throughout the patients stay.
o Discuss medication and alternative therapy options.
o Discuss the Comfort-Function goal and realistic goal-setting.
o A Team Approach: We want to work WITH patients to manage pain.
Use the SCRIPTING developed by the Pain Committee for patient/RN interactions.
Discuss medication and non-medication options.
Know what PRN medications are available for your patient
Be sure to rate and chart your patients pain and encourage your patient to discuss and
describe the type of pain they are having. Ensure 1 hour re-assessment post-intervention is
occurring
If needed, discuss a pain medication schedule with your patient and update the whiteboard
so they can anticipate their next dose of pain medication.
HOURLY ROUNDING - Pain is one of the 5 Ps of hourly rounding and should be explicitly
addressed whenever rounding on patients.
o Communication with MEDICAL TEAMS: RN will communicate with the medical team to
ensure pain is well controlled for all patients.
Ensure PRN medications are available in the MAR - advocate for your patients if you feel
adjuvant medications or non-medication pain relief could be useful.
o Keep the team up to date if higher or lower doses are needed to adequately control pain.

2. RESPONSIVENESS OF HOSPITAL STAFF: Goal: 67.1% (Percentage of patients who feel we are responsive to
their needs)
Current Score: BMT 58.8%, ONC 59%
Areas that need greatest improvement: 1 - Call button help soon as wanted
2 - Help toileting soon as wanted

PHONES AND PHONE ETTEQUETTE:
To help customer service scores, when responding to a patient call light over your phone, please make
attempts to use your patients name and let them know who is responding.
o Instead of simply saying May I help you?answer, Hello Mrs. Stevens, this is Sarah your RN, How
can I help you?
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o Phones can and should be answered in the contact isolation rooms by removing a glove before
answering the phone. Sani-wipe your phone upon leaving the room.
o If unable to answer your phone, return your missed calls by checking your phone log.
o Hand off your phone to your shift buddy when appropriate (bed bath, teaching, dressing change, etc.).
o If you are the caller, do not let the phone ring more than 5 times. The person is most likely busy and will
call you back.
When feasible, respond to the call light in person. Patients would rather see a face than hear a voice.
****Utilize your resources (CNA/ACPs, PSCs, RNs, Charge RNs)****


3. OVERALL SCORE: GOAL: 76% (Percent of patients that rank our hospital a 9 or 10)
o Current Score: BMT (76.8%) Onc (76.2%)
o HOURLY ROUNDING: Hourly rounding on ALL patients regardless of fall risk
5Ps of rounding: Pain, Potty, Position, Personal Needs, Presence
Signs will be placed in patients rooms and magnets outside the patients doors to ensure hourly
rounding has been completed and to cue nurses when the last hourly rounding has been
completed.
o CNA/ACP are responsible for even hours (With Vitals and I/Os)
o RN are responsible for odd hours (with scheduled pain and IV assessments)
Charge nurses and nurse managers will be randomly checking in with patients and asking
them:
o If they have seen a staff member in their room every hour AND If they were asked if they
needed any of the 5 Ps of rounding
o Utilize LOOK Report with EVERY patient
o Update white board
o Discuss plan for the day. Include patient and family.
o Approximate times (bed bath, walks, turning, pain meds, etc.).
o Update fall tool
o Demonstrate AIDET communication:
o Always ask what else you can do for the patient. Be specific.
o Do you need anything for pain/nausea?, May I help you to the bathroom
while I am here?, Can I get you some fresh water?
o Give patients a timeframe of when you will be back and when they can expect their
request to be met.
o I will come back between 3:00 and 4:00 to help you walk.
o Family and friends are our customers too. Please do your best to communicate and
accommodate them when feasible.

COMMUNICATE with your colleagues.
o Coordinate your day at the beginning of your shift with your shift buddy and CNAs. Set times that you
would like to go to lunch and any tasks that require them holding your phone (dressing change,
discharge teaching, wound care, etc.). Decide when big tasks will be done (walks, bathing), who needs
help with ADLs, identify high fall risk patients, etc.

NO ONE SHOULD IGNORE
A beeping pump. They are a nuisance to our patients and should be fixed as soon as possible. If you hear a
beeping pump, take care of it.
The console. If a call goes overhead, the customer has already been waiting too long!
A call light. If you are walking by and see a call light blinking, please enter the room and find out what the
patient needs. Remember, every patient is your patient and we are a team.

I have had the opportunity to review and understand the above information. By signing this contract, I
agree to adhere to these standards. I also agree to hold my peers to the same standards. Through
teamwork and cooperation we can greatly improve our workplace for our patients and fellow
employees. I am a proud and willing member of this team!

2013 11
th
Floor Oncology/BMT RN Action Plan

Print Name: _____________________________________

Signature: _______________________________________ Date: ______________


Charge Nurse Signature: _________________________________