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
I noticed that a lack of communication, recognition, and education amongst the C!"!C# group
had been a concerning problem since I began as an !C# in $%%&. I performed a few literature searches and
found that continuously educating C!"!C#s lead to better patient outcomes and overall 'ob satisfaction.
I 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. I 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. I 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
, /igh *isk , /igh Impact on #erformance
- /igh 0olume , /igh #otential for Improvement
- #roblem #rone , .upports Critical .uccess 1actors
- 2ow 0olume , #atient .afety

(O) Organize a team that knows the process:
List Team Members:
3ennifer 4wink, *, 5., 6C (urse 5anager); 3amie ordhagen, *, 7., 6C (!ssociate
urse 5anager); 5andy 3ohnson, *, 5/#, CC* (!ssociate urse 5anager); 8yle /ammond, *,
7., 6C (Clinical urse -ducator); !nnsley 7uffington, *, 7., 6C (Clinical urse -ducator);
7arbara 9enger, 5., *, !6C., C*I (Clinical urse .pecialist).
(C) Clarify the current knowledge
What do we know about the process?
9hen I started this pro'ect there was not a council or a committee solely for C!"!C#s. :here
was a lack of communication among this group, recognition, and continuing education. !fter a
comprehensive literature search, it was 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. :he 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?
6ther 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. 1ederal law mandates <$ hours of continuing education
every year. :his level of training and continuing educations is considered inade;uate in preparing direct
care workers for providing ;uality care (.engupta et al, $%<$). 7urnout 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, $%<%). :his council was designed to help with staff recognition, training, and staff
satisfaction. Currently the only ongoing training for C!"!C#s is an annual 9-22. center training. 9e
also only touch base with them on an annual basis for their reviews (unless disciplinary action is re;uired).
It 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:
<) .end 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.
$) Improve communication among C!"!C#s (currently there is very minimal communication
other than the annual competency).
>) *ecogni)e staff through email, in person, and at shift huddles to increase 'ob satisfaction.
?) #rovide monthly educational emails to C!"!C#s
(P) #lan the impro!ement:
<) #lan monthly meetings agenda.
$) #lan mandatory meetings in !pril to discuss the new e(pectations of this group. :his 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.
?) 5eet with 3amie ordhagen to gain access to .hare#oint and approve meetings. @et a budget
for C!"!C# council to give out gift cards for e(cellent service.
(D) $mplement the impro!ement:
<) .tart a C!"!C# council and implemented monthly meetings for support"teaching
opportunities.
$) 5andatory training for C!"!C#s in !pril in addition to the mandatory 9-22. center
training in 5ay.
>) .tart posting online (.hare#oint) to deliver information and allow for discussions in a safe
environment. :his online option will allow a way for C!"!C#s to participate and obtain valuable
information. !ttendance at staff meetings has been notoriously low for this group and this now give a way
for them to participate without having to physically come in to work.
?) #ost,survey sent out to see if 'ob duties, educational needs, and work environment improved.
(C) Check the results:
#ost,.urvey results
(A) %ct to hold the gain:
I plan to continue posting discussions to .hare#oint bi,weekly. I also plan to send out an
education email once a month with important tips. Auarterly I will plan meetings for C!"!C# council
for them to attend in person if they desire (possibly making mandatory). :his will allow them to have some
time with management too. 3amie ordhagen and"or 5andy 3ohnson have agreed to attend these meetings.
I also plan to bring in guest speakers for these meetings. I have successfully obtained an annual budget
from management and will continue to reward C!"!C#s for their service e(cellence. 1inally, I will work
with my nurse educators to develop a continuing educational program for our C!"!C#s ;uarterly.
Repeat PDCA as needed and maintain documentation in your department.
-eferences
<. 7reedlove, 3. (<&&>). C!sB 6pening the career door. ursing /omes, ?$(C), D,<$
(26- D).
$. 7rown, 5., *edfern, *. -., 7ressler, 8., .wicegood, :. 5., E 5olnar, 5. ($%<>).
-ffects of an advanced nursing 'ob satisfaction, turnover rate, assistant education
program on and clinical outcomes. 3ournal of @erontological ursing, >&(<%), >?,C%.
doiB<%.>&$D"%%&D&<>?,$%<>%F<$,%$
>. Choi, 3., E 3ohantgen, 5. ($%<$). :he importance of supervision in retention of C!s.
*esearch in ursing E /ealth, >C($), <DG,<&&. doiB<%.<%%$"nur.$<?F<
?. Cready, C. 5., =eatts, +. -., @osdin, 5. 5., E #otts, /. 1. ($%%D). C! empowermentB
-ffects on 'ob performance and work attitudes. 3ournal of @erontological ursing,
>?(>), $F,>C.
C. 8leinman, C. .., E .accomano, .. 3. ($%%F). *egistered nurses and unlicensed assistive
personnelB !n uneasy alliance. :he 3ournal of Continuing -ducation in ursing, >G(?),
<F$,<G%.
F. eff, !. ($%<$, ). C! program addresses need for advanced training. 7angor +aily
ews
G. #ine, . ($%%%). ! partnership for C! training. ursing /omes, ?&(>), ??,?D.
D. #restia, !., E +yess, .. ($%<$). 5a(imi)ing caring relationships between nursing
assistants and patientsB Care partners. 36!B :he 3ournal of ursing !dministration,
?$(>), <??,<?G. doiB<%.<%&G"!.%b%<>e><D$?D?efd
&. .engupta, 5., -'a), 1. 8., E /arris,8o'etin, 2. +. ($%<$). :raining of home health aides
and nurse aidesB 1indings from national data. @erontology E @eriatrics -ducation,
>>(?), >D>,>&C (26- $).
<%. 9ashington, @. :. ($%<>). :he theory of interpersonal relations applied to the #receptor
ew graduate relationship. 3ournal for urses in #rofessional +evelopment, $&(<), $?,
$&. doiB<%.<%&G"+.%b%<>e><D$Gd%aDa
<<. 9est, #., .culli, @., 1ore, !., 6kam, ., +unlap, C., eily, 3., E 5ills, #. ($%<$).
Improving patient safety and optimi)ing nursing teamwork using crew resource
management techni;ues. 36!B :he 3ournal of ursing !dministration, ?$(<), <C,$%.
doiB<%.<%&G"!.%b%<>e><D$>c<GcG
<$. =eatts, +. -., Cready, C., .wan, 3., E .hen, =. ($%<%). :he perception of Htraining
availabilityH among certified nurse aidesB *elationship to C! performance, turnover,
attitudes, burnout, and empowerment. @erontology E @eriatrics -ducation, ><($), <<C,
<>$. doiB<%.<%D%"%$G%<&F<%%>G&CG$$ (26- <).