At Kaiser Permanente Roseville, the Perioperative Collaborative Group which includes frontline preoperative, postoperative, and intraoperative nurses, identified a recurring issue impacting operating room efficiency: incomplete documentation. Delay codes related to missing history and physicals, interval notes, or consents were among the most frequently reported by staff.

Through peer surveys and data review, the team uncovered a gap in the workflow: there was no standardized process for notifying surgeons about missing documentation. In response, the nurses partnered with surgeon champions to develop a consistent communication strategy using alphanumeric paging. The new process includes two scripted pages. The first is sent by Unit Assistants the day before surgery if a consent is missing. The message includes the physician’s name, missing item, patient name, and surgery date. The second page is sent by the primary nurse during initial assessment if documentation remains incomplete. This message includes the physician’s name, issue, patient name, bay number, nurse name, and the standard charge nurse contact number.

This nurse-led initiative has significantly reduced delay codes related to documentation, improved interprofessional communication, and enhanced patient safety. It exemplifies how frontline nurses at Kaiser Permanente Roseville are driving meaningful change through data-informed decision-making and collaborative practice.