Empirical Quality Outcomes

In early 2023, Kaiser Permanente Sacramento Ambulatory Surgery Center (ASC) faced significant challenges in patient satisfaction, ranking 27th out of 29 Kaiser facilities with a care experience score of 71.6%, well below the group average of 79.9%. Identifying issues with discharge instructions, the unit’s Care Experience Committee, a clinical nurse led group, and the leadership team revised their process and workflow in providing discharge instructions, which earned the center the 2024 Outpatient Surgery Magazine OR Excellence Award for Patient Satisfaction and Experience. 

The ASC team found in their gap analysis from patient feedback that unclear recovery instructions and the absence of family members during discharge teaching contributed to low patient satisfaction scores. Patients often struggled to retain or process information while recovering from anesthesia. Not only does this impact patient satisfaction, but it can also negatively affect patient compliance and safety during recovery. In response, the center implemented a quality improvement plan, including: 

• Delivering recovery instructions pre-operatively before sedation. 
• Using “recovery” instead of “discharge” to clarify expectations. 
• Enhancing materials with bold “Recovery and Home Care Instructions” labels. 

The initiative also emphasized staff training in patient-centered care, caring moments, and nurse-patient communication strategies and launched recognition programs to reward and promote excellence in patient-centric care.  

By January 2024, the care experience top box score rose to 86.9%, a 15% increase, surpassing the original 10% improvement goal. Scores continued climbing, reaching a record 92.5% in February 2024. “We’re proud of the progress, but our mission to improve never ends,” said Erica Osborne, BSN, RN, Nurse Manager. “Providing the best possible care experience remains our top priority.” 

(Excerpts from Outpatient Surgery Magazine)  

Effective communication between nurses and patients is essential in improving patient outcomes by building trust, enhancing adherence to treatment plans, and increasing patient satisfaction. It also helps prevent medical errors, promotes patient autonomy, fulfills nurses’ legal and ethical obligations to keep patients well informed, and ensures continuity of care across different health care settings. 

In the last quarter of 2023, before the intervention, the unit’s HCAHPS top box-composite score on nurse communication was 77.1% on 4 East and 87% on 4 West. To further improve the patient experience, the 4th Floor Care Experience Committee, a nurse-led group under the Unit Practice Council at Kaiser Permanente Sacramento Medical Center, has implemented initiatives to improve RN-to-patient communication by focusing on inconsistent RN-to-patient communication related to explaining the plan of care and progression towards discharge.  

The team used the Kamishibai card system to provide a structured and standardized 10-step process for conducting a Nurse Knowledge Exchange (NKE) at the bedside, including an explanation of the care plan and discharge. To reinforce the practice, the NKE Nurse Leader Validation was also implemented as a process observation to ensure that NKE consistently practiced at the bedside. 

Post-intervention data indicates a shift and improvement in the nurse communication composite’s satisfaction scores of 78.6% on 4 East and 90.9% on 4 West. Staff feedback also indicates improving practice ownership, confidence in the process, and team dynamics. “We are seeing the positive impact of this initiative on both our patients and our team,” said Vanessa Stammler, BSN, RN, Staff Nurse II, 4th floor Care Experience Committee lead. “Patients feel more informed and connected to their care, and our staff has embraced the importance of clear, consistent communication.” 

Hospital-acquired infections (HAIs) such as Central Line-Associated Bloodstream Infections (CLABSI) remain a critical concern, particularly in the Intensive Care Unit (ICU), where up to 48% of patients require central lines for treatment delivery and are vulnerable for infections due to underlying conditions and invasive procedures. Central Line-Associated Bloodstream Infections are linked to negative patient outcomes, including high morbidity, mortality, and substantial health care costs.  

A quality improvement initiative led by the ICU Unit Practice Council- Quality Committee addressed the increasing incidence of CLABSI observed in unit-level trended data. From 2023 continuing to 2024, the initiative focused on identifying practice gaps and implementing measures to reduce CLABSI occurrences. Surveys and clinical audits revealed key issues such as non-adherence to dressing change procedures, inconsistent knowledge among staff regarding the CLABSI bundle, and inadequate auditing processes. 

The Quality Committee team provided in-depth, one-on-one peer-to-peer education sessions to over 90% of ICU RNs to address these gaps, enhancing their central line management and care competency. The education also included CLABSI bundle components, proper dressing changes, and blood sampling techniques. As a result of the ongoing gap analysis, the team also introduced practice changes such as replacing the piggyback bags every 24 hours, using port-less IV tubing to minimize contamination, and using pre-installed leur-lock and manifold for multiple drips to avoid manual assembly. Additionally, the frequency of audits was increased to twice daily. 

The ongoing quality improvement initiatives have led to a notable sustained reduction in the CLABSI incidence in the unit. Though fluctuations in data have been observed, the overall trend shows positive progress, with staff continuing to adapt and improve practices. This staff nurse-led initiative has improved CLABSI and enhanced patient safety in the ICU through ongoing education and peer-to-peer feedback.