Empirical Quality Outcomes

In July 2024, the Medical-Surgical CUSP team, led by Chair Carlyna Deragish, BSN, RN, and Chair of Operations Aleta Ross-Ku, Unit Assistant, launched the “Safety Stop-Sign” initiative. This program aimed to improve the identification of patients with safety risks by using color-coded stop signs placed outside patient rooms. The signs enable all staff members, regardless of role, to quickly recognize specific safety precautions required when entering a patient’s room. 

This initiative was a collaborative effort with the Kaiser Permanente Santa Rosa (KP SRO) Security team, including the Health Protection Officers, who play a critical role in addressing patient safety needs within the hospital. 

The “Safety Stop-Sign” initiative is part of a broader Prevention of Workplace Violence Program at KP SRO, which has evolved significantly since the COVID-19 pandemic. The program incorporates multiple components: 

• APPIH Training (Assessment and Prevention of Patient-Initiated Harm): Tailored for clinical staff to recognize and mitigate potential harm. 

• Threat Management Team (TMT): Utilizes a close watch list and Health Connect advisory engagements to monitor high-risk situations. 

• Enhanced Safety Stop Signs: Nurse-driven visual cues for patients at risk of elopement, suicide, behavioral concerns, or violence. 

• Physical Security Enhancements: Includes Armed Protection Officers, Healthcare Protection Officers, and Emergency Department Weapons Screening. 

Since implementing these safety measures, KP SRO has observed improved safety metrics shown by sustained decrease in employee injury rates. Positive Staff Feedback as evidenced by an 8-point increase in staff reporting that their department takes necessary steps to ensure employee and physician safety and a 7-point increase in nursing staff feeling safe working in their department, as measured by People Pulse surveys. 

The success of the “Safety Stop-Sign” program has been met with widespread approval from clinical staff. As a testament to their leadership and dedication, Deragish and Ross-Ku were awarded the prestigious “Safety Angel” award for their outstanding contributions to creating a safer environment for staff, patients, and visitors. 

In an effort to enhance patient care experience scores, KP SRO launched the Purposeful Hourly Rounding (PHR) project in May 2024. 

The COVID-19 pandemic significantly limited interactions with our patients, creating challenges in maintaining high levels of engagement and communication. To address this, we developed a simulation to reinforce the principles of purposeful hourly rounding using the 5 P’s: 

• Pain 

• Position 

• Personal Needs 

• Periphery/Pump 

• Plan 

Evidence-based research has demonstrated that purposeful hourly rounding minimizes call bell use, reduces patient falls, decreases HAPIs (hospital-acquired pressure injuries), improves care team efficiency, and enhances overall patient experience. While hourly rounding is ideal, the emphasis is on purposefulness, acknowledging the constraints of real-world healthcare environments. 

This simulation allows care team members to practice narrating care as it is performed. Actions that seem routine to staff can often be misinterpreted by patients, so clear communication is vital. Studies show that 80% of patients may not voice their needs or concerns unless prompted, making proactive and purposeful rounding critical. 

The project focused on staff training and simulations to ensure that all members of the care team were confident in their rounding skills. Practicing with colleagues in a safe environment prepared staff to effectively implement these practices with patients. 

Since the launch of PHR, Adult Services units have surpassed the goal of 80% PHR documentation in both October and November. Additionally, there has been a significant correlation between the implementation of PHR and improved care experience scores, specifically in the “Likelihood to Recommend Hospital” and “RN Listened Carefully” metrics. 

Under the leadership of Damian Gulbransen, DNP, MBA, RN, NEA‑BC, Director of Emergency Services, the Kaiser Permanente Santa Rosa Emergency Department implemented a groundbreaking workflow to reduce door-to-EKG times, significantly improving care for ST Elevation Myocardial Infarction (STEMI) patients. 

The key initiatives of this project included the creation of a dedicated EKG Technician role, an additional Emergency Department (ED) technician was assigned solely to performing EKGs, ensuring rapid response and efficiency. Additionally, the team created a standardized Rapid Cardiac Assessment Workflow streamlining the process from patient arrival to EKG completion and transfer, enabling faster identification and treatment of STEMI cases. 

The measurable outcomes included:  

• Reduced Door-to-Transfer Times: The time required to transfer STEMI patients to specialized receiving centers decreased by nearly 10 minutes. 

• Shorter Door-to-EKG Times: The new workflow demonstrated a significant reduction in the time required to perform EKGs upon patient arrival. 

• Decreased Length of Stay: STEMI patients experienced shorter stays in the ED, allowing for faster access to specialized care. 

• Prior to the project, in 2023, 28% of chest pain patients and 30% of STEMI patients did not receive an EKG within 10 minutes of arrival. Following implementation, compliance with door-to-EKG times under 10 minutes increased to 86% for chest pain patients and 100% for STEMI patients over four months. 

The KP SRO ED team exemplifies Kaiser Permanente’s commitment to improving outcomes through innovation, teamwork, and evidence-based practice. Their efforts set a new standard for prompt cardiac care and highlight the importance of multidisciplinary collaboration in achieving best-in-class patient outcomes. 

In 2022, the ICU CUSP (Comprehensive Unit-based Safety Program) Committee conducted a meeting centered on addressing the 2022 catheter-associated urinary tract infection (CAUTI) rate and analyzing a CAUTI case identified in July 2022. The team conducted a thorough chart review to identify gaps and opportunities for improvement. Key findings included: 

• Inconsistent Documentation: Daily necessity documentation for the catheter was incomplete. 

• Missed Care Opportunity: One instance of missed catheter care was noted. 

These insights informed the development of an action plan designed to enhance CAUTI prevention practices. The CUSP team established a comprehensive strategy, emphasizing the reinforcement of existing practices and introducing targeted improvements: 

• Multidisciplinary Rounds: 

• Morning rounds include the interprofessional care team: ICU physician, primary nurse, respiratory therapist (RT), occupational therapist (OT), and physical therapist (PT). 

• The primary nurse reviews patient lines, prompting discussion of necessity, including for indwelling urinary catheters. 

• The team prioritized daily assessments and timely removal of Foley catheters. 

• High-Risk Patient Review Process: 

• Introduction of a practice change to identify high-risk patients for hospital-related infections, including CAUTI. 

• Criteria included: indwelling lines/catheters, ICU length of stay, and comorbidities. 

• Assistant nurse managers reviewed these criteria daily to identify prevention opportunities, with findings communicated to the clinical nursing team. 

In late 2022, the CAUTI reduction action plan was presented to the ICU department highlighting the reduction strategies developed collaboratively by the interprofessional team. The practices have been maintained since and following the introduction of the CUSP-driven strategies, the KP SRO ICU has not had a CAUTI for over 857 days (as of December 1st, 2024).  

The initiatives demonstrate KP SRO’s dedication to improving patient outcomes through evidence-based practice, multidisciplinary collaboration, and continuous learning. These efforts reflect a proactive approach to enhancing patient safety and quality of care.