PROJECT CHARTER FORM

Student Names: Allison Brown, Bethany Zimmerman, Kayla Myers, Madelyn McLain and Morgan Tolbert
Project Title: Improving Nurse Responsiveness
Location/Organization Name: Bon Secours Memorial Regional Medical Center

What Are We Trying to Accomplish?

Problem to be addressed (Defines WHAT broadly – provided by location)

Impact of hourly rounding on HCAHPS question of responsiveness of staff. What do patients value about these
interactions, and how do we use that information to improve the process?
Analysis of problem to be addressed (What aspect of care will be improved? What elements will be affected?
Consider: staff training, processes, policy, cost, etc. 2-3 sentences)
Our goal is to understand patient perception of responsiveness of staff and how it relates to patients’ needs
being met and HCAHPS scores. On the Surgical Telemetry unit at Memorial Regional Medical Center the
overall goal is that responsiveness of staff is improved and patient satisfaction and HCAHPS will increase as
well.

Aim statement (How is this good? For whom? By when? 1-2 sentences):
We aim to increase HCAHPS scores on nursing responsiveness by 10% on the Surgical Telemetry unit at
Memorial Regional Medical Center by January 1, 2020.

Reason for the effort (Defines WHY? Why is the effort important? How will this improvement benefit patients?
What is the potential downside of this effort for patients? What background information [data/analysis/literature review]
supports the choice of this effort? 4-5 sentences)
It is important to focus on patient satisfaction and nurse responsiveness since they impact HCAHPS scores and
HCAHPS are a portion of how the hospital gets reimbursed. Improving effective hourly rounding and nursing
responsiveness to patient needs ensure that patients are getting the appropriate care they need. Bettering
communication between staff members and patients can increase the effectiveness of hourly rounding.
Effective communication between patients and nursing staff can have a direct positive impact on the patient,
therefore increasing their satisfaction. A downside to this effort is that the when communication is ineffective
it can result in a delayed response to patient calls and need, decreasing the patients satisfaction.
Background information was obtained from a systematic review by Michell, Lavenberg, Trotta, & Umscheid,
2015.
Williams, D. B. (2014, December 12). Improving Staff Responsiveness to Patient-Initiated Call Lights.

Expected Benefits (Defines WHAT specifically, still not HOW. Specific objectives to be accomplished. Anticipated
products, tools, and deliverables as part of a process. 3-4 sentences)
The expected benefit is that patients perception of nurse responsiveness will improve, therefore increasing
the HCAHPS scores on the Surgical Telemetry unit at Memorial Regional Medical Center. The objectives to be
accomplished are to improve nurse responsiveness, HCAHPS scores, and effectiveness of teamwork. Other

5.29.2018
expected benefits that come with an increase in positive perception of nurse responsiveness is higher patient
satisfaction as well as improved communication between patients and staff members.

How Do We Know That a Change is an Improvement?

Expected Outcomes (Identify 1 quantitative benchmark with specific, numerical goals to be attained and 1 qualitative
theme. Discuss balancing measures that need to be considered. 4-5 sentences)

Quantitative Benchmark: As a team, we plan to implement reasonable and cost-effective changes that
increase HCAHPS scores by 10% on Surgical Telemetry unit at Memorial Regional Medical Center by January 1,
2020. HCAHPS scores will be reviewed every 4 weeks in order to watch trends. The hope is that HCAHPS scores
will increase by 1-1.5% each month.
Qualitative Benchmark: In an effort to see if clinician and patient satisfaction is improved we will have
clinicians and patients fill out response surveys asking if their perceptions of communication have been
improved with the proposed interventions. After implementing these changes, we hope the staff will feel an
increase in job satisfaction and patients will feel as though there needs are being prioritized and met
effectively.
Balancing Measures: We will ensure that other parts of the system are not negatively affected by this
increase in compliance. The staff must feel that they are working “smarter, not harder,” with these new
changes to their current system, it should be seen as something that would greatly benefit the patient and
increase their job satisfaction rather than one more thing to add to their workload. Need to consider:
● Stakeholders - Nurses, Nurse leaders, PCPs, Unit Receptionists.
● Cost- 20 voceras, supporting equipment (wireless controllers, servers, charging port, etc), extra
individual badges if needed
● Logistics - Online Vocera education of all staff, purchasing Voceras,educating all secretaries on proper
delegation of calls, and electrical configuration of call bell system to secretary desk.

What Changes Can We Make That Will Lead to Improvement?

Initial Changes Planned: What changes will you make to accomplish your stated aim? What factors led your group to
conclude the change selected is likely to be successful?
Barriers: What are the perceived barriers for your planned changes to be effective? (consider: technology, people, cost,
etc.) How will these be addressed?
Key Stakeholders: Who are the key stakeholders in the planned changes? (4-5 sentences)

Initial activities: To accomplish our stated aim, we decided to implement a two step plan that includes a hands
free communication system and reworking the the current call bell system so that it rings directly to the
secretary's desk on a call bell answering device. An example of a hands free communication device is a vocera
device that will that will allow each team member to communicate directly to one another and increase
communication between team members and patients increasing nurse responsiveness.
Factors that led our group to conclude this change would be successful was our conversations with other
healthcare workers in local hospitals that use the suggested hands free devices with success. We observed
that the current call bell system is not conducive to properly meeting patient and changing it would improve
nurse responsiveness.

5.29.2018
Barriers: Barriers include making a change that is cost effective for the floor and within budget. Another
barrier may be non-compliance of participating staff or resistance to changing the current system in place.
Additionally, if change was put into effect and the technology was not working efficiently, this may be difficult
to implement.

Key stakeholders: The key stakeholders are the nurses, nurse leaders, patient care technicians, unit
secretaries, the hospital, and the patients . The idea is that these changes not only will lead to increased
HCAHP scores, but also increased job satisfaction in the staff as well.

5.29.2018