Quality Improvement Project Proposal Worksheet
Project Goal: Reducing Sundowning in Hospitalized Patients
Keep in mind the IOM Quality Goals: Safe, Timely, Efficient, Effective, Equitable, Patient
Centered (STEEEP) , Magnet Standard
Team Members: other coworkers, PCTs, managers.
Identify your team members
Step 1 - Problem Identification & Baseline Data
Global Aim – fill in the blanks
Data to support - What are some
observations you have made? What
are some of the factors that stand in
the way?
Outcome Data – How prevalent is
the problem? Provide results here.
My global aim is to reduce the number of patients
that sundown using nursing interventions in the
hospital units. I expect that by working on this
problem we will increase safety for our patients
and decrease medication use for cognitive
impairments. It is important to for us to work on
this because as more elderly patients are admitted
to the hospital, their safety becomes at risk. I have
noticed that some patients on my unit sundown by
the evening. This results in them refusing
medications, getting up without assistance, not
sleeping well at night, distracting other patients,
and sometimes caregiver burnout from the
caregiver’s lack of sleep.
Staff and caregivers are increasingly concerned
for the patient’s safety when sundowning
occurs and often request something so that the
patient can go to sleep quickly or try to become
more compliant with nursing activities.
Factors to consider include:
-Doctors typically have a PRN order for when
the patient becomes confused or agitated.
-The use of a roll belt (a belt that goes around
the patient that is fastened with a self releasing
clip) is readily available.
-The family is the one typically to request
medication to “calm the patient down” so they
can go home and rest as well.
On our floor in particular, most of our patients are
well above 70 years old often coming in with
altered mental status as their diagnosis. Coupled
with that is the unfamiliarity of the hospital
environment which can lead sundowning
occurring earlier on in the evening hours or a
delirious state.
Step 2 - Link Current Evidence & Benchmarking Best Processes
Evidence from literature – what evidence
in the literature supports or informs your
goals?
Provide the following for TWO sources of
literature: title, author, intervention, sample,
details, results & your own comments.
Evidence from industry – Find evidence
from other institutions or the industry:
what are others doing that would support
your goals?
Provide the following for TWO sources:
title, hospital/organization, intervention,
population, details, results & your own
comments.
“Frequently observed behavioral abnormalities in demented
patients with exacerbation in the late afternoon, evening, or at
night, pose a significant burden and challenge to caregivers,
families, and nursing staff” (Khachiyants et al, 2011).
Although patients can never be a burden to us, sundowning
patients can take up most of our time in trying to help them
realize where they are and not injure themselves. Reference:
Khachiyants, N. et al. (2011). Sundown syndrome in persons
with dementia: an update. Psychiatry investigation, 8(4), 275–
287. doi:10.4306/pi.2011.8.4.275
“Immediate and long-term outcomes associated with a
delirium episode include increases in the risk of falls, length
of hospital stay, hospital costs, duration of mechanical
ventilation, degree of cognitive impairment, functional
impairment after a hospital stay, long-term care facility
placement, and mortality” (Kalish et al, 2014). Falls are a
huge concern on our unit which is mostly related to the
sundowning or delirium state of the patient. This increases
length of stay and hospital costs.
Reference:
Kalish, V. B. et al. (2014, August 1). Delirium in Older
Persons: Evaluation and Management. Retrieved November
12, 2019, from
https://www.aafp.org/afp/2014/0801/p150.html.
“The Fam-HELP (Family-Hospital Elder Life Program)
program demonstrates that active engagement of family
caregivers in preventive interventions for delirium is
feasible…. which may help to improve effectiveness of HELP
models for delirium prevention, and potentially sustain these
effects after hospital discharge” (Rosenbloom-Brunton, et al,
2010). With this program, family and caregivers participation
can decrease delirium effects during and after hospital stays
by implementing therapeutic, mobilization, visual and hearing
protocols.
Reference: Rosenbloom-Brunton, D. A., et al. (2010).
Feasibility of family participation in a delirium prevention
program for hospitalized older adults. Journal of
gerontological nursing, 36(9), 22–35. doi:10.3928/00989134-
20100330-02
“The nonpharmacological intervention specifically discussed
in the pain, agitation, and delirium guidelines of the American
College of Critical Care Medicine is early mobilization”
(Rivosecchi et al. (2015). As soon as hospitalized patients are
able to ambulate, they should do so to decrease the risk of
sundowning.
Reference: Rivosecchi, R. M. (2015, February 1).
Nonpharmacological Interventions to Prevent Delirium: An
Evidence-Based Systematic Review. Retrieved November 12,
2019, from http://ccn.aacnjournals.org/content/35/1/39.full.
 Step 3A – Understanding the Process (Context – readiness to change, evidence of
teamwork, quality culture)

Directions: Review each principle that determines readiness for change. Score a principle “yes” if you
believe you have established support and readiness. If you have not achieved support, redefine your
opportunity and realign your strategies. (Note: re-evaluating and re-scoring is not necessary for the
assignment, but it would benefit your project.)
When all criteria is scored as a “yes” you should proceed with your improvement strategy. As you
continue, remember to:
1. Use the PDSA process with a focus on continuous evaluation and reflection. (Use only PD from
PDSA cycle)
2. Follow the implementation process as a team
3. Measure effectiveness continuously
4. Market the outcomes to your team and the organization
5. Celebrate success
Define agreed upon project & goals: Do you have Yes. My team members all agree to this recurring
senior leadership buy-in? Yes or no? problem on our unit and want to make a change
Customer Focus: Have you clearly defined the Yes. The customer will be our elderly patients
customer who will benefit from the who experience delirium or sundowning while on
improvement? Yes or no? our unit.
Eliminate Blame: Have you defined the process Yes. Instead of using PRN medications and
(not the people) that requires redesign? Yes or restraints, us as a nursing team can try to use
no? nonpharmacological nursing interventions to
decrease the number of episodes we see on the
unit.
Rely on Data: Have you defined data needs and Yes. We are to keep a chart of how many patients
required support for data management and we receive that sundown and what exact
analysis? Yes or no? symptoms they show. Our nursing interventions
can then be put into place to decrease the
symptoms and increase the safety of the patient
and the staff.
Team Approach: Have you defined an inter- Yes. The nursing staff will come together to
professional team creating a neutral problem identify those patients that have sundowning
solving environment? Yes or no? episodes and also will work together not just for
their patients but the entire unit’s patients.
Include all levels of employees: Have you Yes. Nursing staff will assess those patients
defined all employees involved in every level of usually on day shift to see what symptoms they
process? Yes or no? show during the evening hours. This can be
communicated to the night shift nurses and the
techs. As time goes on and we identify which
interventions worked for the patients, they nurses
and the techs can work together to keep that
patient safe for their length of stay.
Economic Support: Have you identified economic Yes. Some of the nursing interventions require
needs of the project, including time, personnel money (use of a radio, buying photo frames, etc).
and financial support? Yes or no? Time is also required to perform these
interventions.
Celebrate Success 1: Have you identified ideas Yes. The goal is decrease the number of delirium
for various levels and types of team success? Yes or sundown episodes and increase patient safety
 or no?
Celebrate Success 2: Have you obtained buy-in
for celebration of success? Yes or no?
by June 2020. Success will be determined by
keeping a chart of the patient’s symptoms and if
they decrease using interventions throughout their
stay.
Yes. My team members are on board with this
change and have committed to it for the next 6
months. We understand that this change is
important to our unit as we want to keep our
amount of sentinel events low.

Step 3B – Understanding the Process (Diagnosis of system performance, process map,

fishbone diagram)
Fishbone Diagram - We use fishbone diagrams to help identify what caused a particular event to
occur. Begin by placing the event at the head of the fish. Then think about the causes of this event as
they relate to each of six categories: People, Methods, Machines, Materials, Measurements, and
Environment

People Methods Machines

Nurses are No way of knowing No impact.
overwhelmed with the which patients are
constant supervision likely to sundown.
of patients especially No communication as
during evening/ night to which patients are
hours confused and sundown
early. Problem

Patients sundown early on

in the evening hours and
care of the patient
becomes difficult as
patients don’t comply
with nursing care.

Measuring the outcome of this On our unit, there are a lot of

project is very important to patients who are admitted due to
No systematic way determine if nursing an altered mental status and who
to track events of interventions impact Measurements are confused.
sundowning and Environment
sundowning patients for them to
which patients
Step 3B Continuedhave a better night.
sundown
Process Map – Make a process map any way you can, save it as a picture, and include it below. Click
the grey box to insert a picture.
Materials
Step 4 – Specific Aim & Timeline
Specific Aim – What are we trying to accomplish?
Make sure your aim is SMART: Specific,
Measurable, Achievable, Realistic, and Timely
By June of 2020, our unit will decrease the effects
of sundowning syndrome on our “altered mental
status” patients by implementing
nonpharmacological nursing interventions proven
to help patients sleep better throughout the night

Step 4 Continue Proposed

Timeline – Make a timeline any way you can, save it as a picture, and include it below. Click the grey
box to insert a picture of it below.

11/18/19 11/25/19 11/26/19

12/3/2019
Review evidence Introduce Brainstorm systematic way to
based literature to topic to record how many patients Start
determine nursing coworkers sundown, what time symptoms measuring
interventions and start, what symptoms occur, and and
appropriate for managers. what nursing interventions help collecting
sundowning patient during day for patient to data over a 6
patients sleep and rest well. month
period
Step 5- Measures
Survey or interview guide: Create a short survey
or interview guide (2 -3 questions) to collect
additional information from the people who you
work with and a patient regarding the process
you are trying to change.
Outcome Measure: Identify the outcome
measure: what are the desired results?
Outcome Measure: Identify the operational
definition: how will you measure?
Process Measure: Identify the process measure:
are the parts of the system performing as
planned?
Process Measure: Identify the operational
definition: how will you measure?
Balancing Measure: Identify the balancing
measure: are changes to improve one part of the
system causing new problems in other areas?
Balancing Measure: Identify the operational
definition: how will you measure?
1. Out of your 5 patients, how many of them are
exhibiting signs of sundowning? 2. What do you
usually use to help patient with their sundowning
(e.g. medications, distraction, etc)? 3. How many
hours of sleep does the patient and the caregiver
get at night and during the day?
The outcome measure is to decrease the signs of
sundowning so that the patient can interact with
nursing staff and sleep well during the night while
not disturbing other patients and caregivers.
A system will be made to identify which patient
sundown and what nursing interventions worked
with each patient. After 6 months we should have
a good amount of nursing interventions to use
with our sundowning patients so they can sleep
better.
Yes. The system that will be created with nurses
and PCTs will help us to solve this issue with
everyone’s help and support.
The nurses and PCTs will write on the devised
table which patients sundown. Pre-picked
nonpharmacological nursing interventions will be
implemented on these patients. Nursing and PCT
will then report off which interventions worked
for patients.
Other problems wouldn’t occur. We can actually
use these interventions on other units of the
hospital as well.
By determining which interventions worked for
our patients, we can see if these patients have a
better night sleep which decreases the risk for
safety concerns to occur.
Step 6 – Identify and Choose Change Idea (What changes can we make that will result in
an improvement?)
Directions: Fill out the table below. Enter a change idea then answer yes or no to each question in
that row. Give a point for each “yes” response and include the total number of points for the change
idea in the “total” column

Change idea Evidence Available Easy to New Advantage Total?

to resources? implement? innovation? over current
support? process?

Devising a no Yes yes Yes No current 3

simple cardboard process in
worksheet with place
patient room
number and
intervention used
Devise a proper Yes No Yes Yes No current 3
computer computer process in
application with application place
patient room available,
number, when but can
signs of make one
sundowning
begin, effect
having on patient
and family and
what
interventions to
use
Start No Yes No Yes No current 2
implementing process in
nursing place
interventions on
those patients
who only have
an altered mental
status diagnosis