University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet
Department!"
th
Floor AC# Date$%"&%"'!(
Primary Contact PersonCaitlin )o*alski #+tension&"'-,(,-(&-!
(F) Find a Process to Improve (name the process, describe the beginning and ending steps in
the process, name the customers served; state why it is important to work on this now).
.pportunity /tatement
-AC# unit patient0s perception of their 1uality of sleep *hile in the hospital
- 23s documentation of chartin4 the 1uality of sleep patients report

Circle all that apply5

Dimension of Performance5 Dimensions of health care performance are those definable,
preferably measurable, attributes of the system that are related to its functioning to maintain,
restore, or improve health care.
- fficiency - !afety
- !taff !atisfaction - ffectiveness
- "atient #enteredness - #ontinuity
Prioriti6ation5
- $igh %isk - $igh &mpact on "erformance
- $igh 'olume - $igh "otential for &mprovement
- "roblem "rone - !upports #ritical !uccess (actors
- )ow 'olume - "atient !afety

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(O) Organize a team that knows the process:
List Team Members:
ACE leadership team (encourage staff to participate in uiet Time !nter"entions#
$eriatric leadership committee
%iche Committee
(C) Clarif& the current knowledge
'hat do we know about the process(
! suspect that man& nurses on the ACE unit are unaware of the charting on sleep and the )%s
and C%As could use more education on the benefits of patients getting sleep while in the hospital
(U) *nderstand sources of "ariation:
'h& are we looking at this process( 'h& is the process not going the wa& planned(
To impro"e charting+ )%s ma& not be aware of where to chart patient,s -ualit& of sleep
(S) .elect the impro"ement:
!mpro"e charting+ impro"e the -ualit& of sleep patients are getting in the hospital+ impro"e staffs
awareness of the noise le"el in the nursing station
(P) /lan the impro"ement:
Audit charting on sleep in E/!C0 MA) e1tractions and -uestionnaire with patients on the ACE
unit (e1cluding non2English speaking0 pt with histor& of sleep apnea 3 cogniti"e impaired pt#+
Educate staff about ad"erse effects of sleep depri"ation in the geriatric population through clinical
article session and presentation of .leep poster and /ower/oint at staff meeting+ on the unit
displa& 4uiet Time5 poster describing the hours of uiet Time and the inter"entions6 /ut 47acker
Tracker5 in nursing station to monitor the noise le"el and ha"e staff be aware of noise
_
(D) !mplement the impro"ement:
/re2inter"ention charting audits0 patient MA) e1tractions 3 -uestionnaires starting October
89:;*****************************
<anuar& 3 =ebruar&2 Educate staff through clinical article session and present sleep poster 3
/ower /oint about results of preinter"ention data collected0 where to chart in E/!C on sleep and
about the uiet Time pro>ect and different strategies to use to create a -uiet en"ironment0
decrease sleep interruptions0 and how to be proacti"e and educate6
=ebruar& 2 !mplement uiet Time inter"entions Email staff 3 recognize staff who is consistentl&
charting on sleep /ut up uiet Time posters on unit and set up 7acker Tracker
(C) Check the results:
October2 %o"ember 89:; pre inter"ention audits0 MA) e1traction 3 -uestionnaires
*Educate staff with poster of pre2inter"ention results 3 clinical article re"iew session on sleep in
=ebruar&
!mplement 4uiet Time5 inter"ention in =ebruar& 8?th****************
Ma& 89:? Complete post2inter"ention chart audits on sleep 3 patient MA) e1traction and
-uestionnaires to see if there is an impro"ement on charting and patient,s perception of -ualit& of
sleep while in the hospital
(A) Act to hold the gain:
Assess for impro"ement and determine if new plan is needed*****

2epeat PDCA as needed and maintain documentation in your department7