No Pass Zone: Responsiveness Quality Improvement Project Inpatient Acute Care


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Purpose: The purpose of this project was to improve staff responsiveness by implementing a responsiveness intervention plan, known as the No Pass Zone (NPZ) Initiative, for adult inpatients with the goal of increasing the HCAHPS top box percentile and decreasing patient-initiated call bell response times.

Hypothesis: Hypothesis includes that the implementation of the NPZ would: - Increase HCAHPS Responsiveness of Staff top box scores from 57% to 62% in Press Ganey scores within the first three months of project initiation. - Increase Willingness to recommend top box scores from 56% top box to 58% top box scores measured by Press Ganey within three months of project initiation.

Methods: The NPZ Initiative was implemented, requiring each clinical and non-clinical staff member to respond to patient call bells and ensure that immediate needs are acknowledged. In-service education, coaching, and program promotion were integrated into the project. The No Pass Zone Initiative emphasizes the concept that call lights represent patient needs, and the response to those patient needs is a clear reflection of the priorities of that organization.

Results: The 2020-year baseline data measurement of 57% top box (n 976) compared with the post-intervention average top box score of 57% (n 260) representing no change in top box score for Responsiveness of Staff in the inpatient acute care units. However, the hospital's ranking increased from the 13th percentile to the 25th percentile ranking for like-size hospitals in the Press Ganey database. The Willingness to Recommend top box score decreased from 60 (n 729) to 56 (n 282) across the inpatient acute care units when comparing baseline to intervention. The ranking decreased slightly from 16th to 13th percentile of like-size hospitals in the Press Ganey database. Average call bell response times were analyzed pre and post-implementation. Overall, there was a twenty percent reduction in call bell response times across the project areas.

Conclusion: This data will need further analysis to determine the project impact. The initial results indicate improvement in HCAHPS ranking on responsiveness and call bell response times.

Implications: The NPZ has potential for an organization with the goal of improving staff responsiveness and focusing on a patient-centered culture. The opportunities for staff education, prioritizing patient needs, and improving ownership for patient experience are benefits of the program. Additional data will be necessary to determine effectiveness of NPZ intervention.

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Joshua R. Smith, DNP, RN, CCRN-K, NEA-BC

Newark-Wayne Community Hospital, Nursing Management

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No Pass Zone: Responsiveness Quality Improvement Project Inpatient Acute Care