![]() Once staff were re-engaged to focus on the enhancements to their report, leaders committed to direct observation and coaching them regularly to validate that the new process was being executed. Because the team agreed that several components of the best practice had not been fully executed, they recommended a new commitment to executing bedside shift report correctly, with full and ongoing validation of the practice by nursing leaders. ![]() While the organization had already implemented bedside report, everyone agreed that staff were still primarily exchanging most information outside the room and using the bedside for introductions. They recommended a more structured and routine method of sharing information to ensure these assessments were completed with every patient, every shift change. When a quality impact team at Safe Hospital interviewed nurses as part of their root cause analysis diagnoses, they identified communication and a lack of consistent visual validation/assessment of their wounds as a central challenge. Despite several efforts, Safe Hospital has been unsuccessful in their efforts to reduce them. The incidence of Stage 3 and Stage 4 pressure ulcers has nearly doubled from six to 12 per month over the most recent 12-month period, compromising both clinical quality for patients and families and hospital reimbursement (due to financial incentives on this process-of-care measure under value-based care). Imagine a 400-bed hospital, Safe Hospital USA, with six different med-surg units, eight orthopedic/teleoncology/OB units, and several ICUs. ![]() By Lyn Ketelsen, RN, MBA, Studer Group coach and national speaker
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