CapstoneWrittenReport-YoungShinSeosecure1.pdf

Implementation TeamSTEPPS Program in Interventional Radiology Unit

Young Shin Seo

Western Governors University

College of Health Profession

Dr.

December 15, 2022

Note: This document should be used as a template for your healthcare improvement project

(HIP) academic paper. This paper should adhere to the formatting and style standards of the

current edition of the American Psychological Association (APA) style manual. Refer to the

performance assessment tasks and rubrics for specific instructions on submitting each section of

your HIP paper.

D156: Business Case Analysis for Healthcare Improvement

Task 1: Healthcare Improvement Project -Introduction and Project Initiation

Stakeholder Identification

To process the proposed healthcare improvement project (HIP), my preceptor and I had a

meeting and identified the stakeholders that would contribute to the success of the project

proposal for the impacted unit, interventional radiology (IR). The technique we used to identify

the three stakeholders was using the HIP Anticipated Stakeholder Impact Grid. This tool assisted

in determining which stakeholders should be involved in the HIP and their potential impact. This

grid includes the following information for each stakeholder: their title or role in the

organization, experience or expertise, role within the project, influence, and power, and reason

for involving stakeholders in the project.

The first stakeholder I chose was the quality and patient safety consultant. She has

expertise in collecting data, analyzing outcomes, and improving the quality of care. She

facilitates and prepares the necessary tools and equipment to rid barriers. Her role analyzes the

needs and the information for the healthcare improvement project to see if our interventions are

effective or not. The second stakeholder I have chosen was the director of nursing education

(DOE), who has expertise in researching, planning, and implementing professional development

programs based on data and evidence-based practices. She develops and implements the project

for the target population. Her role is to plan and implement HIP based on evidence-based ideas

and information, and evaluate the project's effectiveness. The third stakeholder I have chosen

was the chief nurse executive, who has expertise in defining and implementing policies and

procedures and ensuring the facility meets organizational and regulatory standards. He will be

the sponsor and oversee the influences and powers. He can approve the financial aspect of the

HIP and evaluate and verify if the project meets organizational and regulatory guidelines.

Needs Assessment

I conducted a meeting with the identified stakeholders for the HIP for the IR unit. The

three stakeholders were the chief nurse executive, the director of education, and the quality and

patient safety consultant. We used the sticky note method to reach a consensus to complete the

Affinity Analysis. In this method, each group member identified two ideas on the sticky notes,

and I displayed the sticky notes on a large presentation board. There were several duplicate or

similar ideas from each stakeholder. The issues we identified for the IR unit were specimen

errors and near-miss medical errors such as the wrong patient, site, and procedure. Other

identified issues were skipping or having incomplete briefings or huddles before and after

procedures, poor communication among health care providers in IR, and lack of buy-in from

staff for teamwork training such as Team Strategies and Tools to Enhance Performance and

Patient Safety (TeamSTEPPS®).

We also identified the needs in IR using the sticky notes, and the needs were increasing

patient safety, effective communication, strong teamwork, and implementing the TeamSTEPPS

programs. Upon further discussion, we came to the consensus that patient safety is the highest

priority needed. All stakeholders agreed on a common goal for the IR unit: Implementation of

the TeamSTEPPS program to increase patient safety in the IR.

Problem Identification

The problem that will be the focus of the PHI is ineffective communication among IR

health care providers and the opportunity is the implementation of the TeamSTEPPS training. IR

unit is busy and fast-paced where interprofessional teams work together such as physicians,

radiology technicians, anesthesiology team, and nurses. TeamSTEPPS is an evidence-based

teamwork program that enhances patient outcomes by improving teamwork skills and

communication among healthcare professionals (Adjei, 2022). When this organization's

educational department was preparing to implement the TeamSTEPPS in IR, the COVID-19

pandemic hit, disrupting the educational process. The stakeholders all agreed that implementing

the TeamSTEPPS would be the best opportunity and that we should focus on the HIP to improve

teamwork and communication among IR health care providers, which could lead to higher

quality patient care. The significance of effective communication and teamwork is to prevent

possible medical errors that affect patient safety. According to Ramaswamy et al. (2017), “the

Joint Commission cites that the most common causes of errors are inefficient leadership, human

factors, and communication breakdowns.” Some examples of poor communication in IR were

skipping or shortening the essential pre-procedural checklist during the time-out time and the

traditional hierarchy that nurses assumed that the providers would not like to be reminded to

order specimens. These can impact patient safety, patient satisfaction scores, and finances.

Excellent teamwork and communication are crucial to preventing errors (Ramaswamy et al.,

2017).

Problem Description

The main problem in the IR unit was specimen loss and this procedural error caused a

negative impact in the organizational finance. The stakeholders thought these medical errors

could have been avoided if the interprofessional team members in IR had effective

communications tools or training. Since the IR unit is fast-paced and busy, the staff often

skipped or did incomplete briefing, huddling, and debriefing. According to Kirschbaum et al.

(2018), medical errors more often result from miscommunication among the health care

providers than lack of medical knowledge. From the lack of communication process, the unit

faced some missing specimens and near-miss procedural errors. TeamSTEPPS was developed by

the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ). This

training has been applied across health care settings to increase team awareness, clarify team

roles and responsibilities, and to improve information sharing (Cooke & Valentine, 2021). The

HIP will be focused on team building and effective communication for the IR team by

implementing the TeamSTEPPS training.

Impact Analysis and Template

The two categories we identified for the impact analysis were the staff and the

organization. There were two benefits and two risks associated with each category when

completing the impact analysis. The two benefits the stakeholders discussed for the staff were

increased engagement and work satisfaction, and following an evidence-based practice. The two

benefits for the organization were eliminating medical procedural errors and decreasing financial

loss due to specimen loss. The two risks for the staff were the fear of changes and lack of

motivation, and burnout from new learnings and time management. The two risks for the

organization were the pandemic disruption of the education process and lack of leadership

support.

These benefits and risks were rated based on the low, moderate, and high impact to

determine the feasibility of implementing the HIP. The stakeholders rated all four benefits as

high impact because they were all greatly critical for nurse retention, patient safety, and

prevention of financial loss. For the risks, the fear of changes and pandemic disruptions were

rated as moderate impact because we thought these components could be rerouted and redirected

to a virtual version training. The risks include burnout from new learnings and the lack of

leadership support were rated as high impact because these hinder the completion of successful

training. Calculating the impact ratio gave us an assurance that the benefits outweigh the risks.

The impact ratio was 1.2 with the total benefit score of 12 and the total risks score of 10. The

HIP was determined as feasible, and the impact analysis template is displayed in Appendix A.

SWOT Analysis and Template

The process used to complete the SWOT analysis was holding another meeting with

stakeholders. I created the SWOT template on the white board and transcribed our verbal

communication based on the affinity analysis and the impact analysis. The SWOT analysis was

completed to identify internal and external factors in the organization that may impact the

readiness of the organization for the HIP. When discussing the SWOT analysis for internal

criteria, we all agreed that our strength is the organizational support of education for all staff.

The facility administrators always encourage innovative solutions to improve the quality of care

for patients and staff. Another internal strength was that the organization had standardized

procedures for timeout, briefing and debriefing. However, our concern was lack of motivation

due to a busy and fast-paced work schedule, lack of buy-in from staff due to lack of managerial

support, and the schedule conflict due to possible short staffing.

For the external criteria, we identified the opportunity that the TeamSTEPPS is a popular

teamwork tool that can be used statewide for the organization and could improve the curriculum

statewide. We believe that implementing this program will also increase awareness about

medical error prevention in IR. For the threats of external criteria, the pandemic disruption was

the first threat that we all agreed on because the surge disrupted the education process. Another

example of external threat was that we are unsure of when the pandemic will return. The director

of the nurse education department stated that the TeamSTEPPS version that we will be

implementing in this facility is using the gamification methods. This method is different from the

other national educational department norms of TeamSTEPPS. However, the stakeholder

members agreed that the gamification method might draw more attention and positive feedback

from the staff because this method requires active involvement of the staff by playing games.

According to Fijačko et al. (2020), gamification is a relatively new concept in nursing education

and most research studies reported a positive impact due to increased motivation and

engagement. As indicated in one of the external opportunities, if the project is successful, the

developed knowledge can be shared across the organization. The SWOT analysis template is

presented in Appendix B.

Task 2: Healthcare Improvement Project - Project Purpose and Review of Scholarly

Sources

Purpose Statement

This HIP focuses on promoting patient safety by implementing TeamSTEPPS training for

the IR unit. Medical errors such as specimen loss or procedural errors are associated with poor

teamwork or lack of communication. The TeamSTEPPS is an evidence-based training that will

enhance patient outcomes by improving teamwork skills and communication among healthcare

professionals (Adjei, 2022). To move forward with the HIP, literature reviews were completed,

and the stakeholders all agreed on a common goal for the IR unit, which is to implement the

TeamSTEPPS program to increase patient safety in IR.

The stakeholders started to create the TeamSTEPPS training materials such as course

objectives, training contents, and post-training debriefing using PowerPoint. The TeamSTEPPS

program was based on evidence-based scholarly sources and the AHRQ website. This program

was customized by applying the gamification method, which was a different teaching approach

from all other branches of TeamSTEPPS norms statewide. The stakeholders agreed that this

gamification method might draw more attention and positive feedback from the staff because this

method requires the active involvement of the team by playing games.

Review of Relevant Scholarly Sources and Table of Scholarly Sources Template

The HIP is evidence-based project that strengthens the supporting ideas, such as

implementing a team-building program, TeamSTEPPS, and utilizing the gamification method.

Kirschbaum et al. (2018) support the need for effective team communication skills to prevent

medical errors. The research revealed how medical errors more often result from

miscommunication among the health care providers than lack of medical knowledge

(Kirschbaum et al., 2018). This reinforces the HIP goal to focus on implementing a program to

improve communication among the IR health care providers.

To support finding the right team-building training to fit the IR unit, Adjei (2022)

discovered that the TeamSTEPPS is an evidence-based training that would enhance patient

outcomes by improving teamwork skills and communication among healthcare professionals.

The article supports the project goals, which is to implement the TeamSTEPPS program in IR to

promote patient safety, organizational reimbursement, and patient satisfaction by boosting

teamwork and communication.

Cooke & Valentine (2021) also stated that the TeamSTEPPS approach was successful

and cultivated clear communication and mutual support to areas needing improvement in health

care settings that support the HIP. The article states that the TeamSTEPPS training was

successful across health care settings in increasing team awareness, clarifying team roles and

responsibilities, and improving information sharing (Cooke & Valentine, 2021).

The next article was relevant to the project because it supports the new trial of

gamification in TeamSTEPPS. According to Fijačko et al. (2020), the gamification approach

positively impacted team-building training and engagement. The article stated that most research

studies reported a positive effect of gamification on nursing education in the form of increased

motivation and engagement (Fijačko et al., 2020).

Han et al. (2021) also supports the idea of the gamification method’s positive impact on

increased engagement in learning. The article stated that the gamification method would increase

satisfaction with learning experiences (Han et al., 2021). The article asserts that their research

study indicated the students had a positive emotional attitude towards the course (Han et al.,

2021). The research of the evidence-based articles showed that implementing the TeamSTEPPS

is imperative in the IR unit to enhance their communication and teamwork. Also, the

gamification approach will increase motivation and engagement in the TeamSTEPPS sessions.

More research is needed to strengthen the HIP; however, the number of supporting evidence-

based articles was enough to identify best practices that emerged from the evidence and proceed

with the project to promote patient safety in IR. The Table of Relevant Scholarly Sources

Template is presented in Appendix C.

SMART+C Goal Worksheet (Appendix D)

The SMART+C Goal Worksheet is displayed in Appendix D.

Project Management Life Cycle

1. Guidance from Initiation to Closure

Harris et al. (2020) defined project management as an “application of knowledge, skills,

tools, and techniques to project activities to meet project requirements." Also, the various stages

of the project life cycle must be considered to check the feasibility, value, tools, and key drivers

needed for success. According to Altunel (2017), the project management life cycle is defined as

a set of phases including initiation, planning, execution, and closure.

The project management lifecycle will guide this HIP from initiation to closure, and the

followings are examples. The initiation phase for this HIP identified specimen misplacement and

near-miss procedural errors due to poor communication and teamwork in the IR unit. The unit

manager and stakeholders identified the problems for this project. In the initiation phase, the

assessment, problem, and opportunity identification will be completed in the meeting with the

stakeholders. This will determine the solution to the problem and methods to seize the

opportunity. For the needs assessment, Affinity analysis was used utilizing the sticky note

method to reach a consensus. The stakeholders also utilized the Impact analysis and SWOT

analysis to determine the external and internal strengths, weaknesses, and the feasibility of the

HIP within the organization.

After completing all the groundwork for the HIP in the first phase, we moved to the

second phase, planning. In the second phase, the project was broken down into smaller tasks

utilizing the SMART+C goal worksheet. We identified the specific HIP, which created an in-

person team-building training, TeamSTEPPS, with a gamification approach. We scheduled and

visualized the project timeline that evaluated the number of specimen loss and procedural errors

in IR within four months after implementing TeamSTEPPS. We evaluated and gathered the

resources and tools required to perform the HIP such as the PowerPoint, handouts, and materials

for the games. Estimating budgets and identifying potential risks were outlined and explained to

the team so that team members can quickly move forward to the next stage. During this planning

phase, the stakeholders will reach out to the IR leadership to present the HIP for their buy-in.

In the execution phase, once the project is approved to move forward, the educational

director, an expert in researching, planning, and implementing professional development

programs based on data and evidence-based practices, will take the lead in developing,

organizing, and executing the project for the IR team. Once the IR team completes the

TeamSTEPPS training, they will begin to perform tasks to meet the project goal, eliminating the

specimen loss and procedural errors in the four-month period. The execution stage includes

ongoing support by explaining the tasks, providing necessary guidance on how the task should

be completed for the team members, monitoring the HIP process, and managing the budget.

The final phase is closure. During this phase, we will collect the number of cases of

specimen loss and procedural errors to determine if the HIP goal was met. Post-TeamSTEPPS

training surveys or debriefing will be completed for the IR team to evaluate the failures and

successes of the project. We will also assess the IR team’s performance by collaborating with the

IR leadership. The stakeholders will also have a debrief meeting to determine lessons learned for

future projects.

2. Initiation Phase Activities

The followings are the completed initiation phase activities to meet the requirements of

the initiation phase of this HIP. First, the key stakeholders were identified by utilizing the Impact

Grid. On the Impact Grid, their title or role in the organization, expertise, role within the project,

influence, power, and reason for involvement in the project were indicated. The stakeholders

were the chief nurse executive, the educational director, and the quality and patient safety

consultant. Second, we used the sticky note method to complete the Affinity Analysis to identify

the problems in the IR. Each group member identified two ideas on sticky notes, and I displayed

it on a large presentation board. Third, the Impact analysis was completed to indicate if the HIP

is feasible. The feasibility of this HIP was 1.2, indicating that the benefits outweigh the risks.

Next, a SWOT analysis was done to determine the external and internal strengths and

weaknesses within the organization.

Lastly, relevant scholarly sources for the HIP were reviewed to strengthen the supporting

ideas, such as implementing a team-building program, TeamSTEPPS, and utilizing the

gamification method. Five or more relevant evidence-based articles were found to support the

HIP ideas. One example Kirschbaum et al. (2018) revealed was that medical errors more often

resulted from miscommunication among the health care providers rather than lack of medical

knowledge. This reinforces the HIP goal to focus on implementing a program to improve

communication among the IR health care providers. According to Fijačko et al. (2020), the

gamification approach also positively impacted team-building training and engagement, which

support the new trial for TeamSTEPPS statewide among this organization. This initiation phase

allowed the stakeholders to identify the problems and develop the HIP's statement to move

forward to the next step, planning.

D157: Managing Resources in an Era of Disruption

Human Resource Management

Staffing

The staffing requirement was projected by using RACI (responsible, accountable,

consulted, and informed) chart, project charter, and workflow analyses. Five essential staff

members will be needed to create, develop, and implement the healthcare improvement project

for the IR team. These members include a project lead, a chief nurse executive, a quality and

patient safety consultant, a nurse manager, and a director of nursing education. RACI chart was

an effective tool to assign and allocate each person for the project because it clearly shows who

is responsible for each deliverable or task. For instance, the director of nursing education (DOE)

and the project lead are responsible for all tasks involved in the HIP process. The responsibilities

of the two members are justified because they lead and facilitate the entire HIP process until it

completes. The DOE is also accountable for identifying stakeholders and their expectations,

gathering evidence-based research, and organizing ideas from HIP analysis such as affinity

analysis, impact analysis, and SWOT analysis.

The RACI chart also reveals that the chief nurse executive (CNE) is accountable for

approvals for the presented project ideas and financial proposals for the HIP. The justification for

his role is that he may oversee the organization's finances and be responsible for creating a

budget for the project improvement. Throughout the HIP process, the CNE will be kept updated

on progress and notified when each task is completed according to the RACI chart. Two other

essential members of the HIP development process are the patient quality and safety consultant

(QS consultant) and the IR unit nurse manager (NM). They will be consulted for their expertise

to create a quality project and responsible for advice. According to Mackinson et al. (2018), the

clinical quality improvement consultant nurse has the skills and knowledge of the clinical

workflow to practice quality patient care and leverage well-established collegial relationships

among the clinical team. The nurse manager's responsibility is managing nursing staffing,

maintaining safety for patients and staff, and ensuring well-maintained protocols and

standardized workflow in the unit. Therefore, the two essential staff must be consulted and

included in the project development for a successful HIP outcome.

Costs

The followings are the projection of personnel costs related to the HIP. For this project to

be successful, five essential full-timer staff will be needed for development and implementation

during the HIP period of May 31st, 2022, through January 31, 2023, with a total of $2,990.00

cost. The followings are the breakdowns per projected hours: The project lead

$50x30h=$1,500.00 (annual salary of $105,000.00 including benefits), DOE $110x8h=$880.00

(annual salary of $215,00.00 including benefits), CNE $120x2h=$240 (annual salary of

$235,000.00 including benefits), QS Consultant $50x2h=$100 (annual salary of $105,000.00

including benefits), and NM $90x3h=$270 (annual salary of $180,000.00 including benefits).

The project lead's roles are to outline the project with the preceptor, assign and allocate the tasks

and responsibilities to the essential staff, schedule meetings with staff, and facilitate

communication among the HIP team. The roles of DOE are reviewing and guiding the project

lead’s tasks and being responsible and accountable for identifying stakeholders and their

expectations. Other roles of DOE are gathering evidence-based research, collecting and

organizing ideas from the HIP analysis such as affinity analysis, impact analysis, and SWOT

analysis, and identifying available funds and supply needs. The roles of the CNE are reviewing

proposed project ideas and policies regarding the HIP and approving them accordingly to move

forward. The QS consultant will be consulted on identifying the clinical need for change to

improve quality care and patient safety activities for the HIP. The NM will also be consulted on

planning nursing staffing and reviewing current policies to evaluate the need for standardized

workflow changes related to the HIP.

For the TeamSTEPPS training, there will be a guest educator who charges $500 per day

to educate the three full-time educators in the organization for two allocated days:

$500x2(days)x3(educators)= $3,000.00. The IR full-time staff, including providers, will have

one-hour TeamSTEPPS training and will cost $3,040.00. The followings are breakdowns per

projected hours: $65x9 IR nurses/h=$585.00 (annual salary of $128,000.00 including benefits),

$25x1 NA/h=$25.00 (annual salary of $57,000.00 including benefits), $55x6 IR techs/h=$330.00

(annual salary of $110,000.00 including benefits), and $350x6 IR doctors/h=$2,100.00 (annual

salary of $750,000.00 including benefits).

Other costs will be $30.00 for flyers and e-mail to promote the new training for the IR

team. The flyers and e-mail will provide a quick snapshot of ideas about the TeamSTEPPS

training to the IR team. There will be a total of $50.00 supply costs for the training: 20 Plastic

cups, 100 sheets of 8x11 1/2-inch paper, 18 table tennis balls, two dozen color pens, and three

scissors. TeamSTEPPS technology is at no cost since it is a web-based program

from https://www.ahrq.gov/teamstepps/index.html. IR team can download a free TeamSTEPPS

2.0 application via cellular phones.

Project Team Member Engagement

According to Woo et al. (2017), studies have shown that selecting and training

champions were identified as effective strategies to increase participation in quality improvement

projects and have the potential to improve job satisfaction which may contribute to improving

positive patient outcomes. The strategies that could be used to recruit additional project team

members would be selecting and training two champions from the IR frontline staff and the

physician. For this project to be successful, the leadership should create a process to empower

champions to support the change initiatives.

Team-building strategies for the IR team involve collaboration, establishing trust, and

coaching. Once a patient is on the procedural table in the IR, there are three members in the

team: the physician, radiology technician, and nurse (Ramaswamy et al., 2017). During the

procedure, each team member collaborates with their own skills and specialties. Effective

communication is the key component of successful collaboration, which involves transmitting a

clear message between a sender and a recipient (Ramaswamy et al., 2017). According to

Ramaswamy et al. (2017), losing trust is quicker than establishing it. Therefore, coaching and

stimulating team members with applicable scenarios to form trust and build experience are

imperative. TeamSTEPPS with a gamification method is training designed with specific

scenarios to coach the team to build effective communication and teamwork skills. Selected

champions can be pre-educated about the TeamSTEPPS before the HIP can be initiated in the IR

unit so that the champions can facilitate the collaboration process, establishing trust, and

coaching for the IR team during the project period.

The champions also can participate in team guidelines with communication, conflict

management, and decision-making. Lateef (2018) stated that mutual trust, respect,

communications, and accountability are crucial elements for successful inter-professional

teamwork. The champions and the team members must understand their roles and

responsibilities for mutual respect and clear communication. According to Ramaswamy et al.

(2017), constructive conflict is a key element in building a harmonious team, but too much

conflict is destructive. Recruiting the champions can increase the chance of successful buy-in,

mitigating conflict and contributing to the profitable HIP. Successful teams are committed to the

concept of buy-in when not everyone agrees completely with a new plan (Ramaswamy et al.,

2017). Disagreement could happen during the decision-making process because it clarifies the

project goals (Ramaswamy et al., 2017). Involving frontline staff in the decision-making process

could empower them and increase buy-in.

Support for Team Members

To support project team members and staff during implementation, nurse leaders should

ensure that the workplace is a healthy and joyful environment where diversity, inclusion, and

work-life balance are valued. Work stress can be the source of nurse burnout and staffing

shortages (Hersch et al., 2016). The new project might add more stress to the team since it

requires changes. Therefore, nurse leaders should promote the stress relief method such as a

web-based program, BREATHE, or any similar program to help the team with stress relief skills,

which may promote a healthy work environment and work-life balance (Hersch et al., 2016).

Another way to support project team members and staff is to be open-minded, accept

their diversity, and include them in the decision-making process during the project

implementation. Nurse leaders should frequently emphasize the importance of diversity and

inclusion in the IR staff meeting, which may affect their feeling of belonging, happiness,

productivity, and smooth operation of the project (Diversity & Inclusion as a Mission Statement,

2020). Better productivity and job satisfaction can be realized when employees feel they are

included and have a voice (Diversity & Inclusion as a Mission Statement, 2020).

RACI Chart

The RACI chart is displayed in Appendix E.

Financial Resource Management

Budget Methods and Requirements

Nurse leaders must consider a well-designed and well-written budget plan before

planning a new project and for successful budget approvals. This budget plan should contain

solid financial methods such as a general description of the project, a budget, a description of

cost needs, projections for the first two years, how market research supports the new project, and

the project's likelihood of success (Waddill-Goad, 2017). The financial methods used to create a

pro forma operating budget for planning the implementation and the control phase of the HIP

were descriptions of budget items, the budget amount, and descriptions of budget needs. A total

of $9,110.00 pro forma budget was planned and proposed by the five essential staff for the

development of the HIP. The proposed pro forma budget includes the projection of personnel

costs related to the HIP, education fees, supplies, flyers/e-mail, and the TeamSTEPPS

technology. Planning the budget for the HIP went smoothly because this project was once

prepared before COVID-19 hit the organization, which they had to cancel due to the pandemic

surge. The DOE, one of the project team members, was able to identify those expense items and

estimate the needed financial resources. The DOE influenced the budgeting process by

presenting evidence-based research on value-based care. She emphasized the importance of HIP,

which could positively impact IR teamwork and communication and decrease the number of

specimen misplacement and possible procedural errors. She also shared the screen of a research

paper to the stakeholders that the TeamSTEPPS training consistently demonstrated a marked

improvement in communication, decrease in clinical errors, and improvement in patient

satisfaction (Parker et al., 2019). The project lead also highlighted how the Joint Commission

emphasizes reducing preventable medical errors and increasing patient satisfaction based on

evidence-based research. The stakeholders agreed that the HIP should move forward, and the

CNE agreed to approve the budget proposal for the project.

Pro Forma Operating Budget

The Pro Forma Operating Budget Worksheet is displayed in Appendix F.

Budget Variances

The budget variances would be tracked and managed by creating and completing the

variance analysis during the PHI period with the collaboration of the project lead, DOE, and the

IR NM. The three staff will review the variance analysis weekly or as needed. The variance

analysis indicates unfavorable spending variances by deducting flexible budgets from actual

expenses (Edspira, 2018). By comparing the budgeted expenses to the actual expenses, the

budget can be monitored to determine the cause of problems and to provide accurate financial

reporting. Based on performance, changes can be made for the next budget cycle with the

corrective action plan (Rundio, 2016).

Project Charter

The Project Charter is displayed in Appendix G.

D158: Strategically Planning the Execution of a HIP

Meetings and Organizational Policies

Project Meetings

For the effective approach to organizing and leading project meetings with the method of

reaching a consensus on meeting agendas, I would consider continuing to utilize the strategies I

have used in the past to facilitate communication and collaboration. I would conduct the

meetings with the identified stakeholders on a weekly basis until we meet the consensus, then

twice a week during the implementation phases for the first two months. To facilitate

communication and collaboration during the implementation period, I would conduct monthly

meetings to monitor the IR unit's progress. As I have used in the past for the HIP, I would

continue to use the sticky note method to collect potential ideas. Once the team has identified a

limited list of potential ideas, it is helpful to pick the best solution using the voting method to

reach a consensus on each meeting agenda based on best practices (Kriek, 2019).

Each individual must have strong group communication skills to work effectively in the

team to accomplish specific project tasks and minimize unnecessary conflicts or

misunderstandings. Building rapport with team members and understanding how group

communication works can also help the team members to be motivated to meet the HIP goals

(Stucky, 2022). Ensuring a clear understanding of each team member’s roles and responsibilities

and having clear and honest communication may empower each group member. I would conduct

a policy meeting with the stakeholders, sharing ideas and being open with the group members

during the meetings. I would collaborate with the team members to analyze and develop existing

policies that would support for the HIP.

Review of Organizational Policies

The process I would use to determine whether the organization had existing policies that

could affect the proposed implementation of my project would include the Centers for Disease

Control and Prevention guide for identifying, analyzing, and prioritizing policies (Centers for

Disease Control and Prevention, n.d.). First, as it is indicated in the RACI chart, the project lead,

the chief nurse executive, the IR nurse manager, and the director of nursing education

collaborated to review the current policies. Second, each member reviewed the policies and

procedures separately based on the identified issues, such as missing specimens, poor

communication, and incomplete debriefing or huddle. Third, the members searched and analyzed

the policies via the hospital intranet and shared the information during our meeting. Lastly, the

members prioritized the 'Reporting Protocol for Patient Care Issues' policy and decided to

include it in the TeamSTEPPS training to encourage the IR team to communicate and escalate

any issues as soon as they discover a safety breach.

Action Plan Development

Action Plan Template

The Action Plan Template is displayed in Appendix H.

Development of the Action Plan

To gather input related to the development of the action plan, I would conduct meetings

with the identified stakeholders on a weekly basis until we meet the consensus, twice a week

during implementation phases for the first two months, then monthly until the project is

completed. I would use the sticky note method to collect potential ideas in the planning phase.

The voting method would also be used to reach a consensus among project team members. Kriek

(2019) stated that once the team has collected and identified a limited list of potential ideas, it is

helpful to pick the best solution based on the best practice using voting. In each meeting, any

new ideas will be collected in sticky notes and attached to the whiteboard, and the stakeholder

members will vote them to meet consensus on the best practices.

For the first action item, the project approval, the CNE is accountable for approvals for

the presented project ideas and financial proposals since he may oversee the organization's

finances and is responsible for creating a budget for the project improvement. Throughout the

HIP process, the CNE will be kept updated on progress and notified when each task is

completed. During the second and third action items, which are training the TeamSTEPPS

program for educators and the IR team, the project manager and the DOE will implement the

HIP based on the ideas collected and voted on by the stakeholders and evidence-based practices.

Lastly, during the fourth and fifth action item phases, the project lead and the DOE will evaluate

the effectiveness of the training, and the unit manager will gather the post-training data of the

specimen and procedural errors in the IR. The project lead and the DOE will ensure that each

action plan is complete within the target due dates.

SDOH and Target Population

SDOH and Sociodemographic Characteristics

Social Determinants of Health (SDOH) are conditions in various environments that affect

health, and the SDOH promotes good health for all Americans (Office of Disease Prevention and

Health Promotion, n.d.). The five key determinants include economic stability, education, social

and community context, health and health care, and neighborhood and built environment (Office

of Disease Prevention and Health Promotion, n.d.). The target population for this project

includes patients in the IR, in According

to the data retrieved from the United States Census Bureau (n.d.), the population estimated was

9,829,544, the percentage of female persons was 50.4%, the percentage of Hispanic or Latino

was 49.1%, White alone, not Hispanic or Latino was 25.3%, Asian alone was 15.6%, and Black

or African American alone was 9.0% in The median household income

from 2016 to 2020 was $71,358, and the percentage of persons aged 25 years and above who

were high school graduates or higher was 79.8%, Bachelor’s degree or higher was 33.5% from

2016 to 2020, and the percentage of persons without health insurance under age 65 years was

10.2% in (United States Census Bureau, n.d.). This hospital's patient

population is ethnically diverse: 39% of patients self-identifying as Hispanic/Latino, 29% White,

16% Asian, and 11% Black. Of the individuals served by the hospital, 23% of the children live in

poverty, and 13% of the population are uninsured (

2019). The sociodemographic characteristics of where the

hospital serves, include those who are with obesity, physical inactivity, alcohol-impaired driving

deaths, sexually transmitted infections, and teen births (County Health Rankings and Roadmaps,

2022).

To serve the patients in poverty and uninsured, the hospital has focused on providing free

and low-cost screenings, services, and transportation for better access to care

2019). Also, the organization has been ensured to deliver

programs and services in the language people speak and provide cultural competency/implicit

bias training for providers to serve the diverse population (

2019).

(1) Economic Stability

The target population for does not have economic stability. The

percentage of persons in poverty was 13.2% in lower than the United

States with 11.6% (United States Census Bureau, n.d.). Also, the percentage of total employment

in was lower at 0.4% than in the United States at 0.9% (United States

Census Bureau, n.d.).

(2) Education

The target population for does not have a higher level of education

than the United States. The percentage of persons aged 25 years and older with high school

graduates or higher was lower in with 79.8%, compared to the United

States with 88.5% (United States Census Bureau, n.d.). However, the percentage of bachelor’s

degrees or higher was slightly higher in with 33.5%, than in the United

Sates, with 32.9% (United States Census Bureau, n.d.).

(3) Health and Health Care

The overall health outcome ranking of the target population in was

24 out of the 58 counties in California state, according to the County Health Rankings and

Roadmaps (2022). Also, the length-of-life ranking was 21, and the quality-of-life ranking was 33

in (County Health Rankings and Roadmaps, 2022). Lack of health

insurance coverage could limit access to primary care physicians; the percentage of the

population under age 65 without health insurance was 11% in (County

Health Rankings and Roadmaps, 2022).

(4) Neighborhood and Built Environment

The target population for as related to neighborhood and build

environment include access to healthy food, crime and violence, environmental conditions, and

the quality of housing, according to Office of Disease Prevention and Health Promotion (n.d.).

Food insecurity indicates the population that does not have access to a reliable food source; the

ranking was 26, and the ranking of limited access to healthy foods was 9 for

(County Health Rankings and Roadmaps, 2022). The percentage of owner-occupied housing

units was 46%, raking 57 out of 58 counties, and the target population in

ranked first in severe housing cost burden in all counties (County Health Rankings and

Roadmaps, 2022).

(5) Social and Community Context

Office of Disease Prevention and Health Promotion (n.d.) states that improving social and

economic conditions, including quality of relationships, will create a healthier population,

society, and workforce. The target population for ranked first in school

segregation which students within different race and ethnicity groups are unevenly distributed

across schools (County Health Rankings and Roadmaps, 2022). The gender pay gap ranking was

five, which showed that women’s median earnings were lower than men’s for all full-timers

(County Health Rankings and Roadmaps, 2022).

Benefits of HIP for target population

The goal of the HIP is to implement the gamification TeamSTEPPS to enhance

interdisciplinary communication and thus improve patient safety by eliminating specimen

misplacements and procedural errors for the target population in the IR unit. Office of Disease

Prevention and Health Promotion (n.d.) emphasized that all Americans deserve an equal

opportunity to make choices for their good health. According to Schneiderman & Olshansky

(2021), nurses must perform more organized, seamless health-care delivery and interdisciplinary

advocacy to achieve the target population’s needs and their changes. The main problem in the IR

unit was the lack of communication among the interdisciplinary team in IR. Missing specimens

and near-miss procedural errors caused a negative impact on achieving good health and safety

for the target population. Research has proven that medical errors often result from

miscommunication among health care providers than a lack of medical knowledge (Kirschbaum

et al., 2018). Implementing the HIP will help the IR to eliminate specimen misplacement and

procedural errors. The HIP will improve patient safety and satisfaction; therefore, it would affect

the target population positively.

Force Field Analysis

Force Field Analysis Template

The Force Field Analysis template is displayed in Appendix I.

Positive and Negative Forces

Force field analysis is a basic tool for root cause analysis that can help the organization

consider all aspects of making the desired change by presenting the positive and negative of a

situation (American Society for Quality, n.d.). The positive and negative forces for the HIP were

brainstormed and collected three of each force by the stakeholder team using sticky notes and

voting methods. The first positive force is utilizing a web-based TeamSTEPPS technology

program at no cost for the HIP. The IR team members can download the TeamSTEPPS

application on their smartphones for free, enabling them to extend the learning at their pace. The

second positive force follows the first positive force; the project has financial support from upper

management. Since the HIP does not require a high cost, we could get financial support from

upper management smoothly. Another fact for having financial support from upper management

was that this project was once prepared and approved before COVID-19 hit the organization,

which they had to cancel due to the pandemic surge. The third positive force is the leadership

support for an evidence-based program that is AHRQ standards. TeamSTEPPS has been

successful across health care settings in increasing team awareness, clarifying team roles and

responsibilities, and improving information sharing (Cooke & Valentine, 2021). The strong

leadership support in implementing this successful set of evidence-based teamwork tools will

increase staff buy-in and positively affect the current IR team culture.

The three negative forces that the stakeholder team identified include a possible lack of

buy-in from the IR team due to schedule conflict and short staffing, possible pandemic disruption

even with the upper management support for the HIP, and possible resistance of staff to the new

changes. Determining methods of eliminating or reducing the barriers to completing the HIP will

be necessary if the negative force outweighs the drivers (Agency for Healthcare Research and

Quality, n.d.).

Strategies for Overcoming Negative Forces

The followings are examples of strategies for overcoming negative forces. The first force

that hinders and negatively impacts the HIP is a lack of buy-in from IR staff. Due to possible

schedule conflicts and short staffing, the IR team might not be able to participate in the program.

The strategy would be to plan the program to be simple and practical and work with the IR

leadership to prepare extra staffing for the training day. The second negative force is the possible

pandemic disruption. As I mentioned earlier, this project was once prepared and approved before

COVID-19 hit the organization. However, the project was canceled due to the pandemic surge.

The stakeholder team suggested and planned to implement the project using Teams meetings in

case of pandemic disruption. The third opposing force is that not all staff will accept the new

change and the time needed to change the culture of the IR unit. Support from a super user, a

champion, or the leadership would be necessary for the staff who need assistance with the

changes. Building clear communication tools standardized work and revising policies regarding

the briefing and debriefing process in IR would be the key to improving workplace group

communication (Schoemaker & Day, 2021).

Gantt Chart Information

Screenshot of Gantt Chart

The Gantt Chart is displayed in Appendix J.

Gantt Chart Information

A Gantt chart is a tool for planning and monitoring a project's tasks and timelines, which

has been around since the 1890s (Gantt, n.d.). The Gantt chart is very useful for the HIP because

it visualizes the tasks and timelines and makes it easy to add and revise the tasks, assigned

people, and progress utilizing the Excel program. The stakeholder team held a meeting via

Teams and put efforts into utilizing and organizing previous tasks into the Gantt chart timelines.

Examples of the previous tasks we reviewed together include the needs assessment, affinity

analysis, impact analysis, RACI chart, and SWOT analysis. With the leads of the project

manager and the project facilitator, the team also reviewed the evidence-based literature about

the gamification training and the TeamSTEPPS, policies and hospital regulations related to

TeamSTEPPS, and the budget for the planning of HIP. Because the meeting was via Teams, all

members could see the bar chart that was created and revised by the project manager, and the

team reached a consensus on the finalized Gantt Chart.

Scope Statement

The HIP is implementing a gamification TeamSTEPPS training for the IR team to

promote patient safety, patient satisfaction, and organizational reimbursement. There have been

ongoing issues with specimen misplacement and near-miss procedural errors such as wrong site

or patient in the IR unit. Implementation of the HIP is vital for the IR unit to eliminate specimen

and procedural errors

There were three specimens and procedural errors related to a lack of teamwork and

communication from January 1 through April 30, 2022. Implementation of the TeamSTEPPS

program in the IR unit will be completed by September 30, 2022. The challenge goal will be to

have zero cases of specimen loss and procedural errors due to a lack of teamwork and lack of

communication in the IR by January 31, 2023. The initial goal was to decrease the errors by 50%

but to challenge the organization, we are setting the challenge goal at zero errors.

The identified deliverables include identifying stakeholders, clarifying their roles and

responsibilities, and gathering evidence-based literature and practices. The technique we used to

identify the stakeholders was using the HIP Anticipated Stakeholder Impact Grid. This grid

enabled the project manager and facilitator to analyze the stakeholders’ title or role in the

organization, experience or expertise, role within the project, influence and power, and reason

for involving stakeholders in the project. RACI chart was a tool to organize the stakeholder

team’s roles and responsibilities for each deliverable. Ensuring a clear understanding of each

team member’s roles and responsibilities and having clear and honest communication may

empower each group member (Schoemaker & Day, 2021). Researching and gathering evidence-

based literature revealed that the TeamSTEPPS training consistently demonstrated a marked

improvement in communication, decreased clinical errors, and improved patient satisfaction

(Parker et al., 2019). Also, studies have shown that selecting and training champions were

identified as effective strategies to increase participation in quality improvement projects and

have the potential to improve job satisfaction which may contribute to improving positive patient

outcomes (Woo et al., 2017).

The two key performance indicators (KPI) include the number of specimen loss and

procedural error cases and patient satisfaction scores from baseline to post-implementation. The

healthcare improvement project outcome will demonstrate zero cases of specimen misplacements

and procedural errors in the IR unit. By January 31, 2023, the IR team will be able to utilize and

retain the TeamSTEPPS learning skills in their practice to enhance their teamwork and

communication skills after completing the training. Once the HIP has been implemented, patient

safety will be improved, increasing patient satisfaction and organizational reimbursement.

Communication Management Plan

Prior to the implementation of the HIP, a clear communication strategy was developed by

the project manager. The communication tool was created via the Teams meeting application,

where all invited members can receive updates. The intended receivers include the project

facilitator, key stakeholders, and the IR team leadership; they will be kept informed of the

project's progress. Examples of the context include the project plans, changes of the plans, the

status of the project, data collection, and evaluation of the project; impact analysis, SWOT

analysis, SMART+C goal worksheet, RACI chart, Pro Forma Operating Budget, HIP charter,

Action Field template, Force Field Analysis, Gantt chart were updated in the Teams

communication board for everyone to be on the same page. Communication outcomes will

indicate if the timelines, project goals, and objectives are met and what contributed to the success

or failure of the project. Key messages include the benefits and explanations of each context,

showing the purpose of each action. Evidence-based research would help deliver the key

messages to the receivers. Message mediums used for the HIP are Teams meetings

communication board and e-mail. Verbal communications will also be documented in the Teams

meetings communication board. Using the Teams communication board is to share the right

messages at the right time, using the right venue.

D159: Evidence Based Measures for Evaluating Healthcare Improvement

Project Reports

Team Member Collaboration

First, I met my preceptor to plan how we would collaborate with the project team

members to identify data elements that would be necessary for determining the success of the

proposed project. We decided to have the Teams meeting with the stakeholders weekly to

identify data elements, then twice a week during the implementation phases for the first two

months. We decided to continue monthly meetings to analyze essential data elements to monitor

the IR unit's progress. The process of collaborating with the project team members to identify

data elements was brainstorming. In the Teams meeting, each stakeholders suggested one to two

data elements, and I was able to collect the final key data elements using voting method. The

majority of the stakeholders agreed on the key data elements after having clear and honest

communication. During the procedure, each team member collaborated with their own skills and

specialties.

The project team recognized that effective communication is the critical component of

successful collaboration, which involves transmitting a clear message between a sender and a

recipient (Ramaswamy et al., 2017). Data elements that the project team identified for the

frequency of effective communication are the number of daily morning briefings, the number of

huddling for each case, and the number of debriefings at the end of each case. They also

identified data elements of the total number of specimens, the rate of missing specimens, the

total number of IR procedures, and the rate of procedural errors. These numbers will help the

team identify whether the HIP has met the goal.

The IR team members use the electronic medical records (EMR) system for ordering and

labeling purposes for the specimens and documentation for the procedures. However, the project

team, including the unit manager, decided to use the paper logbook for the measurements

because tracing the data elements via EMR takes longer than the manual logbook. We decided to

place the logbook in the nursing station next to the medication room, where the IR nurses can

grab and document it easily.

Data Elements

TeamSTEPPS is an evidence-based teamwork program that enhances patient outcomes

by improving teamwork skills and communication among healthcare professionals. Common

examples of poor communication in IR include skipping or shortening the essential pre-

procedural checklist during the huddle and time-out time and nurses or radiology technicians

assuming the providers would not like to be reminded to order specimens. The research revealed

how medical errors more often result from miscommunication among the health care providers

than lack of medical knowledge (Kirschbaum et al., 2018). For these reasons, stakeholders

decided to collect the essential data via majority vote as follows, the number of daily morning

briefings, the number of huddling for each case, and the number of debriefings after each IR

case. The daily morning briefing would give a picture of the day to the IR team so that they

could communicate and prepare anticipated procedures and specimens. Conducting huddles for

each case would remind the IR team of all the procedural-related details so that the team would

run the procedure without any errors. Lastly, the debriefings after each IR case would allow the

IR team to review the team's performance, identify any medical errors that might have occurred,

and encourage team members with things that worked successfully.

The target metrics and measures for the HIP are zero missing specimens and zero

procedural errors. Therefore, we decided to collect the total number of specimens, the rate of

missing specimens, the total number of IR procedures, and the rate of procedural errors that will

be used to determine the success of the project. For everyone to be on the same page and to move

towards the same goals together, we decided to share the data among the IR team by presenting

the data through a dashboard. The best person who would be responsible for creating and

running the dashboard we identified was the unit manager. The unit manager, who will be

responsible for the project reports, will collect those data, keep them updated in the dashboard,

and present them to the IR team with the unit charge nurse weekly. DOE will receive the data

from the IR unit manager and share it with the stakeholders for effective collaboration with the

project team members to meet the goal by January 31, 2023.

Data Management Plan

Data Source

The process I would use to identify the data source needed to measure the success of the

proposed project in collaboration with the project team would be brainstorming and voting

techniques. Each project team member would express their ideas in the Teams meeting, and I

would have the team vote on the best ideas to identify the best data source. The data elements

sources that I will use to measure the success of my HIP are the two paper logbooks, one for the

specimens and one for the procedures, briefings, huddles, and debriefings. The manual data

sources would be used as the data sources because a consistent and readily available document is

critical to collect and share the data among the IR and project management teams. EMR was not

selected as the data sources because it takes longer than the manual logbook to trace the records.

The project team designated a location for the logbook as the nursing station next to the

medication room where the IR team members can easily document the numbers. The unit charge

nurse is responsible to transcribe the logbook records to the dashboard, which will be displayed

in the IR suite wall where the daily briefing is held. The unit manager or the charge nurse will

present the collected data to the IR team on Fridays in the daily morning briefing. DOE will

create a shared folder in Teams for the stakeholders to share the data as well.

KPI and Benchmarks

The measures that I would use to determine the success of the proposed project are the

number of daily morning briefings, the number of huddling for each case, and the number of

debriefings after each IR case. I will also use the total number of specimens, the rate of missing

specimens, the total number of IR procedures, and the rate of procedural errors. One KPI that I

would use to verify the success of the HIP would be comparing the rate of specimen errors to

another organizational research. The project’s goal is that 100 percent of the specimens will be

handled without errors. The specimen error data will be recorded by IR nurses in the logbook,

and the unit charge nurse or the unit manager will indicate the data in the dashboard in the IR

suite during the implementation period, October 1, 2022, to January 31, 2023.

One benchmark I would establish for the KPI is to compare the number of specimen

errors to the other organization, the Based on the organization’s

research, there are ten errors for every 1,000 procedural specimens. To equivalent this value to

400 specimens, the frequency of the specimen error would be four. Therefore, if the IR unit

creates no more than four specimen errors during the implementation period, the IR team will

meet the benchmark. However, we will strive to meet the HIP goal of zero specimen errors

because any level of preventable harm is unacceptable, as it could lead to risks of treatment

delay, incorrect therapy selection, or inaccurate diagnosis (Holstine & Samora, 2021).

Data Collection Method and Parameters

The method I would use to collect the quantitative data would be manual tally counting

using the logbook. The IR suite has already been recording a logbook specifically for the number

of specimen collections and the number of procedures. Since they have been documenting them

in the paper logbook, the project team members decided to create another paper logbook just for

the project implementation purpose. The IR staff will indicate quantitative data for the completed

task number of daily morning briefings, huddling on each procedure, and debriefing after each

IR case. Also, the total number of specimens, the rate of missing specimens, the total number of

procedures, and the rate of procedural errors in the IR suite will be included in the quantitative

data for the IR staff to record in the project logbook. The unit manager will be responsible for

transcribing the quantitative data into the IR dashboard. She will also assist DOE in uploading

the electronic dashboard in the Teams shared drive for the stakeholders.

Justification of the parameters to collect the quantitative data are as follows. The

quantitative data will be collected during the implementation period from October 1, 2022, to

January 31, 2023, to monitor and compare the data to the benchmark and the HIP goal to

measure the success of the project. The quantitative data elements that will be collected are the

number of daily morning briefings, huddling on each procedure, and the debriefing after each IR

case. Also, the total number of specimens, the rate of missing specimens, the total number of

procedures, and the rate of procedural errors in the IR suite will be included in the quantitative

data for the IR staff to collect in the logbook on a daily basis. Then, the unit charge and the unit

manager will collaboratively upload it into the IR dashboard, and they will be responsible for

presenting the data to the IR team in the morning briefing on Fridays. The project team members

will monitor the collected data via the Teams shared folder to evaluate the success of the project.

The Teams shared folder will be updated by a collaboration of the IR unit manager and DOE. In

the stakeholder meetings, DOE and I will be responsible for summarizing the data using

descriptive statistics to the project team every two weeks for the first two months and then

monthly during the project implementation period to monitor and evaluate the process of the

HIP. The number of specimen errors will be compared to the HIP goal of having zero specimen

errors.

Data Analysis

Data Analysis Method

The method I would use to analyze high-priority data would be using descriptive

statistics. Descriptive statistics are used to describe the basic features of the data by providing

simple summaries about the sample and the measures (Mishra et al., 2019). Measures of

frequency, measures of central tendency (mean, median, and mode), and measures of dispersion

or variation are three types of descriptive statistics to provide simple summaries of the sample

and the measures (Mishra et al., 2019). Among the three types, I decided to use the central

tendency method describing the mean, median, and mode statistics. I would trend the data on a

monthly basis retrieving the numbers from the two manual IR logbooks during the four months

of the implementation period from October 1, 2022, to January 31, 2023.

Interpretation of Initial Results

The central tendency will be used to find out the representative value of the data set,

mean, median, and mode (Mishra et al., 2019). The mean is the average value, the median is the

middlemost observation of the data, and the mode is a value that occurs most frequently in a set

of observations (Mishra et al., 2019). The process to interpret the initial results of the project will

be using the central tendency method by comparing the specimen error numbers during HIP

implementation to the pre-project period. The unit charge nurse and the manager will ensure that

each IR nurse completes the records in the logbooks. The unit manager will post the central

tendency data in the Teams using the Excel sheet. The statistical interpretation of the initial

results will allow the project team to determine if the HIP is effective, eventually decreasing the

specimen errors.

Contextual Issue

A contextual issue that may potentially affect the proposed project results would be that

the IR staff may not be compliant with recording the accurate specimen error numbers due to

staffing shortages or distractions that may occur. Other related issues that could potentially affect

the project results would be inaccurate data provided by the organization due to the

organization’s data security policy. The pandemic might also impact the organization and the

staff, thus the project results. If the contextual issue affects the results, the HIP might not be

successful.

Results Dissemination Plan

The project team members agreed to the plan my preceptor and I initiated to disseminate

the proposed project results through a Teams meeting. The Teams meeting allows the team

members to see the shared data and flexibility in any pandemic phase. The project members I

would present the results via Teams are DOE, CNE, the patient quality and safety consultant, and

the unit manager. The Teams meeting will be 30 minutes long, and it will be scheduled twice a

week for the first two months, then monthly during the implementation period. The method I

would use to professionally deliver the results is the PowerPoint presentation via Teams. I would

include the Gantt chart, IR dashboard, and descriptive statistics utilizing the Excel program to

make the presentation more visual and effective. After the meeting, I would put the PowerPoint

presentation in the shared folder via Teams for the team’s review. I would also encourage the

project team to e-mail me any feedback from the previous meeting and any agenda for the next

meeting.

Project Closure Plan

Organization Acknowledgement

I would acknowledge the organization for its time and support by sending a thank you

card because the project members work in different locations in the organization. I would ensure

to write specific individual praise and positive feedback in the thank you card. To acknowledge

the IR team members, I would provide donuts and coffee to the IR team on one morning with a

thank you card. I would also send a shout-out letter to the organization administrator leadership

for the project team members and the IR team members.

The project team wrap-up session to discuss any next steps will be scheduled in person in

February 2023 with the project team members. I would prepare breakfast for the meeting to show

my gratitude and to recognize the accomplishments of the project team. We will discuss what

went well and what we need to improve. The team will continue to take responsibility and roles

to monitor the data and will ensure that the TeamSTEPPS training will be maintained every year

to keep up the culture of effective communication among the IR team. DOE will keep her

responsibility as the project facilitator, and I will continue to open myself available in case they

have questions or concerns.

D160: Nursing Leadership and Management Field Experience

Kick Off Process

After obtaining the organizational approval to move forward with the HIP, I conducted a

kickoff meeting with the key stakeholders to introduce the project team. The kickoff meeting

was an hour-long in-person meeting where the stakeholders and the project team could build a

sense of working together toward a common goal, promoting patient safety and satisfaction. The

way to organize the project team was by introducing themselves and sharing their roles and

responsibilities for the HIP. During the kickoff meeting, I presented the HIP plan and why the

HIP would be necessary for the IR unit. Everyone was on the same page that improving

teamwork and communication skills by implementing the TeamSTEPPS is essential for the IR

team because the IR unit had specimen losses and near-miss procedural errors, which caused a

negative impact on the organizational finance.

The stakeholders and the project team decided that the best way to build an alliance of

supporters was to have a mentorship for the HIP. Each stakeholder would be a mentor for each

project team. For example, the patient quality and safety consultant would be a mentor of the IR

unit charge nurse for the HIP. According to Manzi et al. (2017), mentorship can sustain

relationships and transfer skills from a more experienced individual in an area to a less

experienced mentee to support professional development.

Holding the kickoff meeting was a celebration. We cut a cake to celebrate the

organizational approval for the HIP and the successful project implementation process. After

introducing each other, they shared their roles and responsibilities. We shared our goal of zero

missing specimens and procedural errors in IR by January 31, 2023, by implementing the

TeamSTEPPS in the gamification method. As a project lead, I also informed the leadership that I

would need their continued support and approvals for the project’s successful outcome.

We shared and reviewed the goals and timelines utilizing the SMART+C and Gantt chart

that the stakeholders previously created. The RACI chart was an effective tool for assigning and

allocating each person for the project because it clearly shows who is responsible for each

deliverable or task. All these tools allowed everyone in the meeting to make a milestone of the

project and to be on the same page.

Communication Plan Implementation

There are two types of communication plans. A dashboard in the IR unit is for the IR

team, and the Teams shared drive is for the stakeholders to be informed. For the collaborative

communication plan for the project implementation, the IR staff will indicate quantitative data of

the completed task number of daily morning briefings, huddling on each procedure, and

debriefing after each IR case. Also, the total number of specimens, the rate of missing

specimens, the total number of procedures, and the rate of procedural errors in the IR suite will

be included in the quantitative data for the IR staff to record in the project logbook. The unit

charge nurse and the manager will transcribe the quantitative data into the IR dashboard. The

unit manager will assist DOE in uploading the electronic dashboard in the Teams shared drive to

keep the stakeholders informed. One modification in the communication is that the project team

members will also have access to the Teams shared drive to increase the project team’s

participation and transparency.

The project team members will monitor the collected data via the Teams shared folder to

evaluate the success of the project. The Teams shared folder will be updated by a collaboration

of the IR unit manager and DOE. There will be meetings with the stakeholders and the project

team members every two weeks for the first two months and then monthly during the project

implementation period to monitor and evaluate the process of the HIP. DOE and I will be

responsible for summarizing and displaying received data in the Teams shared drive for

everyone to be informed.

Training Plan

The key topics of the staff training plan will be reviewed and will ensure that everything

stays the same as planned. First, a guest educator will educate three full-time educators in the

organization for two allocated days. Second, the educators will hold a one-hour TeamSTEPPS

training session for IR interdisciplinary team. Lastly, all IR team members will be encouraged to

download a free TeamSTEPPS 2.0 application via cellular phones as a resource for the

implementation period and post-implementation stage. The stakeholders and the project team

will continue to take responsibility and roles to monitor the data. They will ensure that the

TeamSTEPPS training will be maintained annually to keep up the culture of effective

communication among the IR team.

The training method of the TeamSTEPPS version we will be implementing in this facility

is gamification. This method is different from the other national educational department norms of

TeamSTEPPS. However, the stakeholder members agreed that the gamification method might

draw more attention and positive feedback from the staff because this method requires the active

involvement of the staff by playing games. According to Fijačko et al. (2020), gamification is a

relatively new concept in nursing education, and most research studies reported a positive impact

due to increased motivation and engagement. This gamification approach will be the pilot project

for TeamSTEPPS across the organization.

The one-time in-person training will be scheduled during lunchtime, and lunch will be

provided. The flyers and e-mail will be sent to the IR interdisciplinary team, and RSVPs will be

collected through e-mail. The stakeholders agreed to schedule another training session if the

attendance or post-education satisfaction rates were poor. Otherwise, the two selected

champions, with the assistance of the project facilitator, will continuously provide support and

education to the IR team during the implementation period.

The post-training survey will evaluate the training outcomes. The survey will be concise

and will measure the level of understanding of TeamSTEPPS before and after attending the

training. The survey will also verify the staff satisfaction rate with playing games to learn the

TeamSTEPPS and the readiness to use the TeamSTEPPS in the IR workflow.

Training Plan Implementation

The implementation of the training plan was initially limited to the IR team and one

session. However, the stakeholders thought it would be a good opportunity for supervisors and

managers in other procedural units to learn about TeamSTEPPS to promote teamwork and

communication skills. The upper management approved extending another TeamSTEPPS

session. Therefore, they opened another training session two weeks after the first session. Emails

were sent to the unit charge nurses and managers in other units such as operations rooms (OR),

post-anesthesia care unit (PACU), and endoscopy unit. Two sessions also helped IR with

staffing, allowing more IR teams to be trained.

Testing of Workflow

The project implementation workflow was tested at a conference room where the actual

TeamSTEPPS training will be held. The stakeholder team participated as the trainee, and they

evaluated the testing of workflow. Printable hand-outs were given to each member, including pre

and post-evaluation of the training. The DOE and the project manager presented the PowerPoint

slides using a projector. The Gamification method was used with the materials such as

disposable cups, spoons, and ping-pong balls. The stakeholders stated that more participants

would result in a better flow of the gamification method training. They ensured and agreed that

inviting more participants other than the IR team would benefit this gamification type of

TeamSTEPPS training. No other issues were discovered with the testing of the workflow.

Implementation and Control Field Experience

Project Journal

The project manager created a reflective project implementation journal to manage the

HIP implementation. The journal was kept in the Teams meeting application shared folder where

the stakeholders and the project team members can access it. The journal provided a big picture

of the HIP to the team and was also valuable as a communication tool for the root cause analysis

during the meetings. Examples of the context of the project journal include the project plans, the

status of the project, changes of the plans, data collection, and evaluation of the project; impact

analysis, SWOT analysis, SMART+C goal worksheet, RACI chart, Pro Forma Operating

Budget, HIP charter, Action Field template, Force Field Analysis, and the Gantt chart.

Using the project implementation journal was effective in managing the HIP

implementation. For instance, it allowed the team to track the progress and find challenges of the

HIP implementation. One challenge we found as we traced the progress of the HIP was the on-

call IR cases. The logbook for the IR nurses to document the briefing, debriefing, and specimen

collection for the on-call case was documented as incomplete for on-call cases. The unit charge

nurse had to follow up with the on-call nurses to complete the logbook. The challenges occurred

when the IR disciplinary team was in a hurry to start a procedure and leave the unit after the

procedure. This issue was disclosed during the meeting. The IR manager informed about this

concern in the IR daily briefing to remind the disciplinary team that on-call cases are included in

the HIP. She also emailed the superuser doctor about his issue to get the doctors’ support on the

HIP. The project manager will keep updating the project journal in the Teams shared folder to

keep the stakeholders, and the project team informed on progress.

HIP Management

Evaluating the effectiveness of how the project manager managed the HIP

implementation was done in different ways, including managing the project in stages, identifying

and removing barriers, using rapid-cycle improvement modification, and adjusting the Gantt

chart as tasks or timelines changed. According to Altunel (2017), the project management life

cycle is defined as a set of phases including initiation, planning, execution, and closure. The

management life cycle was utilized for managing the project in stages. In the initiation phase for

this HIP, the stakeholders identified the problems in the IR unit, including specimen

misplacement and near-miss procedural errors due to poor communication and teamwork.

Affinity analysis was used utilizing the sticky note method to reach a consensus for the needs

assessment. The stakeholders also developed the Impact analysis and SWOT analysis to

determine the external and internal strengths, weaknesses, and feasibility of the HIP within the

organization. The initiation stage was helpful in finding the solution to the problem and methods

to seize the opportunity.

After completing all the groundwork for the HIP in the first phase, we moved to the

second phase, planning. The project was broken down into smaller tasks utilizing the SMART+C

goal worksheet in the second phase. We identified the specific HIP, which created an in-person

team-building training, TeamSTEPPS, with a gamification approach. We scheduled and

visualized the project timeline that evaluated the number of specimen losses and procedural

errors in IR within four months after implementing TeamSTEPPS. We evaluated and gathered

the resources and tools required to perform the HIP, such as the PowerPoint, handouts, and

materials for the games. During this planning phase, the stakeholders reached out to the IR

leadership to present the HIP for their buy-in.

In the execution phase, once the project was approved to move forward, the project

manager and the DOE took the lead in developing, organizing, and executing the project for the

IR team. Once the IR team completed the TeamSTEPPS training, they began to perform tasks to

meet the project goal, eliminating specimen loss and procedural errors by January 31, 2023. The

execution stage includes ongoing support by explaining the tasks, providing necessary guidance

on how the task should be completed for the team members, monitoring the HIP process, and

managing the budget.

During the final phase, closure, the collected number of cases of specimen loss,

procedural errors, and the total number of IR cases will be used to determine if the HIP goal was

met. Post-HIP evaluation will be completed for the IR team to evaluate the failures and successes

of the project. We will also assess the IR team’s performance by collaborating with the IR

leadership. Then the stakeholders will have a debrief meeting to determine lessons learned for

future projects.

To identify and remove barriers for the HIP, the Force field analysis was used. The

stakeholder team brainstormed and collected the positive and negative forces using sticky notes

and voting methods with this tool. The first positive force was utilizing a web-based

TeamSTEPPS technology program at no cost for the HIP. The IR team members can download

the TeamSTEPPS application on their smartphones for free, enabling them to extend the learning

at their pace. The second positive force was that the project had financial support from upper

management. Since the HIP does not require a high cost, we could get financial support from

upper management smoothly. Another fact for having financial support from upper management

was that this project was once prepared and approved before COVID-19 hit the organization,

which they had to cancel due to the pandemic surge. The third positive force is the leadership

support for an evidence-based program that is AHRQ standards. TeamSTEPPS has been

successful across healthcare settings in increasing team awareness, clarifying team roles and

responsibilities, and improving information sharing (Cooke & Valentine, 2021). The strong

leadership support in implementing this successful set of evidence-based teamwork tools will

increase staff buy-in and positively affect the current IR team culture.

The three negative forces that the stakeholder team identified include a possible lack of

buy-in from the IR team due to schedule conflict and short staffing, possible pandemic disruption

even with the upper management support for the HIP, and possible staff resistance to the new

changes. Determining methods of eliminating or reducing the barriers to completing the HIP will

be necessary if the negative force outweighs the drivers (Agency for Healthcare Research and

Quality, n.d.).

The rapid cycle improvement modification will be used because improvement might not

occur as expected if issues arise during the HIP period. The rapid cycle improvement is a

practical method that involves testing interventions on a small scale (Yale School of Public

Health, 2017). For example, Plan, Do, Study, Act (PDSA) cycle will be used to implement using

a logbook to record the number of specimen collections and the number of procedures by the IR

team. The PDSA cycle will allow the stakeholders to determine what adjustments would need to

meet full compliance with the logbook documenting as part of the critical HIP process.

The Gantt chart was utilized for the project team members using the Teams shared folder. The

Gantt chart visualizes the tasks and timelines and makes it easy to add and revise the tasks,

assigned people, and progress. This tool allows the project team and the stakeholders to be on the

same page to complete the tasks within the planned time range. Examples of the previous tasks

we reviewed together include the needs assessment, affinity analysis, impact analysis, RACI

chart, SWOT analysis, TeamSTEPPS training implementation, and post-training evaluation. The

bar charts were easy to be revised as the team reached a consensus on the finalized Gantt chart

while being reviewed by the stakeholders. The timelines were effective, and the team met the

timeline goals as planned in the Gantt chart. No changes were made in the Gantt chart.

HIP Monitoring

Effective monitoring and supporting the staff assisting with the HIP implementation

requires authentic leadership. According to Fateh et al. (2021), authentic leadership brings its

strength from a positive mindset, compassion, transparency, and respect. Authentic leadership,

active listening, and open communication were the keys to successful evaluation for the

implementation. The stakeholders decided to invite the superusers to the monthly HIP meeting to

listen to their honest feedback. While the stakeholders were listening to the superusers’ voices,

they were focused, compassionate, and showed sincere appreciation. When the DOE presented

the zero rate of the missing specimen and procedural errors in the meeting, the stakeholders

decided to celebrate a one-month milestone in the IR unit on the following Friday morning with

donuts and coffee to acknowledge each team member for the accomplishment.

The Gantt chart and the Teams shared folder were the tools to monitor the project

schedule. The Gantt chart is a tool for planning and monitoring a project's tasks and timelines,

which has been around since the 1890s (Gantt, n.d.). The project manager and the DOE informed

the stakeholders, and the project team member of the timeline via the Teams shared folder. They

put efforts into utilizing and organizing previous, current, and future tasks into the Gantt chart to

meet the goal within the effective timeline.

The pro forma budget was a successful plan to get the HIP budget approvals in the planning

phase. The project manager and the DOE have monitored the project budget since the planning

phase. A total of $9,110.00 pro forma budget was proposed. Since another class was opened to

accommodate other team members from the procedural areas, a total of $3,120 was added to the

previous pro forma budget (One more 1-hour program: Nursing $65x8/hr=$520, doctors

$350x6/hr=$2,100 and food $500). The upper management approved the revised budget, and the

project manager, the DOE, and the CNE continued to monitor the expenditures. The budget

excel spreadsheet was shared by the DOE in the Teams shared drive throughout the project for

transparency.

Project Status Meetings

For the effective approach to organizing and leading project status meetings with internal and

external stakeholders, the project manager sent an email to offer multiple dates and time options

to find the best times that work for most stakeholders. After the best dates and times were

chosen, the project manager sent the Teams meeting invitations to the stakeholders to confirm an

RSVP. The invitations also mark the meetings in each stakeholder's calendar for those who

confirmed the RSVP. The virtual Teams meeting started twice a week for the first two months of

the implementation phase, then monthly. To facilitate communication and collaboration during

the implementation period, the unit manager presented the IR unit's progress using the Teams

shared folder. The project manager offered the time to ask internal and external stakeholders

questions to ensure a clear understanding of the progress. During the meeting, the project

manager emphasized each team member's roles and responsibilities for efficient project

implementation. Having clear and honest communication may empower each member of the

team (Schoemaker & Day, 2021).

Project Status Alignment

In order to align the project status with the organizational guidelines, the project

manager, the DOE, the CNE, and the IR nurse manager collaborated to review the current

policies using the hospital intranet and shared the information during the meeting with

stakeholders. In the planning stage, the members prioritized the 'Reporting Protocol for Patient

Care Issues' policy and decided to include it in the TeamSTEPPS training to encourage the IR

team to communicate and escalate any issues as soon as they discover a safety breach. However,

after a careful review, the stakeholders decided not to include the TeamSTEPPS training in the

policy because the Chain-of-Command procedure overlaps with it for the reporting protocol. The

project manager, the DOE, the CNE, and the IR nurse manager held another meeting and

carefully reviewed the 'Reports and Records' policy for the IR unit. Proposed to add the policy

and procedures for the morning briefing, debriefing after each case, and specimen and procedure

record log in the IR unit. The stakeholders and upper management agreed and approved the

proposal.

For the project status to align with the improvement science and methods, the project

manager and the DOE observed that there was a problem in the IR, including specimen loss and

near-miss procedural errors, which caused a negative impact on organizational finance. This was

the first step of the scientific method. Based on the literature review of the best practice from

D156, this project aligns with the research to move on to the next step of the scientific method,

hypotheses. It was hypothesized that we implemented the TeamSTEPPS based on the literature

review to have a better outcome as a resolution of the problem that IR has had. One research

indicated that implementing effective team communication skills would prevent medical errors

(Kirschbaum et al., 2018). For the next scientific method step, we evaluated the data in D159 for

the project to be effective. The stakeholders decided to record the total number of specimens, the

rate of missing specimens, the total number of IR procedures, and the rate of procedural errors.

This idea was to collect the pre-analytic phase data by using a communication tool, a logbook, to

document those measurements during the implementation of the project. The paper logbook was

easy to trace when there were questionable specimens or procedures. Because the logbook

indicated who collected and delivered the specimens to the laboratory, it was effective to

increase the awareness of responsibility and accountability of their roles. As the final step of the

scientific method, a report conclusion was made; this project effectively prevented specimen

errors and procedural errors by improving teamwork and communication skills utilizing gamified

TeamSTEPPS training. We found that this project aligns with the improvement science and

method based on the literature review and data analysis.

To align the project status with evidence-based guidelines, the project manager and the

DOE ensured that the project was on the right track based on evidence-based practices.

Kirschbaum et al. (2018) discovered that medical errors more often result from

miscommunication among healthcare providers than lack of medical knowledge. TeamSTEPPS

is an evidence-based training that would enhance patient outcomes by improving teamwork skills

and communication among healthcare professionals (Adjei, 2022). Research showed that the

TeamSTEPPS approach was successful and cultivated clear communication and mutual support

for areas needing improvement in healthcare settings (Cooke & Valentine, 2021). After the

TeamSTEPPS training was provided to the IR team and the implementation of the logbook

system for the specimens, procedures, briefings, and debriefings, the IR team has shown

increased team awareness of roles and responsibilities through improved information sharing.

During the PDSA cycle, evidence-based research will be continued to apply any updated

evidence-based practices as needed.

D161: Nursing Leadership and Management Capstone

Evaluation

Evaluating the effectiveness of the HIP goal and project outcome was done by comparing

the results of two KPIs to the SMART+C goal and outcome statement developed in Appendix D

to determine the success of the project. One of the KPIs is collecting the number of the specimen

and procedural errors. IR nurses have recorded the specimen and procedure error data in the

logbook, and the unit charge nurse or the unit manager has been indicating the data in the

dashboard in the IR suite. The project’s goal was to have 100 percent of the specimen handling

and procedures to be done without errors because any level of preventable harm is unacceptable,

as it could lead to risks of treatment delay, incorrect therapy selection, or inaccurate diagnosis.

As of December 12, 2022, it was reported that the HIP goal was met with zero cases of specimen

misplacements and procedural errors in the IR unit.

The second KPI was to measure the number of IR staff who completed the TeamSTEPPS

training to evaluate the efficiency and effectiveness of the project. Training 100% of the IR team

about the TeamSTEPPS program was also part of the HIP goals. The project lead, DOE, and the

unit manager counted the number of IR staff who completed TeamSTEPPS training. As of

December 12, 2022, it was reported that 100% of the IR staff were trained the TeamSTEPPS

program either in the formal TeamSTEPPS training session or by the superusers in the IR team.

The two KPI results determined that the project met expectations and proved a success of the

project; as it is indicated in the outcome statement, implementing the TeamSTEPPS to all IR

staff increased patient safety for the organization by eliminating specimen and procedural errors,

which caused a positive impact on organizational finance.

A method used for efficiency in the project implementation is the following. To

implement the project efficiently and effectively, the project manager and the DOE emphasized

each team member's roles and responsibilities and the timeframe of each phase in every meeting.

Teams shared folder was used to visualize the roles and responsibilities and the timeframe

utilizing the project tools such as the RACI chart, Action Plan template, and Gantt chart.

The result demonstrating the effectiveness of the project implementation was the process

indicator utilizing the PDSA cycle in the Teams shared folder. The project manager and the DOE

communicated with the unit manager and the project team members to record the status of each

phase when planned tasks took place. For example, when the team noticed the result

demonstrating that not all IR team members could attend the TeamSTEPPS session, they

strengthened the superuser system to enhance the effectiveness of the project implementation

using the PDSA cycle. The superuser system result demonstrated the effectiveness of the project

implementation as the team met the goal of training the TeamSTEPPS project to 100% of the IR

team.

The Gantt chart was posted in the Teams shared folder for the stakeholders and the

project team members to keep the project on schedule. When the projected project timeline was

compared to the actual timeline of the implementation, it was noted that educating the educators

and the TeamSTEPPS training stayed on schedule as planned. However, the superusers had to

follow up on the training with staff on vacation and medical leave after the planned

implementation period. Another factor that caused the delay was the on-call cases. The logbook

for the IR nurses to document the briefing, debriefing, specimen collection, and procedural errors

was incomplete for on-call cases in the beginning. The challenges occurred when the IR

disciplinary team was in a hurry to start a procedure and leave the unit after the procedure. The

unit charge nurse followed up with the on-call nurses to complete the logbook, and the IR

manager informed about this concern in the IR daily briefing to remind the disciplinary team that

on-call cases should be included in the HIP. There was no other delay noted in comparison to the

projected timeline and the actual timeline.

The pro forma budget was a successful projected budget plan to get the HIP budget

approvals from upper management. The budget excel spreadsheet was shared by the DOE in the

Teams shared drive for transparency and for all the project team members to be on the same

page. A total of $9,110.00 pro forma budget was approved in the planning phase. The cause of

variance between the projected budget and the actual costs was opening another TeamSTEPPS

session to accommodate more staff from other procedural areas and the IR staff who could not

attend the first session due to staffing shortage. A total of $3,120 was added to the previous pro

forma budget (One more 1-hour program: Nursing $65x8/hr=$520, doctors $350x6/hr=$2,100,

and food $500). The upper management approved the revised budget, and the project manager,

the DOE, and the CNE continued to monitor the expenditures. No other extra expenses needed to

be added, and the financial outcome was successful.

Final Status Report

The Final Status Report is displayed in Appendix K.

Project Closure and Celebration

The processes used to close the project are the following. First, the stakeholders and the

project team members held the final meeting. Due to a time conflict among stakeholders, we

decided to do the Teams meeting. The project manager presented the Final Status Report and

reviewed it together. The contents we reviewed were the project summary and description,

project milestones of each phase and accomplishments, budget overview and outcome, a

summary of project performance in meeting the two KPIs, and project outcome.

We also discussed lessons learned. The challenge of this project was the limited time

frame and short staffing. Some of the IR team staff were educated on the TeamSTEPPS by the

superusers, not from the formal TeamSTEPPS training session. Although the superuser system

fulfilled our goal of training TeamSTEPPS to 100% of the IR staff, some IR team members who

could not attend the formal gamified TeamSTEPPS session did mention that they would like to

attend the class in the future. From lessons learned, the leadership has already planned to open up

two more TeamSTEPPS sessions not only for the IR staff who missed the class but also for the

other procedural areas to start the TeamSTEPPS project.

As a part of the project plans, we had coffee and donuts each month to acknowledge the IR team

member for their accomplishment. We celebrated the closure of the project with coffee and

donuts in the morning briefing to show our appreciation and acknowledge the project's

successful outcome. We called each one of the individual names of the IR team to recognize

their efforts to meet the project goal.

Wrap Up Session

A wrap-up session was held with the project team and key stakeholders. During the

session, the stakeholders recommended that the project team keep the Teams shared folder

updated with the collected data. The data will be helpful to keep the project to be continued

effectively and to compare the data to other procedural areas after they launch the TeamSTEPPS

project in the other units. Although the successful superuser system fulfilled our goal of training

the TeamSTEPPS to 100% of the IR staff, not all IR team members could attend the formal

gamified TeamSTEPPS session due to staffing shortage. The staff who were trained by the

superusers expressed that they would like to attend the formal TeamSTEPPS session. The

lessons learned were that listening and recognizing the front staff's needs are essential for an

effective and efficient project. From lessons learned, the leadership planned to open two more

TeamSTEPPS sessions for those IR staff who missed the formal class.

Opening two more sessions were also part of the next steps for the project. Upper management

approved more TeamSTEPPS sessions for other procedural areas such as OR and PACU. IR unit

will continue the project, including utilizing the structured communication system such as

logbooks, dashboard, and Teams shared folder to share the measurement of the specimen and

procedural errors and briefing and debriefing tasks. As part of the next steps for the project, the

IR team will work as a pilot of the TeamSTEPPS project throughout the facility.

Conclusion

The main problem in the IR unit was specimen loss due to a lack of communication skills

and teamwork, which caused a negative impact on organizational finance. Research showed that

medical errors more often result from miscommunication among healthcare providers than from

a lack of medical knowledge (Kirschbaum et al., 2018). The stakeholders addressed a need for a

quality change in the IR communication skills and teamwork for patient safety. TeamSTEPPS is

an evidence-based teamwork program that enhances patient outcomes by improving teamwork

skills and communication among healthcare professionals (Adjei, 2022). The purpose of the

project was to improve patient safety by implementing the TeamSTEPPS program, which helped

the IR team advance communication skills and teamwork by increasing team awareness,

clarifying team roles and responsibilities, and improving information sharing.

One of the factors that facilitated the adoption of the HIP was utilizing a web-based

TeamSTEPPS technology program at no cost to the HIP. The IR team members could download

the TeamSTEPPS application on their smartphones for free, enabling them to extend the learning

at their pace. Another factor that facilitated the adoption of the HIP was that the project had

financial support from upper management for the following reasons. The HIP did not require a

high cost, and this project was once prepared and approved before COVID-19 hit the

organization, which they had to cancel due to the pandemic surge.

One of the factors that impeded the adoption of the HIP was a lack of buy-in from the IR

team due to schedule conflicts and short staffing. Not all IR team was able to attend the formal

TeamSTEPPS session due to staffing shortage. However, the IR team adopted the superuser

system and met the goal of 100% of the IR team being trained in the TeamSTEPPS project.

Another factor impeding the HIP adoption was staff resistance to the new changes. Some IR staff

complained that they needed more time to do extra tasks because they were busy and doing fine

without recording the rate of briefing and debriefing. With the IR leadership support, the project

was successfully adopted and implemented.

The HIP was significant to the role of the nurse leaders as they evaluated the project's

efficacy and outcomes with evidence-based approaches. With the project manager and

facilitator's lead, the stakeholders and the project team met monthly during the project

implementation period to monitor and evaluate the process of the HIP. The unit charge nurse and

the manager ensured to share the collected data with the IR team members by transcribing the

quantitative data into the IR dashboard. The unit manager assisted the DOE in uploading the

electronic dashboard in the Teams shared drive to keep the stakeholders and the project team

members informed. The nurse leaders increased staff engagement and encouraged the IR team to

escalate any issues as soon as they discovered a safety breach in the daily briefing and in a

written format such as emails. Monthly celebrations with coffee and donut created a positive

environment and helped motivate the IR team to achieve the project goal.

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Appendix A

Impact Analysis Template (D156) Benefits: Identify two categories and two benefits for each category that will be positively impacted by implementing your improvement project. Use a norms-based scale, as a method of quantifying the impact that the benefits will have. Give a “1” rating for Low Impact, a “2” rating for Moderate Impact, and a “3” rating for High Impact. Total these benefit ratings and enter the sum in the “Total Benefits Score” cell.

Category Improvement Project Benefits Rating Staff 1 Increase engagement and work satisfaction 3

2 Following evidence-based practice 3 Unit/Organization 3 Eliminate medical procedural error 3

4 Decrease financial loss due to specimen loss 3 Total Benefits Score 12

Risks: Using the same categories identified above in the “Benefits” section, identify two risks for each of the two categories that may be negatively impacted by implementing your improvement project. As you did in the “Benefits” section, rate the risks using the norms-based scale of “1” meaning Low Impact, “2” meaning Moderate Impact, and “3” meaning High Impact. Total these ratings and enter the sum in the “Total Risks Score” cell.

Category Improvement Project Risks Rating Staff 1 Fear of changes and lack of motivation 2

2 Burnout from new learnings and time management 3 Unit/Organization 3 Pandemic disrupts the education process 2

4 Lack of leadership support 3 Total Risks Score 10

Calculate the impact ratio by dividing the benefits total score by the risks total score, then enter that ratio into the table below. Use the criteria in the table below to determine if the benefits outweigh the risks. Impact Ratio = ___1.2___ [Benefits Rating total score divided by Risks Rating total score] If the ratio is > 1, the benefits outweigh the risks. If the ratio = 1, there is no difference between the benefits and the risks. If the ratio is < 1, the risks outweigh the benefits.

Appendix B

SWOT Analysis Template (D156)

Factors to maintain Factors to address

*Internal Criteria Strengths Weaknesses

I. Collective capabilities

II. Governance, participation norms, and defined roles

I – A. Organization supports staff education I – B. Administrators encourage and empower innovative solutions II – A. Standardizing best practice of briefing, debriefing, and timeout in IR II – B. The organization supports educational resources for all staff

I – A. Lack of buy-in from staff due to lack of managerial support I – B. Time consuming for the health care providers II – A. Possible short staffing II – B. Busy schedule, conflict of scheduling

*External Criteria Opportunities Threats I. Development of

knowledge

II. Uptake in disseminated knowledge

I – A. Implementing successful TeamSTEPPS program from outside facility I – B. If the project is successful, the developed knowledge can be shared across the organization II – A. Improves curriculum national wide II – B. Increase awareness about medical error prevention in IR

I – A. Pandemic disrupts the education process I – B. Potential lack of buy-in for the pandemic stressors II – A. Trying different methods from the national educational department norm II – B. Dealing with uncertainty of the pandemic

Appendix C

Table of Relevant Scholarly Sources Template (D156)

In-text citation Scholarly Source Title

Type of Scholarly

Source Relevance Adjei (2022)

Implementing TeamSTEPPS® Training: using evidence to impact teamwork on a medical-surgical unit.