APPLICATION OF STRATEGIC LEADERSHIP AND FUTURE DELIVERY MODELS — C163 PRFA — BPP2

Leadership in healthcare is crucial during change management as healthcare organizations strive to meet the evolving demands of their patients. Strategic leadership is required to effectively work towards meeting the organizational goals and this aspect is determined by good leaders. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a tool recognized to guide quality improvement in many hospitals in the US. These surveys present a true reflection of organizational performance in many aspects and guide the implementation of quality improvement in various areas. This discussion analyzes the HCAHPS scores of healthcare institutions and demonstrates how strategic leadership can be used to improve organizational performance in poorly performed areas.

1. HCAHPS Scores: St. Luke’s Medical Center

	Survey Response Rate
Patients who reported that their nurses “Always” communicated well	69%
Patients who reported that their doctors “Always” communicated well	73%
Patients who reported that they “Always” received help as soon as they wanted	52%
Patients who reported that staff “Always” explained about medicines before giving it to them	53%
Patients who reported that their room and bathroom were “Always” clean	65%
Patients who reported that the area around their room was “Always” quiet at night	54%
Patients who reported that YES, they were given information about what to do during their recovery at home	82%
Patients who “Strongly Agree” they understood their care when they left the hospital	40%
Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)	57%
Patients who reported YES, they would definitely recommend the hospital	50%

B1. State and National Averages

	Survey Response Rate	State Average	National Average
Patients who reported that their nurses “Always” communicated well	69%	77%	81%
Patients who reported that their doctors “Always” communicated well	73%	77%	82%
Patients who reported that they “Always” received help as soon as they wanted	52%	67%	70%
Patients who reported that staff “Always” explained about medicines before giving it to them	53%	64%	66%
Patients who reported that their room and bathroom were “Always” clean	65%	72%	76%
Patients who reported that the area around their room was “Always” quiet at night	54%	57%	62%
Patients who reported that YES, they were given information about what to do during their recovery at home	82%	86%	87%
Patients who “Strongly Agree” they understood their care when they left the hospital	40%	50%	54%
Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)	57%	70%	73%
Patients who reported YES, they would definitely recommend the hospital	50%	69%	72%

Located in Arizona, St. Luke’s Medical Center is a general medical and surgical center that providing care to the larger community of Phoenix. The facility’s HCAHPS scores compare differently to those of the state and the national average with some room for improvement. For instance, all the survey results demonstrate that the overall performance of the institution is below the state and national average. Communication of nurses to patients has a score of 52% compared to 67% and 70% of the state and national averages respectively (Medicare.gov, n.d.-a). Secondly, the institution demonstrates average performance on the aspect of doctor’s explanation of medications to patients before administration. The institution has a score of 53% compared to 64% and 66% of the state and national averages respectfully.

APPLICATION OF STRATEGIC LEADERSHIP AND FUTURE DELIVERY MODELS — C163 PRFA — BPP2

The other aspect of comparison is the cleanliness of the patients’ rooms which has a score of 65%. The score is below the state and national average which have 72% and 76% respectively. The issue of quietness at night is a challenge to many healthcare institutions in the state. A score of 54% requires improvement to reach far beyond 57% and 62% of the state and national averages respectively. An area that is much improved is giving information to patients during their recovery. A score of 82% in this aspect is close to 86% and 87% of the state and national averages respectively.

An area that has a very low score is on patients that agree they understood their care upon leaving the hospital. The facility has a score of 40% which is far below 50% and 54% of the state and national average respectfully (Medicare.gov, n.d.-a). The rating of the hospital by patients on a scale of 0 to 10 has a score of 57% compared to 70% and 73% of Arizona and the national average. The last aspect that also has a low score is the recommendation of the facility by patients. A score of 50% is far below average compared to 69% and 72% of the state and national averages respectfully.

B2. Comparison to Other Hospitals

	St. Luke’s Medical Center	Abrazo Scottsdale Campus	Abrazo Central Campus	State Average	National Average
Patients who reported that their nurses “Always” communicated well	69%	75%	72%	77%	81%
Patients who reported that their doctors “Always” communicated well	73%	76%	70%	77%	82%
Patients who reported that they “Always” received help as soon as they wanted	52%	64%	63%	67%	70%
Patients who reported that staff “Always” explained about medicines before giving it to them	53%	64%	60%	64%	66%
Patients who reported that their room and bathroom were “Always” clean	65%	72%	72%	72%	76%
Patients who reported that the area around their room was “Always” quiet at night	54%	58%	54%	57%	62%
Patients who reported that YES, they were given information about what to do during their recovery at home	82%	85%	78%	86%	87%
Patients who “Strongly Agree” they understood their care when they left the hospital	40%	48%	44%	50%	54%
Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest)	57%	67%	62%	70%	73%
Patients who reported YES, they would definitely recommend the hospital	50%	66%	61%	69%	72%

The two hospitals that can be compared with St. Luke’s medical Center include the Abrazo Scottsdale Campus and Abrazo Central campus. The first aspect of comparison is on nurses’ communication to patients whereby St. Luke’s has a score of 69%. The two institutions have performed better because they have a score of 75% and 72% respectfully. Regarding effective communication of doctors to patients, St. Luke’s has a score of 73% which is slightly above 70% of Central campus but below 76 % of Scottsdale Campus (Medicare.gov, n.d.-b). The institution has a very low score on providing help as soon as required demonstrated by a score of 52% compared to 64% and 63% of Scottsdale and Central campus respectively. Explanation of medication for the two institutions has a score of 64% and 60% compared to 53% of St. Lukes’s Medical Center. These aspects demonstrate that improvement is required in this area.

St. Luke’s Medical Center has a score of 65% on the aspect of the cleanliness of the patient’s rooms. Scottsdale and Central Campus have a score of 72% which is far above St. Luke’s score. Regarding the quietness of the rooms at night, St. Luke’s score is 54% compared to 58% and 54% of the other hospitals. The institution has a better performance than Central Campus on the aspect of information given to patients during their recovery. However, the 82% score is below Scottsdale’s which has 85% (Medicare.gov, n.d.-b).

A low score below the two facilities can be observed on the aspect of patients who “Strongly Agree” they understood their care when they left the hospital. St. Luke’s has 40% compared to 44% and 48% of Central Campus and Scottsdale Campus respectively (Medicare.gov, n.d.-c). Regarding the rating of the institution on a scale, St. Luke’s has a score of 57% compared to 67% and 62% of Scottsdale and Central Campus respectively. The last aspect that demonstrates a slight difference is on patients who reported YES, they would recommend the hospital. St. Luke’s has a score of 50% compared to 66% of Scottsdale and 61% of Abrazo Central Campus.

APPLICATION OF STRATEGIC LEADERSHIP AND FUTURE DELIVERY MODELS — C163 PRFA — BPP2

B3. Survey Response Rates

Hospital	Number of completed surveys	Survey response rate
St. Luke’s Medical Center	640	17%
Abrazo Scottsdale Campus	584	16%
Abrazo Central Campus	579	14%

The survey response rates for the three healthcare institutions compare closely. St. Luke’s has completed 640 surveys which are slightly above the other facilities. Scottsdale Campus has 584 surveys while Central Campus has 579 surveys. There is a little difference in the survey response rates observed with St.Luke’s exhibiting the highest score. A score of 17% puts the facility above Scottsdale and Central campus which have 16% and 14% respectively.

B4. Demographics and Services Provided

St. Luke’s Medical Center is located in the city of Phoenix Maricopa County, Arizona. The institution serves the larger community of Phoenix which has a population of about 1.66 million people. Culturally, the Whites make the largest population with approximately 702 000 Non-Hispanic and 577 000 Hispanics (Data USA, n.d.). The Black or African American is the second largest group with around 113 000 Non-Hispanics and 714 000 Hispanic speakers. The most common language in the city is Spanish spoken by approximately 31.5% of the population. Foreigners in the area account for 19% of the total population which is more than the national average (13.7%). In 2018, the median age for all populations was 33.5 years. Statistics demonstrate that the most common origin for foreigners was Mexico followed by Canada and India.

Economically, the city of Phoenix is the largest in Maricopa County and has a median household income of $57,957. Census Tract 1080 is the largest area with a high median income household in the region followed by Census Tract 1062 (Data USA, n.d.). Statistically, the male household income is 1.26 times higher than the average income of females. The largest industries in the region are retail trade followed by healthcare and social assistance. Regarding the poverty level, the Whites are the largest race or ethnicity living in poverty. Approximately 792 000 people are employed in Phoenix. Education-wise, females occupy the largest population of students (Data USA, n.d.). The Whites are the largest followed by Hispanic or Latino in this aspect. Approximately 86.9% of the people in the region have a health insurance cover and it is observed that the majority of the people (14%) suffer from diabetes.

St. Luke’s Medical Center is the anchor of community healthcare providing healthcare services to diverse populations in Phoenix. Among the services provided in the hospital include Cardiology, Dermatology, Diet/Nutrition, Emergency Medicine, Family or General Practice, Gastroenterology, Infectious Disease, Internist or Critical Care, Medical Management, Neurology, Obstetrics and Gynecology, Orthopedics, Pain Management, Physical Medicine and Rehabilitation, Practice Management, Psychiatry, Radiology, and Surgery (MDLinx, n.d.). Being a general medical and surgical unit, the institution readily provides emergency care for the population and inpatient care limited to 313 beds.

B5a. Cultural Dynamics

Cultural aspects that influence healthcare delivery include race, ethnicity, religious beliefs, and language. Communication is among the factors that hinder healthcare delivery when different groups are involved. For example, the HCAHPS surveys are usually available in English making it difficult for non-English speakers to answer. Apart from the surveys, nurses and doctors might find it difficult to communicate to patients about their medications or when giving discharge information. The result is poor scores on aspects such as nurses’ communication and understanding of the patient’s care upon discharge.

B5b. Educational Dynamics

The level of education is a key factor during healthcare delivery because it affects the health-seeking behavior and understanding of treatment. St. Luke’s Medical Center embodies a wide range of patients from different educational backgrounds. Patients who are educated find it easy to communicate and understand the HCAHPS survey questions. As a result, a proper response is given leading to the realization of good scores. On the contrary, patients who have not gone to school or possess low levels of education might fail to understand their care including information given during discharge. Misinterpretation of survey questions may also lead to low scores.

B5c. Socioeconomic Dynamics

Socioeconomic dynamics majorly focus on the income and employment status of individuals. The socioeconomic status of individuals influences health through the establishment of relationships during care delivery. For instance, individuals who are well off find it easy to listen to healthcare providers and communicate effectively when they need help. Self-esteem can be lowered in individuals who are poor leading to problems in communication. The result is a poor understanding of their care which lowers HCAHPS scores. Additionally, situations like unemployment can affect response to discharge instructions like post-discharge follow-up or buying other medications. The result is poor healing or prolonged healing periods which can hence affect the recommendation of the healthcare facility upon discharge.

B6. Financial Impacts

The data from the surveys point to the congruence between better provider care, patient satisfaction, and reimbursement. HCAHPS surveys’ short term financial impact can be observed through the daily payments received in the organization during patient care. Good results attract patients which increases revenue. Additionally, good scores mean that the institution is going to receive more reimbursements from the CMS which can be used to foster organizational growth. Poor scores mean that fewer or no reimbursements will be provided which can reduce service delivery in the institution. From a long-term perspective, the HCAHPS scores lead to reimbursement which is used to support projects in the facility. These projects later generate revenue and even attract more patients to the facility. Low scores, on the other hand, can cause a lack of essential supplies, and eventually, patients will not visit the hospital. The result is a lack of finances to run activities and eventually the hospital runs bankrupt.

B6a. Impact on Quality

The HCAHPS surveys when properly answered are a true reflection of the quality of an institution. The data from the surveys is used to make important decisions on quality improvement in the hospital. For example, poor scores on the aspect of communication can lead to the implementation of change to improve communication. Improved communication can then promote good relationships between patients and healthcare providers. Failure to address the challenge of communication will lead to medical errors and poor relationships between healthcare providers which will hinder service delivery to patients. The second question is on the maintenance of quiet environments at night. Failure to address this area will lead to a lack of enough sleep for patients at night and it will hinder the quick recovery of patients. Lastly, understanding care delivered upon leaving the hospital is an aspect that reduces readmissions and mortality rates. Failure to understand discharge instructions and follow-up protocols will affect the recovery of patients and increase hospital readmission rates.

1. Causes of Scores

 Low scoring HCAHPS Question

	Potential Causes
Patients who reported their nurses “Always” communicated well	·         Inadequate staffing hindering establishment of patient relationships ·         Poor communication skills ·         Language barrier ·         Poor handling of information during shift change
Patients who reported that the area around their room was “Always” quiet at night	·         Location of patient patient rooms close to the nursing station ·         Overhead intercommunication system utilized at night ·         Alarms, monitors and other alerts
Patients who “Strongly Agree” they understood their care when they left the hospital	·         Poor communication skills ·         Language barriers ·         Failed discharge planning protocol ·         Lack of resources for discharge planning

The first area that has low scores is on patients who reported their nurses “Always” communicated well (69%). Poor communication is probably caused by a lack of adequate staff which hinders the establishment of good relationships with patients. Additionally, factors such as language barriers and ineffective communication of patient information can be a cause of the low scores in this area. The second part that demonstrates poor scores is on patients who reported that the area around their room was “Always” quiet at night (54%). This aspect is affected by the location of the nursing station close to the patient rooms. Because the nursing station is a busy area, it can be difficult to maintain quietness at night. Another probable cause is the presence of overhead communication pagers at night which disturbs sleep. Some patient rooms have machines with alarms that are used for patient monitoring. These alarms can disturb patients at night.

The lowest scoring aspect of the HCAHPs survey is patients who “Strongly Agree” they understood their care when they left the hospital. This area depends on the quality of discharge information given to patients including techniques for communication. The language barrier is one of the causes for poor understanding of discharge information by patients. Secondly, lack of a clear education program during discharge may hinder the understanding of information leading to poor scores in this area. Improvement is required in these three areas to achieve quality in the healthcare facility using evidence-based practices.

 D1: Organizational Change

HCAHPS Score	Organizational Change	Improvement in HCAHPS Scores
Patients who reported their nurses “Always” communicated well	The implementation of bedside shift reporting will ensure that the patient information is effectively communicated (Kostoff et al., 2016). The patients will also have an opportunity to understand their care and ask questions at their convenience.	Bedside shift reporting will improve the area of communication because nurses will understand patient care well. The patients will also be satisfied upon asking questions and being involved in their plan of care.
Patients who reported that the area around their room was “Always” quiet at night	An alternative technology can be used to communicate at night to avoid overhead paging especially in the wards. The IT department can work to establish communication using smartphones at night (Hughes Driscoll et al., 2020).	There will be a significate decrease in reports of sleep disruptions and noise level complaints at night on the HCAHPS survey.
Patients who “Strongly Agree” they understood their care when they left the hospital	Develop a new program to have a discharge team for all discharge planning and teaching. All patients going home will go through the team for further explanation of their plan (Bumpas et al., 2021).	Patients will be able to understand discharge information. Understanding of the information will improve HCAHPS scores on questions related to patients who strongly agree they understood their care when they left the hospital.

 

D2. Structure, Process and Outcomes

Structure	Process	Outcome
Improve on the process of communication between nurses and patients.	Ø  The first step will involve education of the nurses on the importance of communication to patients. Ø  The nurses will be introduced to SBAR communication, its importance and steps during the use of the tool. Ø  Work with the administration to implement SBAR communication and evaluate understanding of the technique through observation.	Improved HCAHPS scores on the question “Patients who reported their nurses “Always” communicated well

 

Structure	Process	Outcome
Decrease noise at night through the implementation of a technology.	Ø  Search literature for evidence-based practices (EBP) to reduce noise at night while taking care of patients. Ø  Communicate with the IT department to implement mobile communication devices to be used at night. Ø  Educate staff on the new technology and how it minimizes noise at night. Ø  Implement the new technology and monitor for its effectiveness.	The new technology should demonstrate decreased noise at night. Improved HCAHPS scores on the question “Patients who reported that the area around their room was “Always” quiet at night

 

Structure	Process	Outcome
Improve patient’s understanding of their care	Ø  Search literature for EBP to improve communication and administration of discharge information to patients. Ø  Work with the nursing administration to select a team responsible for patient education before leaving the hospital. Ø  Establish a checklist to confirm all discharge information given to patients. Ø  Implement the new change and monitor for progress	Improve HCAHPS scores on the question “Patients who “Strongly Agree” they understood their care when they left the hospital

 

D3: Improving Organizational Quality

Evidence-based practice (EBP) is an approach to healthcare improvement that utilizes evidence to improve quality, safety, and patient outcomes (Melnyk et al., 2016). The plan to improve quality using EBP in the organization will involve the use of bedside shift reporting for communication improvement. Secondly, the use of mobile technology to decrease noise at night is supported by evidence to reduce noise at night. I plan to use these approaches to improve the HCAHPS scores in the selected areas. Shared governance is a strategy that involves teamwork and accountability while working together to solve problems that affect practice and patient care. To incorporate this aspect, I will involve diverse members of the healthcare team especially the nurses, doctors, and the administration. These teams will be allowed to make recommendations for the new practice change and identify measures that they think can help improve the new program.

D4: Shared Accountability

Accountability involves taking responsibility for one’s actions, ensuring competency in performing tasks, and putting the patient’s interests first. To ensure accountability among patients, I will organize a discussion to explain the importance of honesty when filling the HCAHPS surveys. For the medicare practitioners, I will encourage the participation of the healthcare providers in meetings and educational programs. I will involve the administration and the nurse leaders to ensure nurses become active players in the educational programs. Disciplinary action will be necessary for those who will not demonstrate cooperation. Additionally, I will ensure feedback is provided during the implementation of change so that the personnel will make necessary changes.

The engagement of payers will be done through collaboration with the finance department. These individuals will respond by providing feedback on the HCAJPS survey scores and the implications to the facility’s financial status. The engagement of payers will also ensure they understand their roles and it will be necessary to provide financial records on reimbursement to ensure accountability. Other personnel in the institution will be asked to participate in meetings to ensure they get to understand their roles. The method to ensure shared accountability for these individuals will be through timely provision of feedback and incorporation of their suggestions into the quality improvement plan. Education and training for personnel will also serve to equip members with knowledge on improving quality in the institution.

 

D5. Technology Trends

The new changes in St. Luke’s Medical Center will incorporate technology through the use of electronic health records and smartphone technology. Electronic health records will be used to document patient information, especially during discharge. The changes concerning the reduction of noise at night will involve the incorporation of mobile technology to replace the overhead paging system.

D6. Improving Care Delivery Systems

Quality. To improve on quality, the new approaches will use evidence-based practices to improve how healthcare services are provided to patients. The use of an educational approach during change implementation will ensure healthcare providers understand the importance of change which demonstrates quality improvement.

Cost. Regarding cost, the plan is to improve the HCAHPS scores through educating staff on aspects of noise reduction and improving communication among nurses. The use of EBP programs to reduce noise at night will ensure patients get to recover faster which will reduce healthcare costs for treatment. The use of EBP to improve communication will ensure a reduction in medication errors which will cut the costs of treatment.

Access. I will ensure access of services to patients by ensuring every healthcare provider understands their roles. I will ensure the new EBP is implemented in the institution to improve communication and reduce noise at night for patients. I will also ensure improved access to healthcare through routine rounding and regular evaluation of the new changes.

Patient-centered care. Regular communication with patients and evaluation of the implemented changes will be an effective strategy to involve patients in their care. I will also ensure the creation of a safe patient environment and experience by allowing access to EHR data. I will ensure patient’s discharge plans and notes are accessible to patients to help in understanding their care upon leaving the facility. Another approach to improve patient-centered care will be a timely provision of feedback through the patient portals and hospital newspapers.

D7. Improve Financial Stability

To improve financial stability, the first strategy will involve implementation of evidence-based practices. I will ensure effective implementation of the new changes so that the HCAHPS scores will improve on aspects of communication and provision of discharge information to patients. Improved HCAHPS scores will mean more reimbursements from the CMS leading to financial stability. The second method will involve reducing the hospital spending through monthly audits to identify aspects that can be minimized. For example, the audits will keep an eye on inventory limits and identify shortages leading to better organization of services.

E1. Stakeholder Roles and Responsibilities

The key stakeholders during the implementation of the new changes will include the registered nurses, nursing educators, hospital administration, and the IT team.

Nurses. The nurses will be active during education sessions for SBAR communication and will communicate effectively during implementation. The team will also work to ensure the patient’s environment remains quiet at night and that the patient’s discharge information is given appropriately. The nursing educator will play a key role in ensuring staff and patients understand the importance of the HCAHPS surveys. The educator will organize education sessions during the implementation of evidence-based practices like SBAR communication and mobile technology for noise reduction. The nurse educator will also ensure the nurses adhere to the set policies on communication and reduction of noise including quiet hours at night.

Administration. The hospital administration will help during the change process by allocating resources and providing financial assistance. Financial resources provided will aid in the implementation of EBP to improve communication and reduce noise at night. The administration will also have the power to influence decision making during process implementation. The administration will work closely with the payers to ensure financial reimbursements provided are a true reflection of the HCAHPS scores.

Information technology team. The IT team will be important during the implementation of EBP to reduce noise at night using mobile phone technology. The team will ensure overhead pagers are disabled at night to allow the use of the new technology. The IT team will function to educate the nurses and other healthcare providers on how to communicate effectively at night to improve the HCAHPS survey scores on the reduction of noise in the facility. Lastly, the team will provide feedback on the implementation of the new change and how the care has improved. E2. Stakeholder Accountability

To ensure accountability for the nursing team, I will ensure communication is maintained and timely feedback is provided. Deadlines for meeting objectives will be used to ensure administration and the nursing team remain accountable. Meetings will be used to involve all the stakeholders in making decisions during the implementation phase. The nursing educator will be held accountable through sharing educational materials and reporting to the administration the plan for quality improvement through education. The IT team will also provide routine reports on the progress of the new mobile phone technology including an analysis of its effectiveness. Health education and provision of feedback from all the stakeholders will demonstrate stakeholder involvement.

The first method of ensuring accountability of these stakeholders is through maintaining transparency. Transparency will involve the provision of accessible and timely information about the procedures and processes of attaining quality in the organization. Secondly, I will ensure regular evaluation of goals and objectives for each stakeholder unit. Through the use of a complaint and response mechanism, I will be able to address the issues raised by each team and involve them in decision making.

E3. Training

The nursing department will require training during the implementation phase on SBAR communication and the use of the new mobile phone technology. The nurse educator will organize sessions to ensure the nurses understand aspects of SBAR communication. The nurses will also be crucial in dealing with the new mobile technology that will replace the overhead paging system. Training will ensure that the nurses will understand when to use the phones and how to communicate effectively.

The first step towards training will involve the selection of the nursing team and allocation of training shifts to ensure continuity of care. The method of training to be used will include small study groups or self-study depending on the nurse educator’s preference. The IHI SBAR communication technique tool will be used to educate nurses on how to communicate care during shifts. Additional resources will be provided through online platforms and all nurses will complete training within a designated time frame. The other training phase will involve the IT team using simulations to demonstrate mobile technology use instead of overhead pagers to decrease noise at night. A thorough assessment will be conducted to ensure all staff is well-trained before implementing the new changes.

 E4. Plan Implementation

The initial plan for implementation of the changes will involve a literature search and selection of the implementation team. A review of the current HCAHPS scores will be done and documentation made to establish baseline data. From the first to the third month the survey scores will be collected, finance allocated for process improvement, and employees informed about the new change. From month four to six, the nurses will be educated on SBAR communication and the use of the new mobile technology to replace the overhead pager system. Additionally, a team for discharge planning will be selected and educated on how to ensure all patients receive comprehensive instructions upon discharge.

The first periodic checkpoint will be during the fifth month to ensure all staff are well educated and prepared for the implementation of the new change. From month seven to nine, the actual implementation will occur. The nurses will implement SBAR communication to improve on the aspect of delivering information to patients. At the same time, the IT team will have developed mobile technology to replace overhead paging. The discharge plan will also be implemented in the institution through the use of a team responsible for giving discharge instructions to patients. The EHR system will be used to document pertinent information about the whole implementation process. From month ten to twelve, the implementation team will obtain feedback from the nurses, administration, and IT regarding the implemented changes. The HCAHPS surveys will also be administered to patients to obtain their response.

1. Evaluate the Strategic Plan’s Success

The success of the strategic plan will be evaluated at the end of the year using the HCAHPS surveys. The periodic evaluation will also be done during the fifth month to ensure that nurses and other members of the healthcare team understand the new changes and what will be needed. The method of analysis will involve a comparison of the previous HCAHPS scores with the new results. Cooperation during the implementation process and attendance of staff to training including the provision of feedback will demonstrate the success of the plan.

F1. Involvement of Stakeholders

The stakeholders will be involved in the implementation of the new plan through the provision of feedback. The nurses, IT team, administration, and the nurse educator will provide feedback on aspects that were achieved during the strategic plan implementation. Additionally, the stakeholders will participate in meetings and benchmarks to discuss the results obtained from the HCAHPS surveys.

F2. Communication of Results

Internal communication of the strategic plan’s results will be done using emails sent to organizational leaders, internal memos, and the hospital newspaper. Meetings will be used to communicate the results to the employees. External communication will involve the use of local television and radio stations, media platforms like LinkedIn and Facebook, and through the use of the organizational website.

References

Bumpas, J., & Copeland, D. J. (2021). Standardizing multidisciplinary discharge planning rounds to improve patient perceptions of care transitions. JONA: The Journal of Nursing Administration, 51(2), 101-105.

doi: 10.1097/NNA.0000000000000977

Data USA. (n.d.). Phoenix, AZ census place.

https://datausa.io/profile/geo/phoenix-az/#:~:text=The%205%20largest%20ethnic%20groups,and%2087.6%25%20are%20U.S.%20citizens.

Hughes Driscoll, C. A., Cleveland, M., Gurmu, S., Crimmins, S., & El-Metwally, D. (2020). Replacing overhead paging with smartphones to reduce hospital noise. Biomedical Instrumentation & Technology, 54(4), 251-257.

https://doi.org/10.2345/0899-8205-54.4.251

Kostoff, M., Burkhardt, C., Winter, A., & Shrader, S. (2016). An interprofessional simulation using the SBAR communication tool. American Journal of Pharmaceutical Education, 80(9). DOI: 10.5688/ajpe809157

MDLinx. (n.d.). St. Luke’s Medical Center.

https://www.mdlinx.com/hospital/st-lukes-medical-center-phoenix-az

Medicare.gov. (n.d.-a). St. Luke’s Medical Center: Patient survey rating. https://www.medicare.gov/care-compare/details/hospital/030037?id=2c036630-8d36-401e-b623-b8d750ff7aa4&city=Tempe&state=AZ&zipcode=

Medicare.gov. (n.d.-b). Abrazo Scottsdale Campus: Patient survey rating. https://www.medicare.gov/care-compare/details/hospital/030083?id=e3c2ac68-e6c5-4b81-8703-473459904aa3&city=Tempe&state=AZ&zipcode=

Medicare.gov. (n.d.-c). Abrazo Central Campus: Patient survey rating. https://www.medicare.gov/care-compare/details/hospital/030030?id=a5d9ff17-5cf8-4229-ba3a-a1071acdd874&city=Tempe&state=AZ&zipcode=

Melnyk, B. M., Gallagher-Ford, L., & Fineout-Overholt, E. (2016). Implementing the evidence-based practice (EBP) competencies in healthcare: a practical guide for improving quality, safety, and outcomes. Sigma Theta Tau.