No Pass Zone: See a Light, Make it Right

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The “No Pass Zone” was developed and implemented by the nursing operations council. This council consists of and is led by staff nurses from across Forbes Hospital.

Every call light represents a patient need. Upon admission, patients are informed that their call light will be answered within 5 minutes. “No caregiver, regardless of job classification, should walk past a ringing or blinking call light.  It is important that every employee be empowered to and expected to respond to a patient need, especially when the need is perceived as urgent to the patient,” said Beth Griffith, RN, Manager Inpatient Nursing. The “NO PASS ZONE: See a Light, Make it Right” encompasses all nursing units in the hospital.

Responding to call lights are service attributes on the Press Ganey standard inpatient and HCAHPS surveys. 

The nursing operations committee educated all departments on this initiative and continues to monitor progress monthly by direct observations. Press Ganey scores will also be a metric monitored in regards to responsiveness of staff.

No Pass Zone
Pictured left to right: Kim Kiley, RN,  Manager, Short Stay Unit, Registry, Agency, Staffing and Bed flow; David Begler, RN, BSN, Nurse Manager ; Amber Egyud, MSN, RN, Vice President of Nursing, Chief Nursing Officer, Forbes Hospital; Kelly Buchinsky, RN, Nurse Manager; Beth Griffith, RN, BSN, Inpatient Nurse Manager; Denise Ratkiewicz, MSN, RN, Education and Development Specialist; Lesley G. Rehak, BSN, RN, CCRN-CSC, Manager, CTICU, ICU, and IV Team; Reese Jackson, President & CEO, Forbes Hospital

The No Pass Zone continues to grow. The committee is working on signage for the hallways.  They do monthly audits, recognizing those individuals that were observed utilizing the no pass zone.  

The committee continues to attend departmental meetings promoting the, answering questions and alleviating fears associated with answering call lights. “We believe that every patient is the responsibility of every employee,” said Forbes Chief Nursing Officer, Amber Egyud.

Expedited Care Improves Patient Experience 

Forbes Hospital Emergency Department, nursing staff implemented a throughput initiative “Direct Back Triage” to improve patient flow and satisfaction. Patients in the ED are now escorted to a room upon arrival to expedite assessment and care. This initiative has allowed the ED to improve satisfaction scores and throughput times in regards to door to provider metrics. 

The Charge nurses in the ED under the direction of, Melissa Barr RN, BSN, TNCC, Trauma Department, Performance Improvement Coordinator; Therese Justus RN, MSN, CEN, TNCC

Education and Development Specialist, Trauma Educator and Janine Nguyen, RN, CEN

Manager Emergency Department led the direct back triage implementation. 

“Our staff drove the process to change the culture, looking at every barrier as an opportunity to improve,” said Nguyen. Teaming up with registration to complete a quick registration all the time and going direct to room was key to the team’s success. The team monitored improvements daily and kept track of the increase. The direct back triage implementation drove our rise of patient satisfaction score to the 90th percentile and we improved our door top physician times dramatically from more than one hour average to less than thirty minutes.

New Process Lowers Infections

The nursing education department in conjunction with the STAR center led an initiative to reduce the number of Catheter-associated urinary tract infections (CAUTI) at Forbes Hospital.  

“CAUTI is the most common type of hospital acquired infections and is associated with increased morbidity and mortality, as well as prolonged length of stay and cost. Asepsis during catheterization and quality catheter care are supported by evidence to decrease the incidence of CAUTI. When the hospitals number of CAUTI increased last year, the department of nursing implemented a plan to address these care practices,” says Denise Ratkiewicz MSN, RN Education and Development Specialist at Forbes.

A 3 week “Foley Festival” was held during which all nursing staff demonstrated the insertion and care of a Foley catheter using simulation. Simulation helped educators identify incorrect techniques and opened the door for the education of the staff on best practice. 

Ancillary staff in transport, physical therapy, and radiology was included in education process to ensure all team members were knowledgeable in proper care and prevention of CAUTI.

With this training, Forbes was able to significantly reduce the number of CAUTI, improving the care of our patients. The nurses continue to monitor our progress on a monthly basis and the educators continue to train all new nurses on the process. 

This included mandatory education for all providers that were involved with Foley care including ancillary departments. Revisions to the current policy and procedures were adjusted based on feedback from nursing staff. Foley rounds were completed daily to monitor compliance and care. Ratkiewicz said that Forbes has reduced its CAUTI rates by nearly 60% from the previous year.