Date of Graduation

Fall 12-17-2021

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Dr. Sara Horton

Second Advisor

Dr. Cynthia Huff

Third Advisor

Dr. Catherine Colemen



Problem: Patients identified on the regional database as specialty palliative care (SPC) patients with congestive heart failure (CHF) have not been consulted annually, as expected by evidence-based practice.

Context: Twenty-three percent of patients with a life-limiting illness on the SPC registry were seen year to date. Patients with CHF are vulnerable populations who benefit from an SPC consult to address quality of life, frequent admissions, and suffering.

Interventions: A rapid experiment of two interventions was evaluated for a solution approach. An electronic report identifying hospitalized registry patients and a standardized triage process were the critically assessed interventions to mitigate the identified care gaps.

Measures: Qualitative data were collected to address process measures, balancing efforts, and outcome measures. Process measures included the evaluation of compliance with handling daily triage and assignment of patients. Outcome measures included improved consultation of CHF patients as an inpatient or outpatient within 30 days of identification.

Results: Interventions tested were accepted standard of practice and will be implemented in the future due to the COVID-19 pandemic.

Conclusion: The quality improvement project successfully identified gaps and interventions for implementation. The innovative approach was effective and efficient for the microsystem involved.

Keywords: specialty palliative care (SPC), life-limiting illness, quality of life, readmissions, timing of care, congestive heart failure (CHF)

Available for download on Friday, November 29, 2024

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