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

First Advisor

Dr. Cathy Coleman


Problem: There has been a national crisis of immobility in hospitalized patients. Of the 1 in 3 hospitalized patients who develop a new onset of physical disability, 50% of them will not return to normal function (Holroyd-Leduc et al., 2019). The impact of immobility could result in increased hospital costs, longer lengths of stay, higher events related to hospital-acquired pneumonia (HAP), falls, and readmission rates (Growdon et al., 2017; Larsen et al., 2019).

Context: Microsystem assessment was conducted to identify a quality performance gap. When compared to the regional Average Maximum Mobility (AMM) benchmark score, the patients’ mobility scores indicated that they are not ambulating adequately. Based on this data, quality improvement initiatives are needed to optimize patient mobility and improve organizational outcomes.

Intervention: The QI project “Mobility Matters: Improving Average Maximum Mobility (AMM) Scores in a Medical-Surgical Telemetry Unit” was developed and implemented to improve the AMM score. Three core and evidence-based interventions were utilized in the project to incorporate mobility culture in clinical practices and increase patients’ ambulation.

Measures: The quantitative data displayed in the run chart to evaluate mobility interventions were obtained and assessed to measure whether changes occurred. The outcome, process, and balancing measures are identified on the Project Charter objective feedback form. The Average Maximum Mobility (AMM) score was selected as an outcome measure. The process measures evaluated the percentage of team members who received 1:1 educational intervention. The balancing measure represents the number of patients who fell during hospitalization.

Results: Over a two month period, the AMM score increased from 3.8 to 4.3. Thirty-five in 55 team members (64%) received 1:1 staff education during PDSA cycles. The number of patient falls improved from 2 falls in September to 0 falls in October. The QI project positively increased the AMM score toward expected targets.

Conclusions: The project aimed to achieve regional benchmarks mobility scores resulting in improved patient mobility. Several barriers were identified to inform continuous quality improvement. The positive impact of evidence-based mobility interventions fostered a culture of quality, safety, and accountability (Bender et al., 2019). Furthermore, these interventions created high-quality patient care and improved organizational outcomes, including decreased falls and increased AMM score.