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


MSN project

First Advisor

Dr. Theresa Mostasisa



A High Reliability Organization (HRO), such as this Northern California Medical Center, holds itself to high standards of performance in the areas of recognition, ranking, and accreditation. The commonality between these high-scored and valuable acknowledgements is the pillars of Quality Outcomes. As benchmarking and reporting allow this facility to measure outcomes against self and other plans, it greatly strengthens the internal focus for continual improvement and goal setting in direct patient care and outcomes. A deeper layer of the Quality Department includes the bundle “ERAS – Enhanced Recovery After Surgery”, which is compiled of principles aiming to minimize opioid use, initiate nutrition, and support early ambulation during the first 12 hours of perioperative care among other elements which lead itself to quality care.

In this Quality Improvement (QI) Intervention Plan, the ERAS bundle (documented nutrition, ambulation, and carbohydrate drink as applied to both Urgent and Non-Urgent surgical cases for 2021) is critically analyzed. Results were then reviewed, and intervention constructed using LEAN and TeamSTEPPS Methodology. Through this process opportunities have been identified for improved application and documentation of the bundle within surgical services; a plan intervention has been devised; execution and review of interventions has been planned. Diversity Awareness Model (DAM) was a driving factor in the development of the model.

This QI plan supports the importance and effectiveness of using the Sidebar Summary and the Daily Tracker Tools in meeting the ERAS targets of Quality Measures and Outcomes. Target outcomes of ERAS bundle compliance (Urgent Cases 65% and Non-Urgent cases 75%) is attainable through the use of the Sidebar Summary within the EHR patient chart by Floor Nurses and the Daily Tracker (real time tracking) by the Nurse Managers.

Key Words: enhanced recovery, ERAS, quality, quality outcomes, benchmarking, patient care, quality improvement, QI, target outcomes, tool, sidebar summary, real time, daily tracking