Date of Graduation

Summer 8-12-2022

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-Deutsch


Problem: Frequently, communication from the Quality Department (QD) needs to be filtered through several organizational layers without first-hand knowledge of what message was given to frontline staff. Current mechanisms of communication between the QD and front-line microsystem teams have barriers preventing them from being consistent and reliable.

Context: Research has found that collaborating with and supporting frontline staff was key to establishing a culture that supports change and a focus on safety. Establishing open communication and effective teamwork with individuals on the frontline leads to shared values within a team and better collaboration which drives performance improvement.

Interventions: For trended data such as performance and outcome metrics, one metric was posted each week showing both local and comparative data. A short summary of harm events anywhere in the hospital was posted as they occurred, on white boards, exclusive for this use.

Measures: Frontline staff in the med/surg unit chosen for this project were surveyed about their perceptions of data sharing related to their unit’s performance, safety events on their unit, safety events outside of their unit, and their overall feeling of inclusion in hospital operations.

Results: The slight decrease in communication related to metrics from 4.1 to 3.9 shows the data postings were not effective in increasing the overall feeling of being informed in the frontline staff. The overall number of responses did increase from 7 in the pre project data to 13 in the post project data. The average number for how included staff felt in hospital operations increased from 2.4 to 3.5. These increases seem to contrast with the lack of increase in feelings of communication. It is possible that while the staff do not feel there is more data being communicated with them, the conversations about communication and what might work for them is being noticed.

Conclusions: Despite challenges in the department during the timeframe of this improvement project, some positive change was measured. Given the increases in participation with the survey and feelings of involvement, it would be a reasonable decision to continue information sharing. This would communicate to staff there is an ongoing reciprocal commitment to communication with them directly and involving them in hospital operations.