Date of Graduation

Fall 12-16-2022

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. Theresa Mostasisa


Hospital acquired pneumonia’s (HAPs) are unfortunate and preventable events quality improvement efforts should focus on. At a Northern California Hospital, there was an unmet HAP rate goal of 2.3 (20 out of 8795 patients) against a target goal of 2. This increase in HAP rates, both non-ventilated and ventilated was a call to action to reduce HAP to the target goal. The quality improvement project specifically aimed to reduce HAP rates on medical-surgical units through an ultra-brief refresher on the hospital validated and endorsed ROUTE bundle. The education focused on oral care completed by the patient care technicians (PCT’s). The second aim focused on pinpointing barriers PCT’s face in completing oral care. This was collected through survey questions. Additional visual aids (e.g., color ROUTE flyers) were distributed to the PCT’s and posted on each floor visited. We expect a decrease of HAP rates once data is collected in the quarterly report early next year 2023. This collected data will become available in the Crossing Quality Chasm (CQC) quarterly reports. Themes noted from the survey questions: addressing barriers to oral care included poor staff to patient ratio and patient refusal. Recommendations for future steps include focusing on how to motivate and educate patients on the negative ramifications of omitting oral care.

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