Date of Graduation

Spring 3-18-2023

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


MSN project

First Advisor

Bob Patterson



Problem: One emergency department (ED) in an urban hospital in San Francisco has instituted a sepsis performance measure bundle known as CMS SEP-1 to address the high mortality and high costs associated with sepsis. The unit has experienced consistent gaps in meeting CMS SEP-1 composite measure benchmarks, dipping below the unit’s goal of 90%.

Context A microsystem assessment, SWOT analysis, cost-benefit analysis and gap survey distributed to nursing staff was carried out to identify areas for improvement. The assessment revealed inconsistent data trends in meeting CMS SEP-1 bundle compliance, feedback that nurses were not always completing the sepsis screening tool in its entirety due to the fast-paced environment of the ED and ineffective coordination between nurses and physicians.

Interventions: The intervention involved an educational slide deck, recorded voiceover video presentation distributed to nursing staff and an educational poster displayed in the breakroom for staff to reference.

Measures: The desired change of this quality improvement project is to improve timely sepsis care on the unit through increasing CMS SEP-1 bundle compliance to 90% across all measured benchmarks by the end of the second quarter of 2023.

Results: Results will be determined when CMS SEP-1 data becomes available at the end of the second quarter of 2023.

Conclusions: This quality improvement project has high potential to bring about long-term improvement of the microsystem, as well as other units in the mesosystem, due to its low cost, easily replicable structure, and data-driven focus.

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