Date of Graduation

Fall 12-18-2026

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)

College/School

School of Nursing and Health Professions

Program

Kaiser cohort MSN capstone

First Advisor

Dr. Liesel Buchner

Abstract

Problem: Poor adherence to the ticket-to-test protocol on the 3 South unit led to unnecessary C. difficile testing, inappropriate isolation, and workflow variation. These issues mirror national concerns about over-testing and misdiagnosis, which can inflate hospital‑onset C. difficile rates and increase costs.

Context: This project was implemented on a medical‑surgical unit, a team with a strong culture of collaboration, education, and engagement in quality improvement. The unit benefits from structured oversight through the C. difficile committee, which reports to the performance improvement team.

Interventions: The Institute for Healthcare Improvement Model for Improvement guided four PDSA cycles, with the initiative running from May 2026 through July 2026, to improve adherence to the ticket-to-test protocol. During this period, the team focused on simplifying the workflow, reinforcing education, and supporting consistent completion of the tool to ensure appropriate C. difficile testing.

Measures: Outcome, process, and balancing measures were used to evaluate improvement. The outcome measure was adherence to the Ticket‑to‑Test protocol, assessed through weekly Ticket‑to‑Test reports from Quality Management and validation of each form. Process measures included 1:1 weekend education provided by the C. difficile Committee, with attendance monitored to ensure full staff coverage. A balancing measure tracked overall C. difficile testing volume to ensure appropriate tests were maintained.

Results: Adherence to the Ticket‑to‑Test protocol increased from 65% at baseline to 74% after the 12‑week intervention, based on weekly Ticket‑to‑Test reports and validation audits. Staff participation in the weekend 1:1 education session was consistently high, and documentation accuracy improved as the workflow became more standardized. Testing volume remained appropriate, indicating that improved adherence did not reduce clinically necessary C. difficile tests.

Conclusions: Focused education, weekly validation, and simplified workflows effectively improved adherence to the Ticket‑to‑Test protocol on the 3 South unit. The combination of direct 1:1 teaching, visual reminders, and real‑time feedback strengthened diagnostic stewardship and reduced unnecessary testing. These results demonstrate that structured, microsystem‑level interventions can reliably improve testing practices and support long‑term patient safety.

Keywords: C. difficile, ticket to test protocol, appropriate testing, medical-surgical nurses, testing criteria adherence

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