Date of Graduation

Summer 8-7-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Dr Nancy Taquino

Second Advisor

Dr Elena A Capella



Problem: Center for Medicare Services (CMS) created a new quality measure pair to collect data on hospice visit patterns by a registered nurse in the last three days of life (Measure I), and at least two visits by a social worker, home health aide, licensed vocational nurse or spiritual counselor in the last seven days of life (Measure II). A hospital-based hospice organization created a quality improvement project to address this problem and improve both parts of the measure pair, but special emphasis was placed on improving Measure II, as initial data revealed the team met the goal only 41% of the time (Jan 2017, n=34).

Context: The organizational hospice must rely on non-LVN staff members to meet Measure II scores, such as home health aides, medical social workers and/or spiritual counselors. As a result, RN staff increase their visit frequencies as death nears. The unintended, but positive effect is it helps to meet Hospice Item Set (HIS) Measure I. One could argue it also improves the overall patient and family care experience.

Interventions: Interventions include creating a team secure text messaging for coordination of care, utilizing an imminence filter in the electronic medical record and creating a new report to utilize the imminent filter to track imminent patients daily. Interventions are organized through Plan/Do/Study/Act (PDSA) cycles.

Measures: Three main measures were created. Firstly, we measured least two visits by non-RN clinician in the last seven days of life, using a monthly run chart. Secondly, we reviewed the percent number of patients with >2 visits scheduled prior to death, measured with a daily imminent report. Finally, we created a spreadsheet to measure how often the clinicians were notifying each other that a patient was imminent.

Results: The project showed dramatic improvement in meeting visit metrics, reaching 80.77% for Measure II. Equally dramatic improvement was seen in patient satisfaction scores from 72.7% (Q2, 2017) to 80% (Q1, 2018), with Q2, 2018 scores increasing to 83%, an ~11% increase.

Conclusions: Measure II improved via new workflow to track visits and report on imminent patients. HIS visit frequency improvement was tied to increases in patient satisfaction. The sustainability plan includes ensuring hard-wiring of imminent workflow tracking for clinical, clerical and supervisory staff.