Date of Graduation

Fall 12-14-2018

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. Cathy Coleman




Staff responsiveness is an important Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Star Rating composite tool that hospitals monitor because it is consumer-driven information. The intent is that the HCAHPS composite promotes patient satisfaction, contributes to the prevention of harm, and can save millions of dollars (Danaf et al., 2017). On admission, the patient is orientated to their room, provided a nurse call light button to use, and told not to get out of bed alone and to wait for their nurse (Mitchell et al., 2014). On Three North, a gap exists in the delay it takes for nursing staff to respond to the patient call light. Studies have shown that a disparity in call light response is due to staff perception of the call lights as burdensome (Danaf et al., 2017). Understanding that a knowledge gap exists in staff responsiveness, authentic hourly visits (AHV) and the four P’s highlight the need to bring attention to why promptly answering the patient call light is valuable. There is no standardized process explaining to the staff the expectations when performing AHVs and the four Ps. Practicing the four P’s helps in the reduction of hospital-acquired injuries like pressure injuries, pneumonia, and falls. In preventing patient harm, the cost savings can be significant for the organization.


The quality improvement project took place in a large not-for-profit suburban healthcare organization. The improvement project was limited to the 40-bed medical-surgical respiratory unit, one of 6 units on the Adult Care Service. The Staff Responsiveness coalition included nurses, patient care technicians, unit assistants, nutrition ambassadors, assistant nurse managers, and the unit manager. The microsystem assessment was conducted and the A3 lean project improvement tool was used as a guide in this project.


A unit-wide evaluation was completed to assess staff awareness of the HCAHPS Star Rating composite, AHV, and the four Ps. To help fill the knowledge gap identified in the Three North unit, a staff responsiveness coalition team was created composed of frontline staff and the Three North management team. The coalition team aimed to establish an education and training plan to standardize a process of practicing AHV and the four Ps.


A review of the staff responsiveness coalitions progress on the education and training on Three North concluded that of 120 team members, 40 have submitted the read and sign describing the metrics of AHV and the four Ps. Due to the limited amount of staff trained to effectively perform measurable AHV and the four P’s, the coalition team delayed an official implementation. The coalition team set a target of 40% of the staff to be trained before an official rollout. The focus continues to be on education and training of the remaining staff and a target start date was changed to January 2019, initially targeted to be completed on or before December 31, 2018. The current HCAHPS analytics tool still has Three North at a Star rating of 2, with patient verbatim comments supporting the low score. The strategy will be to continue to offer education and training for staff to participate in this new learning measure. The outcome measure was to determine how many of the Three North nursing staff are aware of the HCAPHS staff responsiveness survey, AHV, and the four Ps. It was determined that 18 of 120 nursing staff members were familiar with Staff Responsiveness, AHV, and the four P’s, but none knew how to competently practice this bundle of care. The process measure included the creation of a team of frontline staff to create an education and training, implementation of scripts, and observations by leadership. Balancing measures were measured in terms of patient and staff satisfaction.


Post-assessment of the staff responsiveness education and training revealed that 40 or 33% of the 120 staff members returned the read and sign for staff responsiveness expectations. 27 of 40 or 67.5 % initiated or completed the education and training. 100% of the assistant nurse managers on Three North completed the education and training. 93 or 77.5% of staff remain that need to participate in the education and training. The Three-North coalition unit will continue to work on successfully implementing a standardized process for the nursing staff to perform AHV and the four Ps. Due to the challenges faced in getting staff trained for the official rollout, the summary star rating composite on Three North remains a 2 on a scale of 1 to 5, with 5 being the best score given.


Literature supports that authentic hourly visits and the use of the four P’s does improve the patient experience. It provides opportunities to establish a nurse to patient relationship, decreases patient anxiety, reduces hospital-acquired harm, and increases patient and nurse satisfaction (MGH, 2013). The Three-North coalition is working to implement a standardized Staff Responsiveness process with practicing AHV and the four Ps.

Keywords: staff responsiveness, authentic hourly visits, the four P’s