Literature Review: Improving Stroke and Patient Satisfaction
AM42
TheyRespondedWeListenedImprovingStrokeEducationandPatie.pdf
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They Responded, We Listened: Improving Stroke Education and Patient Satisfaction Melissa Meighan [email protected]
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Running head: WE LISTENED: IMPROVING STROKE EDUCATION 1
They Responded, We Listened: Improving Stroke Education and Patient Satisfaction
Melissa M. Meighan, DNP(c), MS, RN, NEA-BC, CNRN, SCRN
Presented to the University of San Francisco
Committee Members:
Dr. Juli C. Maxworthy
Dr. Elena Capella
in
Partial Fulfillment of the Requirements for the
Degree of Doctorate in Nursing Practice
November 10, 2018
WE LISTENED: IMPROVING STROKE EDUCATION 2
Acknowledgements
I would like to thank the University of San Francisco’s Executive Leader Doctor of
Nursing Practice (ELDNP) program for creating a rich, safe, learning environment for
exploration of exemplary evidence-based health care design led by nurses on the path to a
terminal nursing practice degree. To Dr. Juli C. Maxworthy, thank you for your patience,
thoughtful insight, persistence, and time to improve the work to provide the best possible service
to a vulnerable patient population.
I would like to thank Kaiser Permanente, Northern California Regional Accreditation,
Licensing and Regulatory Services, for their support, as well as Kaiser Nurse Scholars. In
particular, I would like to thank Dr. Carmen Adams for her inspirational leadership in the
implementation of evidence-based practices in a large integrated health care system; Anne
Goldfisher, Executive Director, Quality and Regulatory Services; and Laure Lisk, Regional
Director Clinical Quality Program and Analytics, for their kind support during the program.
Thank you to the team who worked on the project: Kathryn Snow, Joseph Mojares,
Melissa Hathcoat, Hermelinda Gonzales, and Noreen King. For the stroke coordinators who
soldier on regardless of how many other hats they are wearing. And, a special thank you to
Kathryn and Pat Zrelak, the advanced practice nurses dedicated to care of patients who have
suffered a neurological injury. Your collegiality and support are the wind beneath my wings.
For my amazing Cohort 8, I learned so much from your experience, contribution, and
service as role models for nursing. Your presence, care, and wit are a delight and an inspiration. I
will forever treasure the memories of our intensives, including our Friday morning specials.
To my family and friends, thank for your support and encouragement. My life partner,
Drew Letchworth, for manning the fort and its menagerie of inhabitants. For my parents, Arno
WE LISTENED: IMPROVING STROKE EDUCATION 3
and Susan, for their inspiration. To my sister and brother, Sandy and Eric, for their help to keep
me on track. And lastly, to the survivors of a stroke who must soldier on in the face of a
frightening, traumatic event. If there is one part of the body that we rely on not to fail us, it is our
minds. The ability to move as we wish, express love to others, and to even be aware of
depression may all be suddenly taken away by a clot the size of a strand of hair. Thank you to
those who have taken this event to teach and help others through stroke survivor support groups.
You are amazing.
WE LISTENED: IMPROVING STROKE EDUCATION 4
Table of Contents
Section I. Title and Abstract
Title ........................................................................................................................... 1
Abstract ..................................................................................................................... 8
Section II. Introduction
Problem Description ................................................................................................. 10
PICOT Question ........................................................................................................ 12
Available Knowledge ................................................................................................ 12
Rationale ................................................................................................................... 18
Specific Aims ............................................................................................................ 21
Section III. Methods
Context ...................................................................................................................... 22
Interventions ............................................................................................................. 23
Work Breakdown Structure .......................................................................... 24
SWOT Analysis ............................................................................................ 25
Project Responsibility and Communication Plan ......................................... 26
GANTT Chart ............................................................................................... 27
Cost Benefit and Return on Investment Analysis ......................................... 28
Stroke Survivor Engagement. ........................................................................ 30
Front Line Staff Survey. ................................................................................ 31
Stroke Flyer. ................................................................................................... 32
Education Module. ......................................................................................... 34
Study of the Interventions ......................................................................................... 37
Outcome Measures .................................................................................................... 37
Data Collection ......................................................................................................... 38
Analysis ..................................................................................................................... 40
Ethical Considerations .............................................................................................. 41
WE LISTENED: IMPROVING STROKE EDUCATION 5
Section IV. Results .............................................................................................................. 43
Section V. Discussion
Summary ................................................................................................................... 45
Interpretation ............................................................................................................. 47
Limitations ................................................................................................................ 48
Conclusions ............................................................................................................... 51
Section VII. References ....................................................................................................... 54
Section VIII. Appendices
Appendix A. Map of Kaiser Facilities ...................................................................... 63
Appendix B. Stroke Discharge Volume per Facility ................................................. 64
Appendix C. ICD-10-CM Codes Related to Stroke .................................................. 65
Appendix D. Stroke Education and Patient Perception Evidence Table .................. 67
Appendix E. Evaluation Table .................................................................................. 70
Appendix F. Learning Needs Assessment ................................................................ 71
Appendix G. Caring Science Applied to Stroke Education ...................................... 72
Appendix H. Stroke Education Documentation Compliance .................................... 73
Appendix I. Joint Commission Standard Addressing Patient Education .................. 74
Appendix J. Joint Commission Standard Addressing Patient Satisfaction ............... 75
Appendix K. Gap Analysis ....................................................................................... 76
Appendix L. Sample Stroke Education Agenda ....................................................... 77
Appendix M. Work Breakdown Structure ................................................................ 78
Appendix N. SWOT Analysis ................................................................................... 79
Appendix O. Project Responsibility and Communication Plan ................................ 80
WE LISTENED: IMPROVING STROKE EDUCATION 6
Appendix P. GANTT Chart – Initial ......................................................................... 81
Appendix Q. GANTT Chart – Final ......................................................................... 82
Appendix R. Budget .................................................................................................. 83
Appendix S. Program Costs. ...................................................................................... 84
Appendix T. Return on Investment ........................................................................... 85
Appendix U. Email from Stroke Survivor Advocate ................................................ 86
Appendix V. Staff Survey ......................................................................................... 87
Appendix W. Staff Survey Response Summary ....................................................... 88
Appendix X. Stroke Flyer Placement on Stroke Portal ............................................ 89
Appendix Y. Stroke Flyer Grade Level and Reading Ease Scores ........................... 90
Appendix Z. Survey for Community Input on Flyer ................................................ 91
Appendix AA. Community Survey Script ................................................................. 92
Appendix BB. Translation Request ........................................................................... 93
Appendix CC. Stroke Flyer English .......................................................................... 95
Appendix DD. Stroke Flyer Spanish ........................................................................ 96
Appendix EE. Stroke Flyer Chinese .......................................................................... 97
Appendix FF. Stroke Flyer Vietnamese..................................................................... 98
Appendix GG. Stroke Flyer Tagalog ......................................................................... 99
Appendix HH. Stroke Module Title Page ................................................................. 100
Appendix II. Health Stream Educational Platform ................................................... 101
Appendix JJ. Excerpt from Novel Approaches to Teaching Stroke Patients ........... 102
Appendix KK. Stroke Module Post Test .................................................................. 104
Appendix LL. Nurse Practice Alert ........................................................................... 106
WE LISTENED: IMPROVING STROKE EDUCATION 7
Appendix MM. Just the Facts on Stroke Education ................................................. 108
Appendix NN. Data Management Variables ............................................................ 109
Appendix OO. Pre-Intervention Stroke HCAHPS Data ........................................... 110
Appendix PP. Post-Intervention Stroke HCAHPS Data ............................................ 111
Appendix QQ. Initial Presentation Mode with Suspected Stroke Symptoms .......... 112
Appendix RR. Stroke Alerts Initially Cancelled ....................................................... 115
Appendix SS. Signed Statement of Non-Research Determination Form ................. 116
Appendix TT. Letter of Support from Organization ................................................. 118
WE LISTENED: IMPROVING STROKE EDUCATION 8
Abstract
The annual decrease in stroke mortality rates in the United States has slowed, but in certain
populations, such as Hispanics and in southern U.S. states, mortality rates are increasing. Stroke
remains the number one cause of adult disability. A previous stroke is a risk factor for a second
stroke. Prompt treatment is essential for positive outcomes. Patients need to present to the
hospital no more than 4.5 hours from last known well for intravenous alteplase treatment and six
to 24 hours from last known well for endovascular therapy. Based on the literature, the majority
of patients are not presenting to the hospital in time for treatment.
Patients should be educated in the hospital prior to discharge on Joint Commission
required elements of stroke education, which include the importance of calling 911, stroke signs
and symptoms, disease processes, risk factor management, and follow up. However, in 2016,
40% of Kaiser Permanente stroke survivor members reported they were not adequately educated
in the required elements, despite nursing documentation of education. Increasing patient
knowledge and perception of adequate education may increase the number of patients who
present in time for treatment. Interventions to increase patient perception of adequate education
included engagement of stroke survivor’s view of educational material, the evaluation of current
educational material, the development of a fourth-grade reading level flyer, and the development
of a training module for nurses working on stroke units or units with stroke-designation.
Preliminary results were not conclusive, and more data points are needed. The percentage
of positive responses to the question, “Staff Explained Disease Processes,” rose from 51%
(21/41) to 64% (32/50). However, the positive responses for the other two stroke-related
questions for risk factors and stroke signs and symptoms decreased from 54% (23/42) to 44%
(24/54) and 52% (19/36) to 47% (25/53), respectively. The overall results were not statistically
WE LISTENED: IMPROVING STROKE EDUCATION 9
significant using χ2 for analysis. Behavioral measures, which may be influenced by increased
education such as arriving to the hospital in time for treatment and activation of the emergency
medical system, saw no significant difference for arrival in time for treatment and, unfortunately,
a statistically significant increase in arrival by private car for the month of August. Future work
of the project is to continue to increase training and awareness for the nurses, obtain additional
stroke survivor input, analyze the time to arrival and arrival mode data more closely, and to
explore a regional stroke patient satisfaction assessment process.
Keywords: stroke, cerebral vascular accident, education, patient satisfaction
WE LISTENED: IMPROVING STROKE EDUCATION 10
Section II. Introduction
Problem Description
This intervention took place in an integrated health care system in one of the regions
serving over four million members. The integrated health system consists of a triad of a health
plan insurance arm, hospitals or Kaiser Foundation Hospitals, and the Permanente Medical
Group. The Kaiser Foundation Hospitals are non-profit and have oversight over inpatient care.
The Permanente Medical Group is for-profit and consists of physicians and other providers, such
as nurse practitioners, physical therapists, occupational therapists, and speech therapists. The
TMPG has responsibility for the staffs of emergency departments, pharmacy, laboratory,
radiology, and outpatient clinics. The region consists of 21 medical centers spread over an area
of 17,000 square miles. Two of the medical centers are certified by Joint Commission as
Comprehensive Stroke Centers, while the remaining are certified as Primary Stroke Centers (see
Appendix A). The inpatient bed size of the facilities ranges from 50 to 350 inpatient beds. The
total number of patients discharged annually with an International Classification of Diseases,
Tenth Revisions, Clinical Modification (ICD-10-CM) codes related to stroke for the facilities
range from 132 to 1,135. Stroke discharges are grouped by emergency room visit only, inpatient,
and observation status (see Appendix B for stroke volume by facility and Appendix C for ICD-
10 CM codes related to stroke).
Each stroke program has a team who manages the program consisting of primarily a
stroke coordinator and stroke medical director. The stroke program team meets monthly with
representatives from all the departments involved, including stroke champions from the
emergency departments, radiology, lab, pharmacy, intensive care unit, telemetry units who have
designated beds, rehabilitation physicians, physical therapists, occupational therapists, and
WE LISTENED: IMPROVING STROKE EDUCATION 11
speech therapists. The stroke coordinators work with their local education team to identify
educational needs.
In 2017, the Centers for Disease Control (CDC) issued a stroke call to arms report stating
that stroke mortality and morbidity rate declines had stalled in many states. For certain patient
populations, such as Hispanic and those in the southeastern stroke belt, mortality rates are
increasing, thought to be a result of increased risk factor burdens of diabetes and hypertension
(CDC, 2017). Every day, over $120 million is spent in hospitalization, rehabilitation, and lost
productivity (CDC, 2017). Injured brain tissue puts stroke survivors at risk for a second stroke
(Hickey & Livesay, 2016). Twenty-three percent of stroke survivors who have received
education on risk factor management and stroke signs and symptoms may have a second stroke
(CDC, 2017).
For a stroke victim presenting to the hospital in a timely manner, multiple treatment
options are available. These include intravenous alteplase, intravenous alteplase combined with
and neuroembolectomy, or neuroembolectomy alone (Jauch et al., 2013; Livesay, 2014; Powers
et al., 2018). However, there is a brief time window from onset of symptoms; the patient must
have been seen well up to 4.5 hours prior to the stroke and up to six to 24 hours for
thrombectomy (Powers et al., 2018). Partially due to the brain injury that accompanies a stroke,
patients may decide to sleep off the symptoms, to ignore them, or may not be aware they have
the symptoms (Livesay, 2014). Viable brain tissue enabling speech and mobility may die due to
late recognition related to simple, everyday activities.
Public awareness of stroke symptoms remains low, despite public health campaigns
(Dombrowski et al., 2013; Jauch et al., 2013; Powers et al., 2018; Yu-Feng et al., 2015). Once a
possible stroke is recognized, activation of the emergency medical system (EMS) is an essential
WE LISTENED: IMPROVING STROKE EDUCATION 12
next step in the stroke chain of survival. There may be social and economic factors that inhibit
the activation of EMS (Omelchenko, Saban, Andresen, Klopp, & Lau, 2018; Skolarus et al.,
2013). A disconnect between knowledge and action may be caused by fear of an ambulance bill
or bringing law enforcement into a neighborhood. Hsia et al. (2011) found that first stroke
survivors knew to call 911; however, after a second stroke, they called a friend instead of 911.
Stroke survivors are hungry for knowledge (Danzl et al., 2016). This knowledge is
critical for risk factor management and understanding appropriate actions to take if a second
stroke is experienced. However, stroke survivors and caregivers are discharged home without
feeling adequately educated on the disease process (Livesay, 2014). According to patients, acute
care providers do not explain important elements of stroke education (Danzl et al., 2016). Health
literacy and working memory may be associated with recall of stroke signs and symptoms, a very
important element of stroke education (Ganzer, Insel, & Ritter, 2012). Patient perceptions of the
impact of stroke education in mass media campaigns may be low, even though some individuals
do change their behavior (Dombrowksi et al., 2013).
PICOT Question
For adults over the age of 18, discharged with a stroke diagnosis, can an improved stroke
education intervention increase patient satisfaction, as compared to those who have not received
proper stroke education, over a period of three months?
Available Knowledge
A systematic search guided by the PICOT question was completed through November
2017 using the following key words: stroke, cerebral vascular accident, edu*, education,
retention, patient perception, stroke survivor, and knowledge. Cochrane, CINHL, PubMed,
evidence-based journals, Psych Info, and Scopus were queried. Articles were selected for
WE LISTENED: IMPROVING STROKE EDUCATION 13
inclusion if they were in English and addressed stroke, education, and retention. Articles were
excluded if the study addressed primarily community-based stroke awareness campaigns, stroke
education for children, retention of other types of learning for stroke rehabilitation or were more
than 10 years old. Two studies were slightly older than 10 years; however, they were highly
relevant to the project. The final search yielded 78 journal articles.
The 10 strongest pieces of evidence for the PICOT question included four randomized
clinical trials, one systematic review with meta-analysis, one literature review, two qualitative
studies, and a systematic review. The evidence was analyzed using the Johns Hopkins Research
and Non-Research Evidence Appraisal Tools (Dearholt & Dang 2015). Aspects of the research
studies, such as methods used, adequate sample size, validity, and reliability of instruments used,
were analyzed. The literature review was also reviewed for relevance, up-to-date literature and
classic literature, identified gaps, meaningful conclusions, and recommendations. The meta-
analysis was reviewed for items such as key search terms, multiple databases, and appropriate
synthesis. The qualitative studies evaluated coding, cross-referencing, and conclusions. The
randomized controlled clinical trials are presented first and then the meta-analysis, literature
review, qualitative studies, and system review. Evidence tables are presented in Appendix D and
Appendix E.
Yu-Feng et al. (2015) conducted a randomized controlled clinical trial to examine the
most effective method of stroke education. The methods examined were video, brochure, one-to-
one teaching, a combination of the three methods, or a control group who received no
intervention. Subjects were randomized to one of the five groups and given a reliable and valid
stroke knowledge questionnaire prior to, immediately after, and at one-month post education. A
WE LISTENED: IMPROVING STROKE EDUCATION 14
total of 231 subjects were enrolled, with 225 needed for 80% power. There were no significant
demographic differences between the groups. The one-month follow-up contact rate was 90%.
This study found only the combination method of video, one-on-one counseling, and a brochure
had the greatest retention of stroke knowledge. The researchers acknowledged several
limitations: a lack of reliability assessments between one-on-one counselors, non-English
speakers were not enrolled, and the groups were not stratified by age (Yu-Feng et al., 2015).
Green, Haley, Eliasziw, and Hoyte (2007) conducted a randomized controlled clinical
trial to test the null hypothesis of an educational counseling interview intervention to increase
stroke knowledge and risk factor management in an outpatient clinic. The power analysis
determined 166 subjects would be needed for 80% power to detect differences between the
groups. The study sample size was 200. The subjects were given one-on-one educational
counseling in an outpatient setting and a baseline knowledge questionnaire at the post-clinic visit
and at three months. The authors did not state if the questionnaire was assessed for reliability and
validity. The study did find statistical differences in stroke knowledge. The study did not address
limitations. However, this study did provide good evidence for one-on-one teaching to increase
stroke knowledge (Green et al., 2007).
Byers, Lamanna, and Rosenberg (2010) conducted a randomized controlled pilot study to
evaluate the relationship between a motivational interviewing intervention and stroke knowledge
and satisfaction with care. Twenty patients were randomized into two groups. One group
received the standard of care, with education provided by the nurse through printed material, and
the second group, along with their caregivers, received an educational method enhanced using a
therapeutic motivational interviewing technique. The two groups were then tested using a stroke
knowledge test and a patient satisfaction test. The study did not address the reliability and
WE LISTENED: IMPROVING STROKE EDUCATION 15
validity of the outcome measures; however, the authors stated the stroke knowledge test had
been used in many stroke research studies. Byers et al. did present this study as a pilot,
acknowledging the small sample size. A power calculation was not performed, and the data were
not analyzed using descriptive statistics. The pilot study found a positive relationship between
motivational interviewing techniques and stroke knowledge and patient satisfaction (Byers et al.,
2010).
Hoffman, McKenna, Worral, and Read (2007) examined the relationship between an
individualized computer-generated education package and stroke knowledge, self-efficacy,
anxiety, and depression, perceived health status, satisfaction with content and presentation of the
written information received, and desire for additional information. The study population of 133
patients was randomized to a control group of usual educational methods and an intervention
group of an individualized, computer-generated educational package. A power calculation was
performed to determine the number needed to detect a difference between the control group and
intervention. The study population exceeded the minimum number of 130 patients. A variety of
what appeared to be standardized scales was used; however, the reliability and validity of the
scales were not addressed. Data were analyzed using an independent sample t-test and a
Fischer’s exact test. Interestingly, there was no effect of the computer-generated tailored
information on knowledge about stroke, self-efficacy, depression, or perceived health status;
however, the patients were more satisfied with the information they received than with the
standard method. Hoffmann et al. recommended additional research.
Smith, Foster, and Young (2009) compared studies on stroke education. Smith et al.
identified the databases searched but did not supply keywords used in their search. Seventeen
trials were reviewed, with a meta-analysis drawn from 11 of the trials. Only randomized
WE LISTENED: IMPROVING STROKE EDUCATION 16
controlled trials were included. The trials were considered to be active or passive. The active
trials had an intervention and follow up; the passive trials had an intervention only. Forest plots
were derived from the meta-analysis. The meta-analysis found that active strategies, which
included the patient and family, had increases in outcomes, such as stroke knowledge and
decreased anxiety and depression (Smith et al., 2009).
Cameron (2013) reviewed stroke education literature. The literature review defined the
need for adequate stroke education to reduce readmissions and increase the patient’s quality of
life. Previous research was summarized in physical and social factors impacting patients who had
suffered a stroke. These included patient sensory impairments, visual or pre-existing hearing
loss, assessment of readiness, and family and caregiver needs. Cameron did not clearly identify
gaps, as the review was focused on advice for the nurses, along with the summarization of the
research. However, Cameron did identify next steps to solve gaps, such as a need for longitudinal
research to identify the types of stroke education and individual patient needs.
The next two studies are qualitative and provide crucial descriptions of the patient’s
experience. Danzl et al. (2016) conducted a qualitative study of the stroke survivor experience of
receiving stroke education in Appalachian Kentucky. A multidisciplinary team interviewed 13
stroke survivors and 12 caregivers. The purpose of the study was simply to describe the patient
experience and not to test an intervention. Teams of researchers conducted and coded open-
ended interviews and analyzed pre-existing codes, data-derived codes, and iterative
modifications. Teams coded the interviews and finalized interpretation of the data through a
consensual collaborative process. Individual interviewers then re-analyzed the data. Field notes,
interviews, and reflective memos were cross-referenced to ensure credibility. The findings are
poignant. Danzl et al. found that patients and caregivers are affected by delivery, timing, and
WE LISTENED: IMPROVING STROKE EDUCATION 17
method; individualization of education appears to be critical for perception of adequacy; patients
and caregivers preferred providers who initiated education; and education on the availability of
stroke survivor networks and the chance for recovery were important for patients and families.
Eames, Hoffmann, Worrall, and Read (2010) interviewed 132 stroke survivors and their
caregivers at discharge and three months following hospitalization. Initial interviews were held
with 34 stroke patients and 18 caregivers, and follow-up interviews were held with 27 patients
and 16 caregivers. Eames et al. used qualitative content analysis to evaluate interview transcripts.
Condensed meaning units were derived from divided data, and codes were developed from
condensed meaning units. Themes were chosen from condensed meaning units and codes.
Categories of perceived barriers to stroke education were limited availability of information, the
hospital environment with busy providers, and patient and caregiver factors (Eames et al., 2010).
There were two studies in the quality improvement and quality analysis realm. At a single
site, Ross, Roberts, Taggart, and Patronas (2017) performed a quality improvement effort using
adult learning-oriented teaching methods called teach-back, along with a follow-up phone call.
Outcome measures were Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) scores for the entire unit, not just the patients who had suffered a stroke, and
readmission rates for patients with a stroke. Unfortunately, they were not able to show either an
increase in HCAHPS scores or a decrease in readmission rates (Ross et al., 2017).
Meighan (2018) performed an analysis of a health care system comparing HCAHPS
scores for questions on stroke education returned by patients who had suffered a stroke in
facilities that had video education capability and those who did not have that capability. The
facilities were part of a large integrated health care system. There was no difference seen in those
facilities who did have video and those who did not have video (Meighan, 2018).
WE LISTENED: IMPROVING STROKE EDUCATION 18
There were a number of randomized controlled studies with adequate power, clear
interventions and data analysis, and significant results. The quality of the studies rated from good
quality to high quality. The literature review was extensive, as well as the meta-analysis. The
meta-analysis echoed the randomized trial results that an active intervention involving the patient
was more effective for adequate stroke education. The qualitative studies had extensive analysis
of meaning, codes, and themes to provide insight into the patient experience. The themes from
both qualitative studies were similar in patient and caregiver factors, busy health care providers,
and the information not meeting individual needs. The quality improvement initiative and quality
system analysis did not see improvements in HCAHPS scores, which may be reflective of
limitations in that particular metric.
Due to the paucity of evidence specific to patient satisfaction and mixed results the
PICOT question (For adults over the age of 18, discharged with a stroke diagnosis, can an
improved stroke education intervention increase patient satisfaction, as compared to those who
have not received proper stroke education, over a period of three months) cannot be answered
conclusively. The evidence is clear that stroke survivors and their families respond best to a
multi-modal approach provided by engaged, knowledgeable practitioners who are able to make
the time to spend with patients. More advanced quality initiatives and research are needed in this
area.
Rationale
There were three frameworks used for the project of improved stroke education. These
were Promoting Action on Research Implementation in Health Services or i-PARIHS (Kitson &
Harvey, 2016; Kitson, Harvey, & McCormack, 1998; Stetler, Damschroder, Helfrich, &
Hagedom, 2011), Peplau’s (1992) Theory of Interpersonal Relations, and Watson’s (2008)
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Caring Science. The i-PARIHS was used to guide the implementation of evidence-based
practice. Peplau’s Theory of Interpersonal Relations was used to determine nursing interventions
that best met the stroke survivor’s needs. Watson’s philosophy of human caring was used in the
stroke education module to integrate the work with the nursing framework used by the frontline
staff. The three frameworks (i-PARIHS, Peplau, and Watson) and rationale for their inclusion
will be described.
A team led by Professor Alison Kitson at the Royal College of Nursing Institute at the
Radcliffe Infirmary in Oxford, United Kingdom initially developed the i-PARIHS in 1998. The
framework is an early recognition of the need for a conceptual model to guide the adoption of
evidence into practice (Kitson et al., 1998). The framework has recently been improved to
include innovation (Kitson & Harvey, 2016). While there have been criticisms and refinements
of the i-PARIHS framework, the framework does provide adequate guidance to evaluate
evidence for the implementation of improved stroke education for increased retention.
Based on the evidence, Peplau’s (1992) Theory of Interpersonal Relations provided the
framework for determining the best timing of interventions to increase stroke knowledge. The
conceptual model of Peplau’s theory has four phases: orientation, identification, exploration, and
resolution. Orientation is the initiation of the nurse-patient relationship during the admission
process. Detailed information is recorded, such as neurological status, language preference, and
goals for the hospital stay. The next phase is identification of the patient’s needs and
identification of the readiness for stroke education. In Kaiser Permanente, a separate form is used
to document educational readiness, in general. This form ties into the third phase, which is
exploration. The best method for education (verbal, print, or video) is documented (see Appendix
WE LISTENED: IMPROVING STROKE EDUCATION 20
F). Last, there is resolution of the relationship, which includes teach-back techniques, as well as
any stroke risk management needs.
While Peplau’s (1992) Theory of Interpersonal Relations was used for the process of
stroke education, Kaiser Permanente’s common shared framework of caring science was also
integrated into the stroke education work in order to share common nursing cultural ground with
the frontline staff. Caring science is a nursing theory originated by Jean Watson, which was
adopted at Kaiser Permanente in 2010 (Foss Durant, McDermott, Kinney, & Triner, 2015)
Caring science has 10 Caritas processes, which include the themes of loving-kindness,
compassion, authentic presence, transpersonal relationships, unity of being, healing
environments, and caring-healing modalities (Watson, 2008). The tenants of caring science were
integrated into the stroke education module developed for the frontline staff (see Appendix G).
Based on the evidence, multi-modal education, which actively involves the patient and
caregiver, was most likely to have an impact on the patient’s and the caregiver’s perception of
adequate education. However, active involvement does require engagement of the health care
provider in assessment of the patient’s emotional status at the time. The patient and caregiver
may be overwhelmed by the traumatic event of a stroke, which has fundamentally changed their
life, and yet the knowledge is crucial to receive early after the incident. Assessment, engagement,
and repetition of information are all elements which were addressed in the provision of stroke
education to ensure positive perception and subsequent appropriate actions. The stroke survivor
suffering from a second stroke who activates the EMS system in time may save years of
disability or their life.
Specific Aims
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The specific aims of this evidence-based change of practice project were to develop,
implement, and evaluate a stroke education project to increase patient satisfaction with stroke
education. The objectives for this change of practice project included:
1. Provide staff education and updated evidence-based reference materials to improve
staff satisfaction and reduce perceived barriers to education, thereby improving
practice at the bedside.
2. Improve available stroke educational materials using stroke survivor input and health
education consultation.
WE LISTENED: IMPROVING STROKE EDUCATION 22
Section III. Methods
Context
Key stakeholders for this intervention were frontline staff nurses, nursing managers who
were held accountable for regulatory compliance and patient satisfaction, senior leadership
charged with the financial leadership of the organization, stroke coordinators who are held
accountable for stroke program management and compliance to standards for certification, and
finally stroke survivors and their families. Stroke survivors expressed dissatisfaction with the
information they received, as evidenced by low HCAHPs scores in patient satisfaction surveys
sent to Kaiser members. Approximately 40% of stroke survivors did not report yes to questions
regarding staff explanation of stroke signs and symptoms, disease processes, or stroke
prevention.
As evidenced by a pre-intervention frontline survey, frontline staff members were aware
of barriers to adequate education. Frontline managers are invested in the improvement of patient
satisfaction scores; though the inpatient stroke population was usually relatively small and
response rates by stroke survivors even smaller. However, improvement could affect overall
facility scores across the integrated health care system for the Northern California region.
Improvement in patient satisfaction creates buy-in from senior leadership, as the cost of
replacing dissatisfied members can be high (Joshi, Ransom, Nash, & Ransom, 2014).
Frontline staff are diligent about documenting the stroke education for patients
discharged with a diagnosis of stroke. Documentation compliance is 98% to 100% of all patients
discharged with a diagnosis of stroke are provided with stroke education (Livesay, 2014;
Meighan, 2018). This high rate of compliance is consistent with all California hospitals, all
certified primary stroke center hospitals, and all Kaiser Northern California Hospitals (American
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Heart Association, 2018; see Appendix H). There is a disconnect between diligent
documentation and what the patients perceive as adequate stroke education.
For the local stroke coordinators, the Joint Commission (2018a and 2018b) addresses the
need for compliance to recommended elements of stroke education, literacy level, cultural
sensitivity, and tracking ongoing comprehension under Advanced Disease-Specific Care Primary
and Comprehensive Stroke Center Certification Standards Supporting Self-Management
(DSSE.3.1-5; see Appendix I). In addition, under Performance Measurement (DSPM.5.1-2) for
both Primary and Comprehensive Centers, the standard states the program must evaluate patient
satisfaction and utilize the satisfaction for performance improvement activities (Joint
Commission, 2018a and 2018b; see Appendix J).
The challenge for local stroke programs is to do meaningful performance improvement
efforts with a small number of HCAHPs surveys returned on average two to three per month.
The Joint Commission’s individual surveyor recommendations have been for programs to do
their own surveys, which is fine for stand-alone hospitals. Currently, the Kaiser Regional Stroke
Program does not have a standard patient satisfaction survey for all of the facilities, and this
certainly is an opportunity for future endeavors. Two facilities are completing patient satisfaction
surveys at discharge for internal use; however, the discharge surveys have not been validated and
are not standardized throughout the region.
Interventions
Interventions were multi-pronged: Kaiser stroke survivor members were engaged to
determine what is important to them; frontline staff were surveyed to determine the perceived
barriers to stroke education; a simple, fourth grade reading level flyer accessible through the
medical record was developed and translated; community feedback was received on the flyer;
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and a module to increase staff knowledge on stroke education was developed. At the beginning
of the project, a gap analysis was performed to determine the objectives, current state,
deficiencies, and action plans required (see Appendix K). The objectives were initially to revise a
stroke booklet, which subsequently changed, and to develop a stroke module. There were
deficiencies in starting the project, which had required senior leadership support both from the
physician medical group for the regional health education consultation and support from the
neuroscience clinical nurse specialist on the Kaiser Hospital Foundation side for development of
the module. These deficiencies were corrected through implementation of action plans identified
in the gap analysis.
A committee was formed for the project consisting of four local stroke coordinators, a
business consultant, and a neuroscience clinical nurse specialist. Two of the stroke coordinators
were clinical nurse leader students at University of San Francisco. One stroke coordinator was a
Jean Watson caritas coach. Meetings were held virtually at least once a month, with an agenda
provided. A sample committee agenda included action item report outs, open forum, and an
opportunity for committee members to improve any processes (see Appendix L). Summary
emails were sent out with action items included. A regional health education consultant attended
the meetings, which involved development of the patient flyer. Additional consultation was
received for development of the stroke module from a nurse educator and the administrator for
the health education platform.
Work Breakdown Structure
A work breakdown structure was completed to organize, define the scope of the project,
and to organize the work into smaller increments (Martinelli & Milosevic, 2016; see Appendix
M). The primary areas of work were materials, frontline nursing survey, stroke education
WE LISTENED: IMPROVING STROKE EDUCATION 25
development module, and evaluation of data. Revisions from the original work breakdown
schedule included the addition of educator feedback on the stroke module, revision of stroke
booklet, and edits to development of the flyer. Patient readiness, while a key component of
education, was not addressed in the scope of this project. For materials, the flyer, translations,
and other actions related to the flyer were the primary deliverables. Under consultation with the
regional health educator, the task of obtaining permission for the consultation could have been
included as another level. The nursing survey was created and feedback incorporated from the
regional labor relations manager. The survey was sent to the senior nursing leadership for
approval and discussed with the stroke survivors. The education module steps were delineated
with committee development, feedback incorporation, presentation to regional educator group,
and posting to the educational platform (see Appendix M).
SWOT Analysis
A strengths, weaknesses, opportunities, and threats (SWOT) analysis was done to identify
a strategy that positions the project in the environment for success and endorsement by
leadership (Martinelli & Milosevic, 2016; see Appendix N). Paying attention to the environment
of the project to ensure internal commitment each step of the way is important for success
(Block, 2000). The SWOT analysis did not significantly change between project implementation
and interim point of this report. The project’s strengths include being part of an integrated
system, standardized work culture, and integration of the voice of the customer. The identified
weaknesses of a short length of stay by the patient and multiple demands on nursing time are
issues that are difficult to address. Coordination of the timing of the nursing education at the
facilities was a weakness. The facilities have had competing demands for nursing education,
depending on unexpected events. While the educational hours were approved for all facilities,
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active participation in the project was purely voluntary. An integrated system strength related to
this project is that educational consulting resources within the company are available.
Standardized work culture provides a greater assurance that the education is provided in a
systematic fashion. Integration of the voice of the customer using the Institute of Health
Improvement (IHI, 2016) model of coproduction in health care design with stroke education may
improve the effectiveness. Opportunities included increased professional reputation for
excellence in stroke care through publication of the project in a peer-reviewed journal. The
problem of patient satisfaction in stroke education is well recognized (Livesay, 2014). There is
an opportunity to spread improvement of patient education to other disease processes beyond
stroke. Threats include regulatory changes and budgetary priorities shifting educational dollars
away from the project. This threat did materialize for one committee member, whose senior
leadership decided to postpone the education until 2019. Unfortunately, this was not discovered
until after the decision was made. This might have been mitigated by a request from the regional
stroke coordinator or even regional senior patient care services leadership who have been in
support. While a lack of support for regional health education consulting and the neuroscience
clinical nurse specialists was perceived to be a possible threat, this did not materialize. The threat
of a shift in regional executive sponsorship priorities that might limit or even eliminate the
project also did not materialize.
Project Responsibility and Communication Plan
The project responsibility and communication plan were developed to clarify project
roles, responsibility, scope, and timelines (Martinelli & Milosevic, 2016; see Appendix O). For
project responsibility, there was a steering committee consisting of a neuroscience clinical nurse
specialist; four stroke coordinators, who were also clinical nurse leader master program students;
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and, for approximately four to five months, a business consultant who was working on a Lean
Six Sigma project. The hope was to add a patient advisor; however, this was not accomplished.
There were monthly executive team meetings, with monthly reporting to mentors. There were
meeting agenda items and recorded meeting minutes. The project was and continues to be a
standing item on the monthly stroke coordinator peer group meetings.
GANTT Chart
A GANTT chart was completed to estimate timelines and tasks at the beginning of the
project and then revised for this report (see Appendix P and Appendix Q). The project
deliverables are listed on the left, with the dates on top of the GANTT chart. As indicated by the
charts, the project was estimated to start January 1, 2018. There were adjustments to the project
timeline, as evidenced by the initial GANTT chart and the interim GANTT chart, due to
development of the flyer and module taking longer than expected. The redesign of the
educational material had to be scaled back based on both stroke survivor and health education
consultant input and timeline for project. Stroke survivor input was that the booklets were not
useful, and they paid little attention to them. Health educational consultant recommendation was
for a shorter flyer. Even with a simple flyer, the redesign of the printed material took
approximately four months. The development of the stroke module also took longer than
planned—four months, opposed to the initially planned three months. Staff training was
estimated to be two months; however, compliance with training was less than hoped for. The
final plan is to continue to encourage training, to aggregate data of sites already trained, and to
continue to collect data. The staff will be resurveyed after 75% of the facilities have done the
interventions to be considerate of both frontline staff and stroke coordinator time.
Cost Benefit and Return on Investment Analysis
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Evaluation of the efficiency and cost -effectiveness of quality improvement
methodologies are essential in the environment of limited healthcare dollars (Hickey & Brosnan,
2017). Regulatory requirements will no longer automatically result in leadership investment
(Waxman, 2018). However, as HCAHPS results are important to the organization, the project
was funded by Kaiser Foundation Hospitals for the committee time, flyer translation, and nurse
training. The Permanente Medical Group provided regional health education consulting and
physician review of the flyer. A proposed budget was completed, with the primary expense being
nursing education (see Appendix R). Regional nursing leadership approves training hours
annually. Stroke education hours were approved, along with other content during that process.
Program costs were calculated (Appendix S). Future annual costs of the project will be training
any new hire nurses into the stroke-designated units and been approved. The capital expense cost
of the training completed so far has been approximately $88,600 (886 nurses trained at
$100/hour). One-time capital expenses for consulting and material costs were approximately
$19,900. Annual material costs for stroke booklets and any other print materials have been
traditionally and will continue to be covered by the stroke units. The annual costs per medical
facility is dependent on stroke discharge volume. The stroke booklet costs $1.61 each. The stroke
inpatient discharge volume ranges from nine to 799/year, for a cost of $14.46 to $1,286.39 per
facility. The annual costs of the booklet were not included in the budget because the budget was
for improvement project costs only, not all stroke education related costs. The annual costs of the
booklet for the units may decrease if only the flyer is distributed and not the booklet. However,
tracking what specific type of printed material is given to the patients was not included in the
current scope of the project, but would be an interesting area of future exploration.
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Reimbursement for quality of service rather than volume will continue to increase as a
percentage of income for hospitals (Waxman, 2018), which will increase the return of investment
for quality improvement projects such as the stroke education initiative. The return on
investment for this project is complex to determine and is dependent on several multi-variate
factors (Appendix T). However, there will be several assumptions for cost-benefit that are
backed by evidence. The first assumption is that education and patient satisfaction are correlated
with an increase in patient empowerment (Yeh, Wu & Tung, 2018). Patient empowerment is the
first step to activation of health behaviors, such as calling 911 when having the signs and
symptoms of a stroke. However, in the stroke community, there has been mixed evidence that
increased stroke knowledge results in an increase in activation of the EMS system (Mellon et al.,
2016; Mellon, Hickey, Doyle, Dolan, & Williams, 2014; Omelchenko et al., 2018; Skolarus et
al., 2013; Skolarus et al., 2016). Mellon et al. (2014) found that a public media campaign
conducted in Ireland did result in increased use of an ambulance for transport; however, the
increase was not sustained. Despite the mixed evidence, stroke education in the hospital does
take place with family present. If the patient and family can be better satisfied with the education
provided, there will be a greater chance that the EMS will be activated. The initial improvement
in the study conducted by Mellon and other community efforts (Omelchenko et al., 2018)
suggests that repeated and targeted education may improve patient arrival to the hospital in time
for treatment.
Assuming there will be an improvement in patient arrival and subsequent increase in
treatment rates, there can be a calculation of cost-benefit. The cost benefit of alteplase has
already been established. There was early recognition that integrated health systems would have
financial incentives to treat with alteplase due to the increased scope of financial responsibility
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(Boudreau et al., 2014; “Integrated Systems,” 1998), with an estimated $2.5 million dollars saved
in health care costs for every 100 patients treated with alteplase, or $25,000 per person through
reduced length of stay, rehabilitation, and nursing home costs.
Kaiser Northern California’s stroke volume or patients discharged with stroke-related
diagnosis for the period June 1, 2017, through June 1, 2018, was 12,747 patients. Eighteen
percent (471/1236) over nine months of the canceled stroke alerts or patients presenting to the
emergency room with suspected stroke symptoms at the emergency room had their stroke alert
canceled due to a change in the last known well, meaning they were too late for treatment.
Mellon et al. (2014) saw an increase from 11 stroke admissions per week to 31 admissions per
week.
Assuming a cost benefit of $25,000 per treated stroke, five more patients treated would
pay for the current budget of $130,400 (130,400/25,000). Given that the system sees
approximately 4,000 stroke patients a year, the potential to increase the number of patients
treated by five or even 10 is probably a conservative estimate. Initiation of the telestroke
program, while probably a greater direct impact on number of patients treated than education,
increased treatments from 34/month to 62/month (Nguyen-Huynh et al., 2018). Overall cost
benefit is especially significant in an integrated system that bears responsibility for the health of
the patient throughout a lifetime.
Cost avoidance was estimated through the cost of regulatory findings. If the facility has a
finding related to not using patient satisfaction to improve care, this would not generally threaten
a certification. However, there are costs associated with findings in time spent by the stroke
coordinator, medical director, accreditation and licensing review and guidance and any required
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additional training of the staff. These costs are difficult to estimate but an estimate of $10,000
(100 hours of $100/hr labor minimum) was chosen.
Stroke Survivor Engagement
Stroke survivors were engaged at the front end of the project. Using the IHI (2016) model
of coproduction in health care, stroke survivors were invited to a stroke coordinator peer group
meeting to give their opinions on stroke education. These stroke survivors have become patient
advocates, teachers, and inspirations for how care can be better provided. Their words echoed the
findings from the qualitative studies, which noted that frequently patients are too overwhelmed
in the inpatient setting to retain much knowledge. Engagement of the stroke survivors also was in
alignment with Watson’s (2008) caring theory, which stresses the need to incorporate the
patient’s voice in health care system design. Fortunately, there were two experienced stroke
survivors who had come back from devastating strokes who were willing to work with the stroke
coordinator peer group. One was a younger man and another an older woman. The younger man
had been a carpenter and spoke to the group about seeing everything that was out of plumb
before his stroke or simply not straight. With vision lost in one eye, he no longer had this skill or
societal validation. The older woman was a tenacious patient advocate who counsels and teaches
after suffering from a basilar artery thrombosis and a subsequent coma (see Appendix U).
Frontline Staff Survey
Frontline staff nurses were surveyed on perceived barriers to adequate stroke education.
Regional labor management consultants reviewed the survey and suggestions were incorporated
into the survey. Regional labor management consultation was imperative at the time because
contract negotiations were ongoing. Suggestions were to remove the number of members who
did not report satisfaction with patient education, but rather to report that a significant number do
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not report satisfaction (see Appendix V). Perceived impediments to effective education were lack
of time, lack of family availability when the patient was neurologically impaired, lack of
knowledge, lack of materials, and language barriers (see Appendix W).
Stroke Flyer
The stroke flyer was developed by the committee with assistance from the Regional
Health Education department. Support for regional health education had to be obtained from an
executive level physician. The Regional Health Education department resides under the
Permanente Medical Group and permission was needed for their time. There was an initial
meeting with a supervisor to scope out the needs of the patient education committee, and then a
consultant was assigned. The consultant advised simplifying the information, which echoed the
stroke survivor input to the stroke coordinator peer group and the literature.
A secondary goal of the flyer to meet the needs of the frontline staff nurses was to
develop an item that would be easily accessible through the chart and not dependent on either the
unit keeping in stock or the coordinator ensuring adequate stock on multiple units. A barrier
stated by the frontline staff was the lack of materials. The plan was to have a link in the chart in
the educational section to an internal stroke web page called the Stroke Portal. All Kaiser staff
can access the Stroke Portal either through the chart or through an internal resource called the
Clinical Library. To ensure the Stroke Portal is patient-centric, the agreement with the
administrator of the portal was to put the flyer link at the top (see Appendix X).
The Joint Commission (2018c) specification manual was reviewed to ensure the flyer
contents were compliant with required elements of risk factor management, stroke signs and
symptoms, the importance of calling 911, follow up with provider, and the importance of taking
medications. A committee member did a rough draft. The committee considered utilizing graphic
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design services to ensure the most professional appearance. However, the committee member did
such a wonderful job that the other members and the regional health consultant decided to use
that version. The regional health education consultant recommended the inclusion of information
for follow up and had recommendations to make the language as caring as possible.
The flyer was analyzed by Microsoft Word 2016 for spelling and grammar usage as the
flyer was developed. The grammar usage and spell check feature in Microsoft Word has become
increasingly sophisticated, checking for gender-specific language as well as incorrect spacing
and passive language (Britschgi, 2018). The flyer was checked for readability and grade level
using the Flesch reading ease test (Flesch, 1948) and the Flesch-Kincaid grade level test
(Kincaid, Fishburne, Rogers, & Chissom, 1975). The score for the reading ease test was 80.7,
grade level was 4.1, and passive sentence percentage was 12.5. An average reading ease test
score is 60 to 70, with a higher result indicating greater ease of reading. (Flesch, 1948). The test
utilizes the sentence length and average number of syllables per word. A similar formula is
utilized to obtain a reading level (see Appendix Y). Then the flyer was taken out to community
members for review. A survey was prepared, as well as a script for the survey (see Appendix Z
and Appendix AA). Comments from the community were incorporated into the flyer. One
comment was to remove redundant language not picked up earlier by the committee members or
regional health consultant. Several community members requested copies of the flyer
immediately for home use.
The flyer was then presented to the stroke coordinators and to lead neurology physicians
for review. There were minimal suggestions from the group. One lead physician needed
reassurance that health education consultation had been obtained. Also, since the flyer was a
simplified communication, the physicians had to be reassured that the essential information was
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covered. The decision was made to have the flyer be the minimally expected requirement, with a
regional stroke booklet that included more detailed information still available.
After the flyer was finalized, the flyer then needed to be translated. A business case
request was presented to the Regional Director Clinical Quality Program and Analytics for funds
for the translation. Initially, the translations were done for Spanish and Chinese. However, there
was a further request from a local stroke coordinator for Tagalog and Vietnamese. After
approval, the translation service was directly requested (see Appendix BB). While the
translations were being completed, the decision was made to go ahead and post the English
version of the flyer, since by that time, the training of the nurses had started. However, in
approximately three weeks, the first two translations to Spanish and Chinese were completed,
with Vietnamese and Tagalog closely following (see Appendices CC – GG). A certification of
translation accuracy was issued for all translations, which are at the bottom of the related flyers.
Stroke Education Module
In conjunction with the flyer development, based on the literature, stroke survivor
feedback, frontline staff nurse feedback, and the frameworks of Peplau (1992) and Watson
(2008), the stroke module was developed by the committee (see Appendix HH). The intended
audience was the nurses on the stroke floor units where the majority of the teaching occurs prior
to discharge. The committee members included one of the neuroscience advanced practice nurses
who was an experienced educator. A presentation was done on the project at Kaiser Vallejo
Rehabilitation Center in December of 2017 for nurses and allied health professionals. This
presentation was used as the basis for the module. Kaiser Northern California uses an
educational platform called Health Stream (see Appendix II) for nursing, medical assistant, and
allied health education. The platform does have limitations in terms of video uploading
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capabilities; however, there are interactive features to enhance learner engagement. Consultation
was done with the administrator on the best methods, and subsequently, a PowerPoint module
was developed with a post assessment.
One element of the module was incorporation of the Jean Watson model of caring
science. A committee member was a caritas coach, an identified local expert in caring science.
The regional lead for patient experience was consulted for visual aids on caritas and also to
ensure currency, as the model has been used in Kaiser Northern California since 2010 (Foss
Durant et al., 2015). Integration of the two models of Peplau and Watson flowed naturally, as
Watson was the overall framework, and Peplau addressed the individual interaction to guide the
intervention.
A second element of the module was the educational strategies specific to stroke patients
who may be cognitively impaired or have sensory deficits (Livesay, 2014). These strategies
included novel approaches, such as having the patient read aloud, asking the patient to draw what
they are thinking about, and using the language translation services for further explanations. The
neuroscience clinical nurse specialist has been working with stroke patients for over 20 years and
utilizes evidence-based practices in her approach (see Appendix JJ).
After the content was finished, a post-assessment was developed and revised (see
Appendix KK). Four principles for developing multiple-choice nursing test items were applied to
the development of the test (Bristol, Nelson, Sherrill, & Wangerin, 2018). The first principle was
reinforcement of important concepts, such as adult learning principles using teach-back for
stroke signs and symptoms. The second principle was the measurement of the grasp of
knowledge, such as the Joint Commission’s requirements for stroke care. The third principle
applied was differentiation of competent from incompetent examinees, including a question on
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appropriate techniques for teaching patients. The fourth principle is one of fairness and inclusion
of only applicable items (Bristol et al., 2018). Advanced neuroanatomy was not included in this
test, and only items in the module were covered. The expectation was and continues to be 80%
correct, or there will not be credit given for module completion and subsequent payment for time
spent.
The module was given to an outside educator at one of the facilities for review with their
staff for alpha testing, and minimal feedback was received. The Health Stream administrator also
had input, which was incorporated. The image permissions were researched. One image was
used from a previously published regional Kaiser stroke booklet, but that was double checked.
Then graphics were used from a company called Presenter Media. Their requirement, which was
reviewed again, is an acknowledgement in the document and that the document is not sold for
other than educational purposes.
The stroke education project was presented to a regional group of educators who would
be responsible for enrolling the nurses into the course. A nurse practice alert was developed and
submitted (see Appendix LL). Feedback from the group was minimal, except later when one
advanced practice educator gave feedback that it took them 15 minutes to complete. The
educational hour had been approved by regional nursing leaders.
It was then realized that nurses in the emergency rooms and intensive care units might
find the flyer useful, but not all of the content might apply. A lack of patient readiness for
education is fairly obvious in the emergency room and intensive care unit. Families may be
ready, but the absorption will be limited (Livesay, 2014). The discharging nurse on the floor is
responsible for ensuring the completion of education, not the emergency department or intensive
care unit. There may be the rare occasion where the patient is discharged directly from the
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intensive care unit, but generally, those hyper acute units are not as responsible for education. A
flyer was developed and distributed to the coordinators to work with their emergency rooms and
intensive care units. The flyer was also distributed to the emergency room education group (see
Appendix MM).
Study of the Interventions
Patient satisfaction scores with stroke education and data on stroke alerts or patients
presenting to emergency rooms with suspected stroke symptoms were used to assess the impact
of the intervention. The approach used to establish whether observed outcomes were due to the
intervention was analysis of the data and review of the evidence. Because this project was done
at a regional level to aggregate local facility data, to take advantage of this regional approach, the
HCAHPS scores were standardized, validated, and easily accessible, despite their limitations.
The impact of the intervention on patient arrival to the emergency rooms and also presenting
earlier for treatment does have mixed evidence (Omelchenko et al., 2018). However, these data
are also available and reliable, as they are based on an automatic upload with stroke coordinator
review from the electronic medical record chart. There have been positive studies on the use of
education with the increase in patient activation of the EMS to present in time for treatment
(Dombrowski et al, 2013).
Outcome Measures
The measures chosen for studying processes and outcomes of the intervention(s),
rationale for the choice, operational definitions, validity, and reliability will be described. For
this change of practice project, there was one nursing related outcome measure and a shared
nursing and patient-related outcome measure. The first aspect of the aim statement was to
provide staff education and updated evidence-based reference materials to improve staff
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satisfaction and reduce perceived barriers to education. The nurse-related outcome measures are
the percentage of staff who complete the education module and pre- and post-intervention staff
surveys on barriers to stroke education. For the interim report, a post-survey will be done when
75% of facilities have completed training through the stroke education module. The second
aspect was about the improvement of the available stroke educational materials using stroke
survivor input and health education consultation. The outcome measures are both patient
satisfaction and staff survey results. Patient satisfaction score data will be drawn from stroke-
related questions reported on HCAHPS surveys, which are surveys mailed to patients who have
had at least a one-day stay in the hospital, are discharged with a stroke diagnosis, and are
discharged to home (Centers for Medicare and Medicaid Services, 2017).
A third set of outcome variables tangentially related to the project; however, important in
the stroke community was the percentage of patients who presented in time for treatment and
those who activate the EMS. Both of these measures are multi-factorial and have been difficult to
increase through community education (Omelchenko et al., 2018; Powers et al., 2018); however,
if the teaching is improved in the acute care setting with families or community, as well as the
patient, perhaps a corresponding improvement might be seen in this population.
Data Collection
Publicly reported patient satisfaction scores (HCAHPS), with three stroke-specific and
one non-specific stroke question, were utilized. The surveys are mailed to patients who were
discharged to home up to six weeks after hospitalization. The patients must have spent at least
one night in the hospital. The stroke-specific questions ask whether the stroke diagnosis, the
stroke risks and prevention, and the stroke signs and symptoms were explained. There is a
comparison question regarding the receipt of information of symptoms to look for. This question
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is asked of all patients, not only those with a stroke diagnosis, at discharge. In theory, the stroke
patient’s response rate should be equal to or possibly greater than the general medical patient
population due to specific regulatory requirements.
Patient demographics are available, along with patient demographics of the general stroke
population, from hospital reports during that same period. One primary known difference is that
surveys are sent only to those patients who are discharged to home. In a system analysis done by
this author, differences between survey respondents and the patient population was not
statistically significant in terms of age, sex, ethnicity, or length of stay (Meighan, 2018);
although, the number of respondents age 18 to 44 was too low to compare to the stroke patient
population of the same age group. Patient demographics were not examined, as the current work
was completed using the same data set, only a slightly different timeframe.
A pre-intervention paper survey of the frontline nurses and their perceptions of barriers to
effective teaching was conducted and can be found in Appendix V, with the results tabulated in
Appendix W, as mentioned previously. The questionnaire is open-ended, on paper, and
anonymous, except for location of unit. A post-survey will be completed when 75% of the
facilities have completed the stroke education training module. The anticipated resurvey date
will be March of 2019. The results from both surveys will then be compared.
The outcome measures related to mode of arrival to the emergency department,
percentage of stroke alerts canceled initially due to not being in the time window, and percentage
of patients not treated due to the time window after an initial evaluation were pulled from a
stroke alert database developed by a regional data team, which included this author. This
database is part of a larger platform used by Kaiser Permanente for a variety of purposes,
including peer review and other quality work called MIDAS. The database is populated by a
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Clarity program, which pulls directly from the Health Connect medical record. A smart phrase is
written by all of the centralized regional teleneurology group who remotely consult on patients
presenting to the emergency rooms or patients in the hospital (Nguyen-Huynh et al., 2018). The
smart phrase has drop-down menus, which then populate an encounter with standardized data
elements. The Clarity program also detects patients who have received alteplase in a specific
dose range to eliminate those who are treated with alteplase to clear intravenous catheters. These
patients may be seen by local neurologists who may not have used the smart phrase; although,
they are encouraged to do so. The stroke coordinators then review the database for consistency.
Since it is a direct pull from the chart, they do not need to validate every element. However,
there are instances when new teleneurologists do not use the smart phrase correctly, incorrect
times are entered, or local neurologists may not use the note. There are also very rare cases
where the database will pull patients who have received alteplase for pulmonary embolism or
femoral artery clearance, which require manual review and removal from the database. Due to
the proprietary nature, screenshots are not provided at this time.
The stroke alerts are divided up into emergency department ambulance, emergency
department onset, emergency department walk-in, and inpatient. There is a separate report for
canceled stroke alerts and then the stroke alerts not canceled with evaluation, treatment,
discharge disposition, and a variety of other elements. The difference between stroke alerts
initially canceled and alteplase not given after treatment is that the initial cancellation may be
due to either challenges in EMS reporting or challenges in emergency room triage. After the
initial evaluation, there may be additional information received from subsequent family arrivals,
which would then give the reason of time window for alteplase not given. Overall, this database
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reflects accurately elements related to patient education and subsequent behavior, such as
presentation to the emergency rooms using the ambulance and presenting in time for treatment.
Balancing measures included a patient satisfaction question, which asks if the patients
had received information on symptoms to look for. This question does not specifically mention
stroke signs and symptoms, and the responses should be roughly similar. For future work, this
balancing measure would be interesting to examine for correlation. Are the stroke survivors
better able to retain education on signs and symptoms of other disease processes, such as
infections or shortness of breath, that are covered in discharge instructions that are not related to
stroke? Could the trauma of the stroke affect perception of adequate education to the specific
disease process, effectively selecting out stroke? These are questions worth future exploration.
Analysis
The results were analyzed using descriptive statistics in Excel. The nonparametric
statistical Chi-square (χ2) test was used to determine if the differences between the pre-
intervention and post-intervention groups were statistically significant (Sylvia & Terhaar, 2014).
Chi-square calculations were done with a free online social sciences calculator
(https://www.socscistatistics.com/tests/chisquare2/Default2.aspx). The flyer was analyzed using
Microsoft Word software. The registered nurse survey results were analyzed by the business
consultant by a simple counting method. Qualitative methods were not used; although, this is an
area of possible future exploration.
Ethical Considerations
Ethical considerations for this implementation of evidence-based practice are based in a
conflict between a paternalistic view of health care and a movement towards co-production of
health care. The paternalistic health care model practiced in the past is a one-way relationship,
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with the provider instructing the patient on the best possible care (Emmanuel & Emmanuel,
1992). For this intervention, regulations state the patient must be provided with information on
specified items in a specified print format. Coproduction of health care is a model where the
patient and provider work together on the most appropriate health care (IHI, 2016). The patients
or their families frequently are not ready for the information, as stated in qualitative research
(Danzl et al., 2016). However, per regulation, this information must be provided. Following the
Jesuit commitment of cura personalis or care of the whole person, provision of this education is
caring for the patient’s future. Delivering individualized education at the right time for the
patient and family is following the American Nurses Association (ANA, 2017) code of ethics to
advocate for patient safety and health.
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Section IV. Results
Data variables; type, source, and range of values; level of measurement; and timeframe
for collection and statistical test are listed in Appendix NN. Overall, except for the survey
results, data were not collected directly by the patient education improvement team. Issues, such
as missing data fields, data cleaning, and verification of accuracy of source data, was not
explored, and this may be considered a limitation of the results of the project. However, part of
data management for the nurse leader is to consider creative use of available data that have
already been tested for validity and reliability (Sylvia & Terhaar, 2014). Reliability and validity
testing of new tools can be resource and time intensive.
There were strengths and limitations of each of the data sets: patient satisfaction scores,
staff surveys, and stroke alert data from the emergency departments. Patient satisfaction surveys
and scores have received increased attention, with reimbursement tied to higher scores. Concerns
have been raised on the uncertain relationship between high patient satisfaction scores and
quality care (Falkenberg, 2013; Fenton, Jerant, & Franks, 2014). Patient satisfaction with
material may not result in an increase in patient knowledge of stroke (Hoffman et al., 2007).
Age has been found to be a confounding variable in patient satisfaction survey responses
(Voutilainen, 2016). Older people tend to report higher satisfaction, but they also skip items they
feel uncomfortable answering (Voutilainen, 2016). The stroke patient survey response rate is low
(Livesay, 2014), and little is known about those who do not return the surveys. The average
response rate for individual project facilities ranges from as low as nine per year to a high of 80
per year. Patient satisfaction data are broken out by facility, but are de-identified for any public
release (see Appendix OO). Individual facility-level data may be too small a sample size to make
any conclusions. One advantage of this project is in the aggregation for statistical meaning.
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Unfortunately, the corresponding percentage of patients who respond yes to adequacy of stroke
education remains a disappointing 54%, at the highest due to multiple factors such as timing of
the education at the beginning of a traumatic event, complexity of the disease process, and
cognitive impairments for many patients (Danzl et al., 2016; Livesay, 2014),
Post-intervention HCAHPS scores are found in Appendix PP. Unfortunately, at this
point, there was not a significant impact on the scores. The percentage of positive responses to
the question “Staff Explained Disease Processes” rose from 51% (21/41) to 64% (32/50).
However, the positive responses for the other two stroke-related questions for risk factors and
stroke signs and symptoms decreased from 54% (23/42) to 44% (24/54) and 52% (19/36) to 47%
(25/53), respectively. The overall results were not statistically significant using χ2 for analysis.
Discomfort and dissatisfaction may play a role in frontline staff surveys; although
initially, when determining an intervention, the willingness to illustrate problems can be an
advantage. Similar to patient satisfaction, the population of those who respond to the survey may
differ from those who do not respond to the survey. This will be a concern on the post-
intervention survey, if there is not a significant change detected in the response. The survey also
had to be adjusted for labor relations’ considerations and not necessarily for the integrity of the
survey; although, the focus was on open-ended questions.
The results from the frontline staff are found in Appendix V. The pre-intervention results
were not surprising. Frontline staff reported lack of time about what to educate patients and
knowledge about stroke. What was surprising, given the number of translation tools available to
the frontline staff, was the consistent reporting of language barriers. However, this is a reminder
that when the nursing staff are overwhelmed, there might not be the time to set up translator
phones or computer applications on the iPad.
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As for completion of the training, as of this report, approximately 886 nurses had
completed the training in six of the 19 facilities. All departments were represented. Emergency
room and intensive care nurses were assigned the full module by one of the facilities. Another
facility decided to educate their maternal health nurses, as maternal cerebral hemorrhage is a
leading complication (Livesay, 2014).
Data on initial presentation mode, such as EMS, walk-in, stroke or stroke worsening in
the emergency room initially after presentation, inpatient stroke alerts canceled upon initial
presentation by teleneurologist, and alteplase not given after initial evaluation, are presented in
Appendix QQ. There are no national benchmarks for EMS versus walk-in; however, it was
interesting to note that Hospital B had a 76% rate of walk-ins. Although de-identified, that
hospital is in an area with a greater population of high socio-economic status residents, who may
be less concerned about an ambulance bill. That particular hospital also had higher rates of
cancellations for time window and not given for time window, which appears to be counter-
intuitive. However, this discussion borders on the edge of the scope of this project. It is included
because, if there was a change in the numbers in the next three months, that would be interesting
to the stroke community
Behavioral measures that may be influenced by increased education, such as arriving at
the hospital in time for treatment and activation of the EMS, saw no significant difference for
arrival in time for treatment, and unfortunately, a statistically significant increase in arrival by
private car for the month of August. The data were aggregated for the year, then July and August
or pre- and post-intervention were pulled out for comparison (see Appendix RR).
.
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Section V. Discussion
Summary
At the time of this project’s write-up, the project aims have not been yet achieved.
There was a glimmer of hope that there was an increase in patient satisfaction to one of the
questions; however, the increase was not statistically significant. Key findings and lessons
learned were the difficulty in using the HCAHPS scores, even with aggregation at the
regional level. There were challenges influencing change across many medical centers with
competing priorities. Working primarily remotely with teams using only influence does have
limitations (Carnegie & Associates, 2011), despite the official role of this author. It is
difficult to solicit challenges on group conference calls. For the stroke coordinator peer
group, those who are engaged and vocal and who will speak up about problems were the
facilities who did the training. Exploration of a post-meeting survey for those who do not feel
comfortable speaking up in a group will be done.
Even though the training hours were approved, many centers did not utilize the time.
For those that did train, engagement of the local stroke coordinator, local nursing education
department, and regulatory requirements contributed to that success. The nurse training
occurred later in the project, so a re-survey of the frontline staff was not practical at this
point.
New possibilities that have emerged are to suggest to the stroke coordinator group a
standardized discharge survey process to obtain more meaningful feedback rather than
HCAHPS scores. Another possibility is to analyze and aggregate scores from the facilities
that did not do the training for comparison. A third possibility is to distribute the flyer widely
and get more systematic feedback.
Reassessment of the frontline staff will be done when 75% of participating facilities
have completed training. There were 19 facilities that did not have active ongoing stroke
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education improvement efforts and agreed to participate. Six of those did train, with two
more indicating they will train, for a total of eight facilities or 42%. Fourteen facilities will
need to do training to bring it to 75%, leaving a gap of six remaining facilities. Two of those
facilities are under one umbrella. The remaining facilities will be contacted individually to
inquire about the status in the first quarter of 2019.
The current dissemination plan is to monitor the HCAHPS data further and then, if the
results are clear, to consider publication. Another large facility has stated they will initiate
training, so the potential for more responses is possible. If the patient arrival mode and
presentation in time for treatment data changes, I will examine that data more closely for
stroke survivors who have a second stroke. A crosswalk may be able to be done using the
MIDAS stroke alert database, and another stroke coded population report.
The implications for advanced nursing practice in this project were all the clinical,
administrative, and educational decision-making skills required to apply evidence-based
practice for stroke survivors (Dearholt & Dang, 2015). Clinical skills included knowledge of
the stroke survivors’ educational needs, which may be influenced by cognitive and sensory
impairments. The administrative skills included resource management, project management,
and communication skills to ensure the needed resources were obtained. Educational skills
were required for flyer development and stroke module development.
The implications for advanced nursing practice include the role of the stroke
coordinator. The facilities who did train had successful stroke coordinators. Although the
stroke coordinator role is not recognized as advanced practice, it should be. The stroke
coordinators are charged with implementing evidence-based practices across the continuum
of care, from emergency room presentation to admission, to discharge and back to the
community (Hickey & Livesay, 2016). The coordinator must interact with a wide range of
people and departments, from the security guards, the general public, to emergency room
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physicians and intensivists. Although the role is recognized as essential to many physicians,
unfortunately, it has not been as recognized by hospital administration, and there is not a
standardized training for the role (Livesay, 2014). Many advanced practice nurses fill this
role and are able to adapt.
Interpretation
The results of this project illustrate the challenge of moving performance
improvement efforts from process to outcomes. A change in outcomes may not be the result
of a single provider and patient interaction (Hickey & Brosnan, 2017). Process changes are
much easier to control. A project to simply improve compliance of the documentation of the
education would have a greater chance of success if the documentation was an identified gap.
However, the American Nurses Association Standards of Practice do state the need to
identify expected outcomes for a plan individualized to the health care consumer (Dearholt &
Dang, 2015). Satisfaction with stroke education should be an expected outcome for the care
of the stroke survivor, not simply documentation of the education.
The results of this project are similar to other quality improvement efforts, such as
those reported by Ross et al. (2017), who were unable to see an increase in their patient
satisfaction scores or readmission rates. The impact of the project on the Kaiser system is
difficult to assess at this point; however, a re-survey of the frontline staff in March of 2019
may provide insight. The flyer and its translations may increase awareness of stroke
education elements. The project costs were under the approved budget due to the smaller
number of nurses trained. Strategic trade-offs were the time spent by the committee, which
could have been spent on other projects. The implications for the mixed findings for the
leadership of change indicate the need for greater skill of influence and greater skill of virtual
team building.
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Assumptions were made that if the staff training hours were approved and the
educators were presented the information, the expectation was that the training would be
done in a timely manner. But, this was a learning for the author to be applied to future
endeavors.
The findings at this point support the conceptual and theoretical framework when
viewing the increase in satisfaction scores from a descriptive statistical view. If the patient is
assessed correctly, the nurse has time to spend with the patients and families using authentic
presence, and adequate material, based on the qualitative literature (Danzl et al, 2016; Eames
et al., 2010), patients and families report satisfaction with the educational experience. The
means necessary to sustain new levels of performance include local nursing leadership
engagement and staff nurse endorsement and buy-in.
Limitations
There are several limitations to this change of practice project, which include patient
factors, factors related to nursing, and material factors. Patient factors include patient and
family readiness, neurological factors, and physical factors. Are the patients and families
ready for any intervention, regardless of print, one-on-one counseling, or video mode, while
still an inpatient? Focus on patient readiness for education and acknowledgement of the
current state may alleviate patient anxiety. Neurological and physical factors may limit the
effectiveness of the education for both the patient and family. Stress plays a role in patient
and family readiness (Danzl et al., 2016). Patient factors are difficult to mitigate; however,
acknowledgement can alleviate conflicts, such as the nurse needing to educate for regulatory
requirements and the patient or families not being ready to receive the education.
If patients and their families are ready for education, do the nurses have the resources
of time and materials to provide this education? Time consideration is the most concerning.
The average length of stay for a stroke patient is three to four days (Livesay, 2014). The short
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length of stay may impact the perception of the adequacy of education. Nurses have multiple
demands on their time to develop the therapeutic relationship. The patient’s neurological
status may affect the therapeutic relationship in regard to education. The therapeutic
relationship may be centered on physical rather than educational needs of the patient.
Families are also included in the education; however, frequently, they are only available
during the evening shift, which can be active in terms of admissions and discharges for the
nursing staff.
Implementation of the project has had its limitations. Naturally, action items, such as
the flyer design and stroke module, took longer than planned. There was the challenge of
accountability when the project depended solely on influence due to the reporting structure of
the health care enterprise. Silence in a large group meeting held on the web does not always
mean assent. While feedback is always encouraged in peer group meetings, raising objections
can be a challenge. One possible action to take would be an anonymous survey after the
meeting.
There is a significant limitation of managing in a setting of influence without
authority (Block, 2000; Carnegie & Associates, 2011). The structure of the integrated system
is that the medical centers do not report to the regional offices but to the Kaiser board. The
regional offices set the standards, provide initiatives to move care forward, and provide
support for regulatory compliance. However, local leaders manage their medical centers for
their local populations. Participation in initiatives is voluntary to an extent. There are
initiatives with scorecards, dashboards, and financial incentives for area managers. However,
even those initiatives with financial incentives can experience challenges in engagement by
local medical centers. The stroke education project, while important, was not on a significant
financially incentivized scorecard, as are those strategically decided upon depending on the
quality initiatives for the year. While patient satisfaction is always on a dashboard,
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unfortunately, the stroke response rates are too low to make a practical difference. One must
rely on managing through influence greater than it appears from the outside.
The problem of managing in an environment of influence without authority was
known before the project was started. Affecting change through influence requires many
different strategies (Block, 2000; Carnegie & Associates, 2011; Patterson, Grenny, Maxfield,
McMillan, & Switzler, 2008). One well-known strategy first popularized by Tom Peterson in
the early 1980s and then used effectively by Stephen Jobs is management-by-walking around
(Tucker & Singer, 2012). This strategy involves middle management routinely walking
around the nursing units engaging in face-to-face conversations with frontline staff to
determine the problems, to communicate key objectives, and to celebrate successes.
Management by walking around remains an important tool despite a large geographical
setting. The physical mode may not be walking, but driving or using modes of public
transportation, such as the train combined with a car service.
Besides obvious physical challenges, there are financial sensitivities in the
relationship between the local medical centers and the regional offices which affect in-person
contact. Any travel expenses incurred by the regional offices to the local facilities are the
responsibilities of the local facilities. Therefore, the culture of the regional offices is to wait
for a request from the local facilities first before planning a visit. Another strategy employed
was to acknowledge when training was done or deliverables were accomplished in a public
manner. Ensuring team member contributions, such as flyer design, was a key tactic used.
There were processes of the change that were dependent on local facility willingness
to train the nurses. One facility did decide to do the training in 2019. Efforts to encourage the
facilities to do the training included presentations at the stroke coordinator peer group
meetings and inclusion of unofficial stroke coordinator leaders, along with newer stroke
coordinators, on the executive committee. The what is in it for me approach was used by
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acknowledging the coordinator’s needs in the presentations (Block, 2000). The challenge of
individual facility low rate of return of HCAHPs stroke surveys was reiterated. The
opportunity to satisfy regulatory requirements and make meaningful performance
improvement efforts was presented. Another local characteristic would be the willingness to
use the flyer. Some facilities may have felt the flyer was too minimal and were concerned
about stroke surveyor comments. This is partially why the stroke booklet was not removed as
an option. Tracking the use of the flyer was not considered because the link is available to all
Kaiser employees.
There was also a minor problem in maintenance of the link in the medical record
chart. The stroke care plans that populated the educational section are contracted out to a
third-party vendor. The vendor made a change in the care plans, which then affected the link
to the flyer. This occurred after the first measurement of HCAHPS scores in October 2018. It
will be difficult to assess the impact of the flyer separate from the training.
Conclusions
The project will be sustained through continued training of the remaining facilities of
the nurses in the provision of stroke education, education of new nurses on the provision of
stroke education, continued monitoring. and evaluation of the data. The stroke education
materials will continue to be available on the units. Regulatory requirements and standard
patient satisfaction surveys will reinforce the need for attention to this patient educational
need. Communication of the results of the work will not be done until positive results are
obtained due to underlying, multi-factorial resistance from the staff on satisfaction results
(Joshi et al., 2014). If the results do not become positive, then communication will be done
with careful explanation of the reasons why the results were not positive, such as the need for
a better measurement of patient satisfaction with stroke education. Development of
alternative methods to measure patient satisfaction with stroke education may be a much
WE LISTENED: IMPROVING STROKE EDUCATION 53
needed area of future research. If the patient education is able to impact the numbers of
family and community members who suffer a stroke, and then are able to activate the
emergency medical services and present to the hospital on time, this could have implications
for other disease processes such as diabetes management.
The CDC (2017) has raised a call to arms in stroke care, with the mortality rate
decrease slowing down and in a subset of vulnerable populations reversing and experiencing
an increase in stroke mortality. Due to the increase of stroke risk factors, such as obesity,
diabetes, and hypertension in younger patient populations, previous population gains are at
risk of being lost (CDC, 2017). There is treatment available when patients get to the hospital
in time. Patients and their families may not be ready for stroke education; however, if even
one life is saved by early recognition and action, progress will have been made.
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Section VII. References
American Heart Association. (2018). Get with the guidelines® (GWTG). Retrieved from
http://www.heart.org/en/professional/quality-improvement/get-with-the-
guidelines/get-with-the-guidelines-stroke
American Nurses Association. (2017) Code of ethics for nurses with interpretive statements.
Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-
Nurses.html
Block, P. (2000). Flawless consulting: A guide to getting your expertise used. San Francisco,
CA: Pfeiffer.
Boudreau, D. M., Guzauskas, G. F., Chen, E., Lalla, D., Tayama, D., Fagan, S. C., &
Veenstra, D. L. (2014). Cost-effectiveness of recombinant tissue-type plasminogen
activator within 3 hours of acute ischemic stroke: Current evidence. Stroke, 45(10),
3032-3039. doi:10.1161/STROKEAHA.114.005852.
Bristol, T. J., Nelson, J. W., Sherrill, K. J., & Wangerin, V. S. (2018). Current state of test
development, administration, and analysis: A study of faculty practices. Nurse
Educator, 43(2), 68-72. doi:10.1097/nne.0000000000000425
Britschgi, C. (2018). Microsoft word spell check. Reason, January 2018. Retrieved from
https://reason.com/issues/january-2018#page/71
Byers, A. M., Lamanna, L., & Rosenberg, A. (2010). The effect of motivational interviewing
after ischemic stroke on patient knowledge and patient satisfaction with care: A pilot
study. Journal of Neuroscience Nursing, 42(6), 312-322.
doi:10.1097/JNN.0b013e3181f8a5e7
Cameron, V. (2013). Best practices for stroke patient and family education in the acute care
setting: A literature review. MEDSURG Nursing, 22(1), 51-55. Retrieved from
http://www.medsurgnursing.net/cgi-bin/WebObjects/MSNJournal.woa
WE LISTENED: IMPROVING STROKE EDUCATION 55
Carnegie, D., & Associates, Inc. (2011) How to win friends and influence people in the
digital age. New York, NY: Simon & Schuster.
Centers for Medicare & Medicaid Services. (2017) HCAHPS: Patient’s Perspective Survey.
Retrieved from: . https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.htmlon November
13, 2018.
Centers for Disease Control and Prevention. (2017) Stroke facts. Retrieved from
https://www.cdc.gov/stroke/facts.htm
Danzl, M. M., Harrison, A., Hunter, E. G., Kuperstein, J., Sylvia, V., Maddy, K., &
Campbell, S. (2016). “A lot of things passed me by”: Rural stroke survivors’ and
caregivers’ experience of receiving education from health care providers. Journal of
Rural Health, 32(1), 13-24. doi:10.1111/jrh.12124
Dearholt, S. L., & Dang, D. (2015). Johns Hopkins nursing evidence-based practice: Model
and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.
Dombrowski, S. U., Mackintosh, J. E., Sniehotta, F. F., Araujo-Soares, V., Rodgers, H.,
Thomson, R. G., … White, M. (2013). The impact of the UK ‘act FAST’ stroke
awareness campaign: Content analysis of patients, witness and primary care
clinicians’ perceptions. BMC Public Health, 13(1), 915. doi:10.1186/1471-2458-13-
915
Eames, S., Hoffman, T., Worrall, L., & Read, S. (2010). Stroke patients’ and carers’
perception of barriers to accessing stroke information. Topics in Stroke
Rehabilitation, 17(2), 69-78. doi:10.1310/tsr1702-69
Emanuel, E., & Emanuel L. (1992). Four models of the physician-patient relationship. JAMA.
267(16), 2221-2226. doi:10.1001/jama.1992.03480160079038
WE LISTENED: IMPROVING STROKE EDUCATION 56
Falkenberg, K. (2013, January 21). Why rating your doctor is bad for your health. Retrieved
from Forbes online https://www.forbes.com/sites/kaifalkenberg/2013/01/02/why-
rating-your-doctor-is-bad-for-your-health/#1ac3fb9b33c5
Fenton, J. J., Jerant, A. F., & Franks, P. (2014). Influence of elective versus emergent
hospital admission on patient satisfaction. Journal of the American Board of Family
Medicine, 27(2), 249-257. doi:10.3122/jabfm.2014.02.130177
Flesch, R. (1948). A new readability yardstick. Journal of Applied Psychology. 32(3), 221-
223. doi:10.1037/h0057532
Foss Durant, A., McDermott, S., Kinney, G., & Triner, T. (2015). Caring science:
Transforming the ethic of caring-healing practice, environment, and culture within an
integrated care delivery system. Permanente Journal, 19(4), e136-e142.
doi:10.7812/tpp/15-042
Ganzer, C. A., Insel, K. C., & Ritter, L. S. (2012). Associations between working memory,
health literacy, and recall of the signs of stroke among older adults. Journal of
Neuroscience Nursing, 44(5), 236-243. doi:10.1097/jnn.0b013e3182666231
Green, T., Haley, E., Eliasziw, M., & Hoyte, K. (2007). Education in stroke prevention:
Efficacy of an educational counselling intervention to increase knowledge in stroke
survivors. Canadian Journal of Neuroscience Nursing, 29(2), 13-20. Retrieved from
https://www.cann.ca/~ASSETS/DOCUMENT/ARTICLES/CJNN-29-2-2007-
green.pdf
Hickey, J. V., & Brosnan, C. A. (Eds.). (2017). Evaluation of health care quality for DNPs
(2nd ed.). New York, NY: Springer.
Hickey, J. V., & Livesay, S. L. (2016). The continuum of stroke care: An interprofessional
approach to evidenced-based care. Philadelphia, PA: Wolters Kluwer.
WE LISTENED: IMPROVING STROKE EDUCATION 57
Hoffmann, T., McKenna, K., Worrall, L., & Read, S. J. (2007). Randomized trial of a
computer-generated tailored written education package for patients following stroke.
Age & Ageing, 36(3), 280-286. doi:10.1093/ageing/afm003
Hsia, A. W., Castle, A., Wing, J. J., Edwards, D. F., Brown, N. C., Higgins, T. M., …
Kidwell, C. S. (2011). Understanding reasons for delay in seeking acute stroke care in
an underserved urban population. Stroke, 42(6), 1697-1701.
doi:10.1161/STROKEAHA.110.604736
Institute for Healthcare Improvement. (2016). WIHI: The new world of co-producing health
and health care. Retrieved from
http://www.ihi.org/resources/Pages/AudioandVideo/WIHI-The-New-World-of-
Coproducing-in-Health-and-Health-Care.aspx on February 1, 2018,
Integrated systems may have economic incentive for using alteplase in stroke patients.
(1998). American Journal of Health-System Pharmacy, 55(12), 1248. Retrieved from
http://www.ajhp.org/content/55/12/1248.2?sso-checked=true
Jauch, E. C., Saver, J. L., Adams, H. P., Jr, Bruno, A., Connors, J. J., Demaerschalk, B. M.,
… Yonas, H. (2013). Guidelines for the early management of patients with acute
ischemic stroke: A guideline for healthcare professionals from the American Heart
Association/American Stroke Association. Stroke, 44(3), 870-947.
doi:10.1161/STR.0b013e318284056a.
Joint Commission International. (2018a). Advanced disease-specific care comprehensive
stroke center standards manual. Specifications manual. Oakbrook Terrace, IL:
Author.
Joint Commission International. (2018b). Advanced disease-specific care primary stroke
center standards manual. Specifications manual. Oakbrook Terrace, IL: Author.
WE LISTENED: IMPROVING STROKE EDUCATION 58
Joint Commission International. (2018c). Specifications manual for joint commission
national quality measures (v2018B). Oakbrook Terrace, IL: Author.
Joshi, M. S., Ransom, E. R., Nash, D. B., & Ransom, S. B. (Eds.). (2014). The healthcare
quality book: Vision, strategy and tools. (3rd ed.). Chicago, IL: Health Administration
Press.
Kincaid, J. P., Fishburne Jr., R. P., Rogers, R. L., & Chissom, B. S. (1975). Derivation of new
readability formulas (automated readability index, fog count and Flesch reading ease
formula) for Navy enlisted personnel (Research Branch Report 8-75). Retrieved from
http://www.dtic.mil/dtic/tr/fulltext/u2/a006655.pdf
Kitson, A. L., & Harvey, G. (2016). Methods to succeed in effective knowledge translation in
clinical practice. Journal of Nursing Scholarship, 48(3), 294-302.
doi:10.1111/jnu.12206
Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence
based practice: A conceptual framework. Quality in Health Care, 7(3), 149-158.
doi:10.1136/qshc.7.3.149
Livesay, S. (Ed.). (2014). Comprehensive review for stroke nursing. Chicago, IL: American
Association of Neuroscience Nurses.
Martinelli, R. J., & Milosevic, D. Z. (2016) Project management toolbox (2nd ed.), Hoboken,
NJ: John Wiley & Sons.
Meighan, M. M. (2018). Stroke education video does not affect patient satisfaction scores: A
system analysis. Journal of Neuroscience Nursing, 50(4), 233-237.
doi:10.1097/JNN.0000000000000383
Mellon, L., Doyle, F., Williams, D., Brewer, L., Hall, P., & Hickey, A. (2016). Patient
behaviour at the time of stroke onset: A cross-sectional survey of patient response to
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stroke symptoms. Emergency Medicine Journal, 33(6), 396-402.
doi:10.1136/emermed-2015-204806
Mellon, L., Hickey, A., Doyle, F., Dolan, E., & Williams, D. (2014). Can a media campaign
change health service use in a population with stroke symptoms? examination of the
first Irish stroke awareness campaign. Emergency Medicine Journal, 31(7), 536-540.
doi:10.1136/emermed-2012-202280
Melnyk, B. M., Gallagher-Ford, L., & Fineout-Overholt, E. (2016). Implementing the
evidence-based practice (EBP) competencies in healthcare: A practical guide for
improving quality, safety, and outcomes. Indianapolis, IN: Sigma Theta Tau.
Nguyen-Huynh, M. N., Klingman, J. G., Avins, A. L., Rao, V. A., Eaton, A., Bhopale, S., …
& Flint, A. C. (2018). Novel telestroke program improves thrombolysis for acute
stroke across 21 hospitals of an integrated healthcare system. Stroke, 49(1), 133-139.
doi:10.1161/strokeaha.117.018413
Omelchenko, N., Saban, K. L., Andresen, P., Klopp, A., & Lau, J. (2018). Empowered to
serve: Implementing community stroke outreach using peer educators to improve
readiness to act among local community members. Journal of Neuroscience Nursing
50(2), 111-115. doi:10.1097/jnn.0000000000000344
Patterson, K., Grenny J., Maxfield, D., McMillan, R., & Switzler, A. (2008). Influencer.
McGraw-Hill: New York
Peplau, H. (1992). Interpersonal relations: A theoretical framework for application in nursing
practice. Nursing Science Quarterly, 5(1), 13-18. doi:10.1177/089431849200500106
Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker,
K., … Tirschwell, D. L. (2018). 2018 guidelines for the early management of patients
with acute ischemic stroke: A guideline for healthcare professionals from the
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American Heart Association/American Stroke Association. Stroke, 49(3), e110.
doi:10.1161/STR.0000000000000158
Ross, S. Y., Roberts, S., Taggart, H., & Patronas, C. (2017). Stroke transitions of care.
MedSurg Nursing, 26(2), 119-123. Retrieved from http://www.medsurgnursing.net
Skolarus, L. E., Murphy, J. B., Zimmerman, M. A., Bailey, S., Fowlkes, S., Brown, D. L., …
Morgenstern, L. B. (2013). Individual and community determinants of calling 911 for
stroke among African Americans in an urban community. Circulation:
Cardiovascular Quality and Outcomes, 6(3), 278-283.
doi:10.1161/circoutcomes.111.000017
Skolarus, L. E., Zimmerman, M. A., Bailey, S., Dome, M., Murphy, J. B., Kobrossi, C., …
Morgenstern, L. B. (2016). Stroke ready intervention: Community engagement to
decrease prehospital delay. Journal of the American Heart Association, 5(5).
doi:10.1161/JAHA.116.003331 doi:10.15171/hpp.2015.005
Smith, J., Foster, A., & Young, J. (2009). Cochrane review: Information provision for stroke
patients and their caregivers. Clinical Rehabilitation, 23(3), 195-206.
doi:10.1177/0269215508092820
Stetler, C. B., Damschroder, L. J., Helfrich, C. D., & Hagedorn, H. J. (2011). A guide for
applying a revised version of the PARIHS framework for implementation.
Implementation Science, 6(1), 99. doi:10.1186/1748-5908-6-99
Sylvia, M. L., & Terhaar, M. F. (2014), Clinical analytics and data management for the
DNP. New York, NY: Springer.
Tucker, A. L., & Singer, S. J. (2012). The effectiveness of management-by-walking-around: A
randomized field study (Working Paper 12-113). Retrieved from
http://www.hbs.edu/faculty/Publication%20Files/12-113_9a2bc5e8-2f70-4288-bb88-
aeb2de49e955.pdf on May 23, 2018
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Voutilainen, A. (2016). Meta-analysis: Complex relationships between patient satisfaction,
age and item-level response rate. Journal of Research in Nursing, 21(8), 611-620.
doi:10.1177/1744987116655595
Watson, J. (2008). Nursing. The philosophy and science of caring (Rev. ed.). Boulder, CO:
University Press of Colorado.
Waxman, K. T. (Ed.). (2018). Financial and business management for the doctor of nursing
practice (2nd ed.). New York, NY: Springer.
Yeh, M., Wu, S., & Tung, T. (2018). The relation between patient education, patient
empowerment and patient satisfaction: A cross-sectional-comparison study. Applied
Nursing Research, 39, 11-17. doi:10.1016/j.apnr.2017.10.008
Yu-Feng, Y. C., Richardson, L. D., Nagurka, R., Hao, K., Zaets, S. B., Brimacombe, M. B.,
& Levine, S. R. (2015). Stroke education in an emergency department waiting room:
A comparison of methods. Health Promotion Perspectives, 5(1), 34-41.
doi:10.15171/hpp.2015.005
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Section VIII. Appendices
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Appendix A
Map of Kaiser Facilities
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Appendix B
Stroke Discharge Volume per Facility
0
200
400
600
800
1000
1200
A B C D E F G H I J K L M N O P Q R S T U
Emergency Inpatient Observation
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Appendix C
ICD-10-CM Codes Related to Stroke
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ICD-10 Discharge Codes Related to Stroke
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Appendix D
Stroke Education and Patient Perception Evaluation Table
Reference Conceptual
Framework
Design/
Method
Sample/
Setting
Variables
Studied and
Their Definitions
Measurement Data Analysis Findings Appraisal:
Worth to
Practice
Yu-Feng et
al. (2015)
None Randomized
control trial
N = 231
Emergency
room
Video brochure,
printed material,
one-on-one
teaching,
combination of
three methods
13 multiple
choice
questionnaires
prior to education,
immediately after
education, and
one month post-
education
Linear models to
conduct pairwise
comparisons, P
value was
corrected using
Bonferroni
methods
All groups
showed
improvement in
stroke knowledge;
however, the
combination
group showed the
highest level of
knowledge.
Level IA
Green et al.
(2007)
Transtheoretical
Stages of
Change Model
Randomized
control trial
N = 200 One-on-one
motivational
interviewing
Baseline
knowledge
questionnaire
post-clinic visit
and three-month
questionnaire
Two group t-test
and a paired t-test
The group who
received one-on-
one teaching did
show
improvement in
retention of stroke
knowledge.
Level IB
Due to stroke
questionnaire not
validated and
limitations not
addressed in
conclusion.
Byers et al.
(2010)
None Randomized
trial
N = 20 Motivational
interviewing
Stroke knowledge
test and patient
satisfaction test
Descriptive
statistics
A positive
relationship
between
motivational
interviewing
techniques, stroke
knowledge, and
patient
satisfaction.
Level 1C
Due to lack of
validation of
stroke knowledge
test and patient
satisfaction test.
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Reference Conceptual
Framework
Design/
Method
Sample/
Setting
Variables
Studied and
Their Definitions
Measurement Data Analysis Findings Appraisal:
Worth to
Practice
Hoffman et
al. (2007)
None Randomized
trial
N = 113 Usual educational
methods and
computer-
generated
educational
package
Standardized
stroke knowledge
scales
Data analyzed
using an
independent
sample t-test and
a Fischer’s exact
test
There was no
effect of the
computer-
generated tailored
information on
knowledge about
stroke, self-
efficacy,
depression, or
perceived health
status; however,
the patients were
more satisfied
with the
information they
received than
with the standard
method.
Level IB
Scales not
validated;
however, results
reflect system
analysis by
Meighan.
Smith et al.
(2009)
None Systematic
review
11 Trials Active or passive
interventions
Forest plots Active strategies
were associated
with positive
patient outcomes.
Level 1A
Danzl et al.
(2016)
None Qualitative N = 13 N/A
Qualitative coding
technique using
pre-existing
codes, then
derived codes
with
modifications
Research dyads
analyzed the data,
with final analysis
by the interviewer
Central themes of
delivery, timing,
and method were
critical for
perception of
adequacy.
Level IIIA
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Reference Conceptual
Framework
Design/
Method
Sample/
Setting
Variables
Studied and
Their Definitions
Measurement Data Analysis Findings Appraisal:
Worth to
Practice
Eames et al.
(2010)
None Qualitative 132 patients
and
caregivers
initially
screened,
initial
interviews
with 34
stroke
patients and
18
caregivers,
follow-up
interviews
with 27
patients and
16
caregivers
N/A Interviews
transcribed using
qualitative content
analysis
Condensed
meaning units,
codes, and themes
Limited
information,
hospital
environment,
patient, and
caregiver factors.
Level IIIA
Table adapted from Dearholt, S. L. and Dang, D. (2012). Johns Hopkins nursing evidence-based practice: Model and guidelines. Indianapolis, IN: Sigma Theta Tau
International.
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Appendix E
Evaluation Table
Table adapted from Melnyk, B. M., Gallagher-Ford, L., & Fineout-Overholt, E. (2016). Implementing the evidence-based practice (EBP) competencies in healthcare: A
practical guide for improving quality, safety, and outcomes. Indianapolis, IN: Sigma Theta Tau.
Yu-Feng et al.
(2015)
Green et al.
(2007)
Smith et al.
(2009)
Danzl et al.
(2016)
Eames et al.
(2010)
Byers et al.
(2010)
Hoffman et al.
(2007)
Intervention
Brochure/printed material x
Video/computer x x
One-on-one counseling x
x
Combination x
One-on-one counseling
x
Active intervention
x
x
Passive intervention x
Outcome
Increased patient stroke knowledge x x x x x
Themes identified for stroke survivor experience x x
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Appendix F
Learning Needs Assessment
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Appendix G
Caring Science Applied to Stroke Education
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Appendix H
Stroke Education Documentation Compliance
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Appendix I
Joint Commission Standard Addressing Patient Education
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Appendix J
Joint Commission Standard Addressing Patient Satisfaction
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Appendix K
Gap Analysis
As of January 2017
Strategic Objective Current Standing Deficiency Action Plan
Revise online education
Not started Resources needed from Regional Health
Education
Contact Executive Leader for support
Revise booklet Not started Resources needed from Regional Health
Education
Contact Executive Leader for support
Print version of booklet Not started To be done when booklet is done
Start draft by November 1
Module for nursing staff
Not started To be started by November 1
Consult with Neuroscience Clinical Nurse Specialist at
Redwood City
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Appendix L
Sample Stroke Education Agenda
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Appendix M
Work Breakdown Structure
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Appendix N
SWOT Analysis
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Appendix O
Project Responsibility and Communication Plan
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Appendix P
GANTT Chart – Initial
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Appendix Q
GANTT Chart – Final
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Appendix R
Budget
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Appendix S
Program Costs
Costs
2018 2019 2020 2021 2022 Five Year Total
Capital Expense
Nurse Training 88,600 88,600
Translation of Flyer into Spanish,
Chinese, Tagalog and Vietnamese 600
600
Regional Health Consultant 300 300
Regional Work Group 5 members 10,000 10,000
Capital Expense Sub Total 99,500
Operating Expenses
New RN Training *($100 x 60/year) 6,000 6,000 6,000 6,000 6,000
Flyer Printing ($50/year x 6 medical
centers) 300 300 300 300 300 1,500
Regional Stroke Coordinator 10,000 10,000 10,000 10,000 10,000 50,000
Operating Expense Sub Total 10,300 10,300
Total Program Costs 109,800 16,300 16,300 16,300 16,300 175,000 Notes.
Patient Education Return on Investment (ROI)
For subsequent training assumes 10 nurses hired per year in the stroke unts x 6 medical centers x $100/hour for an hour of
training.
Program Costs
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Appendix T
Return on Investment
2018 2019 2020 2021 2022 Five Year Total
Regulatory Compliance* 60,000 60,000 60,000 60,000 60,000 300,000
2018 2019 2020 2021 2022 Five Year Total
Program Costs 109,800 16,300 16,300 16,300 16,300 175,000
Cost Benefit** 250,000 250,000 250,000 250,000 1,000,000
Cost Avoidance 60,000 60,000 60,000 60,000 60,000 300,000
Return on Investment (ROI) (49,800) 293,700 293,700 293,700 293,700 1,125,000 Notes.
**Assuming an increase of 10/patients per year receiving treatment as a result of calling 911 and presenting to the hospital in
time.
Patient Education Return on Investment (ROI)
*Regulatory compliance costs assumes the cost of an action plan at $10,000 for the development of the action plan by the stroke
Program Cost Avoidance
Program Cost Avoidance Calculation
Regulatory compliance costs assumes the cost of one action plan at $10,000 for the development of the action plan by the stroke
coordinators, leadership approval, response to Joint Commission and any needed training. The action plan would be in response to
the program failing to use patient satisfaction data to improve care.
Cost Benefit - Cost Avoidance - ROI
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Appendix U
Email from Stroke Survivor Advocate
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Appendix V
Staff Survey
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Appendix W
Staff Survey Response Summary
Of Barriers Perceived By Staff
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Appendix X
Stroke Flyer Placement in Stroke Portal
(Screen Shot of an Internal Extranet Site)
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Appendix Y
Stroke Flyer Grade Level and Reading Ease Scores
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Appendix Z
Survey for Community Input on Flyer
“Stroke: What You Need to Know” - TELL US WHAT YOU THINK!
Please circle your answer and provide comments after each response.
1) When I first saw this tip sheet, I was interested in reading it:
YES NO
Why or why not?
2) I learned new information from this tip sheet:
YES NO If YES, what did you learn that was new to you?
3) This tip sheet clearly explains what a stroke is:
YES NO
If NO, what would make this information more clear?
4) This tip sheet clearly explains signs of stroke:
YES NO If NO, what would make this information more clear?
5) This tip sheet clearly explains when I should call 911:
YES NO If NO, what would make this information more clear?
6) This tip sheet clearly explains how to prevent stroke:
YES NO
If NO, what would make this information more clear?
What do you LIKE about this tip sheet?
7) What do you NOT LIKE about this tip sheet?
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Appendix AA
Community Survey Script
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Appendix BB
Translation Request
Translation Services
Translation Request Form
The purpose of this document is to scope the translation requirements for a project prior to starting any
translation work. Please complete all requested fields below and submit this form to one of the preferred
translation vendors or to [email protected], with appropriate English documents. For
additional guidance on completing this form, please contact the Translation Project Manager at tie line
510-987-3422.
Fields marked with asterisks are mandatory. Document Name/File Name can be a zip file name if
files are batched together in a single zip
Contact Information: Please provide basic information on requesting department and a content expert
who may be contacted for questions about the project.
*Date of Request: *Department:
*Name of Requester (as listed in Lotus Notes): *Requester Phone: ( )- -
Subject Matter Expert (if different from Requester): Subject Matter Expert Phone: ( )-
-
Department Cost Center (entity-location-cost center format): - -
Region: NCAL SCAL Other
Translation Request Information: Please list all documents for which translation is being requested.
*Document Name/
File Name and
Format/zip file name
Word
Count
(if known)
Source
Language
*Target
Language(s)
and Variant/
Dialect(s)
Subject
Matter/
Topic
*Final
published
format (native
format
documents or
PDF)
Desired
Due Date
Example: 2007
Summer Member
Newsletter, MS Word 1,000 US English
Spanish
Chinese
Member
Outreach MS Word
3/13/07
Reading level of source documents (if known):
*Delivery Options (please select one):
E-mail E-mail address:
Fax Fax number: ( ) -
Mail Mailing address:
Repository Please specify:
Other Please specify:
Additional Services Needed:
Desktop Publishing
Cultural/Linguistic Review
Certificate of Accurate Translation
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Previously Translated Content:
Yes, my department has translated content similar to this request. The translation was performed
by:
Avantpage Transcend Other - please specify:
Agnew Multilingual Global Language Solutions
No, my department has never requested translation of this content.
Authorization Information: By signing below you acknowledge that you have the authority to sign
for the Cost Center provided above.
Signature: Print Name:
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Appendix CC
Stroke Flyer English
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Appendix DD
Stroke Flyer Spanish
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Appendix EE
Stroke Flyer Chinese
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Appendix FF
Stroke Flyer Vietnamese
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Appendix GG
Stroke Flyer Tagalog
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Appendix HH
Stroke Module Title Page
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Appendix II
Health Stream Educational Platform
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Appendix JJ
Excerpt from Stroke Novel Approaches to Teaching Stroke Patients
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Appendix KK
Stroke Module Post Test
(Answers in Yellow)
1. Stroke mortality rates continue to decrease steadily due to decreases in rates of diabetes
and obesity in younger patient populations.
a. True
b. False
2. Select all correct answers about the stroke survivor patient experience.
a. Stroke is an overwhelming experience.
b. Patients worry about going home.
c. Patients are hungry for information on complex neuroanatomy.
d. Patients are not ready for stroke education immediately after a stroke.
3. The required elements of Joint Commission stroke education are:
a. Stroke signs and symptoms, importance of calling 911, and risk factor management.
b. Activation of emergency medical system, need for follow-up after discharge,
medications prescribed at discharge, risk factors for stroke, and warning signs and
symptoms of stroke.
c. Disease process, activation of emergency medical system, need for follow-up after
discharge, medications prescribed at discharge, risk factors for stroke, and warning signs
and symptoms of stroke.
d. Joint Commission does not have required elements, but the patient and families should
be taught according to their specific disease process and needs.
4. The stroke flyer will completely replace the stroke booklet.
a. True.
b. False.
5. Select all items that are true when applying adult learning principles to stroke education.
a. Teach back – have the patient and family repeat the signs and symptoms of a stroke.
b. Use the adult learner’s experience, i.e. the signs and symptoms the patient came in with.
c. Provision of printed material, no further explanations are required.
d. Assessment of the student, patient and family is key.
6. Techniques for teaching patients with frontal injuries that may result in cognitive or
memory challenges include (select all that apply):
a. Recruit family members for teaching.
b. Turn off the TV or close curtains to remove distraction.
c. Speak slowly using repetition and stay calm.
d. Speak loudly as people with cognitive defects may also be hard of hearing.
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7. Patients with neglect should always be approached from their neglected side first to
stimulate that part of the brain.
a. True
b. False
8. Patients with left sided brain injury have deficits in:
a. Speech and reading.
b. Speech, cognition and intelligence.
9. Other novel ways of approaching stroke patients include (select):
a. Asking patients to draw the material they are thinking about.
b. Talking with the family instead of the patient.
c. Asking the patients to read the material out loud.
d. Rhyming or singing the material to help retain.
10. Caring Science principles of assessment, diagnosis, planning, implementation and
evaluation have direct application to stroke education.
a. True
b. False
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Appendix LL
Nurse Practice Alert
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Appendix MM
Just the Facts on Stroke Education
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Appendix NN
Data Management Variables
Variable Brief Description Data Source Possible Range
of Values
Level of
Measurement
Timeframe for
Collection
Statistical
Test
HCAHPS
score
Explained stroke
signs/symptoms - patient
response is yes/no and then
transformed into a percent
HCAHPS 0% - 100% Continuous 3 months before and 3
months after
intervention
Chi2
Explained stroke diagnosis -
patient response is yes/no and
then transformed into a
percent
HCAHPS 0% - 100% Continuous 3 months before and 3
months after
intervention
Chi2
Explained stroke
risk/prevention - patient
response is yes/no and then
transformed into a percent
HCAHPS 0% - 100% Continuous 3 months before and 3
months after
intervention
Chi2
EMS/walk-
in
Percent who present via EMS
versus private care
MIDAS stroke
alert database
0% - 100% Continuous 3 months before and 3
months after
intervention
Chi2
Stroke alerts
cancelled
due to LKW
changed
Percent of stroke alerts
cancelled immediately at
triage due to last known well
time changed and out of
window
MIDAS stroke
alert database
0% - 100% Continuous 3 months before and 3
months after
intervention
Chi2
Alteplase
not given
due to out
of time
window
Percent of patients not treated
due to being out of time
window over all cancellations
MIDAS stroke
alert database
0% - 100% Continuous 3 months before and 3
months after
intervention
Chi2
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Appendix OO
Pre-Intervention Stroke HCAHPS Data
De-identified
Medical
Center Question
Num
(Y) Denom (n)
Hospital A N16.1 41046 STK Staff explained stroke diagnosis _N 3 4
_Score 75.00%
Hospital B N16.1 41046 STK Staff explained stroke diagnosis _N 4 10
_Score 40.00%
Hospital C N16.1 41046 STK Staff explained stroke diagnosis _N 4 10
_Score 40.00%
Hospital D N16.1 41046 STK Staff explained stroke diagnosis _N 3 6
_Score 50.00%
Hospital E N16.1 41046 STK Staff explained stroke diagnosis _N 6 10
_Score 60.00%
Hospital F N16.1 41046 STK Staff explained stroke diagnosis _N 1 1
_Score 100.00%
Composite 21 41
51.22%
Hospital A N16.2 41047 STK Staff explained stroke risk/prevention _N 2 5
_Score 40.00%
Hospital B N16.2 41047 STK Staff explained stroke risk/prevention _N 7 11
_Score 63.60%
Hospital C N16.2 41047 STK Staff explained stroke risk/prevention _N 5 10
_Score 50.00%
Hospital D N16.2 41047 STK Staff explained stroke risk/prevention _N 4 6
_Score 66.70%
Hospital E N16.2 41047 STK Staff explained stroke risk/prevention _N 5 10
_Score 50.00%
Hospital F N16.2 41047 STK Staff explained stroke risk/prevention _N 0 0
_Score
Composite 23 42
54.76%
Hospital A N16.3 41048 STK Staff explained stroke signs/symptoms _N 2 4
_Score 50.00%
Hospital B N16.3 41048 STK Staff explained stroke signs/symptoms _N 5 10
_Score 50.00%
Hospital C N16.3 41048 STK Staff explained stroke signs/symptoms _N 4 10
_Score 40.00%
Hospital D N16.3 41048 STK Staff explained stroke signs/symptoms _N 3 6
_Score 50.00%
Hospital E N16.3 41048 STK Staff explained stroke signs/symptoms _N 5 10
_Score 50.00%
Hospital F N16.3 41048 STK Staff explained stroke signs/symptoms _N
_Score
Composite 19 36
52.78%
HCAHPs Stroke Related Questions (Q2 2018)
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Appendix PP
Post-Intervention Stroke HCAHPS Data
De-identified
Medical
Center Question Num (Y) Denom (n)
Hospital A N16.1 41046 STK Staff explained stroke diagnosis _N 0 3
_Score 0.00%
Hospital B N16.1 41046 STK Staff explained stroke diagnosis _N 18 25
_Score 72.00%
Hospital C N16.1 41046 STK Staff explained stroke diagnosis _N 4 7
_Score 57.00%
Hospital D N16.1 41046 STK Staff explained stroke diagnosis _N 3 3
_Score 50.00%
Hospital E N16.1 41046 STK Staff explained stroke diagnosis _N 4 9
_Score 60.00%
Hospital F N16.1 41046 STK Staff explained stroke diagnosis _N 3 3
_Score 100.00%
Composite 32 50
64.00%
Hospital A N16.2 41047 STK Staff explained stroke risk/prevention _N 0 3
_Score 0.00%
Hospital B N16.2 41047 STK Staff explained stroke risk/prevention _N 12 25
_Score 48.00%
Hospital C N16.2 41047 STK Staff explained stroke risk/prevention _N 5 7
_Score 71.00%
Hospital D N16.2 41047 STK Staff explained stroke risk/prevention _N 1 3
_Score 33.30%
Hospital E N16.2 41047 STK Staff explained stroke risk/prevention _N 4 8
_Score 50.00%
Hospital F N16.2 41047 STK Staff explained stroke risk/prevention _N 2 3
_Score 100.00%
Composite 24 54
44.44%
Hospital A N16.3 41048 STK Staff explained stroke signs/symptoms _N 0 3
_Score 0.00%
Hospital B N16.3 41048 STK Staff explained stroke signs/symptoms _N 13 25
_Score 50.00%
Hospital C N16.3 41048 STK Staff explained stroke signs/symptoms _N 3 7
_Score 42.00%
Hospital D N16.3 41048 STK Staff explained stroke signs/symptoms _N 3 6
_Score 50.00%
Hospital E N16.3 41048 STK Staff explained stroke signs/symptoms _N 3 9
_Score 50.00%
Hospital F N16.3 41048 STK Staff explained stroke signs/symptoms _N 3 3
_Score 100.00%
Composite 25 53
47.17%
HCAHPs Stroke Related Questions (July 2018)
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Appendix QQ
Initial Presentation Mode with Suspected Stroke Symptoms
Hosp A Hosp B Hosp C
(n) Percent (n) Percent (n) Percent
ED Ambulance 31 59.62% 68 76.40% 33 66.00%
ED Stroke Onset in ED 3 5.77% 2 2.25% 0 0.00%
ED Walk In 15 28.85% 18 20.22% 15 30.00%
Inpatient 3 5.77% 1 1.12% 2 4.00%
Total 52 89 50
Hosp D Hosp E Hosp F
(n) Percent (n) Percent (n) Percent
ED Ambulance 44 55.70% 17 51.52% 20 60.61%
ED Stroke Onset in ED 2 2.53% 2 6.06% 1 3.03%
ED Walk In 19 24.05% 12 36.36% 12 36.36%
Inpatient 14 17.72% 2 6.06% 0 0.00%
Total 79 33 33
Aggregate
(n) Percent
ED Ambulance 213 63.39%
ED Stroke Onset in ED 10 2.98%
ED Walk In 91 27.08%
Inpatient 22 6.55%
Total 336
Mode of Stroke Alert Initial Presentation 1.1.18 to 7.31.18
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Hosp A Hosp B Hosp C
(n) Percent (n) Percent (n) Percent
ED Ambulance 12 64.00% 14 70.00% 6 27.27%
ED Stroke Onset in ED 0 0.00% 0 0.00% 0 0.00%
ED Walk In 4 25.00% 6 30.00% 15 68.18%
Inpatient 0 0.00% 0 0.00% 1 4.55%
Total 16 20 22
Hosp D Hosp E Hosp F
(n) Percent (n) Percent (n) Percent
ED Ambulance 16 42.11% 6 66.67% 8 72.73%
ED Stroke Onset in ED 0 0.00% 0 0.00% 0 0.00%
ED Walk In 17 44.74% 3 33.33% 3 27.27%
Inpatient 5 13.16% 0 0.00% 0 0.00%
Total 38 9 11
Aggregate
(n) Percent
ED Ambulance 62 72.94%
ED Stroke Onset in ED 0 0.00%
ED Walk In 17 20.00%
Inpatient 6 7.06%
Total 85
Mode of Stroke Alert Initial Presentation 7.1.18 to 7.31.18
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Hosp A Hosp B Hosp C
(n) Percent (n) Percent (n) Percent
ED Ambulance 13 72.22% 16 72.73% 11 31.43%
ED Stroke Onset in ED 0 0.00% 0 0.00% 1 2.86%
ED Walk In 4 22.22% 6 27.27% 15 42.86%
Inpatient 1 5.56% 0 0.00% 8 22.86%
Total 18 22 35
Hosp D Hosp E Hosp F
(n) Percent (n) Percent (n) Percent
ED Ambulance 19 48.72% 3 33.33% 20 60.61%
ED Stroke Onset in ED 1 2.56% 0 0.00% 1 3.03%
ED Walk In 14 35.90% 6 66.67% 12 36.36%
Inpatient 5 12.82% 0 0.00% 0 0.00%
Total 39 9 33
Aggregate
(n) Percent
ED Ambulance 82 52.56%
ED Stroke Onset in ED 3 1.92%
ED Walk In 57 36.54%
Inpatient 14 8.97%
Total 156
Mode of Stroke Alert Initial Presentation 8.1.18 to 8.31.18
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Appendix RR
Stroke Alerts Initially Cancelled
Stroke Alert Not Cancelled and Alteplase not Given Due to Time Window
Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F Total
Not given due to time window 4 20 3 6 7 3 43
Total Not Given 19 54 23 47 26 15 184
% Not given due to out of time window 21.05% 37.04% 13.04% 12.77% 26.92% 20.00% 23.37%
Total Treated 34 27 25 38 7 17 148
Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F Total
Not given due to time window 1 3 0 0 0 1 5
Total Not Given 4 9 2 7 0 1 23
% Not given due to out of time window 25.00% 33.33% 0.00% 0.00% #DIV/0! 100.00% 21.74%
Total Treated 6 27 0 6 0 1 40
Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F Total
Not given due to time window 0 6 2 2 0 0 10
Total Not Given 1 10 6 7 0 2 26
% Not given due to out of time window 0.00% 60.00% 33.33% 28.57% #DIV/0! 0.00% 38.46%
Total Treated 5 2 7 5 0 0 19
Stroke Alerts not Cancelled, Alteplase Not Given Due to Out of Time Window 1.1.18 to 7.31.18
Stroke Alerts not Cancelled, Alteplase Not Given Due to Out of Time Window 7.1.18 to 7.31.18
Stroke Alerts not Cancelled, Alteplase Not Given Due to Out of Time Window 8.1.18 to 8.31.18
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Appendix SS
Signed Statement of Non-Research Determination Form
Student Name: Melissa M. Meighan, MS, RN, CNRN
Title of Project:
Empowerment of Nurses and Stroke Survivors
Brief Description of Project:
Stroke survivors are hungry for knowledge (Danzl et al., 2016). This knowledge is critical for risk factor
management and understanding appropriate actions to take if a second stroke is experienced. However, stroke
survivors and caregivers are often discharged home without feeling adequately educated on the disease process
(Livesay, 2014). According to patients, acute care providers do not explain important elements of stroke
education (Danzl et al., 2016).
Currently only 40% of Kaiser’s Northern California stroke patient population is reporting adequate education in
disease process, when to call 911 and risk factor management in their HCAHPS responses. This is in spite of an
apparent compliance rate of 90-100% of stroke education documentation that is required by Joint Commission
for primary and comprehensive stroke center certification.
A) Aim Statement:
By August 1, 2018, Kaiser Regional efforst will improve, expand and provide additional infrastructure for the
current stroke education program.
B) Description of Intervention:
Based on the evidence, multi-modal education which actively involves the patient and caregiver is most
likely to have an impact on their perception of adequate education.(Danzel, M.M., et al., 2016; Eames
Eames, S., Hoffman, T., Worrall, L., & Read, S. ,2010; Green, T., Haley, E., Eliasziw, M., & Hoyte, K.,
2007; and Yu-Feng et al, 2015). Active involvement does require engagement of the health care provider in
assessment of the patient’s emotional status at the time (Danzel, M.M., et al, 2016). The patient and caregiver
may be overwhelmed by the traumatic event of a stroke which has fundamentally changed their life (Danzl et
al, 2016 and Livesay, 2014) and yet the knowledge is crucial. Assessment, engagement and repetition of
information are all elements to be addressed in the provision of stroke education to ensure positive
perception, and then subsequent appropriate actions. The stroke survivor suffering from a second stroke who
activates the EMS system in time may save years of disability or a life.
Development of a comprehensive educational program module for the nursing staff for Kaiser Northern
California Region assist in improving, expanding and providing the necessary infrastructure. The program
will utilize evidence-based practice, the expertise of facility stroke coordinators, input from front line staff
and stroke survivors. A stroke booklet which is given to all stroke survivors in Kaiser Northern California
will be revised based on new evidence and stroke survivor input. Online educational material which is
available for staff to print out when the booklets are not in stock will be reviewed and revised. Assessment of
available video kiosks and promotion of obtaining educational kiosks will be part of the project.
C) How will this intervention change practice?
By developing a comprehensive educational program there will be the potential increase in the ability of staff
nurses in adequately assessing the patient’s readiness for education and provide focused evidence-based
education which also incorporates input from stroke survivors.
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D) Outcome measurements:
• Increase the knowledge of proper stroke education of front line staff by 10% from baseline.
• Increase patient’s perception of adequate stroke education received while in the facility from the current baseline of 40% to at least 60% for Kaiser Northern California Region
References
Danzl, M. M., Harrison, A., Hunter, E. G., Kuperstein, J., Sylvia, V., Maddy, K., & Campbell, S. (2016). "A lot
of things passed me by": Rural stroke survivors' and caregivers' experience of receiving education from
health care providers. Journal of Rural Health, 32(1), 13-24. doi:10.1111/jrh.12124
Eames, S., Hoffman, T., Worrall, L., & Read, S. (2010). Stroke patients’ and carers’ perception of barriers to
accessing stroke information. Topics in Stroke Rehabilitation, 17(2), 69-78. doi:10.1013/tsr1702-69.
Green, T., Haley, E., Eliasziw, M., & Hoyte, K. (2007). Education in stroke prevention: Efficacy of an
educational counselling intervention to increase knowledge in stroke survivors. Canadian Journal of
Neuroscience Nursing, 29(2), 13-20.
Livesay, S. (Ed.). (2014). Comprehensive review for stroke nursing. Chicago: American Association of
Neuroscience Nurses.
Yu-Feng, Y. C., Richardson, L. D., Nagurka, R., Hao, K., Zaets, S. B., Brimacombe, M. B., & Levine, S. R.
(2015). Stroke education in an emergency department waiting room: A comparison of methods. Health
Promotion Perspectives, 5(1), 34-41. doi:10.15171/hpp.2015.005
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Appendix TT
Letter of Support from the Organization
To Whom It May Concern.
This letter is to state executive leadership support of the Northern California Regional Stroke
Education Improvement Project.
The goal of the project is to increase the percentage by 10% the number of yes responses by
patients over 18 discharged with a stroke diagnosis to Hospital Consumer Assessment of
Healthcare Providers and Systems stroke related questions and one balancing question. The
specific stroke questions are:
• N16.1 41046 STK Staff explained stroke diagnosis(Yes, definitely)
• N16.2 41047 STK Staff explained stroke risk/prevention(Yes, definitely)
• N16.3 41048 STK Staff explained stroke signs/symptoms(Yes, definitely)
The balancing question is:
• H09.2 Received info re: symptoms to look for: Yes
The proposed plan is to:
• Revise a current regional stroke booklet based on voice of the customer input and
expert consultation.
• From the printed booklet design a web based easily printable version.
• Revise the currently available on-line education material.
• An on-line education module on how to educate the stroke patients will be
designed. The voice of the customer will be incorporated into the design.
• The health stream module will be completed by the nurses working on the stroke
units in the twenty one medical centers.
• A survey of the front line staff has been completed before the survey and one will
be conducted after the survey.
• Estimated kick off date is by the end of January 2018.
Funding for the nursing education hours has been approved by regional nursing leadership.
This project is in alignment with the organizational priorities to increase patient satisfaction.
Improvement of stroke education is also in alignment with the Center for Disease Control’s
call to action on improvement of public awareness of stroke symptoms as the rate of stroke
mortality decrease has slowed and is increasing for subsets of the population.
Thank you for your time.
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From: Anne M. Goldfisher To: Melissa M Meighan Subject: RE: Letter of Support for Patient Education Project Date:
Tuesday, November 07, 2017 9:38:22 AM
I approve
Anne M.Goldfisher, RN,MA, CPHQ, CENP
Executive Director, Quality & Regulatory Services NCAL
Kaiser Foundation Hospital and Health Plan
1950 Franklin St 14th Floor
Oakland, CA 94612
Email: [email protected]
Office Phone: 510-987-3702 ( Tieline 8-427-3702) Executive Assistant: Loranth Otvos
Office Phone: 510-987-4156 ( Tieline 8-427-4156)
Email: [email protected]
From: Melissa M Meighan
Sent: Tuesday, November 07, 2017 9:37 AM
To: Anne M. Goldfisher <[email protected]>
Subject: Letter of Support for Patient Education Project
Hi Anne, Attached please find a leadership letter of support for the patient stroke education
improvement project for your review. Feel free to edit. It can be returned to myself via email and I will PDF the response for documentation. Thank you again. Melissa M. Meighan, MS, RN, CNRN
Regional Stroke Coordinator/Clinical Practice Consultant Regional Quality, Accreditation, Regulation & Licensing Department
1950 Franklin Street, Oakland, CA. 94612
Kaiser Foundation Hospitals
Office: (510) 510-987-3433/Tie Line: 8-427
Fax: (510) 987-3548
Cell: (510) 301-5177
E-mail: [email protected]
- The University of San Francisco
- USF Scholarship: a digital repository @ Gleeson Library | Geschke Center
- Fall 12-4-2018
- They Responded, We Listened: Improving Stroke Education and Patient Satisfaction
- Melissa Meighan
- Recommended Citation
- C422885258912037I0T422885293402778
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