Doctor of Nursing Practice , Case Western Reserve University, 2024, School of Nursing

Among hospitals, the number of chief executive officers (CEO) who are nurses is small. For example, only two of the 400 major academic medical centers-health care systems are led by nurses (Bean et al., 2022). Even fewer hospital and health system CEOs are advanced practice registered nurses (APRNs). The CEO is the highest ranking executive leader in an organization, in this case, a hospital. APRNs have grown from less than 68,000 before 1990 to over 355,000 in 2023 (American Association of Nurse Practitioners, 2023). The APRN brings essential and possibly unique knowledge, skills, and attitudes to the CEO role, as they are well versed in providing bedside nursing care, similar to a CNO's expectations. They are also licensed independent providers and can relate to other advanced practice providers (APPs) and physicians, much like the expectations of a chief medical officer (CMO). This project is a theory-driven narrative exploring the evolution of two nurse-manager-led quality improvement (QI) projects in which one chief executive officer-APRN (CEO-APRN) provided the initial vision and oversight and how reflection on this narrative led to an organizing, hard-wired framework to reduce patient harm through multiple QI projects hospital-wide. This report is a program evaluation specific to one institution and is not ready for generalizability outside one hospital system.

Committee: Chris Winkelman (Advisor); Peter Pronovost (Committee Member); Terry Winemiller (Committee Member); Shelly Loop (Committee Member) Subjects: Nursing

Doctor of Education (EdD), Ohio University, 2023, Educational Administration (Education)

This study explored the Deming System of Profound Knowledge as a method of leadership and management in K-8 education. The study focused on the process of acquiring and understanding Deming's teachings as they related to the principalship and educational leadership. Using autoethnography as methodology, I leverage personal qualitative data and related educational leadership literature to present my personal journey of becoming an educational leader who practices Deming's System of Profound Knowledge as their primary method for leading and managing a school. Upon reflection and analysis, I found W. Edwards Deming's System of Profound Knowledge practical and valuable as a leadership method in today's schools. Though the mastery of Deming's teachings was a long, complex process, it greatly improved my leadership practice. The findings highlight essential knowledge and skills required to understand and practice the System of Profound Knowledge. It connects educational leadership and Deming's method and recommends further research.

Committee: Michael Hess (Committee Chair); Leonard Allen (Committee Member); Mustafa Shraim (Committee Member); Jesse Strycker (Committee Member) Subjects: Adult Education; Armed Forces; Behavioral Sciences; Business Administration; Business Education; Communication; Continuing Education; Early Childhood Education; Education; Education History; Education Philosophy; Education Policy; Educational Evaluation; Educational Leadership; Educational Psychology; Educational Sociology; Educational Theory; Elementary Education; Higher Education; Higher Education Administration; Management; Mental Health; Middle School Education; Military History; Military Studies; Operations Research; Pedagogy; Preschool Education; School Administration; Statistics; Sustainability; Systems Design; Teaching

MS, University of Cincinnati, 2018, Medicine: Clinical and Translational Research

Objective: Childhood-onset systemic lupus erythematosus (cSLE) is associated with poor health outcomes, and initial benchmarking of cSLE quality measures has revealed suboptimal performance and significant variation in cardiovascular and bone health screenings. The aim of this study was to implement a reliable intervention to improve performance of recommended health maintenance screenings of annual serum vitamin D, annual serum lipid profiles, and bone mineral density testing via dual x-ray absorptiometry (DXA) in a local cSLE cohort. Methods: Quality improvement methodology was applied. The primary intervention implemented was standardized pre-visit planning, including pending electronic orders for screenings prior to a visit. The primary outcome measure was the percentage of clinic visits with compliant screenings over time. Additional analyses were completed to assess the reliability and effectiveness of the intervention. Results: During the study period, a total of 123 cSLE patients were evaluated over 619 visits. After the intervention was implemented, performance of recommended screenings improved from 60% to 90% for vitamin D, 53% to 80% for lipid profiles, and 60% to 76% for DXA, which was sustained for over a year. The majority of abnormal test results were acted on by clinicians without implementing a treatment algorithm. Higher disease activity, damage index, and number of clinical encounters were observed in the group of patients with 100% screening completion compared to patients with only partial screening completion at the end of the study period. Conclusion: In addition to improving performance for cardiovascular and bone health screenings, our study suggests that more active disease may encourage successful completion of screenings. This is an initial step towards enhancing preventive care and health maintenance for cSLE.

Committee: Erin Haynes Dr.P.H. (Committee Chair); Bin Huang (Committee Member); Esi Morgan (Committee Member) Subjects: Surgery

Doctor of Business Administration, Cleveland State University, 2014, Monte Ahuja College of Business

I investigate the effect of supply-chain disruption on a firm's decisions on investment in quality, and on ordering decisions, when there is a choice between suppliers, and a variable rate of knowledge transfer. I find that supply-chain disruption has a negative effect on profit, which can be mitigated by appropriate policies for order allocation and supplier development. When the probability of disruption is high, the firm should seek alternative sources of supply (even if they have lower levels of quality). Under certain conditions, the firm can improve its profit by investing in quality improvement efforts at the alternative supplier. I consider three different policies for supply-chain management and quality investment, and find that investment in supplier development is warranted when the initial quality level of the new supplier is relatively low; when the expected rate of improvement from such investment is relatively high; when the effectiveness of inspection is relatively low; and when the cost of inspection is relatively high.

Committee: Susan Slotnick PhD (Advisor); Raymond Henry PhD (Committee Member); Birsen Karpak PhD (Committee Member); Walter Rom PhD (Committee Member) Subjects: Business Costs; Management; Operations Research

Doctor of Nursing Practice , Case Western Reserve University, 2025, School of Nursing

Proficiency in ultrasound-guided peripheral intravenous (PIV) line placement is crucial for Student Registered Nurse Anesthetists (SRNAs), particularly for ensuring timely and effective patient care in the operating room (OR). While traditional PIV techniques are widely taught, the integration of ultrasound (US) guidance is less uniform, despite its demonstrated benefits in enhancing success rates and reducing procedural complications. This gap points to a disparity in SRNAs' education and clinical readiness. To address this, a training initiative using the Plan-Do-Study-Act (PDSA) framework was implemented to establish the efficacy of simulation-based US education for PIV line placement. Evaluation of the program's effectiveness was conducted using the National League for Nursing (NLN) Simulation Design Scale. Findings from this initiative emphasized that US simulation training is an effective method for teaching SRNAs, significantly improving their competencies in PIV placements. The adoption of this US-guided PIV simulation into SRNA curricula marks a stride forward in nursing education, providing a safe and controlled learning environment that fosters the development of essential intravenous access skills and underscores a commitment to advancing healthcare education and patient care standards Keywords: SRNA, USGPIV, Quality Improvement Project, PDCA

Committee: Juan R. Delvalle (Committee Chair) Subjects: Nursing

DNP, Kent State University, 2024, College of Nursing

Lateral violence (LV) in healthcare remains a critical issue, impacting both staff well-being and patient care quality. This quality improvement (QI) project aimed to raise awareness of LV and provide practical strategies for healthcare professionals to address it effectively. Educational sessions were developed to define LV, explore its causes and consequences, and teach Cognitive Rehearsal (CR) techniques to combat LV. The project also emphasized organizational policy reviews, scenario-based learning, and promoting a culture of safety through continuing education. The QI initiative was conducted in a 269-bed acute care hospital, with two educational sessions held: one virtual session open to all hospital employees and an in-person session with the Nursing Practice Council. In total, 33 healthcare professionals attended the sessions. Participants were provided with educational materials, including an infographic and a pocket card summarizing LV concepts and CR responses. Data collection involved interactive polls and post-session evaluations, with results indicating 70% of participants had experienced LV and 91% reported feeling more knowledgeable about its impact. Participants expressed increased confidence in recognizing and addressing LV, with 73% rating the sessions as excellent. The project's findings highlight the value of combining educational interventions with policy reinforcement to promote awareness and improve responses to LV in healthcare. Limitations of the project include small sample size, limited post-session feedback, and the short-term nature of follow-up, all of which restrict the ability to assess the long-term impact of the intervention. Despite these limitations, this project has demonstrated positive results in enhancing awareness and offering practical strategies to address LV. Future initiatives could expand participation, include long-term assessments, and incorporate simulation exercises to further strengthen staff competency in (open full item for complete abstract)

Committee: Denise Pacholski DNP, APRN, NP-C (Committee Chair); Tracey Motter DNP, RN (Committee Member); Karen Mascolo DNP, RN (Committee Member) Subjects: Health Care; Nursing

DNP, Otterbein University, 2024, Nursing

Nurses are known to be overworked, overwhelmed, undervalued, and understaffed atdangerous levels throughout various inpatient hospital units across the United States (U.S.). Nurses are known to be overworked, overwhelmed, undervalued, and understaffed at dangerous levels throughout various inpatient hospital units across the United States (U.S.). Hospital registered nurse (RN) turnover is a significant issue that has accelerated since the COVID-19 pandemic, resulting in economic impacts and other burdens for organizations, individuals, and communities. Evidence suggests that evaluating Registered Nurses' Turnover intention (NTI) and Organizational Commitment (OC) can help maintain a ready and capable team of skilled RNs; however, most healthcare organizations (HCOs) do not collect or analyze NTI and OC data and focus on staffing numbers and monetary incentives to get adequate nursing numbers. Research shows that RNs with higher OC tend to demonstrate lower NTI and stay in their profession, jobs, and HCO longer. In a local example of one 32-bed stroke unit at a large regional medical center in the Midwest, high staff RN attrition resulted in inadequate RN staffing and closed unit beds, delaying patients' access to timely care. Despite increasing staffing by 3.6 Full-Time RNs, the degree of NTI and OC among nurses working on the stroke unit remains unknown, placing the unit at increased risk of closing beds and disrupting care access in the future. Therefore, the purpose of this Quality Improvement (QI) Project was to provide new data to the Nursing Leadership and the healthcare executives who oversee RN staffing. The project was guided by the Plan-Do-Study-Act QI framework and aimed to evaluate the relationship between NTI and OC through a systematic record review of staff RN questionnaire response data following a unit's recent increase in RN staffing levels. Due to the sensitive nature of the data, the project's data collection could not occur. Despite the limitat (open full item for complete abstract)

Committee: Chai Sribanditmongkol (Advisor); Amy Bishop (Committee Member); Joy Shoemaker (Committee Member) Subjects: Health Care Management; Nursing; Organizational Behavior

PHD, Kent State University, 2024, College of Public Health

Background: Hypertension or sustained high blood pressure (BP) is one of the strongest risk factors for most health complications and a major contributor to premature death. Despite awareness and existing knowledge to prevent and control the condition, it remains a major public health challenge and a significant burden on health systems. The multifaceted complexity of the condition, lack of standardized recommendations for all clinical settings, and conflicting evidence of patient outcomes necessitated further research. Methods: This dissertation is comprised of three retrospective cohort studies that explored outcomes of patients with a hypertension diagnosis within a major healthcare system in the United States. First, using a quasi-experimental approach, we assessed whether an outpatient quality improvement program was equally effective at improving BP control among Black and White patients before (N=71,964) and after (N=94,176) program implementation. Next, we investigated the impact of a secondary diagnosis of hypertension (i.e., another condition was established as the cause of hospital admission) on all-cause inpatient mortality among a propensity-weighted cohort (N=90,388). Finally, among a sample of patients with a hypertension diagnosis (N=44,076), we evaluated whether BP control status at admission predicted the location to which the patient was immediately discharged at the end of their hospital stay. Results: We found that the gap in BP control attainment between White and Black patients widened after the outpatient program was introduced (7.4% in 2015 vs. 10.0% in 2016, p<.0001) and treatment differences during program implementation may have contributed to the increased racial disparity. Within the hospital setting, those with a hypertension diagnosis had a lower incidence of inpatient mortality compared to those without a hypertension diagnosis (1.0% vs. 1.6%, p<.0001). Several primary diagnoses and clinical factors were identified as factor (open full item for complete abstract)

Committee: Lynette Phillips (Committee Chair); Elizabeth Pfoh (Committee Member); Maggie Stedman-Smith (Committee Member); Melissa Zullo (Committee Member) Subjects: Epidemiology; Public Health

Doctor of Philosophy, The Ohio State University, 2024, Health and Rehabilitation Sciences

This dissertation presents the development and evaluation of the Agile Healthcare Performance Index (AHPI), a novel methodology designed to improve quality and measure performance within healthcare settings. It offers a framework designed to capture the complexities of healthcare delivery. Chapter 3 introduces the AHPI, emphasizing its significance in enhancing resource allocation and operational decision-making through an analysis of synthetic data across hospital service lines. The results underscore the adaptability and temporal sensitivity compared to static, unweighted indices, highlighting the potential to refine healthcare performance measurement. Chapter 4 extends the application of the AHPI to quality improvement (QI) initiatives, hypothesizing its effectiveness in aligning healthcare decision-making processes with the complex nature of care delivery. A simulation-based case study illustrates the alignment of the AHPI with the Cynefin framework's domains, demonstrating its strategic utility in navigating the dynamic challenges of healthcare. Chapter 5 focuses on the practical application of the AHPI in evaluating hip fracture care among the elderly, utilizing data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). The findings reveal the ability of the AHPI to accurately reflect variations in surgical outcomes, validating its role as a dynamic tool for quality improvement and policymaking across healthcare settings. Together, these studies advocate for the AHPI as a groundbreaking approach to healthcare performance assessment and QI. By integrating multidimensional metrics and a data-driven methodology, using the AHPI can provide a robust solution for enhancing care quality and operational efficiency, paving the way for a more adaptable and effective healthcare system.

Committee: Catherine Quatman-Yates (Advisor); Courtney Hebert (Committee Member); Lisa Juckett (Committee Member); Carmen Quatman (Committee Co-Chair) Subjects: Health Care; Health Sciences; Operations Research; Systems Design

Doctor of Philosophy, The Ohio State University, 2024, Industrial and Systems Engineering

This dissertation addresses two applied problems relating to images. The first relates to images of pipeline corrosion and the second relates to images of the human brain and individuals with Attention-Deficit/Hyperactivity Disorder (ADHD). The corrosion of oil and gas pipelines is important because there are thousands of leaks every year costing billions of dollars for cleanups. ADHD is important because a substantial fraction of the world population has the disorder causing significant suffering and hundreds of billions of dollars of losses to the world economy. To address both image analysis problems, novel statistical and operations research techniques are proposed which have potentially wide applicability. Relating to pipeline corrosion, an established simulation method is called the “voxel” method which permits predictions about how images and pipelines or other media will change as corrosion evolves. In most realistic cases, we find that the parameter values or “inputs” (Xs) needed to run the simulation are unknown. We only have the images which are essentially outputs (Ys) which can be generated by real world experiments or simulations. The phenomenon of having incomplete inputs for simulation is common in many engineering and science situations and a critical challenge for both people and artificial intelligence. We and others have called this important subject, “empirical forward-inverse estimation” since we can gather data (empirically) in the forward manner progressing from assumed inputs (Xs) to measured outputs (Ys) and then generate inverse predictions from Ys to Xs. With (hopefully) accurately estimated X values, the experimental setup or simulation can then predict the future corrosion evolution and whether repair in critically needed. Relating to forward-inverse analyses, 24 variants of an established two stage method or framework are studied in relation to enhanced inverse prediction accuracy for two test cases including pipeline corrosion (open full item for complete abstract)

Committee: Theodore T. Allen (Advisor); William (Bill) Notz (Committee Member); Samantha Krening (Committee Member); Marat Khafizov (Committee Member) Subjects: Engineering; Industrial Engineering; Materials Science; Statistics

DNP, Kent State University, 2023, College of Nursing

Unintended pregnancies cost an estimated $12 billion annually in publicly funded benefits, contributes to intergenerational poverty, and results in lower educational attainment for mothers and their children. Several professional organizations recommend all health care providers counsel women regarding contraception at every visit regardless of the reason for the appointment. However, contraceptive services provided in any setting is considered inadequate overall (ACOG, 2022; CDC, 2016). This quality improvement project used the plan, do, check, act methodology to assess patient satisfaction with a provider assisted digital contraception education tool. Assessment was also done to ensure that it does not create any type of burden for the provider. Data collection included patient surveys regarding satisfaction with tool use at the conclusion of the visit. Provider perception of helpfulness of bedsider.org will be assessed using a survey at the end of the data collection period. Support staff perceptions of disruptions in office workflow will also be assessed via a one question survey at the end of the data collection period. The convenience sample included 100 patients scheduled for an appointment for the purposes of contraceptive counseling during the designated data collection periods. The provider sample was limited to the physician provider and the nurse practitioner in the office setting. Ancillary staff (medical assistants, secretaries, schedulers) were also be asked to complete a survey regarding the extent of office workflow disruption. The digital contraception educational tool was found to be satisfactory for patients, providers, and ancillary staff.

Committee: Eldora Lazaroff (Committee Chair); Constance Cottrell (Advisor); Karen Mascolo (Committee Member); Lynn Gaddis (Committee Member) Subjects: Nursing

DNP, Kent State University, 2023, College of Nursing

The purpose of this scholarly quality improvement project was to increase utilization of current evidence-based interventions to improve mobilization with instrumentation of visible goal targets, documented mobility goals, continuous feedback, and nurse education. This project was designed to enhance nursing knowledge of current evidence-based practice and clinical practice guidelines regarding initiation of mobilization in populations of critically ill adult patients receiving extracorporeal membrane oxygenation therapy. Data was collected over three periods of time. During the first data collection period, nurses used a visual confirmation tool to record the number of times per day a patient on extracorporeal membrane oxygenation was mobilized, as defined by any nursing-initiated incidence of mobilization qualifying as a 2 or greater on the Johns Hopkins Highest Level of Mobility Scale. Nurses indicated on the Mobility Tracker the number of mobility events initiated by the nurse, or patient-initiated events with nursing assistance. Physical and occupational therapy providers were responsible for tracking events initiated by physical and occupational therapists. After the first data collection period, an evidence-based educational program for nurses was deployed followed by data period collection 2.and 3. Results: During data collection periods 1, 2, and 3, patients were mobilized to a level 2 on the Johns Hopkins Highest Level of Mobility scale at least three times daily, 40% by physical therapy, 25 % by occupational therapy, and 27% by nurses. Total mobility scores for data collection periods 1, 2, and 3, averaged 3.01, 1.75, and 1.89, respectively. Total mobility between D1 and D3 reported a change of 35.14%. Nurse-led mobilization accounted for at least two of the daily mobility counts during data collection periods 1, 2, and 3, reporting a total of 12, 5, and 2 times, respectively. No patient data was collected on five nonconsecutive days of the three data (open full item for complete abstract)

Committee: Amy Petrinec (Committee Chair); Lisa Cascarelli (Committee Member); Kimberly Cleveland (Committee Member); Lisa Onesko (Committee Member) Subjects: Nursing

Master of Science, The Ohio State University, 2022, Dentistry

Objectives: This study explores the association between fluoride varnish (FV) application delivered through Quality Improvement (QI) initiatives in the primary care setting on dental outcomes among children. Methods: We obtained administrative and procedure claims from 2015 to 2019 for children ages 1 to 5 years old in a cohort of Ohio Medicaid beneficiaries. Multivariable logistic and poisson regression analyses were performed to compare dental utilization rates and expenditures among children who received FV from a QI-participating medical provider, a non-QI-participating medical provider, a dental provider, and children who did not receive FV. Results: Among 98,001 children, most were male (51.1%), white (50.5%), qualified for Medicaid by income-based criteria (98.8%), and lived in a metropolitan area (71.1%). Children in the QI group had a significantly higher incidence of preventive dental visits than the dental (IRR=0.93, 95% CI: 0.91 to 0.96) or non-QI groups (IRR=0.86, 95% CI: 0.84 to 0.88). Compared to the QI group, children in the non-QI and dental groups were significantly more likely to have caries-related treatment visits (aOR=2.6, 95% CI: 2.4 to 2.9; aOR=2.9, 95% CI: 2.6 to 3.3, respectively). Children in the dental group were significantly more likely to have dental treatment under general anesthesia (GA) than the QI group (aOR=5.3, 95% CI: 2.0 to 14.4). Conclusions: Children seen at medical practices participating in QI activities around FV application appear to have increased uptake of preventive dental services, which may account for the observed lower incidence of visits for dental caries and dental treatment requiring GA.

Committee: Beau Meyer (Advisor); Andrew Wapner (Committee Member); Homa Amini (Committee Member); Kimberly Hammersmith (Committee Member) Subjects: Dental Care; Dentistry; Public Health

Doctor of Nursing Practice Degree Program in Population Health Leadership DNP, Xavier University, 2022, Nursing

Abstract The purpose of this pilot project is to decrease improper wearing of face masks and reduce miscommunication techniques experienced during a pandemic where mandatory wearing face masks interferes with communication and causes errors from misunderstanding. Nurse educators will receive a behavior awareness intervention and learn proper techniques for communicating when teaching simulations, while wearing face masks. By introducing the TAGEET model and the Eight Ways for Enhancing Communication While Wearing Face Masks tools, educators may be more aware during simulation scenarios of the environment and the actions of the participants. This may help to decrease incorrect face mask wearing and miscommunication between educators and their students. By training the educators, this education could spread throughout the organization.

Committee: Elizabeth Bragg (Advisor); Susan Allen (Committee Co-Chair) Subjects: Education; Educational Leadership; Health Care; Nursing

PhD, University of Cincinnati, 2021, Medicine: Biomedical Informatics

Last-minute surgery cancellation, also known as day-of-surgery cancellation (DoSC), represents a substantial wastage of hospital resources and can cause significant emotional and economic implications for patients and their families. However, only few existing studies attempted to predict risk of cancellation for individual surgical cases, hampering the development of efficient interventions in clinical settings. Also, we currently lack knowledge of actionable factors underlying DoSC and barriers experienced by families (e.g., poor transportation access). The objectives of this dissertation are to 1) identify key predictors and develop machine learning models to predict cancellation for individual surgery schedules, and 2) understand potential underlying contributors to pediatric surgery cancellation at geographic level. In Aim 1, five-year data sets were extracted from the electronic health record (EHR) at Cincinnati Children's Hospital Medical Center (CCHMC). By leveraging patient-specific information and contextual data, a representative set of machine learning classifiers were developed to predict cancellations. Model performance was evaluated by the area under the receiver operating characteristic curve (AUC) using ten-fold cross-validation. The best performance for predicting all-cause cancellation was generated by gradient-boosted logistic regression models, with AUC 0.793 (95% CI: [0.778, 0.808]) and 0.741 (95% CI: [0.725, 0.757]) for the two campuses. Of the four most frequent individual cancellation causes, no show and NPO violation were predicted better than patient illness or patient/family refusal. Models showed good cross-campus generalizability (AUC: 0.725/0.735, when training on one site and testing on the other). Feature importance techniques were applied to identify key predictors. An online tool for predictive modeling was developed using R Shiny package. In Aim 2, a five-year geocoded data set was extracted from the CCHMC EHR and an equiv (open full item for complete abstract)

Committee: Surya Prasath Ph.D. (Committee Chair); Richard Brokamp Ph.D. (Committee Member); Danny T. Y. Wu (Committee Member); Jayant Pratap (Committee Member); Yizhao Ni Ph.D. (Committee Member) Subjects: Health Sciences

DNP, Kent State University, 2021, College of Nursing

The City Department of Public Health (CDPH) Reproductive Health Clinic (RHC) is plagued with long patient wait times. This issue of lengthy wait times is a source of frustration for staff and patients. The purpose of this scholarly project was to implement a quality improvement project utilizing the Lean Methodology with the anticipated outcome of streamlining the patient flow, improving patient wait time, and increasing patient satisfaction. A value stream mapping was created to identify bottlenecks in the current patient flow process and used as a tool to eliminate wasted steps and develop strategies to improve patient wait time. Patients were pre-registered before they entered the clinic, the providers utilized multiple exam rooms, and patients had their blood drawn after seeing the provider, which alleviated a step in the process. This QI project utilized a pre and post-implementation study design. A time study and patient satisfaction survey were conducted during the pre and post-implementation phases of this project. Data was collected via the Patient Tracking Form and Patient Satisfaction Survey and analyzed to determine the impact of the implemented Lean strategies. The results of the QI project were a decrease in 17 minutes in mean patient wait time. The data obtained from the Patient Satisfaction Survey showed a significant increase in the patient's level of satisfaction with patient wait times. By using the Lean methodology, CDPH identified inefficiencies in patient flow, and implemented strategies that reduced wait times and increased patient satisfaction.

Committee: Louise Knox (Committee Chair); Dana Hansen (Committee Member); Lisa Onesko (Committee Member) Subjects: Health Care; Nursing; Public Health; Systems Design

DNP, Kent State University, 2021, College of Nursing

Background and Review of Literature: Emergency departments in the United States have been faced with many challenges that constantly require an evaluation of the current clinical practice. One of these challenges is the increase in patients' emergency room length of stay. Some of the leading causes of the increase in patients' length of stay include improper acuity level assignment, lack of providers, misuse of the emergency department, delay in order placement by providers, and over-ordering or under-ordering by the providers (Grossman et al., 2014). Due to these identified issues that are reviewed in the literature, a gap analysis was conducted to develop an intervention using the PDCA (plan, do, check, act) model. The literature review and gap analysis concluded the need for change of both providers' approach and emergency triage approach in the ED in order to bridge the gap of the identified issue. Purpose/Methods: The purpose of this Doctorate of Nursing Practice (DNP) project was to improve the flow of the emergency department (ED) by decreasing the door to disposition times of ED patients. The door to disposition time is the time a patient presents to the emergency department room to the time it takes to discharge or admit the patient (Adler et al., 2019). This project utilized a modified triage template, in addition to the regular triage information, to help improve on early order placement and ultimately, lead to a decrease in the patiens' length of stay. The additional template contained 5 main history of present illness (HPI) elements. Those are key elements that formulate the provider's perception of the patient's presenting chief complaint (Grossman et al., 2014). The the project was a quality improvement intervention that compared the door to disposition time, in minutes, of patients that had the additional template involved in their care versus those who did not. The comparison between the two groups was completed using a t-test. Implementation/proced (open full item for complete abstract)

Committee: Lynn Gaddis DNP (Committee Chair); Motter Tracy DNP (Committee Member); Cleveland Kimberly DNP (Committee Member) Subjects: Medicine; Nursing

Doctor of Nursing Practice Degree Program in Population Health Leadership DNP, Xavier University, 2021, Nursing

Day of surgery cancellations are multi-factorial and possibly preventable threats to the efficiency of an organization, contributing to delayed surgical care, wasted resources and rescheduling challenges for the patient. The evidence base recommends a comprehensive approach to surgical care quality assessment and multiple interventions to improve patient preparation processes. This organizational systems evaluation followed the Donabedian Model to thoroughly assess the structural features, surgical case preparation processes, and day of surgery cancellation outcomes at an academic outpatient surgery facility. Data from chart reviews and interviews of process experts were evaluated through construction of five process maps, a Pareto chart, and a fishbone diagram. Process failures included pre-surgical care coordination referrals for medically complex patients, scheduling errors, and communication of preoperative instructions. Key drivers for reducing day of surgery cancellations were identified and a process measure was defined for future quality improvement initiatives to reduce cancellations. Overall, variability and deficiencies in information-driven processes and communication were concluded to most likely affect the occurrence of day of surgery cancellations at this facility. In conjunction with other efforts to assess and improve perioperative efficiency, this evaluation supports the opportunity to reduce wasteful care and demonstrate value.

Committee: Betsy List PhD, MPH, RN (Advisor); Susan R. Allen PhD, RN-BC (Committee Member) Subjects: Health Care; Health Care Management; Nursing; Surgery

MS, University of Cincinnati, 2021, Medicine: Clinical and Translational Research

Background and Objectives: Children with medical complexity (CMC) have co-existing chronic conditions and resultant functional limitations that may lead to difficulty achieving adequate nutrition. Ineffective management of reeding intolerance, defined as the inability to achieve target enteral intake combined with symptoms consistent with gastrointestinal dysfunction, can exacerbate this issue. Our primary objective was to decrease median time from admission to goal feeds from 3.5 days to 2.5 days in CMC fed via gastrostomy and gastrojejunostomy tubes admitted for feeding intolerance. Methods: A multi-disciplinary team of nurses, nurse practitioners, pediatric residents, hospitalist and gastroenterology physicians, parents, and a dietitian conducted this local quality improvement project. Key drivers included: standardized approach to managing feeding intolerance, shared understanding of parental goals for their child's feeds, timely delivery of formula to the bedside, and provider knowledge. Plan-do-study-act cycles included development of a standardized feeding algorithm, education of providers, correcting formula room misinformation, addressing physician ordering practices at admission, near-real time reminders and feedback. A run chart tracked the effect of interventions on median time to goal enteral feeds and median length of stay (LOS). Results: Over the course of 6 months, median time to goal enteral feeds for CMC fed via gastrostomy or gastrojejunostomy tubes decreased from 3.5 days to 2 days, meeting special cause variation, and this decrease has been sustained for 1 year. This change coincided with implementation of a standardized feeding intolerance management algorithm. There was no change in LOS. Conclusions: There was a temporal association between implementation of a standardized algorithm for CMC hospitalized with Feeding intolerance and decreased time to goal enteral feeds; LOS did not change. Future work will include incorporating t (open full item for complete abstract)

Committee: Patrick Ryan Ph.D. (Committee Chair); Amanda Schondelmeyer M.D. (Committee Member) Subjects: Surgery

MS, University of Cincinnati, 2020, Medicine: Clinical and Translational Research

Background: An estimated 10% of Americans experience a diagnostic error annually, yet little is known about pediatric diagnostic errors. Physician reporting is a promising method for identifying diagnostic errors. However, our pediatric hospital medicine (PHM) division had only 1 diagnostic-related safety report in the preceding 4 years. We aimed to improve attending physician reporting of suspected diagnostic errors from 0 to 2 per 100 PHM patient admissions within 6 months. Methods: Our improvement team utilized the Model for Improvement, targeting the PHM service. To promote a safe reporting culture, we used the term Diagnostic Learning Opportunity (DLO) rather than diagnostic error, defined as a “potential opportunity to make a better or more timely diagnosis.” We developed an electronic reporting form and encouraged its use through reminders, scheduled reflection time, and monthly progress reports. The outcome measure, the number of DLO reports per 100 patient admissions, was tracked on an annotated control chart to assess the effect of our interventions over time. We evaluated DLOs using a formal two-reviewer process. Results: Over the course of 13 weeks there was an increase in the number of reports filed from 0 to 1.6 per 100 patient admissions, which met special cause variation, and was subsequently sustained. Most events (66%) were true diagnostic errors and were found to be multi-factorial upon formal review. Conclusions: We utilized quality improvement methodology, focusing on psychological safety, to increase physician reporting of DLOs. This growing data set has generated nuanced learnings which will guide future improvement work.

Committee: Patrick Ryan Ph.D. (Committee Chair); Patrick Brady M.D. (Committee Member); Philip Hagedorn (Committee Member) Subjects: Surgery