NR 528 Week 6 Measurement Plan Example

Measurement Plan: What Gets Counted for the Head-of-Bed Practice, When Each Count Is Taken, and Why the Order of the Counts Matters More Than the Choice of Measure

Student Name

College of Nursing, Chamberlain University

NR 528: Leading and Managing Evidence-Based Change in Nursing

Instructor Name

Month Day, Year

Measurement Plan: What Gets Counted for the Head-of-Bed Practice, When Each Count Is Taken, and Why the Order of the Counts Matters More Than the Choice of Measure

The Problem of Order

If the unit counts head-of-bed angles only after teaching, it will measure the teaching: a burst of attention while the practice is new, which says little about whether it will last. If it counts only once before and once after, it cannot tell a real change from ordinary week-to-week variation. The measurement plan for our progressive care unit's head-of-bed practice is therefore built around when counts are taken as much as what is counted. It uses three baseline periods, a weekly count during the change and a monthly count afterward, and it displays every count on a run chart by shift.

What Is Counted

The main process measure. The proportion of observations in which a patient on continuous tube feeding has the head of the bed at 30 degrees or higher, read from the bed's angle indicator. Observations with a documented contraindication count as meeting the practice. This measure matches the practice brief directly and is the one the unit's target, 85% on both shifts, is set against.

A documentation measure. The proportion of observed patients whose flowsheet records the head-of-bed angle for that shift, and, for patients kept lower, whether a contraindication order exists. This shows whether the documentation built for the project is being used, and it will reveal a gap between what is done and what is recorded.

A balancing measure. The number of new sacral or heel pressure injuries of stage 2 or worse among tube-fed patients each month. Raising the head of the bed increases pressure and shear on these areas, and the wound care nurse's concern deserves a number of its own. If the process measure rises and the balancing measure rises with it, the unit has traded one harm for another.

An outcome measure. Suspected aspiration events among tube-fed patients, defined as a rapid response call or a new chest radiograph ordered for suspected aspiration, per 1,000 tube-feeding patient-days. This matters most to patients but will move slowly and noisily on a 24-bed unit, so it is reported but not used to judge the project in its first months. The protocol studied by Metheny et al. (2010) was associated with much lower aspiration and pneumonia, but that was in intensive care, with a combined protocol, and our numbers will be far smaller.

When Each Count Is Taken

Baseline 1, before any announcement. Two weeks of observations at 1000, 1600, 2200 and 0400, taken before the project was mentioned to staff. This produced the 41% figure in the practice brief, with 52% on days and 28% on nights. It is the only count free of any project effect.

Baseline 2, after the announcement and before teaching. One week of observations in week 6, after huddle updates had begun but before any teaching. The difference between Baseline 1 and Baseline 2 shows how much the announcement alone changed practice. If compliance rises sharply here, the unit will know that attention, not the practice itself, is doing part of the work.

Weekly counts during the change. From go-live in week 8 through week 16, the same four observation times weekly, plus two unannounced checks each week at random times, so that staff cannot anticipate every audit.

Monthly counts afterward. From week 17, one week of observations each month at the four set times, continuing indefinitely.

How the Counts Are Read

Each measure is plotted on a run chart, one line for days and one for nights, with the median of the baseline period marked. Run charts allow a unit to distinguish a real shift in performance from random variation using simple rules, for example a long unbroken stretch of weeks sitting on the same side of the center line (Perla et al., 2011). The unit will not declare success from one good week. It will look for a sustained shift above the baseline median on each shift separately, and for the night line to move as well as the day line.

Who Counts and How Consistently

Two nurses who volunteered as auditors, one from days and one from nights, take the observations, using the same bed angle indicator reading on every bed. Before the first baseline, they observed ten beds together and agreed on nine; the disagreement, a bed at 29 degrees on a worn indicator, led to replacing that indicator and a rule that readings are taken with the patient centered in the bed. The project lead enters the data weekly and posts the run charts in the break room every Monday. Consistency matters because an audit that changes its method partway through cannot show whether practice changed or only the counting did.

What the Plan Will Not Claim

This design measures whether the unit keeps the head of the bed up, not whether that prevents aspiration on this unit. The unit is implementing, not testing, a guideline position that tube-fed adults at high aspiration risk sit at 30 to 45 degrees (McClave et al., 2016). A 24-bed unit cannot produce enough aspiration events in a year to show a reliable effect, and a fall in events could reflect other changes, such as fewer tube-fed patients. The report will therefore say that the unit achieved, or did not achieve, the recommended practice, and it will report outcome numbers alongside without claiming they prove the practice worked. That restraint protects the project from an easy criticism and keeps attention on the measure the unit can actually move.

Results will be shared with staff at the Monday huddle each week, with one sentence on what the run chart shows and one on what will be tried next. When the night line moves, night staff will hear about it first.

How Results Are Shared

Results go back to staff within two days of each audit week. The run chart is posted in the break room, and the charge nurse reads the latest day and night figures at huddle. Individual nurses are never named in shared results. If an auditor finds a flat bed, the auditor pauses the feed and raises the bed on the spot, and the observation is still counted as found. Sharing shift-level figures rather than names keeps the audit a measure of the unit's system, not a search for someone to blame, which matters to night staff who already feel watched.

References

McClave, S. A., Taylor, B. E., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., McCarthy, M. S., Davanos, E., Rice, T. W., Cresci, G. A., Gervasio, J. M., Sacks, G. S., Roberts, P. R., & Compher, C. (2016). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 40(2), 159-211. https://doi.org/10.1177/0148607115621863

Metheny, N. A., Davis-Jackson, J., & Stewart, B. J. (2010). Effectiveness of an aspiration risk-reduction protocol. Nursing Research, 59(1), 18-25. https://doi.org/10.1097/NNR.0b013e3181c3ba05

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895