NR 632 Week 4 Process Measure Summary Example

Process Measure Summary: Readiness Checks Done Out of the Times They Were Due, Which Records Made Themselves and the Friday Shift That Never Started

Student Name

College of Nursing, Chamberlain University

NR 632: Nurse Executive Concluding Graduate Experience II

Instructor Name

Month Day, Year

Process Measure Summary: Readiness Checks Done Out of the Times They Were Due, Which Records Made Themselves and the Friday Shift That Never Started

Period Covered

Pilot weeks one to three: 16 to 20 November, 30 November to 4 December and 7 to 11 December 2026. Week four's process figures will appear in the evaluation report.

Occasions, Defined

An occasion is a first case in rooms 3 to 6 that appeared on the published list at 15:30 on the working day before surgery. Add-ons after 15:30 are not occasions, since no afternoon check was possible. Weeks one to three contained 55 occasions: 18, 19 and 18.

Measure 1: Readiness Checks Done

The worklist field records itself with a time stamp when the nurse ticks it. In week three the student checked the paper log, which the nurses still kept out of habit, against the field. They agreed on 15 of 18 occasions. The three disagreements were all patients ticked in the field and missing from the log, which suggests the paper undercounted in earlier weeks rather than overcounted.

Coverage by Day, Not Overall

The overall 84% hides two different processes. On Tuesday to Friday, the check happens 93% of the time. For Monday cases, it happens half the time, and only because week one's dry run had extra staff. In weeks two and three, one of eight Monday cases was checked.

The Shift That Never Started

The Friday afternoon check for Monday cases has never run as designed. The Friday afternoon session in pre-admission testing closes at 15:00, the readiness calls were planned for 13:30 to 15:30, and on Friday the clinic is busiest with the following week's visits. The one Monday case checked in weeks two and three was done by the manager. No nurse has refused the task; the time simply does not exist on a Friday afternoon. The manager's proposal to move Friday checks to 12:30 to 14:30 has been accepted but cannot start until the January rota, which is published six weeks ahead.

Measure 2: Morning Read in Holding

Done on 14 of 15 pilot days, recorded by the charge nurse's initials on the list. Self-reported. The one missed day was a Monday when the list arrived in holding late. This measure is likely to hold, because the read takes place in an existing huddle.

Measure 3: Open Items Found and Resolved

Of 46 patients checked, 14 had at least one open item. By 07:00 next morning, 11 of the 14 were resolved. Self-reported on the paper log by two people.

Measures That Stopped Being Filled In

The "resolved by 07:00" column was filled for every open item in week one, for four of five in week two and for three of five in week three. The holding charge nurse has to find the paper log in the pre-admission testing office each morning, which is a different floor. The student filled the gaps from the record where possible, but the trend is the usual one for a self-reported measure: completeness falls after the first few weeks unless the record makes itself (Proctor et al., 2011). A worklist field for "resolved" has been requested for the handover.

Measure 4: Calls Returned by 16:30

Weeks one to three: 13 of 18 calls to surgeons' offices were returned by 16:30. The two offices that route to voicemail after 15:00 account for four of the five unreturned calls.

How the Figures Will Be Displayed

Each process measure goes on its own weekly chart beside the on-time chart, so the director can see whether the outcome moved in the weeks the process ran. With three weeks of data, these charts are descriptions, not tests; the usual rules for reading a run chart need more points than the pilot will have (Perla et al., 2011).

What Was Checked by Hand

The student checked a sample of five patients each week against the record to confirm that a tick in the log or the field meant the six items had in fact been looked at. All fifteen sampled checks were complete, including the two where the nurse had found and called about an open item. That gives some confidence that the self-reported log does not overstate the work done, though it says nothing about the days when the log was not filled.

Early Signals From Staff

Two pre-admission testing nurses said the checks take about five minutes per patient when nothing is open and fifteen when a call is needed. That matches the ten hours a week estimated in the plan for four rooms, and it suggests extension to more rooms would need more hours in proportion, not a fixed amount. The director will want that figure before any decision about rooms 1 and 2, which run more orthopedic cases with longer histories to check.

What These Figures Mean for the Outcome

The process ran on Tuesday to Friday and did not run on Mondays. Any change in the on-time rate should therefore appear mainly in Tuesday to Friday cases. That is a prediction the outcome comparison can test, and if it does not hold, the readiness call is probably not what moved the figure.

What the Director Can Do With This

Two things. Approve the Friday change early so it appears in the January rota without waiting for the evaluation, since the cost is a shift of two hours within the same session. And ask the analyst for a "resolved" field in the worklist, so the most fragile self-reported measure stops depending on a paper log on another floor.

What They Do Not Mean

They do not show whether the checks prevented late starts; that is the outcome comparison. They do not show that nurses resisted the change; the gaps follow the Friday shift and two offices' phone systems, not any person.

Comparison With Published Work

Blair et al. (2024), auditing timed steps before surgery, separated delays the team could control from those it could not. The pattern here is similar: the steps the department controls are running, and the ones depending on another team's hours or phone systems are not.

References

Blair, K., Mijatovic, O., Thompson, M., Monroe, M., & Davies, C. C. (2024). A nurse-driven plan to diminish first-case operating room delays. The Journal of Nursing Administration, 54(9), 503-506. https://doi.org/10.1097/NNA.0000000000001467

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

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7