Emails will be sent with by the end of year 1 the

 Emails will be sent with
By the end of year 1, the
physician department
will review the
evidence-based
literature to determine a
plan for a decrease in
mortality rate in
pneumonia patients 30
days post
hospitalization.
Informational Event:
 HCAHPS scores
will be shared with
the physician
department to show
a baseline measure
and comparison to
state and national
scores
 Physicians will be
surveyed for interest

11
new communication
strategy and training
information.
Educational Event:
 Educational training on
HCAHPS scores and how
the scores affect
reimbursement will be
presented.
 PowerPoint presentations
will be presented to all
departments about the new
protocol.
 Handouts will be provided
explaining the new
protocol.
 Simulation training on
intentional bedside
reporting will be provided.

Training on documentation
of intentional bedside
reporting will be provided.
updates on the status of
new strategy and
training information.
 New protocol added to
the electronic medical
record as a care set for
all pre-op patients.
Educational Event:
 Educational training on
HCAHPS scores and
how the scores affect
reimbursement will be
presented.
 Handouts will be
provided explaining the
new protocol.
 Training provided on
how to initiate the
protocol on the
electronic medical
record for all pre-op
patients.
 Simulation training on
the use of chlorhexidine
in creating the new
protocol.
 Develop a protocol
for scheduling
follow-up care prior
to patient discharge
 New protocol added
to the electronic
medical record as a
care set for all
pneumonia patients
prior to discharge.
Educational Event:
 Educational training
on HCAHPS scores
and how the scores
affect
reimbursement will
be presented.
 Staff educated on the
new protocol during
staff meetings and
daily energizers.
 Handouts will be

12
cleanser. provided explaining
how to set up patient
follow-up
appointments prior
to discharge.
 Provide in-service
training with the IT
department to show
physicians how to
electronically enter
follow-up
appointments.

Simulation training
on the use of
electronically
entering follow-up
appointments.
Year 2 By the end of year 2, the new
protocol will be completed and
implemented into practice with
75% of the hospital using the
new protocol of intentional
bedside reporting.
Informational Event:
By the end of year 2, the
new protocol will be
completed and implemented
into practice with 75% of
the hospital using the new
protocol and patients will
have a prophylactic
By the end of year 2, the
new protocol will be
completed and
implemented into
practice with 75% of the
hospital using the
protocol and pneumonia

13
 Quarterly informational
events will be shared
showing HCAHPS scores.
 Implement champions to
aid and provide additional
training to non-compliant
staff.
Educational Event:
 Quarterly educational
training sessions providing
data updates about nurse
communications.
 Provide awards to the
departments with the
highest patient satisfaction
scores in communication
antibiotic on the electronic
medical record prior to
surgery.