2014-2015 11

th
Floor ONC/BMT CNA/ACP Action Plan

We are an amazing team that not only takes pride in the excellent care we
provide our patients, but also constantly looks for ways to get even better. Recent
patient surveys have identified some specific areas we can all improve upon.
With these improvements, we can excel in customer satisfaction!

Goal: 75% (Percentage of patients who feel we are responsive to their needs)
Current Score: BMT (insert), OMG (insert)

Areas Patients Have Identified as Being in Need of Improvement

Responding to call lights by immediately going into the patients room.
Performing hourly rounding
Asking patients the 5 Ps and delivering fresh water at least 3 times a shift (unless
NPO).
Using LOOK report
Cleanliness of Hospital Environment

Expectations

Phones
1. RN will be programmed as the primary responder for call lights and delegate
appropriately to the CNA/ACP.
2. If unable to answer your phone, call back your missed calls as soon as possible.
3. If you are the caller, do not let the phone ring more than 5 times. The person is most
likely busy and will call you back.
4. Respond to the call light in person. Patients would rather see a face than hear a voice.

Rounding/5 Ps/LOOK Report
1. Remember the 5 Ps of rounding (Pain, Positioning, Personal, Potty, and Presence)
2. Hourly rounding on all patients and charting of hourly rounding
a. CNA/ACPs even hours
b. RNs odd hours
3. Always use LOOK report and AIDET communication tools
4. Use specific questions when rounding on patients such as Do you need to use the
bathroom while I am here? or May I get you fresh water?
5. Give a timeframe of when you will be back. For example I will come back between
3:00 and 4:00 to take you for a walk.
6. Refill waters at least three times a shift (usually with Is and Os unless NPO)

Communication
1. Update white boards during shift change with oncoming RN and CNA/ACP
2. Use white boards to involve the patient of their plan of care including:
a. Bed bath/shower/oral care
b. Walks
c. Turning schedule
3. Touch base with your RN by 0900 (day shift) or 2100 (night shift)
4. Family and friends are our customers too. Please do your best to communicate with
and accommodate them.
5. Do not ignore pumps or call lights. If primary RN cannot help, please
delegate to charge RN or a peer.
6. Communicate with your peers if you need help. We are a team!

Environment
1. Clear out medical equipment from patient rooms when the patient no longer
is using the equipment or patient has discharged (Make sure to check
drawers).
2. Empty trash cans if they are full.
3. Change/check sharps containers every shift.
4. Empty commodes prior to putting in the dirty utility rooms.
5. Place Oxygen tanks in the Oxygen rooms NOT in the dirty utility rooms.
6. Check nutrition rooms for mess and organize when possible.


I have had the opportunity to review and understand the above information. By signing this
contract, I agree to adhere to these standards. I also agree to hold my peers to the same
standards. Through teamwork and cooperation we can greatly improve our workplace for
our patients and fellow employees.


Print Name: ______________________________________

Signature: _______________________________________ Date: ______________


Charge Nurse Signature: ________________________________