Author(s): Jacqueline Hopkins, MBA-HM
Performance Improvement Coordinator
Atrium Health

Jacqueline Hopkins, MBA-HM is the Performance Improvement Coordinator for Atrium Health Pineville and Cabarrus. She is responsible for the coordination and facilitation of Quality Improvement Performance within the facilities and works intently with leaders to drive improvement in the areas of PSI Composite metrics, Readmissions, and Mortality. She is the co-leader of the Obeya Mobility Workgroup since April 2022.

Competency Domain: Patient Safety

Description: Lack of mobility has been proven to lead to complications and adverse effects on hospitalized patients such as increased length of stay, pressure ulcers, falls and DVTs/PEs. At Atrium Health Pineville, we experienced challenges with both documenting and executing our system goal of providing at least 3 mobility instances each day for every patient.Problem:Lack of mobility has been proven to lead to complications and adverse effects on hospitalized patients. Examples are increased length of stay, pressure ulcers, decreased functional mobility, falls and DVTs/PEs.Measurement:We began tracking our performance, setting goals, and investigating our root causes. Several initiatives, including education, visual tracking mechanisms, improved data tracking and reward and recognition processes were put into place to address our root causes.Analysis:When we began this work in January 2022 only 14.96% of our patients had documentation of 3 instances of daily mobility. As a part of our Obeya structure, a Mobility workgroup was initiated to address this deficiency through a nursing driven mobility program.Implementation:Sending daily mobility compliance report and patient detailed report to Nurse Managers to follow-up with teammates, Weekly Mobility Workgroup Meetings, Mobility Flags, Real-time documentationResults/DiscussionMobility Compliance Improvement from 14.96% in January 2022 to 83% in September 2023. Reduction in falls with injury rate from 0.53 in 2022 to 0.45 in 2023 YTD, Decrease in pressure injuries from 3 in 2022 to 2 in 2023 & PE/DVTs from 4 in 2022 to 0 in 2023

Evaluation: Complete Poster Evaluation