Date Approved

4-22-2025

Graduate Degree Type

Dissertation

Degree Name

Nursing (D.N.P.)

Degree Program

College of Nursing

First Advisor

Donna Rinker

Second Advisor

Janet Winter

Academic Year

2024/2025

Abstract

Background: Specialized adult foster care (AFC) programs have the unique ability to facilitate and coordinate continuity of care with an interdisciplinary approach internally and with community provider collaboration. The lack of communication in the transition of care admissions process leads to negative patient safety outcomes.

Purpose: The purpose of this quality improvement project was to identify barriers to improve communication, continuity of care, reduce negative health outcomes, and provide a culture of safety.

Methods: The Systems Engineering Initiative for Patient Safety (SEIPS) guided this quality improvement project. Assessment of quality measures and outcomes included the administration of pre- and post-implementation surveys to healthcare staff to assess knowledge, practice, and perceptions regarding the admissions process. Chart reviews pre and post implementation assessed comparison of outcome measures related to safety measures. Education and training sessions conducted by the team leader reported 100 % attendance for nursing staff and 46% attendance for all other staff members among the eight residential settings.

Results: Analysis of the data revealed a significant improvement in receiving complete medical history data, medications, and DME decreasing overall negative health outcomes post 30-day admission. The perception and knowledge in utilizing the formal admission process and forms were noted to be positive for improvement among the nurses and other healthcare staff.

Conclusions: Staff reported an increase in knowledge, efficiency in the admission paperwork process, and a culture of safety with the implementation of a formal admissions process. Chart reviews found a reduction of negative health outcomes variables.

Key Words: Safety, Transition of care

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