Student Name

Capella University

NURS-FPX4035 Enhancing Patient Safety and Quality of Care

Instructor Name

Submission Date

Improvement Plan In-Service Presentation

• Slide 01:

Hello and good morning to all. My name is ….. This is the in service presentation on the improvement plan, and some of the measures discussed will be aimed at helping to empower patient discharge education and safe post-operative care. Standardized teaching tools are displayed to prevent essential gaps or lack of knowledge of medication, wound, and activity limitations. Skills and processes are practiced and understood with the help of practical simulations and reference materials. The presentation highlights the design of in-service feedback strategies and the employees’ receptivity to implementing these safety interventions in Cedars-Sinai Medical Center.

Agenda and Outcomes

• Slide 02:

Purpose Statement

To enhance nurse practice in discharge education and culturally competent communication with patients to reduce sentinel events associated with insufficient patient education, including medication errors, wound care, and preventable readmissions.

• Slide 03:

Goals of the In-Service Session

1. Explain the “why” and patient safety issues that result from inadequate discharge education with an example of a sentinel event.
2. Describe the importance of standardized protocols for discharge and the use of the teach-back method, health-literacy-appropriate instructions, and culturally/linguistically supposedly appropriate resources.
3. Explain constructive plans for measuring understanding in patients, recording discharge education in the electronic health record (HER), and supporting instructions before discharge.
4. Describe how structured teaching checklists, bilingual materials, and teach-back simulations can be used to create comprehensive and uniform patient understanding.
5. Identify ways in which nurses can help to raise concerns, clarify issues, and to have a discussion with professional interpreters to maximize the outcome of postoperative cases.

• Slide 04:

Session Overview

In this in-service, the participant(s) will be advised about a sentinel event that resulted from inadequate discharge education in which wound care and medication errors following surgery were not managed properly. Having not assessed patient health literacy, not using the teach-back method, and not using culturally and linguistically competent communication are among the real-world causes considered by nurses. During the session, nurses will be able to utilize teaching aids, use bilingual materials, implement teach-back simulations, determine gaps in understanding, and foster deeper patient education at Cedars-Sinai Medical Center (Joseph and Gregory, 2025). The participants will go home with practical guidelines on how to enhance patient education, decrease readmissions, and avoid the same in their practice.

Safety Improvement Plan

• Slide 05:

A patient’s 62 years of age, and a post-operative wound infection and non-adherence with discharge instructions were due to the discharge instructions being written in a very complex way that was not appropriate for the patient’s literacy level, which was rushed and not specific. Other issues such as high patient turnover, staff lack of time to teach patients individually, and the lack of organized teach-back verification were also contributing factors. Although there is a policy that promotes patient-centered and evidence-based education, the understanding of the patient is not assessed or documented, which showed human and system-level weaknesses (Engle et al., 2021). The incident highlights the weaknesses in the discharge education, communication, and policy implementation.

• Slide 06:

The improvement plan presents a multi-layered intervention: the obligatory use of the teach-back check will verify all discharge orders to make sure that patients comprehend the wound treatment, medications, and post-discharge needs. This practice has been proven to minimize medication errors, complications, and unnecessary readmissions (Hesselink et al., 2021). The electronic health record will have culturally and linguistically specific materials that will alert those patients who require extra assistance (Ademola et al., 2024). Interprofessional simulation training will be used to complement patient teaching strategies, communication, and use of plain language. The training will also create a culture of transparency, as nurses will be able to recognize and resolve gaps in understanding in time (Zenani et al., 2023). There will be standardized discharge checklists, and also bilingual teaching material in the units with high risk, so as to have a consistent and clear teaching process. A multi-layered strategy increases patient knowledge and documentation, and subsequent collaboration and safe post-operative care.

• Slide 07:

Organizational Plan and Its Importance

There are built-in protective factors against unindicated readmissions and medication errors when targeting incomplete discharge education, lack of measurement of health-literacy, and lack of culturally/linguistically adequate communication. Standardized discharge checklists are used as visual cues, and the teach-back technique makes sure that instructions are comprehended and verified, so that the whole process of medication, wound care, and follow-up is not forgotten or presupposed. Addressing this issue is consistent with Joint Commission National Patient Safety Goal #2, which mandates patient education, and is essential to reduce avoidable complications, minimize readmissions, and improve organizational culture (Wadhwa and Boehning, 2023). This way, redundancies, standardization, and culture changes help to make discharges safer and ensure improved patient outcomes.

Audience’s Role and Importance

• Slide 08:

Out of the policy, the frontline nursing staff has a key role to play in implementing the improvement plan in practice. The understanding of medication, wound care and follow-up for each patient will be verified as a result of teach-back training and the use of electronic discharge checklists (Oh et al., 2021). In addition, actively engaging in simulation exercises helps build the skills linked to patient education and improves the practice of checking comprehension in discharge conversations (Thurman et al, 2025). Use of organized teaching tools regularly among the nursing staff guarantees the development of reliable communication channels and pathways without omissions.

Implementation must be shared and on-going feedback. The nursing leadership will track adherence, instruct staff in checklists and teach-back for electronic health records (EHR), and will consider the feedback provided by staff about barriers or opportunities for improvement. Debriefings after simulations and after a discharge in reality will help the team to come to terms with challenges, such as alert fatigue or delayed documentation, and put forward solutions (Holmes and Mellanby, 2022). The involvement in the audit cycles and performance review also gives the staff the opportunity to take ownership of the culture of success and the areas of improvement and therefore to create a culture of continuous learning.

• Slide 09:

In the processes of establishing these changes into the organizational culture, clinical staff loyalty is needed. The threat of misinterpretation of instructions can be minimized by introducing a consistent standardized discharge process and the ready accessibility of culturally-appropriate educational resources, which should result in improved patient adherence (Cook et al., 2022). Nurses, as primary users of the teaching resources and discharge checklists, have a direct impact on patient outcomes, re-admission rates, and safety indicators as a whole. The engagement scores also reflect trust-building leaders where the voice of the frontline is heard and valued, and enables a shared strategy to patient-centered safety.

New Process and Skills Practice

• Slide 10:

An in-service tool will be introduced that incorporates the teach-back method with an electronic discharge-education checklist as a combination of the safer patient discharges. This resource will provide a brief explanation of the major teach-back steps, which comprise explanation of the care plan, repetition of instructions, clarification of misunderstandings, and confirmation of understanding of medications, wound care, and follow-up appointments of all high-risk discharges (Hesselink et al., 2021). The EHR module will be demonstrated using screenshots of the auto-populated discharge checkboxes, which will help remind the staff of the process and remind the patient that they have understood the process before the discharge. Concise online tutorials and pocket cards to be printed out as reference materials will be used to facilitate continued independent review.

• Slide 11:

In order to implement these new processes, the participants will be requested to be involved in a structured simulation practice. Groups of three will be given a simulated patient scenario, a recently discharged patient with complex medication and wound care instructions, biased documentation, and an evaluation of health literacy (Callender et al., 2021). The “educator” will be one member of the team who will give the discharge instructions in the teach-back format, and the “patient”, will be another member of the team who will repeat the instruction, and will also be expected to demonstrate knowledge about the medications, wound care, and follow-up in a role-played EHR format. The third, the ‘observer’, will indicate any omissions/short-cut. Five minutes later, roles will be swapped, and everyone will experience the opportunity to educate, repeat and observe.

During the debrief, the observers will discuss concur collective points of concern, such as forgetting important steps or not fully grasping patient understanding and the group will brainstorm solutions such as pre discharge huddles with the high-risk patients or pocket cards in the workstation. Proposing prioritization of full teach back to high-risk patients and an abbreviated template in stable patients (Joseph, 2025) will be addressed in the expected questions, such as time management in a busy medical-surgical unit. The slowing of workflows due to concerns over EHR can be overcome by using a quick confirmation phrase (understanding confirmed) in place of extensive written notes. If a junior is not confident in challenging a senior, then issues of hierarchy will be resolved by reminding them that hierarchy is objective, based on tools and applicable to all team members. The mix of these resources and exposure to the field allows them to be competent and confident in their ability to deliver standardized discharge education in the real world.

Soliciting Feedback

• Slide 12:

The discharge education improvement plan should be an ongoing process that includes regular input and feedback from those with whom patients interact for their care. To collect practical information on both the enhancement strategy and the in-service training, the participants will be required to fill a short, anonymous electronic survey right after the training (Huebner and Zacher, 2021). The questions will be used to assess the understandability of the teach-back method and EHR discharge-education checklists presentation, confidence in the new patient-education process, and barriers to the new process (time pressures, workflow constraints). In addition, a verbal feedback session will be invited at the end of the session, and five minute open discussion will take place where they are encouraged to ask what went well, rushed, and where they may have any suggestions for resources. A compilation of transcripts or notes of that debrief will be made with the results of the surveys.

The patient safety committee will discuss the feedback received during one week. When it comes to action, themes that are identified as recurrent will be given priority, such as the shorter reminder for pocket cards or a call to more micro-sessions that are culturally tailored (Zhou et al., 2025). The committee will be reviewing and adjusting the materials (making checklists easier to follow, adding short videos for quick reference, etc.) and will be modifying future in-service plans (shorter modules on busy medical-surgical units, etc.). The essential findings and changes will be shared with staff members through an email and put on the quality improvement board in the unit to complete the feedback loop and show that the input on the frontline is directly affecting the current patient-education safety initiatives.

Conclusion

• Slide 13:

An integrated approach of standardized discharge education using the teach-back, incorporation of EHR education checklists, and skill practice in simulation fills the gaps in the communication process, ensures patient understanding, and gives nurses the ability to confirm their patients’ understanding of medications, wound care, and follow-up. This type of comprehensive solution helps to quickly stop medication errors and reduce preventable readmissions and fosters a sense of responsibility. Continuous monitoring, feedback, and leadership promotes change. Last but not least, such measures will keep the patients safe, reduce complications, and improve overall care quality.

References

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Callender, L. F., Johnson, A. L., & Pignataro, R. M. (2021). Patient-centered education in wound management: Improving outcomes and adherence. Advances in Skin & Wound Care, 34(8), 403–410. https://doi.org/10.1097/01.asw.0000753256.29578.6c

Cook, J. L. E., Fioratou, E., Davey, P., & Urquhart, L. (2022). Improving patient understanding on discharge from the short stay unit: An integrated human factors and quality improvement approach. British Medical Journal (BMJ) Open Quality, 11(3), e001810. https://doi.org/10.1136/bmjoq-2021-001810

Engle, R. L., Mohr, D. C., Holmes, S. K., Seibert, M. N., Afable, M., Leyson, J., & Meterko, M. (2021). Evidence-based practice and patient-centered care: Doing both well. Health Care Management Review, 46(3), 174–184. https://doi.org/10.1097/HMR.0000000000000254

Hesselink, G., Sir, Ö., Koster, N., Tolsma, C., Munsterman, M., Olde Rikkert, M., & Schoon, Y. (2021). Teach-back of discharge instructions in the emergency department: A pre-post pilot evaluation. Emergency Medicine Journal, 39(2), emermed-2020-210168. https://doi.org/10.1136/emermed-2020-210168

Holmes, C., & Mellanby, E. (2022). Debriefing strategies for interprofessional simulation: A qualitative study. Advances in Simulation, 7(1). https://doi.org/10.1186/s41077-022-00214-3

Huebner, L.-A., & Zacher, H. (2021). Following up on employee surveys: A conceptual framework and systematic review. Frontiers in Psychology, 12(12). Frontiersin. https://doi.org/10.3389/fpsyg.2021.801073

Joseph, J. (2025). Enhancing patient understanding and reducing readmissions: Implementing a structured discharge teaching protocol in a medical-surgical unit. DigitalCommons@SHU. https://digitalcommons.sacredheart.edu/dnp_projects/98/

Joseph, R. A., & Gregory, L. (2025). A structured approach to patient education: empowering nurses through a framework. Journal of Pediatric Surgical Nursing. https://doi.org/10.1177/23320249251374301

Oh, E. G., Lee, H. J., Yang, Y. L., & Kim, Y. M. (2021). Effectiveness of discharge education with the teach-back method on 30-day readmission. Journal of Patient Safety, 17(4), 1. https://doi.org/10.1097/pts.0000000000000596

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