Project Title: Patient Satisfaction with Privacy
Report Date: July 1, 2009
Department/Division/Unit/Committee: Patient Satisfaction Improvement Committee
Project Team Leader: Florence Nightingale Phone # 12345
Report Prepared by: Same Phone #
Project Start Date: April 1, 2009
Anticipated/Actual End Date: October 1, 2009

PLAN

1. Opportunity/Aim Statement with Measurable Goal
   To ensure that our patients and families perceive that their personal privacy has been maintained. Our goal is to achieve a Press Ganey ranking of the 95th percentile for privacy and to reduce privacy related patient complaints.
2. Most Likely Causes (Data Collection Method:____________________)
   • Semi private rooms
   • Significant traffic in/out of patient rooms
   • Patient transportation to other departments
   • Lack of caregiver awareness (ie knock before entering, introduce self, caregiver comments)
3. Potential Solutions and Data Needed for Evaluation (Tools used_______________________________________)
1. Identify 3 pilot nursing units to test changes
2. Increase caregiver awareness – staff performance
3. Enhance patient comfort – patient reports; supplies utilized
4. Re-configure patient rooms to all private rooms (not feasible!)

DO
4. Solutions Implemented
Change One – Staff Awareness:
· Educational posters on all units
· Signage on doors reminding to knock
· Announce/Introduce self in patient encounters
· Staff report held away from bedside
Change Two – Improve Patient Comfort:
· Privacy curtains in private rooms
· Provide extra large patient gowns
· Provide slippers
· Provide extra blankets for transport
· Designate elevators for patient use only

STUDY

5B. Data Analysis (Determine this from the study results above)
After the first 90 days of implementation, the Press Ganey percentile ranking for privacy improved from 45% to 67%. Patient/Family complaints related to privacy decreased from 12 per week to 6 per week.
ACT
6. Next Steps

1. Conduct patient focus group to learn about their expectations for privacy
2. Develop a service recovery program for privacy complaints
3. Explore opportunities for pilot units to share learnings with other departments
4. Identify incentives for active participation in privacy initiative
5. Add privacy question to Press Ganey ambulatory survey to determine if privacy is an issue in ambulatory areas
6. Further exploration of room re-configuration