Healthcare Improvement Project: Introduction and Project Initiation
A standardized weekly nursing assessment can improve the quality, consistency, and clinical usefulness of documentation for patients admitted to acute psychiatric units. By bringing important information about physical health, medication adherence, behavioral patterns, treatment response, and discharge readiness into one structured assessment, the project can strengthen interdisciplinary communication and support more informed clinical decisions. The initiative addresses a documentation gap in which relevant patient information is currently distributed across nursing notes, mental health technician observations, and other interdisciplinary records.
Organizational Problem
The healthcare improvement project addresses inconsistent and fragmented nursing documentation in an acute psychiatric setting. Nurses document patient care associated with safety monitoring, including one-to-one observation and 15-minute checks, while mental health technicians record observations at designated intervals. Registered nurses also conduct comprehensive weekly assessments; however, information communicated to social workers for discharge planning may rely heavily on observations documented by non-licensed staff.
Although behavioral observations are clinically valuable, they may not provide a complete picture of treatment response, medication adherence, physical health status, or discharge readiness. As a result, social workers and other members of the interdisciplinary team may not consistently receive the full clinical context needed to coordinate referrals, community placement, and discharge services.
A standardized, nurse-driven weekly assessment would consolidate these data into a single clinical summary. This approach could reduce documentation gaps, improve continuity of care, and provide the interdisciplinary team with a more complete understanding of the patient’s current condition.
Effect on Patient Care and Discharge Planning
Fragmented documentation can make it more difficult for healthcare professionals to identify changes in patient status and communicate important information efficiently. When clinical information is dispersed across several documentation systems or staff roles, providers may need to review multiple sources before developing an accurate picture of the patient’s progress.
The problem is particularly important during discharge planning. Social workers and other team members need reliable information regarding behavioral stability, medication use, functional abilities, medical concerns, and progress toward treatment goals. A structured weekly nursing assessment can make these details easier to locate and interpret.
The proposed tool would therefore function as both a documentation standard and a communication resource. It would provide a consistent framework for recording clinically relevant information while supporting interdisciplinary collaboration and discharge preparation.
Key Stakeholders
The project requires participation from individuals who understand clinical care, nursing documentation, education, discharge planning, and organizational administration. Stakeholder involvement is important because successful implementation depends not only on creating the assessment tool but also on integrating it into existing workflows.
| Stakeholder | Role and Expertise | Influence and Authority |
|---|---|---|
| Amanda Rivers, CNP | Provides advanced clinical decision-making and treatment expertise | Influences clinical protocols and evidence-based treatment practices |
| Maggie Donohue, RN, BSN | Provides frontline nursing and documentation experience | Identifies workflow requirements and practical documentation needs |
| Bobbie Steinle | Director of Social Services | Oversees discharge coordination and community placement referrals |
| Susan Lynch | Director of Nursing Education | Leads staff education, competency validation, and policy development |
| Rachel Smith | Hospital Administrator | Supports policy changes, resource allocation, and organizational implementation |
These stakeholders provide complementary perspectives. Clinical and nursing leaders can evaluate the assessment’s content, social services can determine whether the documentation supports discharge planning, nursing education can facilitate training, and administration can address organizational resources and policy requirements.
Project Team Roles and Responsibilities
The project manager coordinates the initiative from planning through evaluation. This role includes defining project activities, coordinating stakeholder participation, monitoring deadlines, identifying barriers, and supporting implementation of the standardized assessment.
The project manager also acts as a facilitator and change-management resource. Staff members may have different perspectives about documentation requirements and workflow changes, so effective communication and active listening are essential. Analytical thinking is equally important because project data must be reviewed to identify documentation trends, implementation problems, and opportunities for improvement.
The project manager is also responsible for maintaining accountability throughout the project lifecycle. Regular communication with stakeholders can help ensure that responsibilities are understood and that problems are addressed before they interfere with implementation.
Nursing Education Leadership
The Director of Nursing Education plays an important role in converting the project’s clinical objectives into a practical documentation process. Susan Lynch would support development of the assessment template, coordinate staff education, validate competency, and assist with revisions to organizational policies.
Education should explain not only how to complete the assessment but also why the information matters. Connecting documentation requirements to patient safety, continuity of care, discharge planning, and regulatory expectations can help staff understand the purpose of the change.
Needs Assessment
The need for the standardized weekly nursing assessment was identified through a review of existing documentation practices and a 5 Whys root cause analysis. This approach helps organizations move beyond identifying a visible problem and examine the underlying factors contributing to it.
The analysis indicated that inconsistent communication about patient behavior and treatment progress was partly related to reliance on daily progress notes written by non-licensed staff. Mental health technicians provide important observations of patient behavior and safety, but these observations do not necessarily include the broader clinical assessment performed by a registered nurse.
The needs assessment therefore identified an opportunity to combine observational information with nursing assessment findings in a structured weekly summary.
Essential Documentation Elements
The proposed assessment should capture information that is clinically meaningful and directly relevant to ongoing treatment and discharge planning. Key elements include the patient’s physical assessment, medication adherence, PRN medication use, behavioral patterns, activities of daily living, treatment participation, and significant medical concerns.
A consistent assessment format can make it easier for nurses to document comparable information from week to week. It can also help other members of the interdisciplinary team identify changes in the patient’s condition without relying exclusively on multiple disconnected notes.
SWOT Analysis
A SWOT analysis was used to examine internal and external factors that could influence implementation and sustainability.
| Category | Key Findings | Strategic Response |
|---|---|---|
| Strengths | Experienced nurse supervisors and a strong nursing education department | Use supervisors for auditing and mentorship and education staff for training |
| Weaknesses | Reliance on agency staff and lengthy administrative approval processes | Pilot the tool on one unit and strengthen recruitment through academic partnerships |
| Opportunities | Alignment with applicable CMS and Joint Commission expectations | Incorporate relevant regulatory requirements into the assessment and audit process |
| Threats | Staff resistance and excessive stakeholder input | Use a focused workgroup, provide education, and reinforce expectations through supervision |
The SWOT analysis demonstrates that organizational strengths can be used to address implementation barriers. For example, experienced supervisors can provide coaching and auditing, while nursing education leadership can help staff develop confidence with the new process.
Impact Analysis
The project has potential benefits as well as implementation risks. A major anticipated benefit is improved medication monitoring. Consistent documentation of medication effectiveness, adherence, and PRN use can help clinicians recognize concerns that may require further assessment or intervention.
The project may also improve communication among nurses, providers, social workers, and other members of the interdisciplinary team. However, implementation can temporarily increase documentation workload and may create staff concerns about auditing or performance expectations.
| Area | Anticipated Benefits | Potential Risks |
|---|---|---|
| Medication monitoring | Better monitoring of medication effectiveness and earlier identification of concerns | Increased identification and reporting of medication-related problems; staff discomfort during initial audits |
| Nursing documentation | Improved communication, consistency, and regulatory alignment | Additional documentation time and potential documentation fatigue |
The original project analysis calculated a benefit-to-risk ratio of 1.57. This finding was used within the project to support implementation while recognizing the need to actively manage workload, training, and staff acceptance.
Project Justification and Purpose
The purpose of this healthcare improvement project is to implement a standardized weekly nursing assessment for patients receiving care in acute psychiatric units. The assessment is intended to provide a consistent method for documenting treatment response, patient engagement, medication use, behavioral patterns, physical health findings, and discharge-related information.
Standardization can improve the accessibility and consistency of clinically important information. Rather than requiring team members to locate relevant information across multiple documentation sources, the weekly assessment can provide a structured clinical summary.
The project also supports quality improvement by creating an opportunity to establish measurable documentation expectations, educate staff, monitor compliance, and use audit findings to identify additional improvements.
Evidence From the Literature
Research supports the importance of complete and clinically meaningful nursing documentation. Moldskred et al. (2021) examined strategies for improving nursing documentation and emphasized the relationship between documentation quality and nursing practice. Their work supports the broader principle that structured and accurate documentation can strengthen continuity and quality of care.
Research concerning psychiatric nursing also highlights the importance of careful monitoring and documentation of medication use. Wong and Muller (2023) examined nurses’ use of PRN medications in adult acute mental healthcare and identified the importance of appropriate assessment and documentation surrounding PRN medication use.
Ameel et al. (2019) reviewed nursing interventions in adult outpatient psychiatric care and demonstrated the broad clinical contribution of nurses to psychiatric treatment. This supports the importance of ensuring that nursing documentation captures more than behavioral observations alone.
Medication monitoring is another relevant component. Schoretsanitis et al. (2020) discussed the clinical value of therapeutic drug monitoring in antipsychotic treatment. Incorporating medication-related information into a standardized nursing assessment can therefore provide useful information for ongoing clinical evaluation.
Barr et al. (2019) examined approaches to promoting positive and safe care in forensic mental health inpatient environments. Their work reinforces the importance of therapeutic relationships, communication, and structured approaches to maintaining safe psychiatric care.
Collectively, the literature supports the need for nursing documentation that is accurate, clinically relevant, consistent, and useful to the broader healthcare team.
Regulatory and Organizational Environment
The project is designed within the regulatory environment governing hospital and behavioral health documentation. CMS hospital requirements address documentation of patient care and clinical progress, while The Joint Commission provides standards relevant to behavioral health organizations and patient safety.
The proposed weekly assessment incorporates information related to physical health, medication adherence, behavioral status, treatment participation, laboratory or monitoring needs, and discharge planning. Aligning the documentation process with applicable organizational policies and regulatory requirements can help establish a consistent standard of practice.
Regulatory requirements should be verified against the current version of applicable CMS and Joint Commission standards before the tool is formally adopted because requirements and interpretive guidance can change over time.
SMART Goal
The project uses a SMART goal to establish measurable expectations for implementation.
| SMART Element | Project Goal |
|---|---|
| Specific | Develop and implement a standardized weekly nursing assessment addressing physical health, patient engagement, behavioral status, and medication adherence |
| Measurable | Achieve a 95% completion rate among eligible patients |
| Achievable | Use nursing leadership, nursing education, and supervisors to provide training, monitoring, and support |
| Relevant | Improve documentation quality, interdisciplinary communication, patient care, and regulatory alignment |
| Time-bound | Initiate the project on February 14, 2024, and achieve full implementation by May 29, 2024 |
The 95% completion target provides a clear metric for evaluating adoption. Compliance can be measured through routine audits, allowing the project team to determine whether additional education or workflow modifications are needed.
Project Management Lifecycle
The project follows four major phases: initiation, planning, implementation, and evaluation/closure.
During initiation, the organizational problem is identified, project objectives are established, and key stakeholders are engaged. The project team also defines the scope of the documentation improvement initiative.
During planning, responsibilities, timelines, resources, educational requirements, and implementation strategies are established. The assessment tool is developed with input from nursing, clinical, social services, education, and administrative stakeholders.
During implementation, staff members receive education and the standardized assessment is introduced into the selected clinical workflow. Supervisors can provide coaching and monitor completion while staff feedback is collected to identify practical barriers.
During evaluation and closure, project data are reviewed to determine whether the implementation target was achieved. Completion rates, staff feedback, documentation quality, and workflow concerns can be examined. Findings can then guide revisions and determine how the assessment process can be sustained or expanded.
Conclusion
A standardized weekly nursing assessment provides a structured approach to improving clinical documentation in acute psychiatric care. By combining physical assessment findings, medication information, behavioral trends, treatment participation, ADL support, and discharge-related information, the tool can create a more complete clinical picture for the interdisciplinary team.
The project is supported by stakeholder expertise, nursing education resources, quality-improvement methods, and relevant literature concerning psychiatric nursing, documentation, medication monitoring, and patient safety. Establishing a measurable completion target and using a structured project-management lifecycle also creates a framework for evaluating implementation and supporting long-term sustainability.
References
Ameel, M., Kontio, R., & Välimäki, M. (2019). Interventions delivered by nurses in adult outpatient psychiatric care: An integrative review. Journal of Psychiatric and Mental Health Nursing, 26(9–10), 301–322. https://doi.org/10.1111/jpm.12543
American Nurses Association. (2010). ANA’s principles for nursing documentation: Guidance for registered nurses. https://www.nursingworld.org
Barr, L., Wynaden, D., & Heslop, K. (2019). Promoting positive and safe care in forensic mental health inpatient settings. International Journal of Mental Health Nursing, 28(4), 793–814. https://doi.org/10.1111/inm.12588
Centers for Medicare & Medicaid Services. (2024). State Operations Manual Appendix A: Survey protocol, regulations and interpretive guidelines for hospitals. https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information
D156 Updated HIP Paper Template for Nursing Weekly Assessment
Hansmann, M. L. (2018). The top skills every healthcare process improvement leader must have. Health Catalyst. https://www.healthcatalyst.com
Moldskred, P. S., Snibsøer, A. K., & Espehaug, B. (2021). Improving the quality of nursing documentation. BMC Nursing, 20, Article 94. https://doi.org/10.1186/s12912-021-00629-9
Schoretsanitis, G., et al. (2020). Blood levels to optimize antipsychotic treatment in clinical practice. The Journal of Clinical Psychiatry, 81(3).
The Joint Commission. (2018). Behavioral health care standards sampler. https://www.jointcommission.org
Wong, S., & Muller, A. (2023). Nurses’ use of PRN medication in adult acute mental healthcare settings. International Journal of Mental Health Nursing. https://doi.org/10.1111/inm.13148