Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2022


Doctor of Nursing Practice (DNP)

Primary Advisor

Christine Pintz, PhD, FNP-BC, FAANP; Lisa Kidin, PhD, MHA, MSN, RN, CPHQ, NEA-BC


Centers for Disease Control Framework; Program Evaluation; emergency department; trauma services


Background: Patient satisfaction scores are an area of priority for hospitals throughout the United States because of their association with quality outcomes for the patients (Davenport, O'Connor, Szychowski, Landry, & Hernandez, 2017). This healthcare organization implemented the practice of nurse leader rounding over the last five years with the goal of leaders rounding on 75% or greater of the units' populations without any organizational sustainment or achievement of upper decile patient satisfaction scores.

Aims: The aim of this project was to utilize the Centers for Disease Control Framework for a Program Evaluation to evaluate the redesigned leadership rounding program for patients in the emergency department and trauma services within a tertiary care hospital.

Methods: After engaging the stakeholders and obtaining a current description of the leader rounding program and available data as a guide, the group proposed three key changes that they felt would improve the rounding process and the associated outcomes as measures of programmatic success.

Results: The leader rounding compliance showed that there was a significantly higher proportion of days with leaders meeting target rounding although there was no statistical difference in the mean likelihood of recommending the facility patient satisfaction scores This QI process provided an objective review of the program evaluation in order to provide clear vision around leader rounding.

Recommendations: The utilization CDC's framework (2011) for program evaluation is a validated and functional instrument in determining the value and effectiveness of a leader rounding program resulting in this key recommendation:

•Continued monitoring of the program effectiveness and/or the need for interventions steering the implementation of this leadership practice.

•Continued evaluation of the current unit's HCAPHS scores for the next three months

•Development of sustainability for stakeholders, patient experiences partners, and nursing leaders

Open Access


Included in

Nursing Commons



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