No Formula Before the Film Is Read: A Quality Improvement Charter, Aim Statement and First PDSA Cycle for Feeding Tube Placement on a Neuroscience Step-Down Unit
Student Name
American College of Education
NUR5053: Quality Improvement and Safety
Module 4 Assignment
Instructor Name
November 3, 2026
Problem Statement
On the composite neuroscience step-down unit this course has followed, a 30-bed floor, enteral feeding sometimes begins before a radiologist has confirmed where a newly placed small-bore feeding tube lies. The unit's two known misplacements in the past year, one caught and one that ended in aspiration pneumonia, were examined in the earlier modules of this course. The root cause analysis traced the harmful event to an imaging status that reads Completed once the film is taken, an order that can be started without a filed result and routine overnight read times. The failure mode analysis then showed that the same process can also fail earlier, when a patient at high risk of airway placement is not recognized as high risk.
A baseline audit made the problem countable. The clinical nurse specialist reviewed the records of the 48 placements on the unit during August and September 2026. In 11 of them, 23%, the first feeding was documented before a radiologist's result was filed; the gap ranged from 20 minutes to just over five hours, and nine of the 11 occurred between 1900 and 0700. Of the 48 patients, 19 met the risk criteria the team had drafted, which were reduced alertness, an absent or weak cough, or an artificial airway, and every one of the 19 had a blind bedside insertion. The median time from insertion to a filed result was 3.4 hours at night and 1.1 hours during the day.
Aim Statement
Langley and colleagues build their Model for Improvement on three questions that ask about the goal, the evidence that would show progress and the changes worth trying (Langley et al., 2009). The first question is answered by the aim, which must say what will improve, by how much, for whom and by when, so that the team can tell at the end whether it succeeded.
The project's aim is as follows. By April 30, 2027, on the neuroscience step-down unit, the percentage of first enteral feedings started after a radiologist's placement result is filed will rise from 77% to 100% and stay there for eight consecutive weeks, and the percentage of high-risk patients whose tubes are placed with electromagnetic guidance will rise from 0% to at least 80%. The aim is set at 100% for the first measure because a feeding through an unconfirmed tube is a hazard that should never occur, not a rate to be trimmed. The second target is lower because guided placement depends on trained staff being available at every hour, which the project cannot guarantee in its first six months.
Measures
The project will track one outcome measure, two process measures and two balancing measures. The outcome measure is the number of airway or other misplacements detected after any feeding has begun, counted monthly, with the expectation that it stays at zero; because it is rare, it cannot show improvement by itself, and the process measures will carry the weekly signal. The first process measure is the weekly percentage of first feedings started after a filed result, drawn from the pump documentation and radiology timestamps. The second is the monthly percentage of patients screened as high risk who received guided placement.
The balancing measures look for harm the changes could cause. Locking the feeding order until a result is filed could delay nutrition, so the team will track the median hours from placement order to first feeding. A new priority category for feeding tube films could slow other overnight reads, so radiology will report the median night turnaround for all portable chest films. Each measure has an operational definition written into the charter's appendix, including which timestamp counts as the start of feeding, so that two people pulling the same record reach the same number.
Scope, Team and Changes to Test
The project covers nasal small-bore feeding tubes placed at the bedside on the step-down unit, on all shifts, for adult patients. Tubes placed in interventional radiology or endoscopy, gastrostomy tubes and the neurological intensive care unit are out of scope for now, although the intensive care unit has asked to join a later phase. The sponsor is the director of neuroscience nursing, who controls the budget for guidance equipment and can open doors in radiology and informatics. The project lead is the unit's clinical nurse specialist. Team members are two staff nurses, one from nights, an informatics nurse, a radiology supervisor and a dietitian; a quality department coach will meet with the team every two weeks.
The team will test four changes drawn from the earlier analyses. The first is a three-question risk screen added to the placement order, which routes high-risk patients to guided placement. The second is a forcing function that keeps the enteral nutrition order from releasing to the pump workflow until a result is filed; because an electronic build takes about ten weeks, a paper version will be tested first. The third is a feeding tube film priority in radiology with a 60-minute target. The fourth is a rebuilt placement competency. The changes are ordered so the ones that block the most severe failures are tested first.
The First PDSA Cycle
Plan. The first cycle will test a paper stand-in for the forcing function on night shift for two weeks. When a tube is placed, the nurse will hang a red tag on the feeding pump reading No feeding until the placement result is filed, and only the nurse who reads the filed result may remove it, initialing the tag with the time. The question is whether the tag stops feedings from starting early at night without adding more than an hour to the time before a feeding begins. The team's prediction, written before the test, is that at least nine of every ten night placements will reach a filed result before feeding and that the median delay will grow by less than 45 minutes, because the tag makes the rule visible at the moment of decision without speeding up the read.
Do. Two night nurses will carry out the test on the first four or five placements, and the clinical nurse specialist will review each record the next morning, noting any tag removed early and any comments from staff.
Study and act. The results will be compared with the prediction, and the team will decide whether to adopt, adapt or abandon the tag. If the tag works but the delay grows beyond an hour, the next cycle will pair it with the radiology priority rather than widen the tag to day shift. In a review of 73 published applications, Taylor et al. (2014) counted only 14 that reported a full series of linked cycles, and only 7 of the 47 fully analyzed studies used monthly or more frequent data to decide what to test next, and Reed and Card (2016) warned that PDSA is often reduced to a single large implementation with a new name. This cycle is kept small, short and predicted on purpose, so that its failure would cost two weeks and teach the team something.
Conclusion
The charter gives the unit a problem it can count, an aim it can check, measures that watch for harm as well as gain and a first test small enough to fail safely. The next module sets out how the weekly process measure will be plotted and read over the life of the project, so the team can tell a real improvement from an ordinary week.
References
Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.
Reed, J. E., & Card, A. J. (2016). The problem with Plan-Do-Study-Act cycles. BMJ Quality & Safety, 25(3), 147-152. https://doi.org/10.1136/bmjqs-2015-005076
Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862
How this NUR 5053 Module 4 example is structured
NUR 5053 Module 4 in many sections drafts a QI project charter with an aim statement and a PDSA cycle; your classroom's instructions decide the charter template and whether results from the cycle are expected. This example states the problem with baseline data, writes one aim that names what, how much and by when, sets outcome, process and balancing measures, draws the scope, names the team, and plans the first cycle small enough to run in two weeks.
NUR5053 Module 4 questions, answered
What does NUR5053 Module 4 usually ask for?
NUR5053 Module 4 in many sections asks for a quality improvement project charter: the problem with baseline data, an aim statement, measures, scope, team and a planned PDSA cycle. Your classroom's instructions decide the template and whether you report results from the cycle.
How specific does the aim statement need to be?
Specific enough that someone could check at the end whether you met it. Name the measure, the population or unit, the starting value, the target and the date. If a target is 100%, say why a lower number would not be acceptable.
What is a balancing measure?
A measure that watches for harm the change might cause somewhere else. If your change adds a step, track whether it delays care; if it adds work for another department, track that department's turnaround.
Write yours, or have the desk draft it
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