Early SLP Consults for Feeding/Swallowing Difficulties and Failure To Thrive

The example below uses the Model for Improvement framework.

What are we trying to accomplish?

• SMART Aim—Reduce the time from hospital admission to SLP consult for pediatric patients with feeding/swallowing difficulties or failure to thrive (FTT). Within 6 months, we aim to receive SLP consults within 24 hours of admission.
• The goal is to
  • support earlier SLP intervention,
  • reduce reliance on alternative nutrition and hydration (ANH), and
  • shorten the hospital length of stay (LOS).

How will we know that a change is an improvement?

• We will see the following changes:
  • higher percentage of eligible patients receiving an SLP consult within 24 hours
  • shorter LOS for patients with timely SLP involvement

What changes can we make that will result in improvement?

• Implement automatic SLP consults (“triggers”) in the EMR software for patients admitted with pediatric feeding disorder (PFD) or FTT.
• Educate nursing and medical staff about the importance of timely SLP referrals.
• Include SLPs in multidisciplinary rounds for at-risk patients.

PDSA cycle: testing the changes

Plan

• Test the proposed changes on one pediatric unit.
• Review baseline data, educate staff, and activate the EMR triggers.

Do

• Implement the new process for a 4-week period.
• Track percentage of eligible patients receiving an SLP consult within 24 hours, LOS, and staff feedback during this time.

Study

• Analyze the data:
  • SLP consults received within 24 hours of admission for eligible patients increased from 40% to 65%.
  • LOS decreased by an average of 1.2 days for eligible patients with SLP consults received within 24 hours of admission.
  • Staff found EMR triggers helpful, but requested clearer guidance on patient selection criteria.

Act

• Refine the workflow based on lessons learned:
  • Update staff education materials.
  • Adjust EMR trigger wording.
  • Continue chart audits to track consult timing and LOS.
  • Assign staff the roles of “rehab champions” (SLPs, physical therapists, occupational therapists), “nursing champions”, and “physician champions” to support ongoing accountability

Reducing Environmental Noise in the NICU To Enhance Neurodevelopmental Outcomes   

The example below uses the Define, Measure, Analyze, Improve, and Control (DMAIC) Framework.

Define

• Problem: Neonatal intensive care unit (NICU) noise levels often exceed 45 decibels (dB), disrupting infant sleep and neurodevelopment, which can increase stress responses and affect feeding and growth patterns in preterm infants.
• Goal: Lower the average NICU noise levels to below 45 dB.
• Stakeholders: SLPs, physical therapists (PTs), occupational therapists (OTs), nurses, and physicians.

Measure

• Baseline Data: Sound levels were > 45 dB at multiple time points, especially during care transitions.
• Data Monitoring Includes the Following Components:
  • spot checks with a sound-level meter
  • use of a visual “stoplight” system showing when noise exceeds healthy limits

Analyze

• Top Noise Sources
  • alarms
  • TVs
  • loud voices
  • door closures
  • workflow in high-traffic areas

• Contributors
  • reduced staff awareness
  • lack of quiet-hour protocols
  • environmental design

Improve

• The interventions below offer some strategies for improvement:
  • Provide staff and caregiver education addressing the impacts of noise on neurodevelopmental outcomes.
  • Institute a quiet-hours policy.
  • Adjust alarm volumes.
  • Install soft-close mechanisms on incubators and doors.
  • Add noise-reducing floormats and wall panels.
  • Prominently post clearly worded signage and environmental cues.
• Outcome: Average noise levels dropped below 45 dB over the course of 6 months.

Control

• Next Steps
  • Perform ongoing sound checks, and sustain the visual “stoplight” system.
  • Provide continued staff and caregiver training.
  • Evaluate additional environmental modifications—such as noise-dampening materials.

Appoint NICU “noise champions” to maintain and monitor the unit’s noise-reduction efforts.

Improving Timely SLP Consults for Patients Post-Stroke 

The example below uses the Focus–Analyze–Develop–Execute/Evaluate (FADE) framework.

Focus

• Problem: Many stroke survivors with cognitive-communication deficits do not receive follow-up SLP services after hospital discharge, often due to unclear referral processes and limited understanding of the benefits of therapy. As a result, these patients may struggle with returning to work, managing medications, or engaging in social participation—leading to long-term functional impairments and decreased quality of life.
• Goal: Increase timely, consistent outpatient SLP referrals and improve follow-up after hospital discharge.

Analyze

• Baseline Data (Patients Post-Stroke Recommended for Outpatient SLP Services):
  • 40% had referrals placed before hospital discharge.
  • 25% had an appointment scheduled within 2 weeks of discharge.
  • 50% were lost to follow-up within 30 days.
  • Among patients with scheduled appointments, the no-show or cancellation rate was 15%.

• Barriers Identified
  • Referrals were not embedded into the patient’s EMR.
  • Patient and medical provider did not fully understand the SLP’s role.
  • Inpatient and outpatient SLP teams experienced gaps in their communication.

Develop

• Interventions
  • Implemented an auto-referral order in outpatient EMR software for all patients post-stroke who received inpatient SLP services.
  • Shared a plain-language flyer about the SLP’s role post-stroke, and reviewed it with patients before hospital discharge.
  • Made outpatient scheduler follow-up calls to all patients post-stroke after hospital discharge.
  • Conducted brief in-services for case managers and inpatient rehab teams.

Execute/Evaluate

• Results After 6 Weeks (Patients Post-Stroke Recommended for Outpatient SLP Services):
  • 70% had referrals placed before hospital discharge (up from 40%).
  • 50% had an appointment scheduled within 2 weeks of discharge (up from 25%).
  • 25% were lost to follow-up within 30 days (down from 50%).
  • Among patients with scheduled appointments, the no-show or cancellation rate rose to 20% (up from 15%).

• Next Steps
  • Standardize the automatic referral protocol in the EMR software and the outpatient scheduler follow-up calls.
  • Use patient and care partner feedback to revise educational materials.
  • Explore telehealth options and community partnerships to improve access to services.

Improving Adherence to Swallowing Precautions Using Standardized Communication

The example below uses the Lean A3 framework.

Background

• SLP-recommended swallowing precautions and diet modifications are inconsistently followed, increasing the risk of aspiration, pneumonia, and poor nutrition. Inconsistent communication across teams is a key contributor.

Current Condition

• Signage and EMR documentation of swallowing and diet precautions vary.
• Staff are unclear about roles in implementing swallowing precautions.
• After SLP evaluations, care team members do not consistently use Situation, Background, Assessment, Recommendation (SBAR) communication—a standardized communication tool used in health care settings to share concise, relevant information during handoff.

Problem Statement

• Lack of consistent communication following SLP swallowing evaluations leads to reduced implementation of swallowing precautions and increased risk of swallowing-related complications.

Target/Goal

• Standardize documentation and signage.
• Implement SBAR communication after all SLP swallowing evaluations.
• Reduce swallowing-related safety incidents.

Root Cause Analysis

• There is no standardized communication method (e.g., care team members do not use SBAR communication).
• Staff awareness and accountability vary.
• Communication gaps occur during shift changes and handoffs.

Countermeasures

• Use SBAR communication for nurse and/or certified nursing assistant (CNA) handoff after each SLP evaluation.
• Prominently post signage—addressing swallowing precautions—at the head of the bed when permitted.
• Provide brief in-services to staff.
• Select nursing staff members to be unit-based “dysphagia champions.”
• Document swallowing precautions and modified diets consistently in the patient’s EMR.

Action Plan

• Weeks 1–2: Start by testing the changes on a single unit.
• Weeks 3–4: Expand the program facility-wide; conduct weekly team check-ins with the SLP and the nursing staff.

Results After 1 Month

• SLPs document SBAR communication in 80% of swallowing evaluations (up from 0%).
• SLPs document swallowing precautions and modified diets in the EMR at a rate of 100% (up from 95%).
• Staff have posted room signage for 75% of applicable patients.
• Documented aspiration events decreased from four to two.

Follow-Up Plan

• Make the SBAR communication method a required step during every SLP-to-nurse/CNA handoff.
• Incorporate training into onboarding and quarterly refreshers.
• Explore EMR alerts for swallowing precautions.
• Reassess every 6 months with chart audits and an incident review. 

Improving Communication Access to Facilitate Patient Safety and Participation 

The example below uses the Plan–Do–Study–Act framework.

Plan

• Problem: Residents with communication disorders or differences may struggle to fully participate in their care. Without accessible communication—like plain language, visual aids, or augmentative and alternative communication (AAC)—they face greater risks of misunderstandings, safety issues, and avoidable hospitalizations. Health care providers are responsible for tailoring communication to meet individual needs as part of equitable, patient-centered care.

• Goals
  • Improve communication access for residents with communication disorders or differences.
  • Increase the staff’s ability to tailor communication methods—e.g., with written information, visual aids, or AAC.
  • Support residents’ participation in their own care planning.

• Measures
  • percentage of residents with communication plans documented in their EMR
  • percentage of staff trained in communication access
  • percentage of residents’ participation in care meetings
  • percentage of residents with documented use of interpreter, transliterator, or translator services in the EMR (when appropriate)
  • residents’ feedback on their understanding of health care interactions

Do

• The SLP
  • screens new residents for communication needs,
  • writes individualized communication plans following comprehensive evaluation,
  • collaborates with facility administrators to train staff using ASHA resources and role-plays,
  • implements communication supports,
  • uses the SBAR communication method to document communication needs in patient handoffs, and,
  • involves care partners in all planning.

Study

• Results
  • 55% of residents had communication plans (up from 0%).
  • 70% of staff were trained in communication access (up from 0%).
  • 80% of residents with communication access needs attended care meetings (up from 20%).
  • Documentation of interpreter, transliterator, or translator use rose to 75% (from 40%).
  • Resident interviews showed better understanding of health interactions.
  • Staff reported more confidence but noted barriers to using plain language.

Act

• Next steps
  • Make communication planning a standard component of care conferences.
  • Add documentation of communication accommodations and tools to the facility’s admission protocol.
  • Provide quarterly training, and identify nursing staff members to serve as “communication champions.”
  • Sustain by doing a monthly audit, updating patients’ communication accommodations and supports to ensure they are still effective.