Implementation of a Nurse Leader Rounding Program in the Emergency Department

Practice Problem: The identified practice problem was the low “Likelihood to Recommend” patient experience survey scores within the ED at the identified project setting. PICOT: The PICOT question that guided this project was “In ED patients (P), how does the implementation of Nurse Leader Rounding (I) compared to the prior state of no Nurse Leader Rounding (C) affect the “Likelihood to Recommend” top box score (O) within eight weeks (T)?” Evidence: In a review of 13 articles, the evidence consistently showed that Nurse Leader Rounding was a proven intervention for increasing patient engagement scores. Intervention: Nurse Leader Rounding is defined as the department leader rounding on the patient within the department and providing: 1) feedback to the primary care team related to observations of care expectations by the leader and 2) in the moment service recovery if needed Outcome: The outcome of the project was a clinically significant increase in “Likelihood of Recommending” by 2.3% while no statistical significance in scores. Conclusion: The conclusion of this project found that COVID-19 played a big part into the small increase in engagement scores. However, it did show that Nurse Leader Rounding, as an intervention, has the ability to increase patient engagement scores. NURSE LEADER ROUNDING 4 Implementation of a Nurse Leader Rounding Program in the Emergency Department Emergency department (ED) patients are often seen due to an acute illness or traumatic injury. ED’s are often the main entrance to the hospital inpatient units, and the stressful experience while in the ED can have lasting effects on the patient (Meade et al., 2010). This project paper will discuss the implementation of a nurse leader rounding (NLR) program and the effects it had on the overall experience of the ED patients. Significance of the Practice Problem The identified practice problem was the low “Likelihood to Recommend” patient experience survey score within the ED at the identified project setting. Patient experience scores have a direct correlation with a patient’s health outcomes (Heath, 2016). The patient experience within the ED has lasting effects throughout the entire inpatient stay (Setia & Meade, 2009). In 2006, the Center for Medicare and Medicaid Services (CMS) implemented the Hospital Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey which is intended to measure the experience of the patient during their hospital stay (McFarlan et al., 2019). HCAHPS scores have a direct relationship with the amount hospitals are reimbursed for their services and thus their overall financial margins (McFarlan et al., 2019). This connection between HCAHPS results and reimbursement rates has many hospital leaders focusing on patient experience to make sure they are providing the best care and achieving high scores. At the beginning of this project, the “Likelihood to Recommend” score is a top box score of 67.13% and a percentile ranking of 38% when compared to the Press Ganey database (J. Stewart, personal communication, May 27, 2020). A percentile rank of 38%, indicated 62% of the over 2,000 Press Ganey hospitals had a higher patient recommendation score. This project was necessary to assist in achieving a higher “Likelihood to Recommend” score. The practice of NURSE LEADER ROUNDING 5 tying patient experience to reimbursement rates for hospitals is relatively new: it began in 2006 with the creation of HCAHPS (McFarlan et al., 2019). However, it is a key indicator because positive experience by the patient suggests the patient will return and will not skip seeking medical care due to a negative previous experience (Tan & Lang, 2014). This connection between patient experience and returning to the ED based off previous experience when needed speaks to both financial and patient safety organizational goals. Hospitals must perform well financially if they want to keep providing care. Like any business, profitable margins allow for the company to retain employees and continue to provide its product (Betts et al., 2016). For hospitals, this product is caring for the community. Hospitals, just like any business, volume drives profits. Improved patient experience will increase patient loyalty, building a positive reputation and brand which will increase referrals provided by patients (Betts et al., 2016). A review of hospital profit margins and patient engagement scores showed that hospitals with top-box scores increased their net margin by 1.4% compared to hospitals with bottom-box scores (Betts et al., 2016, para. 5). While financial performance is important, patient health outcomes should be the driving factor for improving patient engagement scores. While the exact reasoning is not yet known, increased patient engagement scores have a positive relationship with patient outcomes (Glickman et al., 2010). This could be due to the trust and open communication shared by the patient and clinic staff (Luy et al., 2013). It could also be because patients who had a positive experience were more likely to complete needed follow up visits and to return to the hospital if they had a negative side effect post discharge (Luy et al., 2013). NURSE LEADER ROUNDING 6


Implementation of a Nurse Leader Rounding Program in the Emergency Department
Emergency department (ED) patients are often seen due to an acute illness or traumatic injury. ED's are often the main entrance to the hospital inpatient units, and the stressful experience while in the ED can have lasting effects on the patient (Meade et al., 2010). This project paper will discuss the implementation of a nurse leader rounding (NLR) program and the effects it had on the overall experience of the ED patients.

Significance of the Practice Problem
The identified practice problem was the low "Likelihood to Recommend" patient experience survey score within the ED at the identified project setting. Patient experience scores have a direct correlation with a patient's health outcomes (Heath, 2016). The patient experience within the ED has lasting effects throughout the entire inpatient stay (Setia & Meade, 2009) (McFarlan et al., 2019). This connection between HCAHPS results and reimbursement rates has many hospital leaders focusing on patient experience to make sure they are providing the best care and achieving high scores.
At the beginning of this project, the "Likelihood to Recommend" score is a top box score of 67.13% and a percentile ranking of 38% when compared to the Press Ganey database (J. Stewart, personal communication, May 27, 2020). A percentile rank of 38%, indicated 62% of the over 2,000 Press Ganey hospitals had a higher patient recommendation score. This project was necessary to assist in achieving a higher "Likelihood to Recommend" score. The practice of tying patient experience to reimbursement rates for hospitals is relatively new: it began in 2006 with the creation of HCAHPS (McFarlan et al., 2019). However, it is a key indicator because positive experience by the patient suggests the patient will return and will not skip seeking medical care due to a negative previous experience (Tan & Lang, 2014). This connection between patient experience and returning to the ED based off previous experience when needed speaks to both financial and patient safety organizational goals.
Hospitals must perform well financially if they want to keep providing care. Like any business, profitable margins allow for the company to retain employees and continue to provide its product (Betts et al., 2016). For hospitals, this product is caring for the community. Hospitals, just like any business, volume drives profits. Improved patient experience will increase patient loyalty, building a positive reputation and brand which will increase referrals provided by patients (Betts et al., 2016). A review of hospital profit margins and patient engagement scores showed that hospitals with top-box scores increased their net margin by 1.4% compared to hospitals with bottom-box scores (Betts et al., 2016, para. 5).
While financial performance is important, patient health outcomes should be the driving factor for improving patient engagement scores. While the exact reasoning is not yet known, increased patient engagement scores have a positive relationship with patient outcomes (Glickman et al., 2010). This could be due to the trust and open communication shared by the patient and clinic staff (Luy et al., 2013). It could also be because patients who had a positive experience were more likely to complete needed follow up visits and to return to the hospital if they had a negative side effect post discharge (Luy et al., 2013).

PICOT Question
In ED patients (P), how does the implementation of NLR (I) compared to the prior state of no NLR (C) affect the "Likelihood to Recommend" top box score (O) within eight weeks (T)?

Population
The population for this project was the patients admitted to the 42-bed emergency department of a mid-sized, 220 bed hospital. More specifically, the population was the patients seen and discharged from this department that received and completed a patient engagement survey that was distributed by a third-party company.

Intervention
This project implemented the intervention of NLR to increase patient engagement scores within the ED. This intervention has been used both within the ED and inpatient settings and been shown to increase many aspects of patient engagement surveys while ultimately increasing the overall ranking of ED patient engagement scores (Littleton et al., 2019;McFarlan et al., 2019). In this paper, NLR is defined as the department leader rounding on the patient within the department and providing: 1) feedback to the primary care team related to observations of care expectations by the leader and 2) in the moment service recovery if needed.

Comparison
At the start of the project, the setting had no structured approach to NLR or patient engagement. While research findings support the ability of NLR to help raise patient engagement scores, this department had not implemented such a strategy (McFarlan et al., 2019). The comparison for this project was the previous state patient engagement scores prior to the implementation of NLR.

Outcome
The intended outcome of this project was to see a statistically significant increase in ED patient engagement scores. Specifically, the "Likelihood to Recommend" question was tracked, as this question is used to compare overall patient engagement at the local, system, and national levels. The project team also identified two key domain questions that would be directly influenced by NLR. "Nurses concern to keep you informed about your treatment" and "How well the staff cared about you as a person."

Timeline
The timeline for this project was eight weeks starting on November 1 st and ending December 26 th . It allowed the project team to develop the project details, educate needed stakeholders, implement the program, collect, and interpret data.

Quality Improvement Framework & Change Theory
Employing a guiding framework and change theory keeps the project organized and structured. While there were many to choose from, it was important to select options that would work within the scope of the implemented project and that were supported within the sponsoring organization. The Kotter's Change Theory (1995) was selected for this project to assist in the execution of necessary change. The Kotter Change Theory (1995) andLEAN framework (1988) were selected for this project due to their routine use within the organization.
The LEAN framework supports reducing waste and limiting actions to only needed steps (Mostafa, et al., 2013). This reduction in extra steps ensures that standardization is used when possible. This standardization was seen within the literature and the LEAN framework was utilized throughout the project development to each required step was both within the literature but also needed so that nothing extra was completed resulted in additional time.
While the LEAN framework was present throughout the project, the Kotter Change Theory (1995) was the driving theory to organize the implementation of this project. The Kotter Change Theory was being used and also taught to all staff as the sponsoring organization went through its High Reliability Organization journey. The Kotter Change Theory is an 8-step theory and framework that provided the project manager a structure from start to finish (Kotter, J., 1995). The project began after the organization had already established a strong significance for need, "Likelihood to Recommend" survey scores in the 38-percentile rank. It followed the steps of project team development, vision creation, working through communication and barrier removal (Kotter, J., 1995). The project team worked through short term goals and on sustainability measures that will continue the project after the short-term implementation and analysis. These steps were directly related to the Kotter (1995) model.

Evidence Search Strategy
A robust literature search was completed to support this project. The PICOT question was: "In ED patients (P), how does the implementation of NLR (I) compared to the prior state of no NLR (C) affect the "Likelihood to Recommend' top box score (O) within eight weeks (T)?" The three databases used were Google Scholar, CINAHL Complete, and PubMed. When searching, the following keywords were used: "emergency department," "patient engagement," "patient experience," "patient satisfaction," "nurse leader rounding," and "leader rounding." Inclusion criteria were articles written in English, published in 2009 or more recently, speaking to leader rounding on patients, peer reviewed research, and set setting within an acute care hospital. Exclusion criteria eliminated articles that spoke to nurse leader rounding on staff instead of patients, were outside of the acute care hospital setting, and were published before 2009. Once results from the initial search were gathered, the DNP student read abstracts. Articles that met both inclusion and exclusion criteria were then fully reviewed to analyze their appropriateness for the project.

Evidence Search Results and Evaluation
Using the previously mentioned search strategy, a review of three databases was completed. The initial search, presented in the Figure 1 by use of a PRISMA diagram, resulted in 43 articles for review (Moher et al., 2009). After removal of duplicates, 21 articles were left to review. Once a review of all abstracts was completed and inclusion and exclusion criteria were applied, 14 remained as evidence for performance of the intervention established for this project.
Reduction from 21 to 14 articles resulted due to articles not meeting inclusion criteria and/or meeting exclusion criteria. Following these steps, this author was able to confidently say that all articles were reviewed from 2009 to 2020 related to NLR or Leader Rounding to improve patient engagement scores.
The SORT methodology was then used to grade individual articles and assign each a strength level based on type of research, outcomes, and consistency (Ebell et al., 2009). See Table 1 for article strength. The individual systematic review was reviewed and graded separately (see Table 2). A consistent message appeared that implementation of NLR had a direct effect on the increase of overall patient engagement scores. The consistent results and conclusions of the presented data resulted in a SORT grade of a B (Ebell et al., 2009). While consistent outcomes were found and large sample sizes were used, identified studies did not include higher level research, such as randomized control studies or meta-analyses. The research that was found was well done and did show a consistent correlation between NLR and patient engagement scores. This consistency confirmed a grade of B on the SORT grading system (Ebell et al., 2009).

Themes from the Evidence
Three primary themes were identified to support this evidence-based project: a consistent relationship of NLR and patient engagement, a structured approach to rounding, and standard communication during all rounds.

Consistent Relationship of NLR and Patient Engagement
A major theme that was seen through the research was consistent and proper NLR resulted in increased patient engagement scores (Babaev, 2017;Baker, 2010;Gillam et al., 2017;Hudson-Covolo et al., 2017;Littleton et al., 2019;McFarlan et al., 2019;Morton et al., 2014;Pattison et al., 2017;Reid, 2017;Setia & Meade, 2009;Sturdivant et al., 2020;Tan & Lang, 2014;Tothy et al., 2018;Winter & Tjiong, 2015). While there were slight differences in process, the NLR was judged to be an effective intervention for patient engagement improvement in all of the studies' results. This consistency provided substantial support for implementation of the intervention for increasing patient engagement scores.

Structured Approach
While variation occurred in the literature, a well-defined and structured approach was seen in many of the articles reviewed (Babaev, 2017;Hudson-Covolo et al., 2018;McFarlan et al., 2019;Morton et al., 2014;Sturdivant et al., 2020). Sturdivant et al. (2020) spoke to a welldefined, detailed process that assigned the acronym "PATIENT" (p. 159). Although the PATIENT process was not identified within all articles, others did address the same expectations of the need for a standard, consistent, and structured approach (Babaev, 2017;McFarlan et al., 2019;Morton et al., 2014).

Standard Communication
Along with a structured approach, standard communication was a consistent theme seen throughout the articles reviewed (Gillam et al., 2017;Hudson-Covolo et al., 2018;Littleton et al., 2019;Reid, 2017;Setia & Meade, 2009;Tothy et al., 2018). Gillam et al. (2017)  A review of the 13 articles indicated there were differences within the process, communication, and expectations of leaders during rounding. However, all of the studies reported the process of rounding increased the overall patient engagement score within the department. While consistent messaging was seen throughout all articles, no randomized controlled trials have been published that address NLR and its effect on patient engagement scores. The consistent findings through quality improvement studies and well documented outcomes give confidence NLR will be an appropriate evidence-based intervention to improve patient engagement scores.

Practice Recommendations
According to the completed literature search and presented results, NLR exhibited an evidence-based intervention for improving overall "Likelihood to Recommend" patient engagement scores within the ED (Babaev, 2017;Gillam et al., 2017;Hudson-Covolo et al., 2017;Littleton et al., 2019;McFarlan et al., 2019;Morton et al., 2014;Pattison et al., 2017;Reid, 2017;Setia & Meade, 2009;Sturdivant et al., 2020;Tan & Lang, 2014;Tothy et al., 2018;Winter & Tjiong, 2015). While there was a lack of random control and meta-analysis studies addressing this topic, the evidence was consistent within multiple quality improvement projects and indicated that NLR was associated with significant increases in patient engagement scores.
This consistency of intervention and outcome ensured that NLR would achieve the same desired outcome within this project. Therefore, the literature supported development of a standardized tool to ensure standardized questions and structure for the rounding leader. Standardization was consistent through the literature and ensured that the process was reliable (Babaev, 2017;Hudson-Covolo et al., 2018;McFarlan et al., 2019;Morton et al., 2014;Sturdivant et al., 2020).
Within the literature, a direct relationship was seen between increased patient engagement scores, clinical patient outcomes, trust between clinicians and patient, and financial benefits to the organization (Bresnick, 2015& Heath, 2016. Due to these reasons and consistency within the available research, NLR was a supported intervention to increase patient engagement scores.

Project Setting
This project's setting was an urban, level one trauma center ED. The ED was within a 236-bed tertiary hospital located in Jefferson County, Colorado. The average patient within the department was 55 to 65years old, Caucasian, and male (J. Stewart, personal communication, May 27, 2020). The setting was the referral hospital for an extensive health system within Colorado made up of 17 hospitals.
A SWOT analysis was completed to identify strengths, weaknesses, external opportunities, and threats (see Table 3). Identified weaknesses and threats were mitigated where possible while strengths and opportunities continued. The strengths were the significant support of and motivation by the hospital's Chief Nursing Officer (CNO), and an external opportunity was the support from the system patient experience director. One weakness was the limited time of the unit leadership team. External threats were changing priorities within the system associated with COVID-19 due to changes in needs of both staff and patients. Leadership time constraints were mitigated by ensuring that leadership had dedicated time free of meetings supported by the CNO.

Project Overview
This project implemented an evidence based NLR program. The expected outcome was to increase the quality of patient rating of their experience during their stay in the ED. The mission of the program setting was "We extend the healing ministry of Christ by caring for those who are ill and by nurturing the health of the people in our communities" (Centura Health, n.d.).
The project's expected outcome addressed and helped to fulfill the organization's mission.
The risk of meeting the project's shortand long-term objectives was related to the organization's priorities and the department leadership team's commitment. To be effectively implemented, NLR requires a significant time commitment from the department leadership.
While the risk of leadership prioritization cannot be mitigated and must be accepted, the risk of department leadership time constraints was mitigated by effectively demonstrating the project's benefit, how daily tasks could be accomplished during NLR, and reserving dedicated time for rounding, free of meetings.
While the long-term objective is to increase patient engagement scores, the short-term objectives were to establish a NLR plan with the department leadership group that was both effective and sustainable. The long-term objective of increasing patients' experience while seeking care could only be met by meeting the short-term objective first.

Project Plan (Method)
Kotter's Change Model was the framework for this project (Kotter, 1995). This model has proven success in establishing guidelines for large-scale changes across an organization (Appelbaum et al., 2012). This was also the change model promoted within the organization. The Kotter Change Model is an eight-step process that guided the project leader to gain urgency and anchor the change as standard work within the department (Kotter, 1995). The Doctor of Nursing Practice (DNP) student assumed the role of the project lead. The project team, which assisted in the implementation, was made up of department and hospital team members.

Create a Sense of Urgency
A meeting took place to understand the current state within the project setting and to create a sense of urgency. The project lead met with the system and local patient engagement leaders to understand current and future state expectations. Before the NLR program was implemented, the department was not meeting hospital or system-wide goals related to patient engagement. The department was also seeing increased competition across the market area as additional freestanding EDs and urgent care centers opened. The increase in patient engagement scores was therefore vital to the survival of the department.

Build a Guiding Coalition
The project lead developed a project team, which involved department leadership, the patient engagement manager, quality department leadership, department medical director, Press Ganey representative, and system patient engagement director. The project lead gained approval and support from the hospital's Chief Executive Officer (CEO), CNO, and Chief Medical Officer (CMO). Although development of the project was the project lead's responsibility, the project team was essential to provide expertise and support implementation.

Form a Strategic Vision and Initiatives
The project lead created a strategic vision for the project: "To increase patient engagement scores within the ED by use of a sustainable NLR program." This evidence-based approach to increasing patient engagement scores presented many challenges and opportunities for the project team.
In collaboration with the system patient experience director, a four-hour class was held to kick start the NLR program within the ED. The clinical nurse manager (CNM), assistant nurse managers (ANMs), and the hospital patient experience manager attended. This class reviewed literature findings related to the benefits of NLR, the understanding of the current state of the department, and the need for improvement. Activities included sharing the project expectations, job aids that were used, process expectations, role-playing to practice, and obtaining feedback.
Once IRB approval was gained, training was completed with the CNM and ANMs. The CNM and ANMs were allowed to practice NLR with actual patients and feedback with staff members. Once the CNM and ANM had time to practice before the project started, the CNM and ANMs were validated on their NLR adherence by the project lead using a validation tool (see Appendix A).
Once they were approved to continue, the CNM and ANM began NLR and data collection with the assistance of the project lead on the project start date. The project's timeline expanded over 45 weeks and included the development of the project proposal and ended with dissemination (see Appendices B through D). Once the project started, the project lead met weekly with the hospital patient experience manager, CNM, medical director, and quality director to review Press Ganey data and all collected data by the CNM and ANMs. Data were reviewed for completeness, and feedback was given based on the prior week's accomplishments.
These weekly meetings continued throughout the project, and the project team continued to evaluate the project's status.
The data collected by the Press Ganey survey were, date of visit, "Likelihood to Recommend" daily survey results, "Nurses' concern to keep you informed about your treatment" daily survey results, and "How well the staff cared about you as a person" daily survey results.
Data collected around NLR were the leader completing the rounding, date, and number of rounds completed.

Communicate a Vision for Change
Communication was an essential component of this process change. Communication was structured to ensure the project team understood the vision. The project lead developed the project's communication plan. Data were distributed weekly to the project team. This communication included the most recent Press Ganey scores, current NLR progress by the group, reiteration of expectations, and short-term wins.

Enable Action by Removing Barriers
As the project team worked through the process of the project, members identified barriers. These barriers included time constraints, increased COVID-19 numbers, COVID -19vaccination plans, leadership changes, and staff burnout. The project lead worked through these barriers and removed as many as possible to ensure the project could move forward and be successful. Removing barriers required collaborating with the department, local, system leadership, and other departments within the hospital. However, the COVID-19 pandemic and changes within leadership were barriers that could not be avoided.

Generate Short-Term Wins
Frequently, in the writer's experience, projects can take many months to years before the end goal is achieved. This extended timeframe of work can cause stakeholders to become discouraged. By providing short-term goals, the stakeholders had short-term wins to celebrate as the process continues. These short-term wins motivated the group to work towards the final goal.
This project had many short-term wins: completion of education and validation, the first week of data collection, four weeks of data collection, and six weeks of data collection. These milestones allowed continued celebration and encouragement through the project.

Sustain Acceleration
Once the project was completed, the continuation of the NLR was successful. The weekly project team meetings will continue. In these meetings, Press Ganey data will continue to be reported. Additionally, NLR numbers and findings will be presented Monday through Friday at the hospital operational huddle. Although the project lead will no longer serve the communicative role, reporting expectations will ensure sustainability and allow barriers to be presented and solved by department and hospital.

Anchor Change
To further support sustainability, anchoring the change into the culture of the department was needed (Kotter, 1995). This process began during the eight weeks of the project. The continued sustainability plan will assist in pushing the project forward. Culture changes take time, and this project intervention is no exception. The department leadership's daily and weekly accountability will ensure that this intervention becomes anchored into the department's culture for years to come.

Results
This project's expected outcome was to see an increase in the patient engagement survey "Likelihood to Recommend" top box score. Data were collected externally by the third-party company Press Ganey and given to the project lead in a HIPAA compliant report by the host organization's patient experience manager. Baseline data were pulled from the eight weeks before the implementation of NLR. Data related to the numbers of NLR were collected during the implementation phase of the project. Six weeks after the completion of the project, patient engagement data was collected. This delay in collecting patient engagement data was required to allow all surveys to be completed and returned. See Table 4 for all collected variables.

Descriptive Data
The project completed NLR on 49 of the 56 implementation days or 87.5%. During this time, three nurse leaders completed a total of 1120 rounds which resulted in rounding being completed on 17% of the 6,590 patients that sought care in the project setting during the implementation phase. 57.14% of days were compliant in rounding on 20% of patients that day and 41% of the days saw rounding on both the day and night shifts. During this time, 278 patient surveys were completed resulting in a top box score increase of 2.3% for "Likelihood of Recommending," 1.28% increase in "Staff cared about you as a person," and no change in the "Nurses kept you informed" question.
The implementation data were compared to pre-data using the generated survey.
Specifically, the question "Likelihood of your recommending our Emergency Department to others" was the primary outcome variable being studied. The question could have been answered five ways; very poor, poor, fair, good, and very good. For this project, the project team evaluated the percentages within each response and looked for a statistically significant difference between the pre-and implementation results.

Statistical Analysis
To analyze data related to the patients' thoughts towards recommending the ED to others, an independent t-test was completed to look for significance in the change of the patient engagement questions. All three questions had p values indicating that there were no significant changes within the mean of patient engagement score and scores during the implementation (see Table 5). However, an increase of 2.3% within the question of "Likelihood to Recommended" has a clinical significance of improvement within the organizational goal looking to see a one to two percent increase over the year (J. Stewart, personal communication, May 27, 2020).

Leader Rounding
Additional variables were tracked related to the number of completed nurse leader rounds as a process measure that assisted in the program's progress. This measure guided the project team along to ensure that the intervention was being completed and followed. The project goal was to round on 20% of all patients presented for care within the ED each day. The tracking tool (see Appendix E) created by the project lead helped collect the completed NLR total. This compliance measure ensured that the project team and lead were completing the expected number of rounds.
A Point, Biserial Correlation test, was completed using the raw data from the Press Ganey survey and NLR data. The test showed no correlation for days that had the rounding numbers meet the 20% expectation and increased patient "Likelihood to Recommend" scores compared to days where compliance was not met (see Table 6). Any project has financial or budgetary aspects All included stakeholders and project team members were salaried, and there was no increase in cost due to the increased expectations.
These new expectations and time commitments were absorbed into their expected roles and salaries.

Impact
The impact of this project was a sustainable intervention that will continue to drive improvements in patient engagement. During the implementation phase, department leadership made NLR part of the department expectation and standard practice. While results did not indicate statistically significant changes to overall patient engagement scores, NLR was adopted as a best practice throughout the project setting. Now that the implementation phase has been completed and COVID-19 is more controlled, the department leadership team has made NLR a high priority within their day-to-day work. Six weeks post-implementation, the department has increased their NLR to 30% of all patients consistently every day of the week and has seen an increase of 4% within the "Likelihood to Recommend" question since the implementation phase was completed.
The intervention will continue to be monitored for success through a weekly meeting with the department leadership and quality department to discuss the unit's patient engagement scores. Additionally, the department leadership will report out daily, Monday through Friday, in a hospital-wide safety huddle to speak to the number of rounds completed the day before. These two interventions will ensure that the NLR project continues in the long-term.
To ensure the rounding's validity, the department director will validate the department management team on their NLR techniques and ensure that consistency and expectations are met at the bedside. This validation will ensure the patient interaction is correct and the interaction with the staff members occurs post rounding.

Dissemination Plan
The project results were disseminated in multiple venues. First, a PowerPoint and verbal presentation took place at the hospital involving the project team, hospital executive team, preceptor, and department leadership. This presentation included the methodology required for the project, evidence of evidence-based practice related to the intervention, successes and barriers, and the results. The presenter discussed why NLR was a success even though the data did not support statistical significance. In addition to success and barriers, the project leaders gave feedback on how to increase the program's success moving forward. The executive team was given feedback about the need for managers to have dedicated time away from meetings to round within the unit and for resiliency training for staff due to the COVID-19 pandemic.
To share results with the greater community, a similar presentation was given to the department and will be presented at the health system evidence-based conference in the coming year. This is an annual conference that allows staff members within the system to present projects and results that have been completed showing evidence-based practice changes. Even though the project results did not show statistically significant improvement, dissemination to the system is essential to show that future work around NLR needs to continue in EDs within this system.

Conclusion
In this paper, an evidence-based plan was created to implement NLR as an intervention to improve patient engagement scores, specifically "Likelihood to Recommend" scores within the ED. This paper included the significance of the practice, the framework to be used, literature review findings, practice recommendations, evaluation of results, impact, and the dissemination plan.
During this project's implementation, the setting was dealing with the COVID-19 pandemic and did not see a statistically significant change within engagement scores. However, the 2.3% increase in the top box showed that the intervention did affect the patient's experience, which supported the decision to continue NLR within the department.
Patient engagement was shown to increase the financial margins of an organization and improve patient outcome. While NLR did not show a statistically significant change in patient engagement scores during this project's timeline, the literature supports continuing NLR within the project setting. As COVID-19 continues to be better controlled within the United States, NLR will continue to be a necessary intervention within the project setting.   NLR has a correlation with patient satisfaction scores.