Documentation of ambulation for patients who are postoperative for Open heart surgery

A quality team identifies a problem in an intermediate care unit concerning documentation of ambulation for patients who are postoperative for open heart surgery and are on a routine schedule. Patients are ambulated sporadically, not per the surgery protocol. On closer analysis, it is noted that the ambulation schedule is adhered to during the day shift because the cardiac rehab nurse worked with each patient. However, the evening shift presents problems; there is no documentation of ambulation or sporadic documentation. The quality improvement (QI) nurse notes only 30% compliance in documented ambulation during the evening shift. The QI nurse determines that the target for this issue is 100% compliance with ambulation schedules.

1. Would it be appropriate to conduct a root cause analysis or failure mode effects analysis on this issue? Explain your response (very brief answers) – (Read the article on Root Cause Analysis and the power point on Quality + Safety + RCA) Found under unit/module content VI
2. Define the problem in this case scenario.
3. What is the key performance indicator in this case?
4. Analyze possible factors leading to ideal ambulation and actual ambulation