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Valley Hospital in Ridgewood, N.J., has implemented the Just Culture program, a  collaborative, nonpunitive effort that encourages staff members to speak up when they see problems that need attention.
Valley Hospital in Ridgewood, N.J., has implemented the Just Culture program, a collaborative, nonpunitive effort that encourages staff members to speak up when they see problems that need attention. At work here are nurses Mihaela Grosu, left, Nicole Lindner and Meliza Garrido.

Nurses in charge

Growing number of patient-safety and quality-improvement initiatives at hospitals are being spearheaded by nurse leaders


By Maureen McKinney
Posted: December 6, 2010 - 12:01 am ET
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In 2003, nurses at 121-bed Seton Northwest Hospital in Austin, Texas, began participating as a pilot site on a Robert Wood Johnson Foundation-funded initiative called Transforming Care at the Bedside. The project's aim was to use nurses' expertise to improve the quality of care in hospitals.

Over the course of the next several years, nurse leaders at Seton Northwest developed more than 120 improvement initiatives in four main areas: safety and reliability; patient-centeredness; waste reduction; and teamwork and staff vitality.

To date, the nurse-led project has been rolled out in 30 units and has spurred improvements in fall reduction, patient discharges, care continuity, efficiency and many other areas, says Mary Viney, vice president of nursing systems and network accreditation at the Austin-based Seton Family of Hospitals, the parent organization of Seton Northwest.

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“It's so important to have nurses in these leadership roles in quality improvement,” Viney says. “They have the intimate knowledge of what works and what doesn't.”

In the early stages of the initiative, nurses at the hospital worried that communicating and collaborating with physicians might prove difficult, Viney says, but they found out quickly that such fears were unfounded.

“We thought nurse-physician collaboration would be a much bigger obstacle than it actually was,” she says. “Physicians were glad to work with us and more than willing to take our lead and listen to our ideas. It was by no means easy, but many of the beliefs we had about our culture were changed pretty quickly.”

For instance, one nurse chose to design a formal process for use in rounding with physicians. She partnered with a physician, and the two worked together to develop standardized questions nurses would ask during rounds, including ones related to discharge plans, patient questions and test results from the previous day.

“We did experience some pushback from that project, but the beauty was we already had a physician on board and because it was only one nurse and one physician working together, they could iron out details and address concerns before rolling it out to the whole unit,” Viney says. “This initiative opened those lines of communication and helped physicians and nurses raise issues that they were concerned about.”

That interdisciplinary approach is critical to creating a culture of safety, especially as nurses increasingly assume more leadership roles within quality improvement, says Pat Folcarelli, director of patient safety at 621-bed Beth Israel Deaconess Medical Center, Boston.

Folcarelli, who is a nurse, says that although Beth Israel Deaconess stresses the importance of nurse leadership, their success comes from incorporating physicians, social workers, pharmacists and other frontline staff in all of their improvement initiatives.

“Our organization is fairly progressive in terms of having all voices included, as opposed to a more siloed system, and I think it would be very difficult for anyone who tried to lead change without identified champions in all of the departments,” Folcarelli says. For example, she says, while patient falls often are viewed as a nursing issue, in reality, some of the factors that can lead to a fall—side effects of medications, inadequate physical therapy—make it clear that it's an issue everyone needs to weigh in on, she says.

And that approach is more important now than ever, as healthcare reform pushes forward new models of care delivery such as patient-centered medical homes and accountable care organizations that rely on teamwork and collaboration, and put more emphasis on preventive care and health promotion.

Paula Hindle, vice president of healthcare services and chief nurse executive at two-hospital Loyola University Health System, Maywood, Ill., echoed Folcarelli. Hindle called nurse leadership “essential” but also highlighted the importance of working in collaboration with physicians and other providers.

The fruits of collaboration

St. Lucie Medical Center in Port St. Lucie, Fla., has expanded its use of clinical nurse leaders. Pictured are Lucie Charest, RN, left, and  Karen Giovengo, RN, CNL.
St. Lucie Medical Center in Port St. Lucie, Fla., has expanded its use of clinical nurse leaders. Pictured are Lucie Charest, RN, left, and Karen Giovengo, RN, CNL.
As a result of such collaborations, Loyola has successfully implemented a mandatory employee influenza vaccination program, with a compliance rate higher than 99%. Hindle also has worked with Jorge Parada, Loyola's director of infection control, to implement checklists and other interventions aimed at reducing infection rates.

“Nurses are very detail-oriented because we are with patients 24 hours, seven days a week,” Hindle says. “And now that the focus has turned more toward evidence-based medicine, it has made that approach to care much more scientific, and that change has made nurse leadership even more important.”

Nurse leaders also need to work to create open, nonpunitive cultures that promote shared accountability and foster system improvements, says Ann Marie Leichman, vice president of patient-care services and chief nursing officer at 446-bed Valley Hospital, Ridgewood, N.J. Leichman took Just Culture, a program she learned about during a yearlong patient-safety leadership fellowship program, and implemented it at Valley Hospital.

Just Culture, she explains, is a system that encourages staff members to speak up when they see a problem and gives them a language to do so.

“We look at how the system is designed and how we can address errors by changing it,” Leichman says. “We try to create an environment where people feel safe because if they are hesitant to speak up, that becomes a major patient-safety issue.” In one instance, a medication error occurred despite the hospital's bar-coding system. An analysis later revealed that the bar-code scanners did not always work well, so nurses had begun to develop work-around processes.

“Was this error related to recklessness and total disregard for the system, or was it the 88th time that the nurse had been unable to scan that day and she said, ‘I know what I'm doing.' You have someone that drifted from safe practices, but you also have a system in place that did not facilitate safe choices,” she says.

Victoria Rich, chief nursing executive at 760-bed Hospital of the University of Pennsylvania and associate professor of nursing administration at the University of Pennsylvania School of Nursing, Philadelphia, also says punitive cultures undermine quality-improvement efforts. Rich says most hospitals still have a long way to go in promoting open communication, but she says nurse leaders need to be at the forefront.

“When you create a culture where people are comfortable giving and receiving feedback, you create something magical that is essential to patient safety,” Rich says, adding that her hospital's staff members also are free to air their concerns honestly on a specially created nursing blog. “My number-one role as a senior nurse leader is to foster communication. It's not enough to say that we hope a mistake doesn't happen again. Hope is not a plan. We need to talk about it and we need to fix it.”

As the emphasis on nurse management in quality and patient safety has increased, a new role known as the clinical nurse leader has also emerged, attracting significant attention from some providers. Introduced by the American Association of Colleges of Nursing more than six years ago, the clinical nurse leader, or CNL, is nurse who has a master's degree with a specific set of skills and responsibilities, explains Joan Stanley, the association's senior director of education policy.

CNLs typically are assigned to a specific unit, usually reporting to the nursing director, and they work with a cohort of patients—often ones with complex needs. Because CNLs are not responsible for the day-to-day care of patients, they're able to step back and anticipate risk, educate patients, facilitate communication with family members and caregivers, coordinate treatments, evaluate patient outcomes and leverage available resources, Stanley says.

“We see the clinical nurse leader as having a primary focus on quality improvement and safety,” Stanley says. “It's not an administrative role, but a clinical management role; it's not a supervisory role, but one that involves overseeing patient care with nurses and other providers.”

Since the first CNLs graduated from specially tailored master's programs in 2006, their ranks have swelled to more than 1,300, she adds, and many hospitals that have hired CNLs are seeing substantial improvement on quality measures such as pain management and infection prevention, as well as on patient-satisfaction scores.

“I think nurses have always tried to look more holistically at patients and families, and now CNLs have the time and capability to look at the bigger picture, implement evidence-based standards of care and figure out where change may improve outcomes,” Stanley says.

In early 2005, swayed by the need for more clinical leadership at the bedside, officials at 194-bed St. Lucie Medical Center, Port St. Lucie, Fla., chose four baccalaureate-level registered nurses to enroll in a CNL graduate program.

And in 2007, the hospital implemented a pilot CNL program in the medical-surgical and progressive-care units. The program has since grown to include several more units and employs seven CNLs who are charged with monitoring patient-satisfaction scores, addressing difficult family dynamics, rounding with physicians and ensuring adherence to the evidence base, says Nancy Hilton, St. Lucie's chief nursing officer. Additionally, Hilton says, the hospital's seven CNLs work to improve emergency department throughput by facilitating early discharges in their units.

Administrators at St. Lucie say they have seen improved performance on core measures for acute myocardial infarction, congestive heart failure and pneumonia, and they also observed a dramatic dip in nursing turnover. “Of course we can't attribute all of those things directly to CNLs, but we've seen great improvement, and I do believe these individuals are having a real impact,” Hilton says.

The change was difficult to implement in the beginning, she adds, because it represented a big shift in the nursing-care delivery model. Charge nurses questioned what their role would be with CNLs in place, Hilton says. But concerns were quelled after the hospital held focus groups clarifying what everyone's role would entail, and after staff nurses were able to work one-on-one with the CNLs.

And when the hospital rolled out new procedures for preventing central line-associated bloodstream infections and catheter-associated urinary tract infections, the CNLs were the ones who taught other nurses at the bedside, Hilton says. “They're the ones who do the follow-up, ask the questions, gather data and help units brainstorm and make decisions. Nurses recognized that value.”

Other hospitals have seen similar successes, including 178-bed Hunterdon Medical Center, Flemington, N.J., and 637-bed Maine Medical Center, Portland, Stanley of the AACN says. And the U.S. Veterans Affairs Department has committed to instituting the CNL role at all of its hospitals by 2016.

It's still early, Stanley acknowledges, and although positive results have been seen in case studies, she says evaluating the work of CNLs across settings will shed even more light on the extent of their effectiveness.

“Right now, in the context of health reform, there is so much focus on advanced-practice registered nurses,” Stanley says. “They are extremely important, but we need to look closely at the impact that CNLs and other master's-prepared nurses can have on the healthcare system as well.”

According to Dori Taylor Sullivan, associate dean for academic affairs at Duke University School of Nursing, Durham, N.C., the CNL role was created to pay particular attention to the issues surrounding patient care. Sullivan, who is a certified CNL, praised the functions of the role and the concerns it was designed to address, but also emphasized the importance of other nursing roles such as doctor of nursing practice.

Sullivan has participated in a variety of nurse-leadership and quality-improvement initiatives including the Quality and Safety Education for Nurses project, sponsored by the Robert Wood Johnson Foundation, which develops and pilot-tests specialized curriculum for evidence-based practice, safety, informatics, and patient-centered care.

“Nurses are at the point-of-care, and some would say they take care of not only the patient but also the system,” Sullivan says. “They have always been involved in quality improvement and they have a special passion for contributing to those areas.”

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