Narrator: Today's webcast is sponsored by GE Healthcare's performance solutions team and the Furst Group. A word about our sponsors: GE Healthcare's performance solutions team is dedicated to helping healthcare systems improve the safety, efficiency and cost effectiveness of its operations. Using process-improvement methodologies, like LEAN and Six Sigma, and patented technologies, like AgileTrac, their experts work with healthcare organizations to streamline the flow of patients and staff to control costs through better asset utilization to determine the ways to help reduce medical errors, develop high performers at all levels of the organization and integrate management and leadership systems that help them to succeed. Furst Group provides a total solution approach to the traditional executive search as well as an array of consulting products. As one of the largest firms specializing in executive healthcare assignments, Furst Group's 25 years of success is built upon a philosophy of partnership. They enhance their clients' internal resources to develop effective human capital strategies. Their clients include hospitals and health systems, managed-care organizations, integrated delivery systems, medical group practices, healthcare products and services companies, insurance companies and end-of-life care businesses. They also partner— [Narrator gets cut off here.]
Webcast Transcript: When nurses lead the way on quality improvement and patient safety
Dave May: Good morning. Thank you for joining Modern Healthcare's editorial webcast. Today, we'll listen to a discussion with three nurse executives on initiatives at a growing number of hospitals and health systems where nurses are leading the way on new approaches to quality improvement. Recent studies have concluded that promoting patient safety in the hospital setting will require dramatic cultural shifts, less hierarchy and more collaboration among nurses, physicians and other caregivers. Before we begin our webcast, we have a few housekeeping items to address: Your phones will stay in listen-only mode during the entire webcast. However, listeners can send questions throughout the event. Our moderator will try to ask as many as possible before the hour is up. You can find the questions window on the right-hand side of your screen connected to the webcast dashboard that appeared when you first joined the call. A recording of today's discussion will be available on our website, ModernHealthcare.com. Within a few days, all attendees will receive a follow-up e-mail, including a link to that recording. Now, I'd like to turn the webcast over to Maureen McKinney, Modern Healthcare's patient-safety reporter and the moderator for today's webcast. She will introduce our panelists. Maureen. [Break in webcast]
OK, thanks everybody for continuing to hold. We're going to start this again. So thank you for joining us today. We're going to listen to a discussion with three nurse executives on initiatives at a growing number of hospitals and health systems where nurses are leading the way on new approaches to quality improvement. Recent studies have concluded that promoting patient safety in the hospital setting will require dramatic cultural shifts, less hierarchy and more collaboration among nurses, doctors and other caregivers. Before we begin our webcast, we have a few housekeeping items to address: Your phones will stay in listen-only mode during the entire webcast. Listeners can send questions throughout the event. Our moderator will try to ask as many as possible before the hour is up. You can find the questions window on the right-hand side of your screen connected to the dashboard that appeared when you first joined the call. A recording of today's discussion will be available on our website, ModernHealthcare.com. Within a few days, all attendees will receive a follow-up e-mail, including a link to that recording. Now, I'd like to turn the webcast over to Maureen McKinney, Modern Healthcare's patient-safety reporter and the moderator for today's webcast. She will introduce our panelists. Thanks for your patience. Maureen.
Maureen McKinney: Good morning, everyone. Thank you, Dave, and thank you so much for joining us. We're very fortunate today to have three accomplished nurse leaders with us who will share with us their lessons that they've learned while overseeing patient safety and quality improvement initiatives, and they'll also share with us some other insights about why nurses are well-suited to head up these kinds of projects. First, we'll hear from Patricia Folcarelli, director of patient safety at Beth Israel Deaconess Medical Center in Boston. Folcarelli has worked for more than two decades at Beth Israel Deaconess, and she assumed her current role three years ago. She's led a variety of initiatives that stress team-based interdisciplinary approaches to safety. Next, we'll hear from Ann Marie Leichman, vice president of patient-care services and chief nursing officer at Valley Hospital in Ridgewood, N.J. Ann Marie has more than 25 years of experience in clinical nursing and leadership. And in her role at Valley Hospital, she's worked to implement solutions to ease patient flow and improve staff communication. Finally, we'll hear from Mary Viney, vice president of nursing systems and network accreditation at Seton Family of Hospitals based in Austin, Texas. Mary has led Seton's nursing staff and a variety of quality-improvement programs aimed at standardizing processes, enhancing communication and reducing errors. Now, it is my pleasure to turn it over to our first speaker, Pat Folcarelli. Patricia.
Patricia Folcarelli: Thank you very much. Good morning, everyone. I want to start by saying that in my office, I have a book that's called Florence Nightingale Measuring Hospital (Care) Outcomes that was published by the Joint Commission. And the quality assurance and performance improvement described in her writings are reviewed there by several healthcare leaders. One of my favorite examples is from Paul Batalden and Julie Mohr, who describe Nightingale's knowledge of processes, systems, structures and waists in this way: ‘Nightingale was a practitioner of many management principles that people seem to think they're discovering. Centralized support services but decentralized operations. Make partners with your suppliers. Understand that hands-offs in processes are a common source of failure. And identify failures and inquire into them.' So if I could have my first slide.
I'd like to reflect on this conversation by describing a framework that we use at Beth Israel Deaconess Medical Center that is needed—that describes competencies needed by nursing leaders. And then I'm going to actually give two specific examples of work that we've done institutionwise and then at the microsystem level to show our decentralized measurements of operation. At Beth Israel Deaconess, as I said earlier, we have a competency model for our nurse leaders that we believe captures what are the competencies needed for success in this arena. They were developed in 2003 in a program that we did collaboratively with our organizational development department that we called ‘Stage': What are the strategies for accelerating growth and excellence in nursing leadership? And you can see the competencies listed here. They are the ability to lead change, to manage unit performance, strategic plan, skillfully communicate, build an effective team, develop individuals on that team, build collaborative relationships across the disciplines and know how to manage yourself. Today, these have evolved so that we're also doing a lot of work with our leadership around focusing on leads and how do you incorporate LEAN leadership into leading initiatives? If I could have the next slide.
For each competency, we have very specific goals. So I'm going to talk about two in particular. The first is managing the performance of a unit that focuses on quality and safety. And the second is on leading change. So for managing unit performance, you can see the competencies that are listed here: to be able to develop a unit-based approach to ensure optimal performance, to understand the basic principles of quality improvement, to manage financial and material resources, and be able to anticipate and implement necessary change. On the next slide, if I could have that, what I'm going to show you is an example of the outcome of that kind of work.
It's an example from one of our med/surg units that is of a unit-based snapshot of quality and safety, and we have these on all of our units. This one reflects what we would see on a typical med/surg unit in our hospital, but we have different-looking dashboards for obstetrics as well as our intensive-care unit. So if you look at this, you'll see that we've been able to on one page pull together a lot of information, and the information at the top you'll see has to do with what is the patient and family experience so that we're able to know unit by unit what are our patients (are) saying about the care and how likely would they be to recommend Beth Israel Deaconess Medical Center to their family and friends. In the next section, we have a lot of things that we're focusing on to reduce patient harm. So first you'll see the examples of the nursing-sensitive outcome data around falls, hospital-acquired pressure ulcers and then some process measures. One of the process measures we're very focused on is: Are we responding to our telemetry alarms appropriately? Are we cleaning our hands? Are we cleaning equipment appropriately? And then in the next section, we focus on pain management, which for us is a very important part of our work to improve the patient's experience. Then finally are things that have to do with just basic quality and safety, like: Are we weighing people every day? Are we completing the care plans appropriately? So these are specific targets that are set for each of these, and our local managers work at the microsystem level to ensure performance on these metrics. The important work for change is led by nurse managers, clinical nurse specialists, physical therapists, pharmacists, who all serve on our governance council, and also committees that we serve on with physicians, who serve as the unit-based medical directors. And for each of the clinical divisions in our medical center, we also have quality improvement directors. So with all of the different departments, there's a quality improvement director. What's most important, I think, though about thinking about managing unit performance is that all goals should be aligned with the organization's priorities. So, we think a lot about alignment from the strategic goals of the organization to the annual operating plans for the organization down to the work of the [unclear: 14:45 ?vice presidents?] of the system. So if I could have the next slide, I'm going to talk a little bit about a second competency, which is the competency to lead change.
So what we expect of our nurse leaders for leading change is that they're able to create a compelling vision for the unit or for our directors and our vice presidents for the whole area that they cover, that there's a shared understanding of the goals and values—so this speaks to alignment with the operating goals of the organization—that they're able to approach challenges with creativity, and it requires a certain amount of creativity and optimism to lead change, that they're able to create a sense of urgency but also be flexible enough to handle the ambiguities that obviously emerge. So if I could have the next slide.
What I'd like to do is use a specific example that I was involved with in around the 2005 time frame [unclear 15:42] that for me, I think, highlights some of the key important takeaways for leading a large-scale change. This is an example of change that I'm particularly proud of because what I'll show you is that it was a sweeping change for our organization that was really aligned with our goal of eliminating harm and has had some wonderful outcomes for our patients. So, one of the things about leading change is to think about how do you create a sense of urgency within the organization? In 2005, at our medical center we had several events where we failed to rescue patients on the general units, and so we had a compelling platform with which to launch a process for rapidly responding to destabilizing patients. So a multidisciplinary team was assembled that I'm going to describe for you. The program was branded, which I'm going to talk a little bit about that. And it was a strategic approach to how to sell this initiative to the organization. It was piloted in 2005, and then from 2005 until now there's been an aggressive, continuous feedback loop about this work. If I could have the next slide, please.
So, assembling a change team is one of the very important things to consider as a nurse leader. So, for this change team, we picked people who were natural leaders within their domain, but also had enough clout in their system to lead change. So we had the associate chief of the department of surgery, the key nursing directors, myself, the associate chief of the department of medicine and also the associate chief of the department of emergency medicine, and then we had a younger faculty member who was an intensivist. This was a very engaged and engaging and well-respected clinician in our intensive-care unit who is very interested in this idea of implementing a full rapid-response team. And he was key in helping us understand how the organization worked. And I was key in bringing a deep understanding of clinical operations at the unit level to think about how would be best implemented large-scale change. So if I could have the next slide, I'm going to talk a little bit about what we did.
The natural thing to do with something like this is to decide that you're going to implement another [unclear: 18:07 ?team?]—you're going to start another team, like a whole other response team. What we decided to do was to standardize what we called it a ‘clinical trigger.' So using a standard approach, these are the things that would activate a rapid-response process. We made a strategic decision though in 2005 not to implement this by resourcing a separate team. I was convinced that we were not effectively using the resources that we had, so our rapid-response process uses existing resources. We have a set of criteria. The intern or resident taking care of the patient has to come to the patient's bedside as does a senior nurse. This is either a clinical nurse specialist or an administrative supervisor of the off-shift. And the intern or resident must call the attending at home if they're not on-site or let them know that the patient has had a destabilizing event. And then we created a multidisciplinary documentation tool so that there's an event note in every record. So as you can imagine, this change was an important one to communicate across a complex organization. So, next slide.
You'll see that we decided—and I think this is something to consider in all change initiatives—that you need to brand what you're doing. So we created a brand that's called ‘Triggers: Rapid Response.' You see the little checkmark in the script there that was used on every single piece of information that had to do with this initiative. We also created multiple mechanisms of communicating this change. So posters were put on every unit that looked like this. Badge cards were given to every employee, every nurse, every physician, every respiratory therapist so they knew what the criteria were, and we were able to keep it to a single page, which I think is crucial. And be highly specific about why we were doing this, what were the clinical triggers, who should respond, what does the response team do and then why are there posters because we added a new trigger? So I think those things: branding, using multiple mechanisms, keeping things simple and then being very specific are the key things for leading this type of change initiative. We piloted this before we rolled it out. We sold it up and down the organization—from the medical executive committee and the board down to all of the governance council—and then for a year we met every single week to review all of the events and to give—progressively give—feedback. And so if I can have the next slide; this is my final slide just to give you an example of the effectiveness of this kind of a rollout and the sustainability.
So the Before slide, the bar represents 2005 at our medical center that there was approximately 0.9 deaths in non-DNR, non-ICU patients, so these are patients on the general units who wanted to be resuscitated. And then in 2008, the After, is at 0.3. And in 2010, we have 0.1 non-DNR, non-ICU deaths per 1,000 discharges. This is a complex change across our organization that has persisted because of the aggressive feedback loop and also the strategic rollout of this initiative. So I'm going to close there and just give you, in closing, I think one of my favorite quotes, which is for all of you to take with you. It's actually from John le Carre, which is: ‘A desk is a dangerous place from which to observe the world.' And so my strategy, or tip to all of you, is to lead in the field and to get out of your offices and to be a presence on the unit as a leader for quality and change. So I'll stop there. Thank you very much.
Maureen McKinney: Thank you so much, Patricia. Before we proceed, one quick question: What mechanism is there for the unit-based leadership team if there is resistance? And how do they address that?
Patricia Folcarelli: So, we don't have an exact intervention. This is part of, I think, coaching by the senior leadership team to the microsystem leadership around resistance. And then, the performance metrics being publically shared and transparently shared—these dashboards are posted on every unit—and we also have posters for patients so that the patients and families can see the results of some of these things. It actually helps to wear down the resistance over time. And I think what happens often is the whole organization changes around highly resistant people, and then one of my favorite leaders here used to say, ‘You have to change people or change people,' and so then you make decisions strategically as leaders about whether these people can continue to practice in an organization that's changed around them.
Maureen McKinney: Great. Well, thanks again. And now I'm going to turn it over to our second speaker: Ann Marie Leichman. Ann Marie.
Ann Marie Leichman: Hi. Good morning. It's good to be here, especially to talk about how nurses at Valley Hospital are leading in important patient-safety initiatives. I want to start with staff engagement, so if I could have the first slide, please, because staff engagement is really critical to nurse-led patient safety initiatives. Direct-care staff need to be involved in building and sustaining a culture of safety if it's to be successful. So in my opinion, this is a critical starting point, and to facilitate staff engagement, we always look to our shared governance structure and whether it supports and allows the maximum staff involvement. We are a magnet-designated hospital, and like many other magnet-designated hospitals, we have a shared governance structure that includes unit-based committees and hospitalwide councils to promote this staff engagement. Nursing services here recently reorganized the performance improvement and patient-safety committee structure to enhance staff participation. And interestingly, after we reorganized the hospital patient-safety committee, which includes nurses, also re-evaluated its structure and recognized that the separate hospital and medical board patient-safety committees did not make sense. So it was agreed to merge these two committees and, hence, the whole organization's patient-safety structure was revamped this year. So I want to think that nursing services and the restructure of this model stimulated this change. Next slide, please.
The next slide is about communication and just can't be emphasized enough. We have found it's important to have an overall communication plan and also to standardize what is important to communicate. Our overall communication plan includes big picture communication to all of nursing services about patient safety through vehicles like the CNO blog and a recently developed nursing services newsletter. At the department or unit level the name of the game really is visibility of data. Over the years we have learned how important it is to have a very visible display of unit or departmental quality outcomes data, which we do on bulletin boards. And we use a similar dashboard. We call it a score card here—I'm sorry, report card that Pat was showing. So similar types of things. Units also have the ability to highlight quality outcomes relevant to them, like things like days from last fall. But one of the biggest projects we took on over the past year was standardizing handoff communication. Using the principles of the checklist, the staff from two medical/surgical units developed this change-of-shift report tool using the SBAR format. They work closely with IS to pull as much data as possible from the EMR into a standardized handoff report tool that highlights patient safety and quality issues, which is risk for falls and pressure ulcer. As it spread from unit to unit, it was modified based on identified needs. So for example, the cardiac units needed other information that the original developers of the tool did not think of. And that would make sense because the original developers of the tools were surgical nurses. Now staff have just completed the development of the same tools that are being used for patient handoff from the ED to inpatient. So by having staff develop these tools and having them intimately involved with the process, they acknowledge what is truly needed and understand what they need to do to safely handoff a patient from one area to another. Next slide, please.
You can't have a discussion on nurse-led patient-safety initiatives without a word or two on patient falls. So here's my word or two: communication, communication, communication. OK, that was three, but it really needs to be said because even with all the emphasis we put on that and even with the SBAR tool, we still find lapses in communication that leads to patient falls. Some of the other things we do here is we have a fall response team, which is a designated group of advanced-practice nurses, nurse managers or supervisors who go to a unit who had a fall or injury to investigate and coach staff. It has been received as being helpful and not threatening because staff really have the ability to talk through the incident and get individualized coaching on how things could have been handled differently. But we've done a ton of work on this and what keeps coming back loud and clear from our direct-care staff is that our classification of risk is too broad and therefore meaningless. According to them, all of our patients are at risk. So therefore we've been working with staff to find another tool that would provide us with a better way to classify patients on decreasing falls. And actually we've been doing some nursing research on this. All of this work we've been doing is resulted in us having a 0.7 falls with injury rate, and we'd like to see that obviously go down. Next slide, please.
The rapid-response team, as Pat described, I feel is—she described it very well—and I feel as if (it) is so crucial for a hospital. I start off with the word ‘redemption' because every chance I get I tell anyone who will listen that RR teams have meant redemption for me. I'm a former med/surg nurse who argued for years that it was unrealistic to every med/surg nurse to know how to run a code or, aka, how to take care of a critically ill patient. But I grew up, so to speak, in an era when this wasn't an expectation, and I can still remember the look of disgust on the critical-care nurses faces who responded to my codes. And I know there are nurses on this webinar who have been in healthcare long enough to know what I'm talking about. So I have to say RRT is one of the best things that has happened in recent years for patient safety. And I recognize that there are mixed reviews on RRT right now, but I really love them. Nurses were finally given permission to call for help even when they could not articulate why they thought the patient might be in trouble. We have had remarkable success with the acceptance and use of RRT, really without much encouragement at all, which I think speaks highly to the need that nurses have to be able to call for help and work with a clinical team to achieve good clinical outcomes. As you can see, we track outcomes. One of the outcomes we track of RRT is cost avoidance related to diverting the need to transfer patients to higher levels of care, and what you see on this slide is a very conservative estimate of one-day avoidance in ICU and as you know that could be much higher. We also recently started family-initiated RRT but really it has not been used much yet. I think it's only been used once that I know of. Next slide, please.
This is my last slide, and I just wanted to have a brief word on reducing medication errors. We use bedside medication verification, and initially we were disappointed with the percent of compliance with scanning, but we had some technology problems. And after we worked these out, we realized that we needed to address individual accountability because we saw a great variation in compliance among nurses who worked on the same unit. So we added individual scanning percent compliance to each nurse's evaluation and found that we jumped from 81% to 87% compliance. And now we're at 93%. And we have definitely seen a decrease in medication errors since the introduction of the BMV—bedside medication verification. And since we're talking about errors, I would like to close on a mention about ‘Just Culture.' Just as staff engagement is critical to the success of creating a safety culture, so is creating a nonpunitive environment for reporting errors and near misses and the like. We're in the process here at Valley Hospital of rolling out ‘Just Culture,' which is an approach designed to look at both the systems we've designed for our employees and the safe choices they make. It's important to look at both because a culture of safety recognizes that human drift from safe behavior, and that systems should be designed to help employees make safe choices. When employees know that errors will be viewed in this light, the likelihood of staff engagement is higher and, hence, so is the organizations' safety culture. I want to thank you for giving me your time today.
Maureen McKinney: Thank you so much, Ann Marie. One question: Since you've implemented the change of shift report tool, what results have you seen and have handoffs improved?
Ann Marie Leichman: Yes. You know what? It was difficult to get people to use the tool the way it was designed, and that's why I highlighted the checklist approach because really you need to go down all of the critical areas and cover that. So it took a lot of work in observation and really having staff understand the importance of that? But we have seen improvement in terms of handoff communication—even just from the point of view of how important it is. I don't know if that was so accepted, and I see a big change in that right now.
Maureen McKinney: Great. Thank you, again. And now I will turn it over to our final speaker, Mary Viney. Mary.
Mary Viney: Good morning, everyone. I would like to add to the comments that have already been set out for us, and I'll let you advance our slide because I want to talk a little bit about the nurse's role in safety. It's not really a new concept. It's always been a role for nursing. And as Patricia talked about earlier, Florence Nightingale was early setting the standard for what nurses were going to be doing for generations that followed her—through the wars and through religious groups [unclear: 33:52], all of those have been working toward getting nursing out into communities and into our hospitals. Today, nurses are at every table. They're at the bedsides, they're in hospitals and homecare, and in rehabs. They're in all of our clinics. So I think the important part about nurses taking up their role in safety is, just by sheer numbers, we are the people to be closest to the patients and the conduit to our physician leads and our other partners. And, I think 1990 began a real new chapter for us when the IOM reports came out on patient safety. There was really a call for everyone to really focus on safety as our No. 1 priority. And I think that nurses participated in our organization in many initiatives, but I think the advancement of the partnership with our pharmacy and with our physicians and with our respiratory therapists and [unclear: 34:52] advanced that. And I think that even larger projects that it's key that nurses [unclear: 35:00 ?are role?] such as implementing our electronic medical records have nurse at the table to really talk about the safety parts of new records as they go into place as well. Another part that I think—not particularly traditional—you think about what nurses with safety is really in working on [unclear: 35:19 ?trim-point?] initiatives of moving patients into our system and across our system—moving from the emergency room to the ICU and back to the floors. I think that these transitions of our patients are risk places we all know for safety and handoffs of our care. So I think that nurses at the table for those are absolutely key.
And in the next slide, I think that what I really want to focus on is, I would say, I'm amplifying very much what Ann Marie was just talking about, which was partnership with organizations like the National (Quality) Forum and Institute for Healthcare Improvement, Joint Commission, Kaiser Family Foundation, many more have really set into action a much more open for us to collaborate to improve safety and quality. And that we know that we don't have to do this alone. And I think that's what's accelerating some of our great work that we've seen in safety, and our communication is that we can learn from each other and be much more open about sharing things that are working. I think we would still be 10 years behind if we did not have some of the great organizations to open up our collaborations in a different way for us over the past 15 years or so. I think that all over the country we are working on things as fall reductions, central-line medication safeties pressure ulcer, which are all nurse-sensitive indicators, but rely on a whole team to make that happen. And the one story that I would share is our focus that we've been working on with pressure ulcers. We felt like we were doing very well with our progress that we were making over a journey that's taken us about five years to get to today. But where we started from was really looking at the very traditional pressure ulcers, the ones that caused so much pain, possible infections and certainly were challenging for our patients to transition to the next level of care because of the—we didn't put enough emphasis on those skin as our organs to care for as much as we do for the other organs. I think we've finally turned the corner over the last two years by pulling in our intensive-care unit and actually having them work side-by-side with us, partnering on our pressure ulcer initiatives and taking a real sense of pride in skin as a key organ. But I will tell you we didn't really make our last push to success until we invited through analysis our respiratory therapy team to the table. We had really gotten our rates down to about a 2% pressure-ulcer rate, and we just couldn't seem to budge it. And when we analyzed that, we recognized that what was left for us were the pressure ulcers that were coming related to devices, things that we attached to patients, things that we have them in their noses for feeding tubes and oxygen and in the [unclear: 38:40 ?trickle?] tubes and various pressure-reducing boots for the DVTs, and so all the different initiatives that we had about increasing the head of the bed or to prevent ventilator-acquired pneumonia caused other pressure issues and so when we brought respiratory therapy to the table and partnered with nursing is when we actually found our opportunities for partnering to reduce those device-related initiatives. The exciting thing for us over the last year was that we had worked with five different suppliers to actually change their products. And they came to the table with us when we talked to them about we needed different cushioning around our nasal cannula. We needed different ways to secure our feeding tubes and our endo tubes, and we, I think, were both delighted but surprised to see the willingness of our suppliers to come to the table and actually change their products based on our recommendations. And I'm very excited to say that our last prevalence results that we came down with a 0.9 pressure ulcer. So we believe when our incidents continue to reduce and certainly our level of harm from pressure ulcers is things that can be easily turned around when found early. But again it was all about nurses out there in the units talking and working with our partners to make it happen and then looking for the possibility about: Would these suppliers listen to us and talk to us about how they might change their product for a better product? I'll also say the challenge of safety is not on its own. It's triple sided when we have to balance our measures with cost, quality and access that as we are trying to improve our quality, we want to keep our costs the same or reduce them while increasing access. So it is a challenge to keep a balanced score card out there not just with quality sitting on its own, and I think nursing being closest to the point of care and present on all the care teams influence a lot of the decisions that are made for both patients and systems.
And our next slide: The new of the healthcare reform as we look at 2010 and how we will be able to contribute to improving care and controlling costs is a lot what are managing chronic illnesses, and I think that's where nursing will really be able to, again, be very influential about how we manage the chronic illnesses and teaching self-management and holistically integrating the family and looking at their home environment to where they're transitioning to one of the works that we are doing in this area is really, truly engaging our patients and their family in plans for transition. And having that discussion and having that up on our white boards and getting out the plan for everybody on the team to really understand where is the patient going next and what timeline and what things have to be accomplished before the patients leave. We spend a lot of time on a technique called ‘teach back.' Many of you might have heard about that but that really is about actually a different way for people to ensure that patients and families are getting the information that they need by doing a teach-back process. And I think holding a space for the coordinating of many active players for patients and families; we really have to purposely make that happen and not keep it under the control of just the caregivers. And then certainly managing the patients back in the home setting and through all the ways we're going to have with technology now I think that's where nursing will also provide very innovative ways that we can help keep our patients in their home and not have to actually drive to their homes or have the patient drive in to seek care, but these are technologies to do those kinds of things.
And then in the next slide, the exciting work that just came up from the Robert Wood Johnson Foundation, IOM on the future, is really allowing the nurses to work at the full extent of their education, training. And I think that we would all agree that we have suboptimized some of our nursing talents because of tasks that have been assigned, that we get focused on, and we have yet to fully realize the potential of nurses using their critical-thinking skills. And I think that the higher levels of education will support that as well, and we definitely have some work to do to become full partners in developing policies, so we have all levels where nurses can improve safety in healthcare for our patients. I do think that the effective work planning and balancing the skills that nursing brings to the table and the nursing perspectives are really going to be key for us to continue with professional development going forward.
And then on the last slide, I would just say this echoes our previous speakers, was really about building the capacity for change. It can't be held in just a few nursing leaders; it has to be those skills, behaviors in every individual staff nurse. And I think that learning improvement skills and the competency that was talked about earlier are really so significant because the more that we can have every nurse participate and looking for opportunities for improvement is going to move us leap years ahead. I think the recognition of nurses when they see opportunities we allow them to take some risks, to try something new, use the skills of small [unclear: 44:53] of change, and then they can have ownership in the actual change that happens. So I think the encourage participation I think that was mentioned by Ann Marie about our shared governance can't be just at the council setting. It has to participation in the units within them finding opportunities, issues, that they think could be different, could be better. Leaders need to ask more and explain less, and I think that when Patricia was talking about go out to the worksite, go out to where the work is done, I think that's where we really will learn what kinds of things that the patients are needing from us from there. And all is challenging and testing our assumptions and being open to people challenging are we sure, are we sure that that's what has to happen. And asking ourselves very difficult questions. And so I think communication is key, but I also think building the skills of the front-line staff and the front-line leaders to be willing and open for the change to happen and know that it's in a low-risk situation where they can take risks, and if it doesn't work when they try them, they can always go back to the way they were doing it. But at least they're trying and learning the skills about testing. And with that, I turn it back to Maureen.
Maureen McKinney: Thank you so much, Mary. One question: You mentioned teach back as a way to ease patient-care transition. Is that intervention in place now and is there a standardized way that nurses are doing it?
Mary Viney: Yes. There's quite a few resources if you go onto IHI or some of these different organizations about the teach back, but it really is about the process of teaching the patient with the perspective that they're going to teach you back that they were going to tell another family member what their responsibility was about medications, about dressing changes, about diet. And it's done in a very supportive way and that the patient by teaching it back to you is going to be able to help you be a better teacher so you can help clarify what points as they go through. And so it's not, ‘Did you get it? Did you understand? Here, tell me that you know what drugs to take at what time.' It's really about the knowledge about why they're doing what they're doing, and can they bring it internally enough so that they could teach it back to another family member. And it's done under the auspices that the patient does this and you need to correct or adjust some of the things that they understood. And that's going to help you be a better teacher as well, so from that perspective, I think it's been a very interesting way to do teaching for patients and families.
Maureen McKinney: Well, thank you again. And now our question-and-answer portion. I'm going to pose some questions from some of our listeners. First for Patricia, a question from a listener: In order to fully integrate a new procedure process and achieve true change, it's necessary to practice new behaviors. How did you get your staff to practice new behaviors and ease them into implementation?
Patricia Folcarelli: That's a very good question. So, because of a lack of—the short amount of time, I really didn't go into how detailed the orientation around the rapid-response team in particular, how detailed the orientation and opportunities for learning were around that large-scale change. But we have over the last five years incorporated education around how to activate a rapid-response team, how to use SBAR as part of communication into all of our stimulation processes around code response and into our orientation programs for all of our nursing staff into the orientation of onboarding for all of the physician staff as they come every July. But I think that it can't be underestimated how much education has to happen. What's also very important is what you learn from your pilot. And I think that a robust pilot of any new initiative really helps to guide you in seeing all the blind spots that you had about what were the potential things that needed to be changed or developed as part of an educational rollout. I hope that's responsive.
Maureen McKinney: That's great. Thank you. And now a question for Ann Marie. Ann Marie, can you describe the circle up portion of your handoff communication process?
Ann Marie Leichman: Sure. This is part of a patient-flow initiative that we have here at the hospital. And we have been working with certain processes to try to streamline and better prepare for patients. And one of them is we have a circle up at the beginning of every shift. It starts exactly at the beginning of the shift. All the nurses circle up and there is communication to them about those things that are critical for them to know—both related to patient flow and patient safety. So, for example, each unit would read off who their high-risk patients are for falls and also talk about things about who their discharges are for the day, what admissions they're expecting, where they're going to go, so there is some very brief gathering at the beginning of every shift. And the other thing that we do is we set the intention for the day. We have one person—the charge nurse who usually leads it—and there are suggested intentions or the unit can set their own. So really to set the moves for the unit for the day and what needs to be accomplished. We also review patient-satisfaction scores and we review those areas that we want to work on. We do it very quickly though. It's a standardized form that we use. It's filled out by the charge nurse from the previous shift, and it gets passed from shift to shift. And it really only takes about two to three minutes to do.
Maureen McKinney: Great. Thank you. I have a question from a listener for Mary Viney. Mary, can you elaborate a little bit more on—you said there were issues with compliance when it came to scanning medication administration?
Mary Viney: I'm not sure that that's mine. I think that might have been Ann Marie's question about scanning medication.
Ann Marie Leichman: I talked about problems with scanning.
Maureen McKinney: Oh, I'm sorry. Go ahead, please.
Ann Marie Leichman: That's OK. What we found in the beginning is that we had just true technical problems. Some of the scanners didn't work well or it was difficult to operate them. A lot of the bar codes didn't work well. And what happened was nurses became very frustrated because it was very tedious—the process—when we launched it became very tedious. So, there was a process in place for nurses to identify the problems, like they were supposed to put the label into a bin and the pharmacist would pick it up. And then we would work on it, on resolving the issue. But what happened was nurses, as they always do, discovered some workarounds to the problem. So instead of scanning they used a manual method. So we were very disappointed in that because the safety—clearly the safety lies in the ability to scan. And after we worked out the problems with the technology and it continued, we realized that some people just adopted the workaround behavior even though it was no longer necessary. And that's where we got into the discussion around individual accountability because it really lies within the nurse to follow the system. You know I talked a little bit about Just Culture in the system and designing the system to help employees make safe choices, so if that was done, then the accountability lies really with the practitioner for using the system. And that's why we decided we would put it on the nurses' evaluation. We run report on individual nurses. We have the ability to do that and their scanning compliance.
Maureen McKinney: Thank you for that. And now a question for Mary. What techniques do you use to sustain involvement from staff?
Mary Viney: Well, we have several different things that we do at different levels, but I think the actual front-line staff part of what we do is we have in many of our units we have our weekly meetings that are touch points where we talk about the changes, the opportunities that they're working on. If they're doing action plans on any concepts they keep them out on a white board like a flip chart by their nurses' station so they could see any one of the number of tests that are going on within units. And so it kind of keeps it alive from that perspective. And I think for those that are not participating, the other place that they do is they have a responsibility to at least one of their staff members to keep them connected like on the night shift or the weekend folks who just work weekend or part time. They have one more person to stay connected, so it's the accountability of keeping the information out there, but once you get staff engaged and they know that their ideas count and that somebody wants to hear their opinions, it's not difficult to keep that motivation going. So I think it really is about the leadership listening, asking opinions and taking action on what they say. And that, in itself, kind of regenerates the energy.
Maureen McKinney: Thank you so much, Mary. A question from a listener for Patricia Folcarelli. What advice would you have about helping nurses to work alongside hospitalists on these kinds of patient-safety and -satisfaction initiatives?
Patricia Folcarelli: That's also a very, very good question. We have—I have actually found in my experience that the hospitalists are brilliant partners for change initiatives. And so to the extent that we've been able to use the hospitalists for change is much easier actually with them than it is with some of our services where we don't have hospitalists. So one of the things that I think has been key in this is that we have a monthly meeting. We use hospitalists mostly in medicine. So we have a meeting that's called the Medical Patient Care Committee meeting where the nurse leaders from all of the medicine units, the hospitalists, the chief of the department of medicine, the quality director for the department of medicine and myself attend. And we talk about—we have a dashboard that like you see in my presentation for the medical units, and we actually talk about what's going on in all of the medical units, what are the performances improvements that we are working on with the hospitalists and the nurses. And then we also talk about things that you didn't see on the dashboard, things around flow and things around unit operation that we need the hospitalists to be more engaged in. So that meeting itself has been an intervention that's been extremely helpful in engaging hospitalists. But it really starts from the senior leadership in the departments. So we have strong nursing leadership in the department of medicine and a very strong chairman of the department of medicine who is a champion for—he's actually the role model for a lot of our other chairmen in terms of leading the quality work. So I think engagement of the hospitalists to the extent that you can in meetings with the nursing leadership team has been enormously helpful for us. I wish all of the services in the hospital—every unit—had a hospitalist, but we don't have that yet.
Maureen McKinney: Thank you so much, Pat.
Patricia Folcarelli: You're welcome.
Maureen McKinney: We've reached the end of our hour today, but we've received so many great questions we're going to stay on the line for just a bit longer. I have a question that just came in from a listener for Ann Marie. Please, if you could, provide a little bit more details describing your shared governance structure.
Ann Marie Leichman: Oh, sure. Be happy to. We have a—it starts at the unit level. All units and departments in nursing services have a nurse practice education committee, which deals with nursing practice issues, clinical practice issues, a performance improvement committee where patient safety and quality improvement are addressed. We have a patient-satisfaction committee and a nursing-research committee. And all of them work at the unit level. They have representation there, and then issues get filtered up to hospitalwide councils, so we make sure that we have practices and recommendations on changes in practice—the entire hospital, so we are consistent in our practice. There are some other councils that are stand-alone. They don't necessarily have unit-based like the holistic practice council and the professional practice council, which is a group of people who work with individuals on just career-advancement programs. And this all really gets filtered up, and the performance-improvement council, when I mentioned that we reorganized at the beginning of the year, that reports up into the patient-safety committee, the hospital patient-safety committee.
Patricia Folcarelli: This is Pat. I would add that Beth Israel Deaconess gave a very similar approach where we have a quality and safety council, practice council, recruitment and retention council that's really much more now focused on retention of our aging workforce and interventions that we need to do around that. And then our education and research council. I think the thing that we've struggled with is just how to have—there's representation on every unit on all of those councils. But how to have access to council meetings at the unit level is more difficult for us. We have centralized meetings with representations from each of the units.
Ann Marie Leichman: Just to add on to that. Some of the unit committees because—depending on the size of the unit and the number of people—they have combined, for example, nurse practice and performance improvement and kind of worked hand-in-hand together. And we just restructured the performance improvement council, the hospitalwide one, because the group was so big it became unwieldy and people had very little in common with each other. It really wasn't aligned clinically, so we broke it off into interventional services and medical/surgical services and outpatient and the like, and have an overall steering committee, or a steering council, and these other groups were working independently. And we really have gotten a lot of positive feedback on that. We hear that the staff engagement really just skyrocketed, that there was really a lot of enthusiasm. But, you know, we're a mature model, but you have to keep looking at it and deciding what is working and what's not and really be open to change and making sure you make appropriate changes that could help foster and really continue to grow and develop that model.
Maureen McKinney: Great. Thank you both. I have another question for Mary from a listener. Since all falls cannot be prevented, one of our listeners said they are looking at injury prevention with mats, lower beds and are considering hip protectors. Do you have any other suggestions?
Mary Viney: I think that our—we have not used those initiatives, but some of the more recent things that we have done is we've done that SWOT analysis. I think that Ann Marie was talking about where she has a team that goes to the actual unit where the fall happened. We have that same type of thing, but we have it at the clinical manager, a quality person, come up. And we do that analysis. But then at the end of the week, all the clinical managers come and discuss their falls and look for trends and look for opportunities. So I think the communication, again, about keeping it in front of people, what are we learning? The other two things that we've done more recently over this last year is really looking at the medications similar to what others have experienced. The risk-assessment tools have not been sensitive enough. Our patients change their conditions so often throughout their visit that we have to have something a little bit more sensitive. So we're really looking at our medications with our pharmacy partners very closely and deciding about time of day that certain drugs can be given and then different levels of assessment for groups of meds, and then a test that we're doing right now is we're—instead of just doing ruby-red slippers for our patients to keep an eye on them—we're actually putting a yellow gown on out patients that are at highest risk for falls, not our everyday risk that every patient comes in with, but ones we think are on an anticoagulant, that have a history of falls that we believe tend to be more impulsive maybe then some of the other patients. We actually have gotten some yellow gowns that we put on, so it's very visual for any member of our team—be it housekeeping or physical therapy or anyone else that would come in a room or see this patient up in the chair or anything that they really require that. So that's something we can take off and on the patient with the writs, so just a couple innovative things that we're trying around that. But we would agree we don't have the right risk assessment tool hammered out yet.
Patricia Folcarelli: This is Pat Folcarelli. Can I go ahead?
Maureen McKinney: Oh, yes, go ahead.
Patricia Folcarelli: I would agree that with everything that was said, that this is a very gnarly issue. And one of the things that we've been doing just as a result of looking at our falls with injury and our root-cause analysis is starting to really aggressively target delirium management and to really—we're adding into our nursing assessment tools for nurses to be able to do a quick assessment of mental status changes using a [unclear: 1:04:52 ??raspore??] and then to implement rapid-response process when there's a change in mental status around delirium and involving delirium because I think this speaks to the multidisciplinary nature of fall prevention and about the importance, as you said, of considering medication but also really looking at the systems of care delivery and what's producing in-hospital delirium that doesn't [unclear: 1:05:23 ??involve with??] injury.
Maureen McKinney: Thank you, Pat.
Patricia Folcarelli: You're welcome.
Maureen McKinney: And this is going to be our last question and directed to Ann Marie. With productivity such a [unclear: 1:05:43 ?media?] focus and a lot of time for staff nurses being cut, how do you justify the time that it takes for them to participate in these patient-safety committees and teams that have been mentioned actually by all three?
Ann Marie Leichman: You know we're very blessed here at this hospital. I will say that we do budget for this that we allow staff a certain amount of hours a month to participate. And I really think if organizations are going to make a commitment to patient safety, you really have to do that. There's no way around it. And I know in this environment that it's probably not a very popular thing to say, but in the future our reimbursement is going to depend on the quality outcomes that we've had. So, it will take an investment on the part of organizations to really allow staff to do those and to free them up and not expect them to go to meetings when they have a full patient care. So I think that's critical.
Patricia Folcarelli: I would just echo everything that you've just said. To be budgeted and compensated
Ann Marie Leichman: Yes. Absolutely.
Patricia Folcarelli: There's no two ways around it.
Maureen McKinney: Thank you so much. That's all the time we have for questions. I'd like to thank our three panelists for their time and for their insights, and I think in summary we're seeing that nurses are assuming more positions of power within the area of quality and patient safety and that their background in direct patient care, communication and process improvement has made them strong leaders. I thank you again everyone. This is Maureen McKinney for Modern Healthcare. Dave.
Narrator: Thank you for joining today's discussion on how nurses are leading the way on patient safety and quality improvement at a growing number of hospitals and health systems. All slides for this webcast are available at ModernHealthcare.com/webinars. For those who want to listen to this webcast again, all attendees will receive a follow-up e-mail with a link to the recording of the webcast available at ModernHealthcare.com/webinars. Today's presentation was sponsored by the Furst Group and also by GE Healthcare's performance solutions team. GE Healthcare's performance solutions team is dedicated to helping healthcare systems improve the safety, efficiency and cost effectiveness of its operations. Using process-improvement methodologies, like LEAN and Six Sigma, and patented technologies, like AgileTrac, their experts work with healthcare organizations to streamline the flow of patients and staff to control costs through better asset utilization to determine the ways to help reduce medical errors, develop high performers at all levels of the organization and integrate management and leadership systems that help them to succeed. Furst Group provides a total solution approach to traditional executive search as well as an array of consulting products. As one of the largest firms specializing in executive healthcare assignments, Furst Group's 25 years of success is built upon a philosophy of partnership. They enhance their clients' internal resources to develop effective human capital strategies. Their clients include hospitals and health systems, managed-care organizations, integrated delivery systems, medical group practices, healthcare products and services companies, insurance companies and end-of-life care businesses. They also partner with major capital and private equity firms serving the healthcare sector. This concludes today's presentation. Thank you.
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