What does “meaningful use” mean to nurses? Nursing Spectrum asked Pat Wise, RN, MS, MA, vice president for healthcare information systems at the nonprofit Healthcare Information and Management Systems Society, what nurses can expect as the iniative unfolds.
Until 2007, nurses at Riley Hospital for Children in Indianapolis relied on traditional shift change reporting methods to communicate patient care information from caregiver to caregiver. But when challenged by Riley’s leadership team to find ways to improve hospital documentation, the Clinical Practice Council began looking at a standardized approach to hospitalwide shift change reporting.
After a six-month pilot program, an educational video and PowerPoint® presentation, and another six-month training process, Riley implemented its hospitalwide nurse-to-nurse shift change report at the bedside with families.
Not only did leadership, the nursing staff, and physicians accept the process, but patients and families also became more involved and felt safer as a result.
Riley was recently recognized for its efforts by the National Patient Safety Foundation with the 2010 Socius Award, which symbolizes the relationship between healthcare providers and the patients and families they serve.
Developing a hospitalwide process
Melanie Cline, RN, MSN, clinical director at Riley, teamed up with a 30-person group of staff nurses, educators, the clinical nurse specialist, clinical managers, and the family-centered care coordinator to review current literature and best practices for shift report processes.
“Our highest priority was to include parents in the process as their involvement and input is critical to achieving the best outcomes for each child,” says Cline.
The old process consisted of the charge nurse gathering information from the nurses going off shift about 30 minutes before the change of shift. Another 30 minutes would pass while the charge nurse documented the information.
In addition to making sure the parents were included in the shift report, Cline also had to keep the staff’s best interests in mind. Nurses commonly complained that the handoff information they received could be 60?90 minutes old with the previous process. The staff nurses coming on shift would often find that their patient’s condition had changed by the time they got to the patient.
“When dealing with pediatrics, a child’s condition can change within a matter of minutes,” says Cline. “Getting to the patient sooner is better so potentially avoidable problems are picked up right away.”
Another factor that was vital to determining the components of the shift report was making sure the nurse going off shift and the nurse coming on shift could visualize the patient together, says Cline. This helped develop an understanding of how the patient was assessed on the previous shift.
Finally, Cline and her team developed five standards that are always included in the shift change report:
Head-to-toe assessment
Nurse-to-nurse involvement in viewing
Medication check
Orders verification
Care plan
The five standards of a shift report
The head-to-toe assessment, the first of the five standards, involves the nurses coming on and off shift as well as the patient’s parents. This assessment enhances patient safety—in fact, it has helped identify a few near misses.
“In one case, nurses were discussing pain in a 3-year-old’s left knee, and the mother spoke up and corrected their information, saying it was actually the right knee that was bothering the patient,” says Cline.
The second shift report standard ensures that nurses examine their patient together and discuss how each patient was assessed and monitored. Cline offers the example of a patient’s breathing: Nurses can establish how the patient is breathing and how each patient’s “normal” breathing looks.
The third standard, medication check, is a safety measure that also saves time. During the old process, nurses coming on shift would often have to call the previous nurse at home to double-check medication information.
“By conducting the medication check in real time, it helps save time and eliminates oversights or omissions on the chart,” says Cline.
The orders verification, the fourth standard, involves reviewing all current physician orders and communicating the implementation status of all new orders.
Finally, nurses discuss the care plan with the patient and the family at the patient’s bedside. This is where the next 12 hours of care are planned.
Cline says the entire process takes 30 minutes to complete, and even though the new process takes the same amount of time as the old one, in the grand scheme of things, it saves the staff time.
For instance, nurses no longer need to call nurses off shift to clarify a medication question because the two nurses review this information together during the shift report. Also, with parents now involved in the process, nurses can get questions answered up front as opposed to trying to find the parents later on during the shift.
Education and training
Before these standards and the bedside shift report could be implemented hospitalwide, Cline and her team developed a PowerPoint presentation and video to help educate staff members on the new process. The video reviewed the process step by step—using staff nurses as actors—and reminded staff of the importance of consistency.
Patients and their families also were involved in making the video. At the end of the video, parents described in their own words how the old process was sometimes scary but the new one helped them feel safer.
“It was very powerful for the staff to hear a parent’s testimony about how the old shift report left them out of the process, which can be frightening,” says Cline.
After viewing the video and PowerPoint presentation, those team members responsible for developing the new process coached and observed nursing staff on three occasions prior to rolling out the new bedside shift reporting.
“The 30 staff members who were part of the developmental process came in days, nights, and weekends to coach and mentor their colleagues,” says Cline.
The process took another six months for all units at Riley to successfully implement, making the total time for implementation one year, Cline says.
Finally, in January 2008, all nurses at Riley were involved in the nurse-to-nurse shift change bedside reporting involving parents.
Buy-in from all levels
Some nurses were skeptical of the new process, thinking it would take more time than before because the addition of family involvement would slow them down, says Cline.
As time passed, however, the skeptics began to appreciate the new bedside reporting for the communication it improves and the questions it eliminates—both of which save time in the end.
“The process kind of sold itself to a lot of the staff because of the situations they avoided, like the near misses,” says Cline. The new process ensures that nurses coming on shift visualize patients before the nurse going off shift leaves the unit.
Words of advice
As family-centered care is the focus at Riley, Cline suggests getting the parents or family members involved early on and keeping them engaged throughout the process.
“Having the patient and their family involved is critical,” says Cline. “It helps with any clarification or mix-up in communication that might occur during handoffs and offers comfort to the patient and family during this critical time.” This article was adapted from one that originally appeared in the August 2010 issue of Patient Safety Monitor (Briefings on Patient Safety), an HCPro publication.
Peer review: the evaluation of the professional performance of individual RNs by nurses with experience in the appropriate subject matter to provide a legitimate evaluation. It sounds simple, but the concept of nursing peer review has its own set of unique challenges. Despite these challenges, it remains a powerful way to educate and bring about quality improvement.
But who is a peer? A nurse peer is an RN who practices in the same role as the RN being reviewed. This means:
Bedside to bedside
Nurse manager to nurse manager
Nurse educator to nurse educator
CNS to CNS
Only nurses who are in the same (or comparable) role can provide the kind of evaluation of patient care and nursing practice required for proper peer review.
“In the clinical or any healthcare setting, I always like to ask, ‘What motivates change?’ ” Meryl Montgomery, RN, MSN, ANCC Magnet Recognition Program® (MRP) coordinator for the Medical Center of Central Georgia in Macon, told a live audience during the webcast “Nursing Peer Review: Improving Clinical Performance, Professionalism, and Accountability.” “How do we ensure quality of care? Improve conditions? What is the best way to address a near miss and be constructive?”
Montgomery has found over the years that peer review has the power to drive system improvement.
“It can be very creative and innovative in where you can go—you can engage your nurses across the board,” she said.
Peer review is a situation where “apples to apples” is a necessity. OR nurses really need to be the ones evaluating OR nurses; likewise with OB nurses to OB nurses and critical care to critical care.
“The distinctions between those roles can be important and need to be looked at,” said Montgomery.
Why is peer review necessary?
Many organizations hospitals work with have incorporated peer review components into their standards or requirements:
The Joint Commission (human resources and leadership requirements)
The American Nurses Association under the Code for Nurses
ANCC’s MRP program (Component 3: Exemplary Professional Practice (EP), EP 20)
Montgomery noted the nursing industry’s reputation for “eating its own young,” as the old saying goes. But those days are fading, she said.
“We have had a preponderance of the shark-and-guppy culture,” said Montgomery. “That environment is changing. Changing slowly in some cases, quickly in others.”
Peer review can help change this fact. In fact, the uses for peer review reach beyond individual performance improvement. The following are some other purposes of peer review:
Spotting barriers and weakness
Identifying opportunities
Collecting data for trending/evaluation
Improving patient outcomes
Strengthening accountability
Enhancing professionalism
Improving performance
Peer review comes in many types, depending on the needs of the organization and the outside agencies the organization subscribes to.
Some types of nursing peer reviews are:
Nursing state boards
Peer review organizations
External: ANCC’s MRP program
Informally structured
Incident-based
There are three key components to implementing informal peer review processes. First, determine what regulatory requirements are involved. Next, define and describe what the peer review process will entail.
“Number of things we want to consider here,” said Montgomery. “For example, we determined we wanted to be MRP designated and increased the depth and breadth of our peer review processes. CMS, The Joint Commission all have PR requirements. We had to ask, ‘Who is going to be responsible for peer review?’ ”
They put the focus on human resources but also included the professional development council, operations council, and education council to help educate and utilize tools.
Finally, peer review must be built into the culture of the organization. This process can be even more complex and challenging than the first two components.
What factors go into enculturating peer review?
Job descriptions
HR processes
Daily operations
Quality assurance/performance improvement
Education
Implementation
Evaluation
Montgomery’s organization also spent a lot of time enculturating—or hardwiring—its peer review process.
“Every job title has responsibility to be a preceptor for peer review,” said Montgomery. “Our education around peer review is included not just when we talk about peer review, but is also clearly articulated in the job description that nurses are expected to review and be reviewed.”
Factors of quality peer review
Peer review needs to be ongoing—not just once a year during performance appraisal.
“It goes on throughout the employment process, through the nurse’s stay with the organization,” said Montgomery.
Reviews can happen in a variety of intervals, whether it’s when your facility has developed new policies, procedures, or practices; implemented the use of new equipment; or when nurses act as preceptors for new hires. In all cases, however, the role of the preceptor must always be comparable to the individual being reviewed; the reviews must happen at all levels of the organization; and the reviews must be focused and narrow in scope.
“They also need to be timely,” said Montgomery. “When you put a child in timeout, it needs to be right after the event. Similarly, when we review medical records or practices, the feedback we give must be current, topical, and at an appropriate time. The peer review needs to be clearly articulated and the education for it needs to be thorough.” And, most importantly, nonpunitive.
“It’s not necessarily part of our culture to give constructive feedback,” said Montgomery. “Sometimes nurses simply don’t know how to have a real face-to-face conversation about another nurse’s practice. This requires feedback, facilitation, mentoring.”
Peer review can help spur a nurse’s career advancement, providing a collegial and systematic process. It fosters refinement of skills and decision-making processes.
“If you’re on your [MRP] journey, under components for exemplary practice, nurses at all levels should use self-appraisal, peer review, and more for performance development,” said Montgomery.
Additional benefits
The individual under review is not the only beneficiary of the peer review process. By looking at outcomes of peer review data, it is possible to spot barriers and weaknesses across the board and find opportunities for improvement.
For example, are the holes in knowledge that show up in multiple peer review sessions a matter of educational deficiencies? Are the staff unaware of the resources available to them?
“At intervals across time, we can assess where the organization’s nurses score,” said Montgomery. “Is it a low score or high? Do they not understand something across the continuum of care? Is our electronic medical record not allowing for ease of documentation? All of this can be used to trend data.”
For example, Montgomery’s organization uses specially trained RNs who focus on skin breakdown.
“We look at the data, and if we notice a lot of breakdown, there is an opportunity to make sure we have the right supplies, make sure we’re following up” appropriately, she said. “It’s an opportunity to improve patient outcome.”
Evaluating the evaluators
Montgomery’s organization also allows the preceptees the chance to evaluate the preceptors in an organized manner. “There aren’t many opportunities for that to happen naturally,” she said. “We’ve been able to improve the performance of the ‘sharks’ out there who have a hard time with the mentoring relationship. We know not everyone is cut out to be a preceptor. Not everyone can break things down to a level the novice can understand.”
The characteristics of peer review
To be valuable and fair, peer review must comply with the following characteristics:
Same skill level
Focused
Nonpunitive
Ongoing
Timely
________________________________________________________________________ This article was adapted from one that originally appeared in the August 2010 issue of HCPro's Advisor to the ANCC Magnet Recognition Program®, [http://www.hcmarketplace.com/prod-7406/HCPros-Resource-Center-for-the-ANCC-Magnet-Recognition-Program.html], an HCPro publication.
Three Twin Cities nurses who crossed their union's picket line during a mass walkout June 10 say they were harassed by the union after the fact through letters calling them to a disciplinary hearing. The nurses, all from Children's Hospitals and Clinics of Minnesota, say they resigned from the union before the 24-hour walkout in order to work behind the picket lines. Nonetheless, they received letters from the Minnesota Nurses Association saying they may be subject to reprimand, censure or expulsion. The nurses filed a complaint against the MNA late Wednesday with the National Labor Relations Board. In the past, it's been the MNA that's filed a flurry of federal complaints against the nurses' employers.
Without sufficient skills, first-line managers do not benefit an organization. The first step to increase the number and education of managers is to provide effective training designed to specifically improve organizational performance.
Currently, healthcare costs are high. When all elements of healthcare reform are implemented, higher costs may ensue. There will be a demand for more change and greater resilience from our management teams. Unless we have managers who are resourceful in their management skills, we will not achieve new and improved ways to succeed in the goals of safe, high-quality care at a reasonable cost.
Promoting a technical worker to a manager role requires training. The new manager needs an educational program with inspired faculty, dedicated mentors, and an innovative curriculum designed to deliver the new skills needed to a diverse group of adult learners.
How do you train up employees to be effective, ethical, strategic, and skilled managers? It is a tall order that requires a constant battle to balance the benefits of training with the requirements of daily operations.
Succession planning for managers is often short sighted. Many organizations spend time and money on planning for successors for their executives, but the vast majority of organizations do not have a plan in place for their middle managers. This leaves organizations with unexpected gaps in the frontline and encourages recruitment of unskilled and frequently poorly prepared staff-level employees to assume these critical positions.
We have a choke point in our educational system because most learning curriculums do not provide the tactical skills required of managers in their daily lives on the job. Most organizations choose only one technique from the myriad options available to them, such as:
Expect that seasoned practitioners will inherently have skills and be selected on the basis of informal leadership traits
Believe all that is needed is an orientation program to how your organization “does things”
Silo each discipline into their own management leadership educational program believing that each has such an abundance of special needs that it justifies a unique program
Hold a boot camp that will provide skill training in short time (and expected it to stick)
Think one-day programs are sufficient
Use faculty who are all internal members of the organization
Use online programs that allow participants to study in private at their own pace
Send one person at a time to single, off-site programs
Pair a novice with an experienced member of the team who will transfer skills on a 1:1 basis
Pick a focus and invest in a process excellence model such as Six Sigma, Lean, or other frameworks and expect this will develop leadership skills
Leave the provision of education to the academics in an executive education program
Choose an approach to curriculum development and buy the package from a consultant.
Select a leadership book and take each chapter as a trigger for discussion
Unfortunately, I usually see these options attempted in isolation to any other option. With so many options, which path should be followed?
We need to mobilize our common sense, mutual talents, mutual experiences, and not expect to come up with a single best method. We should understand that there are some universal attributes of management education.
Let’s stick to what makes sense to the people in operations who know what matters and what skills they, as employers, expect of their management team.
Then we need to chart the best course that will lead to the best impact on the business we are in. We are in the business of providing safe, effective healthcare to our community with skilful engaged employees at a price the community can afford.
Implementing a needed management education program requires skill, experience, courage, and collaboration among all stakeholders.
I suggest we begin this discussion with some validation of two common beliefs or assumptions:
The ripple effect of new managers’ lack of knowledge and self-confidence can be seen in poor statistics for manager retention, staff retention, patient safety, patient satisfaction, physician satisfaction, community engagement, interdepartmental collaboration, and financial survival of the organization.
Management requires a skills and a knowledge base. Not all informal leaders are good managers and not all managers are good leaders. You want frontline managers to perform in both areas of management tactical skills and creative leadership in an effective manner. Most healthcare management candidates do not have a knowledge base of the necessary tactical and leadership skills necessary to adequately contribute to highly functional and performing teams within a dynamic and complex healthcare system.
We need to turn to evidence-based theory of adult education to apply those tenets. Knowles (1998) developed principles that stipulate:
Adults need to know why they should learn something
Most adults were educated in school systems that fostered dependent vs. self-directed learning
Draw upon the experience of the learner
Adults want to be motivated to better their real-life tasks
Adults want to know how new learning will impact their lives
Adults are motivated by issues such as job satisfaction, self esteem, and quality of life
The management education question becomes: what content should be covered, how much content, and which delivery option do you use? But what will matter most in the long run is that learners participate in the program with the encouragement of peers, superiors, and subordinates.
My talking points for your discussion are:
Resolve that management education is necessary.
Executive buy-in and visible support by leaders is essential.
Knowing what business goals you want to achieve from any educational program will ensure better outcomes.
Be clear about what skills managers need to achieve the goals.
Management education programs should have an evaluation method with predetermined outcome metrics to evaluate the effectiveness of your organization’s program. The individual performance and engagement in the participant’s career and positive interactions with colleagues should also be measured.
Select the right faculty: Consider the values of internal and external faculty. Faculty must be credible, but not a person who signs the participant’s annual evaluation. Supervisors could be seen as in a position of authority to jeopardize the participant’s job if they have difficulty in the program. You want faculty who can bring both new ideas into the organization and yet provide support to the culture you wish to enhance.
Select diverse delivery methods that provide prolonged engagement with the learning process. Skills are not embedded into behavior overnight.
Train practically: what is taught in the classroom or online needs to be immediately applicable in the workplace.
Include a work project that will have a meaningful impact on the metrics you have selected to evaluate the program. Offer the participants an opportunity to share and present their project to senior staff and other peers.
Train everyone together. One person or one professional group in isolation does not build a community of managers. Isolation does not teach or reinforce communication skills or build the networks that are required in the collaborative practice of healthcare.
Have a mix of internal and external faculty. Honor and acknowledge organization wisdom and challenge participants to reach out to new voices and new approaches.
Know your first efforts will not be your last efforts.
Reference: Knowles, M. (1998). The Adult Learner: The Definitive Classic in Adult Education and Human Resource Development. Houston, TX: Gulf Publishing.
Betty Noyes, RN, MA, is president of Noyes & Associates, Ltd., a nationwide healthcare consulting service. For more information, visit www.noyesconsult.com.
There were 183 patients at Rock Hill's Piedmont Medical Center on Tuesday. Nurse Betty saw them all. Not most. All. Now in her 55th year at PMC, Betty Jenkins, who has been at the hospital longer than most employees there have been alive, has a new role - patient ambassador. Just a fancy title for what Nurse Betty has always done during decades in obstetrics, where the babies are born and miracles happen - bring a smile to everyone she sees. Only now, it's her full-time job.