When she noticed RNs weren't always able to make patient discharge a top priority, Baptist Health Lexington's CNO created a new nursing position to improve the discharge process. The result has been a direct benefit for pay-for-performance indicators.
Do the worst first. That's advice my preceptor gave me when I was a new nurse.
It was her quick-and-dirty tip on how to prioritize patient care. Her point was that I should focus my attention on the patients with the highest-acuity levels or who were the most unstable. Post-op patients or those with drains, tubes, deep-brain electrodes, or changes in neuro status should have dibs on my time and care intensity.
A few years ago, Karen S. Hill, DNP, FAAN, chief operating officer and chief nursing officer at Baptist Health Lexington (KY) noticed nurses at her facility were also engaging in this type of prioritization.
"If they had an assignment and a patient was going to go to the OR or the cath lab, that patient rose in the level of priority," Hill told me, "and sometimes the patient who was more stable or going to be discharged was not the most important thing they were doing."
But, as she points out, healthcare has evolved and a greater emphasis is now placed on issues such as preventative care, quality outcomes, and continuity of care, which can all be affected by how well patients understand their discharge instructions.
"I've seen a huge transition in my nursing career from high-acuity hospital focused care to, now, a focus on wellness across the care settings," says Hill, who has been a nurse for 37 years. "As we've done that, one of the things that I've tried to do is to help develop a different way to look at hospital care."
That new perspective includes elevating discharge education, and education in general, to a top priority for nurses. To do this, Hill created the role of patient flow nurse.
Going With the Flow
Patient flow nurses are experienced RNs who supplement the regularly scheduled nurses on the units. They work with the primary nurses to educate patients, fill out discharge paperwork, and move patients along the care continuum in an efficient and expedient manner.
Hill created the position, originally called discharge/flow nurse, about six years ago for multiple reasons including to improve quality metrics, transition care, and staff retention.
Even prior to passage of the Patient Protection and Affordable Care Act in 2010, pay-for-performance was coming into vogue, Hill says, and the number of quality indicators that needed to be met for specific diseases was on the rise.
"There were a lot of indicators being added every year and it was difficult for staff to always keep up with those things and know what the expectations were," Hill says.
"When we went into this program with the discharge flow nurses, our expectation was that within a subset of, [for example] congestive heart failure patients, to be successful, all of the indicators that applied to that patient would be met."
Ensuring that care standards—such as heart failure patients being discharged on specific medications—are achieved is an important function of the patient flow nurse position. These nurses have received intensive training on nationally reported public quality indicators Hill says, and are now recognized as "content experts" by their colleagues.
"The other thing the discharge flow nurses have done is as those indicators have been added, they help us educate the medical staff when they're upstairs seeing those patients, too," she says, "which is good team work and collaborative."
Retaining Nursing Knowledge
In addition to meeting quality standards, Hill also wanted the patient flow nurse role to be a tool to foster retention and satisfaction of senior nursing staff.
"I've always been a big believer in trying to keep experienced nurses at the bedside because we have such great wealth of experience in nursing," she says. "And, yet, if we're very traditional, they either have to do a 12-hour shift or we don't have anything for them so they end up leaving the bedside, or going into all sorts of alternative roles or retiring."
Hill wanted to entice experienced nurses to stay at the bedside.
"We tried to do some shorter shifts," she says. Patient flow nurses work 8-hour shifts. "We made it Monday through Friday, so we incentivized the more senior nurses to get their weekends off."
From what Hill can tell, it appears nurses are satisfied with the role. There are currently nine patient flow nurse positions at the facility, and the group's average age is about 50 years old compared to the traditional nurses who average about 43 years old. Turnover in the group is low, and when it does happen, it's because a nurse chooses to enter an advanced practice program or decides to retire.
Hill says when a position opens up, there's no trouble finding qualified nurses to fill the spot.
And it's not just the patient flow nurses who are satisfied with the role. Regular staff RN satisfaction has improved, too. "It's helped me increase the satisfaction of the nurses because they're getting this help," she says.
Risk Equals Reward
While the role has been well received and even expanded to other hospitals in the Baptist Health System, there was an element of risk involved in launching the program.
"I had to get support from our president and the other executives on the senior team to put these extra positions in," Hill says. "I needed new resources to do this."
By focusing on the benefits this type of role could bring to the organization, she was able to convince the hospital's president and her C-suite colleagues that the role was needed.
"When I presented the proposal to him and he saw that there was a direct benefit for the pay-for-performance indicators as well as for patient flow and census and staff satisfaction he was on board," she says.
Overall, both the nurses and hospital leaders have been satisfied with the role's outcomes.
"It's helped me be able to get patients discharged more efficiently and, from the data, it's helping us decrease readmissions and increase patients' levels of education," she says. "We've been very pleased with it. There's a recognition that these nurses are important."
For more on improving care transitions and promoting patients' understanding of their plans of care, join Joseph V. Agostini, MD, of Aetna's Health Plan for the HealthLeaders webcast, "Using Embedded Case Managers to Reduce Readmissions and Streamline Care" on August 26 from 1:00—2:00 PM ET.
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.