It may seem strange that functioning as part of a team would cause discomfort, but the traditional paradigm of the physician as the sole controlling practitioner persists.
This article first appeared in the December 2015 issue of HealthLeaders magazine.
At Seattle's Virginia Mason MedicalCenter, teamwork is the name of the game. Healthcare providers who'd rather call an audible and play by their own rules are in for a surprise.
"Teamwork is one of our core values here, and has been since the beginning," says Charleen Tachibana, DNP, RN, FAAN, senior vice president for quality and safety and chief nursing officer at the medical center, which includes a 336-licensed-bed acute care facility that is part of the larger, nonprofit integrated healthcare system. "So the concept of forming teams and reforming teams and coming together and working together really becomes a way of being. If people want to work in silos here, that doesn't work very well; they're not very comfortable, and they aren't able to move agendas very quickly that way."
"Many healthcare professionals come with a mental model around what they expect when they're working with other healthcare professionals. I just think that's reflective of the profession and how they're educated in silos."
It may seem strange that functioning as part of a team would cause discomfort, but the traditional paradigm of the physician as the sole controlling practitioner persists.
"Many healthcare professionals come with a mental model around what they expect when they're working with other healthcare professionals," says Tachibana, who recalls a physician job candidate who declined a position after learning of Virginia Mason's emphasis on collaboration. "I just think that's reflective of the profession and how they're educated in silos."
But if provider organizations are to have success as healthcare emphasizes value-based payment models, quality metrics, and integrated care models, then team-based care and interprofessional collaboration need to be the rule rather than the exception. Groups such as the Institute of Medicine, the Institute for Healthcare Improvement, and the Robert Wood Johnson Foundation, are championing the cause.
"Interprofessional collaboration is when health professionals and others are able to work effectively together on a team, sharing responsibility, understanding and having respect for each other's roles and points of view, and working well together to accomplish a bigger goal in terms of better care for individuals and families," says Maryjoan Ladden, RN, PhD, FAAN, senior program officer at RWJF, which released the report Lessons From the Field: Promising Interprofessional Collaboration Practices. The report highlights healthcare organizations with strong IPC models, including Virginia Mason.
"When you have a model where the physician is paid and it's fee-for-service, the other professions are cost centers,"
IPC is hardly a new concept—the IOM has called for its use since its 1972 report Educating for the Health Team—but it has not fully taken hold in the workplace or in healthcare education in large part because of traditional payment models.
"When you have a model where the physician is paid and it's fee-for-service, the other professions are cost centers," notes Barbara F. Brandt, PhD, director of the Minneapolis-based National Center for Interprofessional Practice and Education at the University of Minnesota, a nonprofit center dedicated to furthering interprofessional practice and education in healthcare and funded by the Health Services and Resources Administration of the U.S. Department of Health and Human Services, RWJF, the Josiah Macy Jr. Foundation, and the Gordon and Betty Moore Foundation.
That is changing, Brandt says. "There's so much more emphasis on primary care [now], and so the changing incentive systems are really driving the need for teams."
More and more, healthcare facility leadership is realizing that quality of care, and subsequent reimbursement, hinges on the team-based approach to care, says Ladden. "When you think about returning hospitalizations within 30 days and all of the things that you can be financially accountable for that you weren't before, I think it has finally dawned on people that no one health profession or entity can really manage all of these issues alone and produce the financial outcomes and quality and safety outcomes alone," she says.
At Virginia Mason, the team approach to care delivery has been a key part of improving clinical and financial outcomes alike, says Tachibana.
"I don't think we could do what we're doing without having interprofessional collaboration," she says. "We couldn't move our quality agenda the way we're moving it; we couldn't drop our costs of care and have the care coordination that we have if we couldn't work together this way."
Tachibana points to the organization's initiative surrounding sepsis as one tangible example of how interprofessional collaboration can improve care. "Sepsis is our leading cause of death in the hospital, as it is in many hospitals across the country," she says. "We have taken our hospitalist team and our inpatient nursing team and really looked at ways that we reduce the time it takes to deliver the sepsis bundle."
Clinical recommendations from the Surviving Sepsis Campaign call for interventions to be started within three hours of the presentation of symptoms of sepsis. Virginia Mason completed bundled interventions in as low as 24 minutes thanks to the interprofessional problem solving, she says.
Working from interprofessionally developed protocols, nurses are able to implement the first three elements of the bundle prior to the patient being evaluated by a physician, who is required to implement the fourth component, delivery of an antibiotic. When it was identified that there was a delay in the administration of the antibiotic, team members in the pharmacy department stepped in to help address the bottleneck in care, which is how intervention time was dropped to minutes in some cases.
Virginia Mason implemented IPC by looking beyond the professions to the patient. The health system has worked to create a culture and structure that puts the patient first and models collaboration at the leadership level. In 2002, when the organization revamped its strategic plan, the patient was designated as the driving force behind its mission and vision.
"Our true north is centered on the patient and improving our care and our processes and experience from the patient's perspective," she says. "If I'm working with a physician and I'm a nurse, it's clear it's not about me, it's not about the doctor—it's about the patient. The clarity of purpose and the clarity of intent and vision has been a key component as you bring a number of different professions together."
Expectations for physicians, board members, the leadership team, and the organization itself are clearly outlined in Virginia Mason's three compact documents, which detail the responsibilities of each group. For example, according to the leadership compact, the organization is expected to "offer opportunities for constructive open dialogue" and leadership members are expected to "continuously improve quality, safety, and compliance."
"It holds us to our principles a little bit tighter and reminds us all of what we're accountable for, and how we're accountable to the organization," Tachibana says of the compacts. "I think it reestablished those norms and expectations about what teamwork is, and what it is to work together, and what respect looks like, and how we're going to focus on the patient."
Accountability is the key to making IPC part of the organizational culture, says Tachibana.
"If anybody is not willing to work collaboratively and respectfully with others, it's a problem and it's an unsafe situation," she says. "So, it's leaders being willing to do that hard work, to call it out, to coach it, to provide opportunity to improve, but, ultimately, if it doesn't improve, to say it's time to part." Tachibana adds, however, that it has gotten to that point rarely, not even once a year. "If there is an issue, leaders are expected to address it through training, coaching, referral to the employee assistance program, or through the use of other resources."
The health system also fosters IPC through its Virginia Mason Production System, its well-known management methodology based on Toyota's Lean principles. VMPS brings the various professions together during rapid process improvement workshops to improve care delivery processes.
Though collaboration is essential for healthcare systems in today's environment, interprofessional education is lagging, says Ladden.
"What we hear from the health systems is that new health professionals come into the health system very poorly prepared with how to work together because there hasn't been any interprofessional education or experiences at the entry level or the graduate level," says Ladden.
That's where the National Center for Interprofessional Practice and Education comes in, Brandt says. Her organization works with academic healthcare educators to develop team-based learning models that incorporate various disciplines and break down silos.
"We are charged with promoting teaching and learning of team-based skills and practice both in practice with the current practitioners and also with the pipeline, students that are in universities and the like," she says.
The center provides reports, training, and data for those interested in implementing IPE and IPC. Brandt says the center also is working to gather data on what types of teams are most effective in the new healthcare environment.
"As we go to value-based payments and we're redesigning healthcare, all those assumptions, we're throwing them out the window. So really understanding who's going to be on the team and what ways they're going to be working are all going to be called into question," she says.
Physicians, nurses, and other providers who have gotten used to working in silos will be forced to think differently, says Tachibana. "I think our patients will demand more" collaboration and teamwork, she says. "It has to happen because the cost curve on healthcare has to shift; so we have to learn to work differently to optimize everybody's contributions here. The economics of [healthcare], if nothing else, will demand that we begin doing it differently."
A new project will evaluate the effect nurse-led interdisciplinary teams have on chronic disease indicators.
Just before the New Year, I spoke with Donna Marvicsin, PhD, RN, PPCNP-BC, CDE, clinical associate professor at the University of Michigan in Ann Arbor, and she shared something that made me first laugh, but then made me pause and come to a realization about the complexity of patient care.
"I had a faculty [member] once tell me about my pediatric population, 'You know, Donna, it's not rocket science,'" she chuckled. When she said this, I immediately thought of my 15-month-old son. He climbs on top of our end table, stands up, tips it over, and falls. And then does the exact same thing again. And again. No, there's no rocket science going on there.
Donna Marvicsin, PhD, RN, PPCNP-BC, CDE
However, I'd argue that Marvicsin's present project—a new program that aims to improve chronic care coordination for underrepresented and underserved populations by using RNs to lead interdisciplinary teams—is by far more complex and difficult than actual rocket science.
With rocket science you apply the laws of physics, put some numbers into an equation, and voilà, you have lift-off. The laws of human behavior, if there are such things, are not so clear cut.
"Nurses get it," says Marvicsin. "They understand the nuances." And that, in part, is why RNs hold such potential to improve patient care by functioning as team leaders.
Moving Interprofessional Collaborative Practice Into the Community
The program Marvicsin is developing is a partnership between the University of Michigan School of Nursing and southwest Detroit's Community Health and Social Services Center, or CHASS, a federally qualified health center. The project is funded by a three-year, $1.5 million grant from the U.S. Department of Health and Human Services Health Resources and Services Administration.
Marvicsin points out that interprofessional collaborative practice had its roots in improving patient safety and quality of care in inpatient situations and settings.
"Where they are now is trying to migrate that work to the community primary-care-based setting," she says. "HRSA is really looking for sustainable models of interprofessional collaborative practice in primary care settings—true team-based care—and my belief is nursing, as a profession, is well-suited to lead these teams."
Marvicsin sees these registered nurse chronic care coordinators as conductors of an orchestra composed of physicians, pharmacists, support staff, and social workers.
"When a patient presents for a visit, all the information is there," she says, "all their lab results, they've been to ophthalmology, they've been to podiatry, etc. So when the patient walks in the room, we utilize the electronic health record to the maximum capabilities, and the patient and the provider can have this really rich discussion in timely fashion."
A New Captain of the Ship
I asked Marvicsin about a few challenges I'd anticipate cropping up with nurses leading a team of medical providers. The first was the physician's response. After all, they've been used to acting as the captain of the ship for decades.
"In a primary care situation, the physician truly doesn't have the time to do this coordination and to delegate," she told me. "Their heart's there, they're capable, but there's a shortage of primary care providers, and they're just pulled so many ways. They just don't have the time to add this on to all their other responsibilities."
Enter the nurse, who could take on coordination duties, but only if his or her role is changed from utility player to coach.
"RNs traditionally have been case managers," Marvicsin says. "I specifically titled this a chronic care coordinator, not a case manager, because I'm trying to change everybody's terminology and thoughts about that. What I view as the sustainability is [that] the RN won't be suddenly lost in the cause of answering the phone or of triaging. We can do that and do that very well, but they shouldn't be answering the phone. They should be doing so much more."
It's important to note that Marvicsin uses the term sustainability differently than we are used to hearing it used in healthcare. Rather than meaning a venture that is financially viable and self-supporting, she uses it to describe shift in culture.
"By sustainable I mean that that everybody gets comfortable with the new team," she says. "It's a shift in thinking that the whole production doesn't have to stop if the MD is not available to make a decision. Everybody's empowered in a true team to work on this project. So sustainable is really that I want the culture and thinking to shift in a permanent way."
Setting the Rules of the Game
The grant began in July 2015, and the search is on to find an RN to fill the coordinator position. Being a FQHC, CHASS can't compete with hospitals when it comes to pay. Plus, with a heavily Hispanic patient population, a bilingual nurse would be most appropriate. Marvicsin says she is confident the right person will be in place by fall 2016 and then the entire team will be able to hash out "the rules of the game" as Marvicsin calls them.
"Some of the managers are asking for the nitty-gritty details of the position. Well, the team has to decide that, I can't. I'm just the project director. If I come in and say you're going to do this and you're going to do that, that doesn't build the team," she says. "If this is going to be sustainable, it has to bloom from within, not from external control because external control means they won't own it. I want them to own it. So everybody has to agree that these are our positions and on the field, I'm going to throw you're going to catch."
The team will go through AHRQ's TeamSTEPPS® training and then keep tabs on specific metrics related to chronic diseases. Marvicsin says they'll watch for improvement in populations such as diabetes, hypertension, and hyperlipidemia.
"If we're doing a better job, the lipids will be down and the A1C will be down and all those chronic care indicators will shift," she says.
They'll also be assessing patient satisfaction by asking patients to rate their visit compared to those visits without the RN chronic care coordinator. And finally, they'll assess the team itself by doing pre- and post–project satisfaction surveys.
With so many sources of information out there, it can be tough for busy nurse execs to keep up on their reading. Here's a list of five HealthLeaders Media articles and columns you don't want to miss.
What a year 2015 was. My husband and I rang in the New Year knowing that on January 1, 2015, he would be laid off from his job. Fortunately, he found a new position at a new company just months later. In fact, we both started new jobs within weeks of each other. I left my job as a night-shift telephone triage nurse and started as the senior nursing editor here in March. On top of that, we spent the year adjusting to again having an infant in the house and helping my daughter get used to her new baby brother.
Life can be a bit chaotic, to say the least, and I know I'm not unique in feeling like there are times when things just seem to pass me by.
Nurse leaders are certainly familiar with the frenzied pace that both work and life can take, which is why I put together this list of HealthLeaders Media content that I don't want you to miss this year. I know they'll be informative, but I also hope these pieces inspire you to give some thought to how you could apply some of these concepts to help develop the nursing profession of the future. And I've included some challenges to get your wheels turning for 2016.
Whether they're 8 hours, 12 hours, or days or nights, nursing shifts have one thing in common—they're busy. The patient nearing a respiratory arrest doesn't suddenly improve his O2 sats because there are four admissions on the board and two more patients are waiting to receive their discharge instructions so they can go home. But there are ways to help control the chaos.
A few years ago, Karen S. Hill, DNP, FAAN, chief operating officer and chief nursing officer at Baptist Health Lexington(KY) launched the role of the patient flow nurse. These are experienced RNs who supplement the regularly scheduled nurses on the units and 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.
Not only has this helped Hill retain seasoned staff members with a wealth of nursing knowledge, the program has also helped decrease readmissions.
2016 Challenge: Think about new or unique ways to use experienced nurses, and their wealth of knowledge, to improve patient care and outcomes and nurse satisfaction and retention.
Do your nurses sigh and roll their eyes at the mere mention of hospital finances? Well, they shouldn't, says Susan J. Penner, DrPh, RN, MN, MPA, CNL, an adjunct faculty member who teaches courses in healthcare financial management at the University of San Francisco School of Nursing and Health Professions. Nurses actually play an essential role in helping a healthcare institution stay financially viable and that goes far beyond being mindful of overtime.
"I think it's very important that nurses are able to link the high-quality work they do with the costs and savings that are involved," Penner says. "With all the concerns about healthcare costs right now and about performance, nurses are in a really key role to help lower healthcare costs."
For example, nursing is instrumental in preventing hospital-acquired infections, providing patient education, and coordinating care, all of which can reduce readmissions and influence the value-based outcomes tied to financial reimbursement in this changing healthcare system.
2016 Challenge: Show your nurses data on how their work has improved both patient outcomes and hospital finances. Thank them for their work and remind them that even nonprofits need to generate a positive margin in order to invest in services that improve patient care.
I realize I just said that nurses play a vital role in preventing readmissions—and it's true. But they don't have be the only ones making contact with and educating patients to influence outcomes. By coordinating with and overseeing other healthcare workers, nurses can still make a huge difference in patients' lives.
AlexSandra Davis, RN, BSN, heads up Wooster (OH) Community Hospital's Community Care Network, a program that trains and uses college students as community health workers. The students review disease-specific discharge booklets, which all Wooster patients receive upon discharge, and help patients set goals, ensure that patients have the proper resources to maintain or improve their health, and report any issues to the patients' primary healthcare providers.
In addition to the students (who receive college credit for their work), the program's staff consists of Davis, one full-time LPN and one part-time LPN. "You don't need to have a whole bunch of RNs out there," she says.
As patient enrollment has gone up—by January 2016 Davis expects more than 100 patients to be part of the program—hospital use has gone down. According to data collected a year ago, patients enrolled in the program had a 26% reduction of ED use and 51% reduction in hospital readmissions. 2016 Challenge: Consider using nontraditional resources such as college students, retired healthcare professionals, even manicurists, to support your nurses and improve outcomes.
Another first that took place in 2015 was HealthLeaders Media inaugural CNO Exchange, which was held in November. More than two dozen nurse executives from across the country gathered to share some out-of-the-box thoughts on the challenges, solutions, and opportunities facing the nursing profession.
Discussions focused on the people, the practice, and the profession of nursing and how, as healthcare changes, nursing will have to evolve as well; during the discussions, it was clear that leaders expect nurses to create new roles, work at the top of their licenses, and start using a systems thinking approach to achieve the goals of the shifting healthcare system.
2016 Challenge: Ponder this question from Cynthia Latney, RN, PhD, the CNO and vice president of patient care services at Penrose St. Francis Health Services in Colorado Springs, CO: "If you had no boundaries, what would you keep doing today, and what would you give away or delegate?"
HealthLeaders magazine's final cover story of 2015 focuses on how some healthcare organizations, leaders, providers, and payers are tackling big issues in healthcare, such as interprofessional collaboration, healthcare price transparency, patient-reported outcomes, and the relationship between vendor contracts and provider performance.
Though the story is called "Big Ideas," the sources interviewed share more than just theories. They get into the nitty-gritty details of how they are dealing with these challenges.
2016 Challenge: Start thinking about the specifics—cost, leadership structure, partners—that can move you beyond an idea and into action.
Making a personal connection with a patient doesn't take much time, technology, or investment, but it can pay off big when it comes to improving patient outcomes and satisfaction.
Barbara Jacobs, RN, MSN, would like you to know she has the two cutest grandchildren in the United States.
"It's a fact," the CNO at Anne Arundel Medical Center in Annapolis, MD, told me. "Other people think they do, but I actually do. I actually have them."
Her adoration for these two little boys is not exactly a well-kept secret.
"Everyone here has heard about my grandchildren," she laughs.
Why, you may wonder, should we as healthcare providers care about her love for these little guys? Well, because she does.
"If I say that to a caregiver and then another caregiver comes in and says, 'Hey, Mrs. Jacobs, I hear you have two cutest grandkids in the United States,' they've completely transformed our relationship with just that sentence," she told me, "because [they] have made what's important to me, something that they recognize and made me seem like a person."
Jacobs is a huge proponent of these types of encounters and is working to promote the development of what she calls "personal connections" between the staff and patients at Anne Arundel.
Putting the Care Back in Healthcare
Jacobs' interest in fostering personal connections began about five or six years ago, when she noticed the practice of interacting with the patient as a person was starting to get lost amid hectic days and technology.
"We were getting everything into the computers and getting so technologically savvy and had volumes of information on a patient, but we were missing the human side of their care," she says. "If you look at people who went into nursing, what helps us feel good about ourselves is helping other people. We want to do that, but sometimes [because of] the distractions of busy days and all of the multitasking that people do, we lose track of the caring part that makes that patient feel cared for."
So Jacobs, who has been at Anne Arundel since September 2015, has been working with staff to help develop personal connections without making it into another time-consuming thing on an already overflowing to-do list.
"We've talked a lot about how it's important to go into a room and pick something you can connect on," she explains. "If they're knitting, talk to them about their knitting. If their husband sits at the bedside all day long, say that they're lucky that their husband sits at the bedside all day long."
Jacobs is not alone in recognizing the importance of seeing patients as a whole people and not just the hip-fracture in room 315. In its report, "Crossing the Quality Chasm"—issued all the way back in 2001—the Institute of Medicine cited patient-centered care, which it defines as "care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions," as one of six aims for improving the healthcare system.
And in a 2011 article in The International Journal of Person Centered Medicine, a review of outcome studies found that "compassionate care benefits patients with regard to elected treatment adherence, wound healing, satisfaction and well-being."
"It makes sense that if you feel like your caregiver cares about you, you're going to be more compliant with what they recommend," Jacobs says. "And little things like my lunch is not exactly what I wanted or I have to wait for my test, I'm probably not worried about any longer because you've recognized that I'm a person that has a life outside of this sick experience."
Make the Connection
Part of what I like so much about Jacob's initiative is its simplicity. As she points out, it's really only "adding a sentence or two to your conversation." She says the majority of nurses have embraced the idea but, interestingly, there was one cohort of nurses who found the concept challenging.
"The group that had the biggest problem, and these were bright, lovely people, were in the Millennial group," she says. "They struggled more on making these personal connections."
Jacobs says this could be because their generation is so used to communicating via electronic tools rather than face-to-face.
"And so now we say to them, 'Here's your five patients, three of them are 87, and think of a personal connection,'" Jacobs says. "And they would very honestly come out and say, 'I don't know how to do this.' "
Rather than lamenting about Gen Y's social skills, Jacobs saw the value in teaching this group of providers how to feel more comfortable making personal connections. "It made me realize that we had to work specifically on training, on helping them learn how to do this task that, in the end, is positive for them, too," she says.
And she has seen success. She received an email from a nurse who said she thinks she's got this down. The nurse noticed a father in the mother-baby unit watching a football game and she asked him if he liked football. He shared that he had played in college and high school, and in particular, loved his high school team. As they continued to talk, they discovered the nurse's grandfather had been his high school football coach.
"It made all the difference and not just for that patient and family, who feel like they're being cared about as people," Jacobs says. It was also good for the patient's nurse who could, Jacobs says, "go home feeling great and call her grandpa. It's good for us, the caregivers, also."
After a change project centered on an electronic plan of care fell flat, Albany Medical Center's clinical informatics specialist took nurse end-users' feedback seriously and embarked on a mission to improve their perception of the plan of care.
If it's true that beauty is in the eye of the beholder, then just a few years back Albany (NY) Medical Center'snursing staff's electronic plan of care would have been seen as "Dogs Playing Poker" rather than the "Mona Lisa."
Susan Dillon, RN, MS, CNML
In the summer of 2013, the organization had finally taken the plunge and moved from a paper plan of care to an electronic one, says Susan Dillon, RN, MS, CNML, a clinical informatics specialist at the medical center.
"Since electronic health records have come along, these plans of care have been converted to an electronic form," she says. "The idea is that nurses would be able to access this information, enter individualized patient problems, and have interventions associated with them [at their fingertips]"
By making the change from paper to pixels, the organization hoped to give its nurses another tool to improve patient outcomes and to help move patients along the care continuum efficiently.
"The electronic plan of care [helps] identify problems. It actually gives suggestions to nurses on the goals we want to obtain," says Margie Lee, RN, MS, assistant nurse manager in the vascular unit at the medical center.
Margie Lee, RN, MS
"So when you put a certain problem in there, like fall risk for one example, the system will automatically divert you to the goal that there's no falls. It also suggests some interventions that will help the nurses obtain the goal. The suggested interventions are actually based on evidence-based information."
A survey in 2014 survey to assess nurses' perceptions of the electronic plan of care, however, showed clearly that they were not impressed. But instead of shrugging off the results, Dillon chose to use the nurses' input to improve their perception of the plan of care as well as the plan of care itself.
And it worked.
A Call to Action
Dillon was a not involved in the initial planning and launch of the electronic plan of care—she was a nurse manager at the time—but when she moved into the clinical informatics department, managing the plan of care was going to be her project.
"I was hearing a lot of dissatisfaction from the nurses," Dillon says. "I wanted to use the survey as a starting point to say, 'Where am I, what's my baseline, and what are all of these nurses thinking about the plan of care?'"
And the results?
"The results were not wonderful," she says. "But not completely unexpected for me. Some of the things I kind of anticipated."
For example, 68% of the nurses agreed that the electronic plan of care added to their workload.
"We never told the nurses this was going to be a slam dunk and it's not going to add work," Dillon says, "so that wasn't a big surprise that 68% of nurses completely agreed with that. They were right, it did add to the workload. I felt that I could handle that one."
But some of the other results, like the nurses' perception of how the plan of care was impacting quality of patient care, were more surprising and worrisome to Dillon.
"When [I saw that] only 33% felt use of the plan of care improved their patient outcomes—that was unacceptable to me. That was a call to action. I knew I had to do something," she says.
The Action Plan
Dillon's first step was to talk with the plan of care steering committee about adjusting some of the interventions the system suggested.
"A lot of the interventions around the problems were based around education issues," she says. "One of the things that I brought to the team was that we needed things that were going actually to drive patient care and help the nurses in making better decisions that are ultimately going to improve the outcomes."
This lead to a revamp of the pressure ulcer plan of care with assistance from the wound, ostomy, and continence nurses.
"We built a distinct pressure ulcer problem. If a nurse says it is a [stage] 2, they can now go into our plan of care and pull up [that problem]. They can click on that electronically and it brings up all of the interventions, some that are required and some that are optional," she says.
Dillon also addressed the nurses' concern that when there was a problem with the plan of care they weren't getting help to resolve it. This concern was brought back to the units' clinical nurse specialists.
"We did do a blitz with the clinical nurse specialists. [We told them] 'you do need to be the resource. You need to go back and let your nurses know that you are the person they should go to for immediate problems.'"
She also did some reeducation with the nurses on how to use the feedback section of the plan of care. "We realized they didn't really know how to put proper feedback in about things they would like to see in the plan of care or things that should be changed to make it a more workable document," she says. "So we did a big blitz to show them there is a form where they can write anything and when they write in it, if it says anything about plan of care, it comes directly to me. Then my job is to respond to the person, to kind of work through what they're talking about as far as an improvement."
Hard Work Pays Off
As surprising as the results of Dillon's original survey were, the results of a follow-up survey were just as unexpected. "On the survey that I gathered, it actually gave me a good numbers of improvement from the previous survey. It actually surprised me," Lee says.
For example, when asked on the 2015 study if they preferred the electronic plan of care rather than the previous way of doing things, 85% of the nurses reported the preferred the electronic plan of care. In 2014, only 65% preferred the electronic plan of care.
"[Their perception of] the accuracy of the plan of care went from 48% to 71.2%. It's a big improvement," Lee says. "They actually believe in the plan of care and can depend on the plan of care. It serves as their backup on rendering quality care to their patients. It guides them on what to do and it gives a lot of information to be able to meet the goals that we're expected to meet."
From this experience, Lee gathered some wisdom that anyone making changes in a healthcare organization would be wise to keep in mind.
"It made me aware that being sensitive to their thoughts and their perceptions, being valued as part of a team, being heard for their feedback and suggestions are factors that are needed to gain participation in any organizational project or implementation" she says.
"You can't just make a change in an organization without following up on it [to see] if it's working. If it's not working you have to address it, you have to pay attention to it."
Post-acute care providers can help hospitals prevent readmissions. But it will take a change in perspective and the formation of partnerships among care settings to improve patient care along a continuum.
On a shelf in my bedroom, I have a framed wallet-sized photo of myself and a smiling little boy with his head wrapped in a turban dressing of gauze and medical tape. I cared for him when I was a new nurse, not even a year into my career, after he had brain surgery to treat Landau-Kleffner Syndrome, a rare neurologic disorder.
His mother and I really connected, but after he was discharged I never saw them again. I still wonder how he progressed after the surgery. Was it effective long-term? Did he learn to speak? Was he able to attend school?
This "love-'em-and-leave-'em" approach to patient care has been pretty standard for decades. You take great care of patients while they're under your charge, but when they're discharged or transferred, your work is done.
But thanks to an increased focus on outcomes—both clinical and financial—the chasm between acute care and post-acute care settings is starting to narrow.
Rita Vann, RN
Rita Vann, RN, chief clinical officer for Ascension Senior Living, who was head nurse on an orthopedic unit with a large number of patients with hip fractures, is familiar with the old approach.
"We did a lot of transferring and I just have this vivid image in my head of these little ladies being rolled out on stretchers with their transfer form lying on top of their chest," Vann remembers. "The extent of the communication that we had with, what is now known as the post-acute provider, was whatever we wrote on that piece of paper."
"We are [now] being held accountable for hospital readmission numbers with our partners and hospitals are being held accountable by CMS for their readmission numbers, so that is a shared quality goal that we have," she says.
Discharging the Discharge
While the "transfer-form mentality" still exists among some care providers, Vann says alliances between acute care and post-acute care providers are necessary to meet care standards.
"We really have to start building bridges between the two and making sure that we totally understand their role and that acute care totally understands what the next steps are for the patients they transfer to us," she says. "We need to work together to make that seamless."
Ascension has recognized that stronger partnerships mean better outcomes, and part of Vann's role is to cultivate positive working relationships between acute care and post-acute care providers.
One way the organization is shifting away from siloes of care and toward care that follows patients across the continuum is by phasing out the idea of the traditional discharge.
"We are working to get rid of the term "discharge" because if you look up the definition in the dictionary, it really is 'to get rid of, to stop,'" Vann says. "What we have to do is to transition that person from acute care to the next appropriate level of care."
That could mean a senior care community, a skilled nursing facility for rehab, or home with home care. But wherever that next setting may be, out of sight doesn't mean out of mind.
"I think that the key is understanding that even though they are leaving your community, your accountability for that safe transfer and safe transition does not end," Vann says.
I Want to Hold Your Hand
The goal of these partnerships is to create smooth handoffs between the various care settings. In order to achieve this, both sides must improve communication regarding patients.
"What I struggle to do every day is to make sure we have good communication with hospitals, that we're talking with our hospitals days before the planned transfer to know exactly what the particular needs of the resident are going to be," Vann says.
One way to do this is through the use of a clinical liaison who works with the hospital case managers.
"They will contact us about a potential referral and then we begin communication and making sure that that we can meet that resident's needs," Vann says. "We first have to make sure that it's a match and that we have bed availability to get them into our community. Then we work with them on making sure we have all of the information we need."
Vann points out this type of communication is necessary to minimize on-the-fly transfers that could leave a patient in situation that could set them up for a hospital readmission.
"Transition has to start the day they come in, because hospital stays are much shorter," she says.
"Unfortunately, we still see [instances] where we get a call in the morning for someone to be transitioned to our community that afternoon. Many times that is just not enough time for us to get the equipment or the medication in place that the person needs and to be ready to accept them on the other end."
Vann says that at a recent American Health Care Association meeting, healthcare consultant and noted long-term care advocate Mary Ousley, gave a description of patient transitions that resonated with her.
"She described it as a 'warm handoff,' where we're holding hands with the resident until someone else is holding hands with the resident so that the resident's hand never gets cold," Vann explains.
And it's not just a hospital holding hands with a patient until they get to a skilled nursing facility. Vann points out that transfers also occur from post-acute care providers to hospitals, or among different post-acute providers.
"It's imperative that we learn about the various levels of care and where we're transitioning patients and our residents," she says. "We can no longer discharge; it has to be a transition. It really is a true mindset change for all of us."
Nurse leaders share their ideas on the changing shape of nursing roles and care models during the HealthLeaders Media 2015 CNO Exchange.
In Austin, Texas they like to keep things interesting. The city's unofficial slogan is "Keep Austin Weird." Independent music and art are held sacred, and Willie Nelson could be described as the city's patron saint. Creative thinking is encouraged and, perhaps, even required in order to thrive in the capital city.
So it seems fitting that HealthLeaders Media chose The Omni Barton Creekside in Austin as the site for its inaugural, invitation-only Chief Nursing Officer Exchange on Nov. 11 – 13.
More than two dozen nurse executives from across the country gathered to share their at times out-of-the-box thoughts on the challenges, solutions, and opportunities facing the nursing profession.
We Can Do Better
As I write this, two charcoal drawings of cowboys on horseback hang on the hotel wall. They remind me of the lyrics to the song Anything You Can Do I Can Do Better from the musical Annie Get Your Gun. The lyrics are surprisingly appropriate to healthcare since the industry is fixated on the idea of doing things better (think value-based purchasing, improved clinical outcomes, decreased readmissions, and changing payment models).
Though many players are invested in improving care delivery and outcomes, I'd argue it's nursing that bears the brunt of the responsibility in attaining these goals because it's nurses who interact so heavily with patients and who are on the frontlines of care 24/7.
But to incite the changes and meet the goals inherent in this new healthcare environment, nurses can't rest on their laurels and continue to do things the way they've always been done. Instead, we're going to have to borrow from the philosophy that drives the people of Austin and start thinking creatively.
"We're going to have to change the whole way we deliver care," says Steven Seeley, MSN, RN, VP, COO, and CNO at Jupiter Medical Center. "It's just not going to work the way we do it now."
He believes we have to be willing to cast aside old roles and old ways of doing things. "In the future, we've got to get nurses moved away from being the task masters and really to being the coordinators of care."
From Pointillism to Panorama This is a tough concept for many, including nurses, to get their minds around. Cynthia Latney, RN, PhD, CNO and VP of patient care services at Penrose St. Francis Health Services in Colorado Springs, CO, says she once asked her nurses, "If you had no boundaries, what would you keep doing today, and what would you give away or delegate?"
Her nurses found it a challenging question to answer, and I'm not surprised.
After all, in nursing school, we focus a great deal on tasks—Foley insertion, intramuscular injections, making beds, transferring the patients to the commode—but we don't get as much guidance or education on critical thinking, problem solving, and delegation. Old habits die hard when we enter the workforce, and we cling to those easily identifiable tasks.
If we do them proficiently, we are thought of as a "good" nurses. In this new healthcare environment, that's no longer enough.
If we want to improve outcomes, we can't be content with monitoring an acute-care patient's blood glucose level and giving insulin. Rather, nurses must start thinking about the big picture. What do patients need to maintain or improve their health once they move beyond the hospital walls? Do they have follow-up appointments with a primary care provider or endocrinologist to help manage their diabetes? Do they understand their discharge instructions so they won't be readmitted because of a medication error? Do they have a stove to cook healthy meals?
Nursing is a big job, and it can seem even bigger when you start expanding nurses' roles beyond just tasks. The good news is there is an entire care team we can partner with to help us achieve value-based outcomes.
"Let's bring all the skill sets together to really look at what we are going to achieve—an outcome, to reduce admissions, [or] to really reduce the cost on the accountable care side of things," says Barbara R. Medvec, RN, MSA, MSN, principle of BRM Initiatives, LLC, and former senior vice president and CNO at Oakwood Healthcare in Dearborn, MI.
This may mean pharmacists become responsible for medication education upon discharge and making follow-up calls to patients at home. It may mean using support staff such as CNAs or LPNs to ambulate a patient while the RN focuses on educating the family.
While some caution that in the past, certain types of nursing roles, like the admission nurse or the medication nurse, have fragmented nursing care and created silos in the care structure, others like Kathleen D. Sanford, RN, DBA, FACHE, FAAN, SVP, and CNO at Catholic Health Initiatives in Denver, say we can't be limited by what has or hasn't worked in the past.
"I believe we have to think differently," she says, "and not 'remember how it didn't work before, because now we have the tools so we can do it totally differently.'"
Top nurse execs gathering this week for HealthLeaders Media's inaugural CNO Exchange will engage with their peers over rapidly changing care models and new roles for nurses and chief nursing officers.
If you want to convince a busy nurse leader to step out of the office and away from the hospital for a couple of days, you'd better have a really good reason.
I can't think of a better one than an invitation to the inaugural HealthLeaders Media CNO Exchange at the Omni Barton Creek resort in Austin, TX.
This week, more than two dozen top nurse leaders from around the country will gather to exchange ideas about the most urgent issues that nurse leaders—and the nursing profession as a whole—are facing. I expect lots of spirited and thoughtful discussion among this select group of leaders and I can't wait to join them. Here's a preview of some of the topics we'll be covering:
People: Recruiting and Retaining Top-Performing Staff
Recruiting and retaining nurses is an ever present challenge for nurse leaders. The profession has seen its share of nursing shortages, though a recent study estimates the next shortage may not be as severe as once thought.
Still, attracting and keeping the nurses with the right skill mix is no walk in the park.
"One of the things we grapple with here is how to fill our openings," says Kathy Bonser, RN, MS, vice president and chief nursing officer at SSM Health DePaul Hospital in St. Louis. "We've been pretty successful recruiting the graduate nurses because some of our competitors in the market made the choice to only hire BSNs. We've stayed committed [to also hiring ADNs] because of relationships we have with many of our community colleges that surround our hospitals." In 2015, Bonser hired 50 new graduate nurses in January and 54 more in June.
Kathy Bonser, RN, MS
Mary Shehan, RN, DNP, NE-BC, CNO at Weiss Memorial Hospital in Chicago has also had a good supply pool of RNs. "I have not had a lack of applicants," she says. "I would say for every new grad position I had, I had at least 10 applicants."
Keeping those new nurses in the organization, however, is a separate challenge, especially in a market like Chicago where hospitals are just a few miles apart from each other.
"There's quite a bit of a problem with nurses going from one organization to the next, and I see the biggest problem with this is the new grads," she says. "They are constantly moving and mobile. I spend a considerable amount of time bringing new grads on through internship programs and residency programs, only to have them leave and go to the next hospital."
Bonser has seen the same thing among her younger staff. "I'm a baby boomer; I admit it. I've been here for 34 years," she says. "That what my parents did, that's what people my age did. The millennials they want to move and they want to shake it up."
Practice: The Changing Scope of Nursing Roles
More than ever, the healthcare industry is placing greater emphasis on outcomes, quality metrics, patient satisfaction, and the care continuum. Nurses have a huge opportunity to influence changes in these areas. As a result, nursing roles and practice settings will also change.
"Our greatest opportunity is to really work at the fullest level of our capability, to work to the highest level of your degree," Shehan says. "We have so much opportunity to have nurses helping us as hospitalists or even out in the clinic setting."
Mary Shehan, RN, DNP, NE-BC
Shehan sees huge potential in using APNs to help delivery care.
"Here at Weiss, I do have a number of NP hospitalists," she says. "They're helping make tremendous strides in reduction of length of stay and making sure that I am using protocol driven order sets."
Bedside nurses are also influencing nursing practice by providing more input into policies, process flow, and patient care interventions says Bonser.
"I've got to have the people at the bedside making decisions about how the work is done," she says. "I haven't been at the bedside for many years, so I can't be that person."
Bonser says bedside caregivers are the best people to drive nursing practice and standards because they are the ones who are in the thick of things when it comes to delivering patient care. "One of the things we've done to help bridge that gap is we have our shared governance structure," she says.
Each of the SSM DePaul nursing units has a nursing practice council and there is a campus-based practice council. Both are comprised of bedside nurses. In addition, SSM has a St. Louis-region nursing practice council and recently created a system-wide practice council to connect bedside nurses across the four states with SSM facilities.
"[This is to ensure] decisions about practice and what nurses are doing out there every day are made by the right people," Bonser says.
Profession:The Evolution of the CNO
Nurse leaders have to concern themselves with far more than just nursing nowadays.
"I've been a CNO now just a little over 15 years," Shehan says. "I need to be aware of all aspects of healthcare and not just taking care of the division of nursing." Achieving financial and quality outcomes, readmission rates, and other system-wide initiatives all hinge on nursing and the CNO, she says.
"You have to be totally in line with all of the different things that we're faced with," she says. "It's my role to try to let the bedside nurses know that what they do really impacts [things]—whether it be the bottom line or the quality outcomes that were expected."
Nurse leaders must take into account things that would have once been considered outside their realm, such as medical codes and length of stay.
"We're just seeing sicker and sicker patients and the workload is hard," she says. "[When you add in] this patient codes out to being a length of stay of three or four days, and you have ask, 'So what are we doing to get these patients to the appropriate level of care in the most economical time frame?' That to me is a real challenge."
Nurse leaders need to be concerned with process and workflow barriers that could be impeding patient care as well, she says. Plus, they must consider whether an acute care setting is the right place for the patient to receive care.
"It's really about getting them the appropriate care on time," she says, "What are the delays in getting them that care? Can that care be provided in a different setting? Is it time to move them to the nursing home or home with home care? Or are they truly so sick that they're an outlier to that length of stay estimate and they should be still in the facility?"
With all this responsibility, the CNO has definitely earned a seat in the C-suite, she says. "It's truly a partner at the executive table. The CEO, CFO, COO and the CNO and CMO—those five roles are just so important."
Mental illness often overlaps with medical illness. In an acute care setting, which group of providers should lead the patient's care? Nurses are natural integrators, but can't do it without support from leadership.
I have known five people who've lost their lives through suicide—one for each finger on my hand. I don't have enough digits to count the number of people I know who have dealt with anxiety, depression, eating disorders, alcoholism, or bi-polar disorder. And those are the ones who are willing to talk about it.
I'm sure many more friends and acquaintances silently cope with mental illness because of its social stigma, and there's data that supports my hunch. According to the National Alliance on Mental Illness, one in four adults experiences mental illness in a given year.
Martha Whitecotton, RN, MSN
Behavioral health is something worth talking about, and healthcare providers need to get in on the conversation if they want to improve patients' mental and physical health and provide value-based care, says Martha Whitecotton, RN, MSN, senior vice president of Behavioral Health Services at Carolinas Healthcare System.
"The real drive is starting around this now because of population health, because of accountable care organizations, and because of the way that people are going to be paid—placing their payment at risk for overall health and overall cost," she says. "It's forcing the conversation around what do we do about mental illness."
Two Sides of the Coin
Anyone who has worked in a clinical setting knows behavioral health diagnoses and medical diagnoses are often treated with a siloed approach. Whitecotton gives the example of a patient experiencing severe psychosis who is also in need of dialysis. In an acute care setting, which group of providers should lead the patient's care?
"Those two things (dialysis and psychiatric care) don't exist in one place, so nobody wants to take care of the patient because they don't have an essential piece that they need to take care of him," she points out. "It's a real problem that we're going to have to address."
The way CHS has chosen to address these issues is by creating an integrated system, which the SAMHSA-HRSA Center for Integrated Health Solutions describes as systematic coordination of general and behavioral healthcare.
"It's bringing behavioral health treatment into the medical care space, and it's also bringing medical care into the behavioral health space," says Whitecotton.
This is important because behavioral health issues do not exist in a vacuum. Patients with mental illness may also have medical issues such as diabetes. The 2003 National Comorbidity Survey Replication found that "68% of adults with a mental disorder had at least one medical condition, and 29% of those with a medical disorder had a comorbid mental health condition." Often, those with behavioral health issues end up using the emergency department for their healthcare needs.
"The sickest of the sick with mental illness often do not seek any kind of medical care other than the emergency room. They don't have a primary care provider," Whitecotton explains, "so you've got to make sure you're integrating physical healthcare into that side and mental healthcare into the physical side."
Attitude is Everything
Whether it's done in primary care, the ED, or on an acute care unit, nurses can be valuable assets when it comes to integrating behavioral healthcare, Whitecotton says.
"Nurses are natural integrators. That's what we do," she says. "We're taught from a very early educational foundation to think of the whole person and to understand, 'I'm not going to get this person well if we don't address all of these issues.'"
Some nurse leaders, however, are less than enthusiastic about dealing with behavioral health needs.
"Some of them talk about behavioral health patients as if they are poison… as if their issues are secondary to everything else that goes on in that hospital," she says.
"When you start to model that sort of behavior, you send a message that runs counter to what we really want leaders to be thinking about, which is whole person care."
Leaders who have the most success building their staff nurses' confidence in caring for patients' behavioral health needs put providing whole-person care in a positive light.
"At the nursing unit level, the degree to which my team was willing to accept something new was all in how I presented it," Whitecotton says. "It's setting the example of really modeling whole person care, and it's fascinating to watch those that don't and those that do and the impact it has on their staff's confidence."
In addition to a positive attitude, leaders can support staff nurses by providing the tools needed to care for these patients.
"If you have a large number of psychiatric patients in your emergency room, you probably need some technicians that are actually trained on how to do one-on-one care with a psychiatric patient," Whitecotton says. "You can't ask the nurses to be all things to all people in all moments. So how do you support them to do the work that they need to do?"
For more on integrating behavioral health into primary care, join Martha Whitecotton, RN, MSN, FACHE, senior vice president of behavioral health services at Carolinas Healthcare System for the HealthLeaders Media webcast, "Integrating Behavioral Health: Decreasing Costs and Improving Care"on November 17 from 1:00 –2:00pm ET.
The shift to value-based care could lead to expanded hospital-level acute care in patients' homes.
This article appears in the October 2015 issue of HealthLeaders magazine.
For patients in need of the level of care and interventions given in an acute care setting, the hospital is often the only option. And while necessary to handle acute exacerbations of illnesses, hospital admissions can lead to the development of a host of other problems for patients.
"We all know that hospitals can be very dangerous places for older adults," says Amy Berman, BS, RN, senior program officer at the John A. Hartford Foundation, a New York City–based private philanthropy working to improve the health of older Americans. "They commonly experience things like functional decline, complications, and other adverse events when they're inpatient," she says.
According to data collected by the Department of Health and Human Services Office of Inspector General, in 2008 an estimated 13.5% of Medicare beneficiaries experienced adverse events during hospitalization, and an additional 13.5% experienced adverse events that resulted in temporary harm.
The John A. Hartford Foundation has been working to find a solution to hospital-induced complications among geriatric patients since 1995, when it began working with the Johns Hopkins School of Medicine and dedicating funds and other resources to support the creation, study, and dissemination of a safe, high-quality, cost-effective alternative to inpatient acute care that is now known as the Hospital at Home model.