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.
A workshop for nurses at UCSF Medical Center to enhance their palliative care communications skills has been in high demand for five years. Nurses learn to represent patients and their families during acutely vulnerable times.
When Kathleen Turner, RN, BSN, enrolled in nursing school, she intended on becoming a hospice nurse.
"My mother had worked for hospice for a long time, and she and I had cared for my grandmother in the last six months of her life," says Turner. "And seeing how those hospice nurses were with my family, that's what I wanted to do."
But for her final clinical rotation, Turner's instructor threw her a curveball and assigned her to, of all places, an intensive care unit.
Kathleen Turner, RN, BSN
"I was so angry," she recalls with a laugh. "And she said, 'You know, I think this is going to be a good fit for you.' I went, and I understood that there was plenty of suffering in the intensive care unit and there was a huge opportunity to bring what I liked about palliative care into critical care."
Turner, who is now a charge nurse and clinical nurse III in the medical-surgical intensive care unit at the University of California, San Francisco Medical Center, stuck with critical care nursing as a speciality but has retained her passion for palliative care. Today she is a facilitator of a UCSF Medical Center workshop to help critical care nurses improve their palliative care communication skills.
The workshop was developed in 2010 at the request of USCF's bedside ICU nurses, says Kathleen Puntillo, PhD, RN, who is professor emerita in the Department of Physiological Nursing at the UCSF School of Nursing.
"We asked the nurses what their concerns were," she says. "Their biggest one was they felt like they needed more education and more preparation in improving their skills in communicating difficult conversations."
In response, UCSF Medical Center's ICU Palliative Care Committee (formerly called the End-of-Life Care Committee) created an eight-hour workshop for critical care nurses to learn and practice palliative care communication skills. During the workshop, of which Turner and Puntillo are facilitators, nurses' roles and skills in communicating a patient's prognosis and goals of care are defined.
"It's really clear that our primary duty is to that patient, especially in a situation like the ICU where the patient is so vulnerable and so rarely able to speak for themselves," says Turner. "It's not just our right or something extra for us to do, but it's our core responsibility to be that patient's voice and that family's voice during this really difficult time."
Throughout the day, participants practice communication skills through facilitated role-playing sessions. The workshop ends with time for reflection on burnout, distress, and self-care.
According to the journal article, the workshop has been successful. Prior to attending, participants are given a self-evaluation and asked to rate their confidence and skill levels with certain tasks related to communication of prognosis and care goals. They are then asked to again rate their confidence and skills immediately after the workshop and three months later.
The nurses reported an increase in confidence and skills in both follow-up surveys. For example, prior to taking the workshop, 31% of nurses said they had the confidence and skills to ensure that the informational needs of the patient's family were being addressed. Immediately after the workshop, 71% said they had the skills and confidence to meet this need. At three months out, 77% reported improvement.
Nurses Want Palliative Care Training
The workshop was originally intended to be held a few times at most, says Turner, but it's been going strong for the past five years.
"The response from the nurses at the bedside has really been amazing," she says. "Consistently, every time we've opened registration for this workshop, it fills the first day and usually within a few hours."
The workshop has been expanded to four other University of California Health hospitals through a "train-the-trainer program," says Puntillo. Overall, more than 500 nurses have completed the workshop.
As someone who has worked in hospice and had a family member whose end–of-life wishes were not clearly articulated, I hope discussions about palliative care become more commonplace, not just in the UC Health system but at healthcare facilities across the country.
"It's really something that's applicable, I think for all hospitalized patients, certainly all of the patients in the ICU," says Turner. Palliative care discussions are "really about trying to figure out what it is that our patients and families need from their experience. How we can make this experience less traumatic? How we can promote respect and dignity for our patients? How we can make sure that the care they're receiving is aligned with their goals? That's not a death and dying thing, that's a human being thing."
It's imperative for RNs to do the right thing, even if they are frightened about the consequences they may face. And it's the responsibility of nurse leaders to build work environments that foster courage, says the CNO of Oregon Health & Science University Healthcare.
Last week as I was driving my 4-year-old daughter to the park she asked me, "Mama, when you were little, were you ever afraid?"
I was honest and told that yes, when I was her age, I was indeed afraid of things. I told her that many times I didn't do things, like go on an amusement park ride or introduce myself to new people, because I was too afraid.
"But mommy you should still do things if you're afraid," she counseled. "You take a deep breath and count to three and do it."
Not only was it good advice, but my backseat Yoda had unknowingly summed up a recent conversation that Dana Bjarnason, PhD, RN, NE-BC, vice president and chief nursing officer, Oregon Health & Science University Healthcare in Portland, OR, and I had on the concept of moral courageamong nurses and how nurse leaders should commit themselves to building work environments that foster it.
Dana Bjarnason, PhD, RN, NE-BC
Moral Distress and Its Cousin, Moral Courage
Bjarnason, who presented the session Ethical Challenges: Leading in Complex Organizations at theAmerican Nurses Association's Ethics Symposiumin June, defines moral courage as doing the right thing despite fear or potential repercussions. She became interested in the idea as a member of the ANA's board of ethics and human rights.
"One of the things we obviously talked a lot about was the issue of moral distress in nursing which, certainly is a very real problem for us," she says. "It sounded so oppressive and it sounded so helpless."
When a nurse knows the ethical action to take, but is unable to so.
When an RN acts in a way that does not align with his or her personal and professional values
Moral distress occurs because of passivity; moral courage occurs because of action. Having moral courage, however, does not mean there is a lack of fear, says Bjarnason. Moral courage often occurs in the presence of fear. Even though they may be afraid, nurses know what the right thing is to do and, as my daughter says, they take a deep breath and do it.
"I think what we need to understand about courage is that courage doesn't mean that you're fearless," she says. "Many times nurses are called upon to do things in the face of fear that they may have from a situation where someone may have more power or more authority [than they do]."
When Bjarnason was a new nurse manager, she was in a position where she needed to report an impaired physician. She did it because she knew it was the right thing to do, but she faced consequences because of her actions.
"I ended up having to leave the organization because it was clear I was never going to be promoted in that organization because of that," she says. "And so the next time I was confronted with an impaired physician, I was really worried about what to do. But I knew what I had to do and that was to talk to the faculty about it."
Find Your Moral 'North Star'
Fortunately, in the second circumstance Bjarnason experienced a very different outcome, likely because she was at an organization where moral courage was valued.
Nurse leaders are key to creating a workplaces where moral courage is not just accepted but encouraged she says. "There's been a lot of work that has taken courage from nurse leaders to stand up for how we do create those environments where nurses can do their best."
She points to the trend that occurred about three decades ago where, in the hopes of containing hospital costs, nursing jobs were eliminated.
"You may remember when we had issues of meeting the bottom line, one of the first things we did was look at nursing because nursing was a huge cost. And we would systematically decimate the bedside nurses [staffing] in order to meet bottom lines," she says.
"You really don't see that happening anymore. I think it is because there were transformational leaders in nursing and nurses continued to achieve higher levels of leadership roles where we could stand up for what it took to maintain a safe, high-quality environment."
When it comes to exercising courage and doing the right thing, Bjarnason uses patient safety to evaluate whether she is on the right track.
"I have always had a very patient-centered approach and so no matter what the question—whether I was a direct care nurse or now as the chief nursing officer—it's about where is the patient in this question. Whenever you put this patient at the center of the question, it's always been my experience that courage flows from that."
She encourages all nurses to find their own "moral North Star," be it patient safety or something else, to help guide them in creating a morally courageous nursing practice and leadership style.
"I signed on the dotted line when I became a registered nurse to do certain things. That is my obligation and responsibility," she says. "As the CNO I have an even larger obligation to the nurses in this organization to help them to create environments that are conducive to high quality patient care. I really consider it an obligation and responsibility and would suggest to everybody that we hold that obligation dear to our heart."
National Park Medical Center in Arkansas finds that an automated patient callback system gathers emergency department patient satisfaction data more effectively than paper surveys.
The other day as I was checking out at a local department store, the cashier drew a circle on my receipt and asked me to participate in a customer satisfaction survey. There'd be a discount emailed to me after I completed it, she said.
I smiled and shook my head yes, but I had no intention of filling it out.
This morning, the place where I buy my morning cup of coffee asked me to complete a survey.
For my participation, I'd be rewarded with doughnuts. I didn't take that one either.
And, recently, my children's daycare provider asked all the families to take part in a survey about the caregivers and facility. That one I actually did fill out since my children are more important to me than free doughnuts.
As we go about our day-to-day activities, Americans are bombarded by these types of surveys. Throw in healthcare surveys to measure patient satisfaction and experience, and I think we may be reaching the limit on the number of surveys we're willing to complete.
We're experiencing survey fatigue, and it has the potential to affect the data hospitals seek to collect.
Survey Fatigue
As healthcare professionals, we've (sadly) become familiar with the concept of alarm fatigue—that feeling of sensory overload that can desensitize us to the point of delaying our responses, or in the worst cases, not responding at all.
Survey fatigue is similar, except that instead of being overwhelmed by information coming at us, we're being overwhelmed by the frequency and amount of information we're being asked to provide.
Often, doughnuts and discounts aren't enough to compensate for the time and effort it takes to complete surveys. I admit there are a few patient satisfaction surveys in various stages of completion that have been floating around my house since September 2014 when I had my son. It's just one more task I just can't seem to find a chance, or the will, to do.
Much like dealing with the constant bombardment of bedside alarms, the easiest way to deal with the constant bombardment of surveys is to tune them out.
If You Can't Say Something Nice, Say it Anyway
It's easy to ignore surveys when there doesn't seem to be much benefit in it for the respondent. But to healthcare providers, this data is like gold. As reimbursement becomes tied to variables such as patient satisfaction, hospitals and healthcare systems will need to collect more high-quality data in order to get paid.
How do you do that when patients like me leave half-finished surveys sitting around for months and when they decide to take action, the action is to put them in the shredder?
Priscilla Couch, RN, MSN
National Park Medical Center in Hot Springs, AR, is trying one possible solution. Hoping to improve its collection of ED patient experience and satisfaction data, it began using with an automated patient call back system in February.
"We wanted an avenue where patients could basically discuss their ED visit at their convenience," says Priscilla Couch, RN, MSN, assistant chief nursing officer at NPMC. "We felt that having this, where they could do that at their convenience, would give us more feedback than what we were getting."
Couch explains that managers used to make follow-up phone calls to patients discharged from the ED between the hours of 8am and 5pm.
"Our callback rate wasn't as high as we'd like it to [have been]," she says. "The feedback was very, very positive which was not always indicative of our scores."
The discrepancy between what patients were telling managers over the phone and what they were saying through the more standard patient satisfaction surveys may have been due to a few factors Couch explains.
First, because the follow-up phone calls were being made during standard work hours, they may have been missing the group of patients were working. Second, patients may have been hesitant to bring up any negative experiences with a live person.
"We were looking for an avenue where patients felt more comfortable to discuss any issues as far as why they didn't not feel their ED experience was a good as it could have been," Couch says. "I think that's one of the things that appealed to us about the new system. I do think people will talk more and give more feedback and more information when they're texting and emailing versus one-on-one with another person."
If You're Happy (or Disappointed) and You Know it, Send a Text
The new NPMC follow-up call system automatically generates a text or email (based on patient preference) for every patient who was registered in the ED that day. The patient is asked to fill out a four-question survey by following a provided link.
Patients are asked:
Do you have any questions about your discharge instructions including home care, medications and follow-up appointments?
Please rate the nursing staff by the level of care and concern provided.
Please rate the medical staff by the level of care and concern provided.
Would you like to add anything else about your experience?
Couch or a nurse manager is automatically notified of the patient's response and can give the patient feedback within minutes of the survey's completion. It may sound like a great deal of work, but Couch says it is not time-consuming at all since many of NPMC's answers are "preset" in the system.
She can also adjust the responses based on trends in the responses. For example, if a patient says, "I'm still not feeling better. What do I do?" A preset response can be sent, directing the patient to follow-up with her primary care provider or return to the emergency department.
Though the program has only been in place for about six months, Couch says she is pleased with the results thus far. And while the response rate has not changed much yet, the surveys are reaching a much larger group of patients. Couch says the response rate does seem to be increase a bit each month and satisfaction scores are also on the rise.
"We've implemented a lot of new things up there, and yes, we have seen an increase in our satisfaction and our mean score is almost doubled over the almost six months" she says.
Couch hopes to see the program expand to the entire hospital.
"I think the way healthcare is and the generation that we're living in now, that people are going to be more apt to answer a text or an email than phone calls," she says. "The way we feel is that any feedback, whether it positive or negative, we can improve on all encounters."
To simplify the process by which registered nurses attain Bachelor of Science in nursing degrees, the Robert Wood Johnson Foundation recommends that nursing schools adopt standardized non-nursing course requirements.
If you want to get a group of nurses fired-up, ask them if a baccalaureate degree should be the minimal degree required to practice nursing. You won't get a collective yes or no answer, and there will be a division between BSN-proponents and those who feel an associate's degree in nursing is perfectly acceptable.
At least that's been my experience as a staff nurse, nurse manager, and nurse editor. Those in favor of the BSN point to decades of research that show patient outcomes improve with care from BSN-preparedRNs.
It's hard to argue with data, but I've still seen many ADNs become highly upset by the implication that a BSN should become the standard for the profession. I began my nursing career with a BSN, but I understand, in some respects, why so many ADNs respond the way they do. It's a lot of pressure to be told you have to go back to school in order to continue in your profession.
For those who entered nursing 20 or 30 years ago, it feels like the rules are suddenly being changed mid-game. They can't understand why after providing patient care for all these years they're now being told their education is not good enough to do the job they've been doing for decades.
Tina Gerardi, MS, RN, CAE
In addition, if this is not something they planned for financially, coming up with tuition can be a legitimate barrier. And, for those with families, finding time to dedicate to school may difficult. Even if they may want to go back to school, it's not always an easy goal to achieve.
Others in the nursing profession recognize legitimate hurdles to the RN-to-BSN process as well. That's why a group of nurse leaders and educators backed by the Robert Wood Johnson Foundation gathered to identify barriers to academic progression and to find ways to overcome them.
As a result of their work, they are calling on nursing education programs to adopt a standardized set of non-nursing course requirements to help facilitate RN-to-BSN completion.
Making a Plan and Moving Forward
As it stands now, admission criteria, course requirements, and transferable academic credits vary from nursing school to nursing school. This lack of consistency extends the time and increases the expense it takes for an RN to earn his or her BSN.
This was a known issue to members of the group says Tina Gerardi, MS, RN, CAE, deputy director, national program office, academic progression in nursing at the American Organization of Nurse Executives. Instead of rehashing old issues, they decided to come up with solutions to the inconsistency in education requirements in the hopes of simplifying academic progression in nursing.
"In March 2014, we had a 'moving forward meeting,'" says Gerardi. "It was a national meeting looking at barriers to academic progression and what could be done at a national level to either alleviate [or] remove those barriers."
At the end of the meeting, it was determined that the next steps should be taken at a national level to be of most assistance to all involved.
"The one thing that came out of that [meeting] was to look at general education and prerequisite requirements for nurses going on for a baccalaureate degree," she says. "We know students are repeating courses, and people talk about how they've changed schools and taken chemistry three times."
To figure out where the inefficiencies were, a smaller work group compared samples of RN-to-BSN programs and generic baccalaureate programs.
"When we looked at the RN-to-BSN, it all over the map in terms of number of credits," Gerardi says. "So that's where we really concentrated our time and looked at that."
Building a Foundation
The group decided to focus its efforts on foundational non-nursing courses and determine the number of credits that should be included in the prerequisites and what types of courses the students should be taking. They agreed a bachelor's degree should be between 120 and 128 credits to allow for faculty independence and to help meet state- or school-specific mandates.
The recommendations were broken down into categories and the number of credits in each category was determined. They also gave examples on types of courses that should be included. The recommendations were approved by the larger group.
The newly recommended BSN foundational courses consist of the following 60 to 64 non-nursing credits:
Approximately 24 general education credits in areas such as communications, English, humanities and the fine arts, statistics, and logic;
About 12 basic sciences credits in areas such as chemistry, biology, microbiology, and physics;
Roughly nine social sciences credits in areas such as growth and development, psychology, and sociology;
Approximately 16 human sciences credits in areas such as anatomy and physiology, pathophysiology, nutrition, and pharmacology
"Now we've just been pushing it out, distributing it, and asking schools to take a look at what they have," Gerardi says. "It's the first time any kind of consensus has been pushed out there for folks to take a look at or start with as they are putting together these programs."
A greater emphasis on quality of care and public policy recommendations are contributing to a rise in the number of registered nurses seeking baccalaureate degrees. Hospital leaders can help knock the barriers out of the way.
A half-century ago, the American Nurses Association issued its 1965 position paperadvocating for the baccalaureate degree as the minimum standard of education preparation for professional registered nurses. Fifty years later, there's still no consensus that the BSN has become the entry level degree for RNs.
Yet, while no mandate on BSN-preparedness has ever been made, the number of RNs going on to pursue baccalaureate degrees is on the rise.
Carole Stacy, RN, MSN, program director for nursing at Lansing Community College in Lansing, MI, and Mary Lou Wesley, RN, MSN, senior vice president for care services and chief nursing officer at Sparrow Health System in Lansing, MI attribute the shift to factors such as employer preference, greater emphasis on quality outcomes, Magnet designation criteria, and recommendations from the Institute of Medicine.
Data from the American Association of Colleges of Nursing's fall 2014 surveyof baccalaureate and graduate nursing programs, however, shows a 10.4% increase in enrollment in RN-to-BSN programs, which marks the twelfth year of enrollment increases. "The two forces that really brought [BSN-preparedness] to the forefront were the Magnet designation and then the IOM report," says Stacy.
In 2010 the IOM, in partnership with the Robert Wood Johnson Foundation, issued a landmark report recommending that 80% of RNs be prepared with BSNs by the year 2020. The American Nurses Credentialing Center piggybacked on those recommendations, and in 2013 began requiring that hospitals seeking the ANCC's Magnet designation provide action plans for achieving a nursing workforce made up of 80% BSN-prepared RNs within their organizations.
"It's always a goal with a Magnet organization to increase your percentage of BSN nurses," Wesley says.
Magnet recognition aside—Sparrow achieved Magnet designation in 2009 and again in 2014—Wesley is a proponent of BSN-prepared nurses.
Her affinity for them is not just based on personal preference, but rather on years of available research and data on how nurses' levels of education affect patient outcomes. This research—most notably that of University of Pennsylvania nurse researcher Linda Aiken, PhD, RN, FAAN, FRCN—is another reason BSN preparation is becoming increasingly sought by nurses and employers.
"There are very compelling studies out there that go right down to the individual nurse level and are able to demonstrate huge decreases in mortality if 85% of your care was provided by a BSN-prepared nurse," Wesley says. "There's significant improvement in length of stay, decrease in serious safety events, better adherence to quality and safety initiatives and core measures when you have the majority of your care provided by a bachelor's-prepared nurse."
As we know, patient outcomes are of utmost importance in today's healthcare environment and employers expect that BSN-prepared RNs will provide the quality nursing care to needed to achieve them.
Millions Invested in Nursing Education
Despite the research that demonstrates improved patient outcomes when care is provided by BSN-prepared nurses, many RNs list loss of income, cost of tuition, time, or family commitments as barriers to furthering their education.
Currently, Sparrow's RN workforce is made up of 47% BSN nurses and Wesley says there are plans to increase that to 80% as recommended by the IOM, RWJF, and the ANCC Magnet program.
Sparrow has taken steps including financial assistance, professional support, and organizational recognition to make this happen.
"We still hire associate degree nurses and we love our associate degree nurses," Wesley says. "But we've just put into place a requirement that as we hire associate degree nurses they sign a compact with us that says that they will complete their BSN within four years."
In exchange for the RNs' commitment to continue their education, Sparrow funds 100% of the tuition dollars for BSN completion.
Wesley has established an environment that is supportive of nurses who return to school. This includes providing flexible schedules, assistance finding mentors, and leadership rounds that include recognizing RNs who are going to school or who have completed their BSNs.
"It becomes something the whole organization gets its arms around and knows why we're supporting it," Wesley says of this approach. "We wouldn't be investing in our ADN nurses if we didn't believe they were the best nurses we could have. This is millions of dollars of investment."
Simplifying the Pursuit
Having education partners like Lansing Community College is critical to developing a majority BSN workforce, says Wesley. In addition to the barriers mentioned above, nursing school capacity can also be a roadblock to a baccalaureate education. Stacy says that the University of Michigan takes only 50 students once or twice a year while LCC takes 160.
"We always know the day Michigan State posts who got into their regular, traditional program or their accelerated program," Stacy says, "Our phones ring off the hook because we're the next game in town."
LCC has an agreement with Michigan State University for concurrent enrollment. When students are accepted into the LCC program, they may also enroll in MSU's BSN completion program. LCC students may take BSN-completion classes during the summers between ADN semesters. "If they do everything right," Stacy says, "when they finish with their associate's degree, they really just have the five cognate courses left for their BSN."
Wesley advises CNOs who want to boost the number of BSN-prepared nurses at their respective organizations to develop partnership with education providers and then put together a compelling case to convince the executive team that the initiative needs to be supported.
"I feel like it's a moral imperative because the data is so strong," Wesley says. "For us to ignore that, I think is not being good providers of patient care."
Attendees at the HealthLeaders Media 2015 Population Health Exchange detailed two population health management programs that are tackling obesity and improving chronic disease management.
At an invitation-only gathering, healthcare leaders at the forefront of population health shared information on engaging patients, managing their chronic diseases, and leveraging data to improve health outcomes among communities and patient populations.
More than two dozen healthcare executives from a broad spectrum of disciplines shared their thoughts challenges, solutions, and innovations at HealthLeaders Media's 2015 Population Health Exchange at The Park Hyatt Aviara in Carlsbad, CA June 17–19.
Community Engagement is Key
Jean Krause, chief quality and safety officer at Gundersen Health System in La Crosse, WI, shared strategies for improving obesity rates.
Wisconsin's obesity rates are following national trends, up from 10% to 14% in 1990 to between 25% and 29% in 2010, said Krause. During a 2012 La Crosse community-wide assessment, Gundersen identified obesity and food availability as community health issues that the organization could influence.
The health system's main campus and surrounding neighborhood reside in a food desert, which isdefined by the USDA as urban neighborhoods and rural towns where fresh, healthy, affordable foods are not easily accessible. "[Residents] end up buying less healthy items at gas stations," she said. "In order to improve the health of the population, we have to get outside of our own walls."
So Gundersen began working with the community to support interventions such as exercise groups and the "Chefs in the Schools" program. "We're teaching the kids how to grow vegetables and make good meal choices," she said. "Then they're going home and teaching their parents."
There are now healthy food selections in highly visible areas in gas stations, 500-calorie meals on restaurant menus, and 15 schools with gardens. During the Minute-in-Motion event recently, 5,000 community members clocked 7 million minutes of exercise.
"This work takes time, talent, and engagement," Krause said. "It doesn't take a lot of money in some cases." She stressed that success to any population health-based intervention depends on community engagement and ownership.
Now Gunderson is starting to see a bend in the obesity curve. "It's the community that's got the hand in it. We happen to be there to support them."
Better Engagement; Better Disease Management
The medical home model is a well-known approach to population health, but gastroenterologist Lawrence Kosinski, MD, president of Elgin Gastroenterology Endoscopy Center in Elgin, Illinois, is taking the concept one step further with a specialty intensive medical home in its specialty.
Lawrence Kosinski, MD
"We're the first intensive medical home that Blue Cross Blue Shield Illinois has formed a partnership for in Illinois. We're very proud of what we've accomplished with this," said Kosinski.
Chronic diseases overall are responsible for two-thirds of the cost of healthcare today, he said. And "In the gastroenterology space, inflammatory bowel disease is one of the major cost drivers. It's a very high-risk, high-cost patient population. Most of them are young and a lot of them have a single morbidity—Crohn's disease."
These patients cost about $11,000 per patient per year, and half of the cost is attributable to inpatient work. "Treatment of complications—fistulas, abscesses, bowel obstructions—these are serious things that happen to these people," Kosinski said.
"Gastroenterologists, who are the experts in the disease process, received 3.5 cents of the dollars that Blue Cross spends," he said. "It immediately became obvious to us that there was a care management issue here. The wrong people were taking care of a very high-risk group of patients and not doing a very good job at it."
As a result, morbidity and mortality were occurring along with excess cost, he explained. Based on this data, Kosinski wondered if there was there an opportunity to improve care at the provider level and if that could be the basis of a shared savings program with their payer Blue Cross Blue Shield of Illinois.
When he looked at data on hospitalization rates, he noticed that less than one third of the patients admitted to the hospital for a complication had a CPT code for a physician visit in the 30 days prior to the admission.
"They were sick enough to go in and have a bowel obstruction, an abscess, a fistula, [or] an infection, but miraculously they weren't sick enough to be seen by a doctor in the 30 days before," Kosinski said. "Patient engagement problem. Major."
After going live in December 2014 with the shared savings program, Kosinski knew there had to be two goals—engage the physicians and engage the patients.
To support the physicians, an elaborate set of clinical decision support tools were created and embedded in the EHR. Patient engagement was achieved by using the patient portal to send a monthly questionnaire from the Crohn's Activity Index. Patients' responses to five questions generate a "Sonar score" which assigns a number to symptom intensity.
"We're able to plot patient symptoms over time," Kosinski said. "We're able to encourage our physicians to practice according to guidelines that were set in the clinical decision support tool."
The portal eventually became too cumbersome, so the group developed its own Sonar application that works on smartphone technology. They send out the same questionnaires and if a patient has an abnormal Sonar score, a nurse care manager receives a text so she may follow up with the patient and create a plan to provide appropriate medical care.
The program is in its early phases, but it is generating significant data already. Leadership is able to monitor physicians based on performance such as preventing a hospital admission. Doctors will be paid based on their performance rather than volume.
As for what the future may hold for this model of population health, Kosinski said "Specialists need to convert from fee-for-service proceduralists to masters of chronic disease management."
And he believes a team-based care philosophy and approach must be adopted. "I always use this funny line, 'MD stands for My Decision.'" Kosinski joked. "That is no longer adequate. You have to work within a team."
At the 2015 HealthLeaders Media Population Health Exchange, an interdisciplinary group of healthcare leaders discusses the tools necessary for successful population health management.
If you had to create a bumper sticker to sum up the concept of population health management, "It takes a village to care for a village" would get the point across.
Because communities and patient populations are simultaneously diverse and interconnected, providers must take an integrated, interdisciplinary approach to care delivery in order to make the population health model work.
In the spirit of cross-professional collaboration, more than two dozen invited healthcare leaders gathered June 17–19 at the 2015 HealthLeaders Media Population Health Exchange at The Park Hyatt Aviara in Carlsbad, CA. Attendees included a national sampling of chief medical officers, chief information officers, chief quality officers, and other executive healthcare leaders involved in propelling care delivery towards population health.
In break-out sessions on data analytics, clinical redesign, and strategic partnerships, they discussed the challenges, benefits, and tools needed to shift from fee-for-service care focused on acute care to a value-based model that stretches across care delivery sites and into the community.
Fine-tuning the Data
When it comes to narrowing down the needs of a patient population, healthcare providers can find data analytics to be extremely valuable. "We've had a fair amount of success using analytics to help with readmission reduction work," says Andrew L. Masica, MD, MSCI, vice president and chief clinical effectiveness officer at Baylor Scott & White in Dallas.
Andrew L. Masica, MD, MSCI
"The tool in use classifies patients as having certain risk levels," he says. "Those who are categorized as high-risk for readmission during their hospital stay get a comprehensive care coordination intervention, and in many patients greater than age 65, home visits from a nurse practitioner to help with the transitional period following discharge. Medium and lower risk patients receive lesser degrees of intervention, for example, phone follow-up, tailored to meet any specific identified needs."
In addition to reducing high-risk patient readmission rates, data analytics has also helped to provide fiscally responsible care, says Masica.
"That's been a very efficient way to manage resources," he says. "The nurse practitioner model for transitional care has been shown to be effective, but can be resource-intensive from a hospital operational standpoint."
While there is value in numbers, however, Masica explains that the benefits of analytics can only be had if the numbers are strong. "Too much information, particularly if delivered in the wrong fashion, isn't helpful, and can sometimes be harmful," he says.
In fact, attendees ranked inadequate or incomplete longitudinal clinical data as the biggest challenge facing their organizations in performing data analytics in a pre-event survey by HealthLeaders Media.
Putting a Population in Perspective
Another consideration regarding data analytics is that there's more to a population health than just percentages. There are nuances to care outcomes that can be found hiding within subjective data.
"When you talk about population health and you limit the conversation to data analytics—that's just the tiniest sliver of that solution," says Alan Pitt, MD, professor of neuroradiology at Dignity Healthcare in Phoenix. "I think there's a big role for the objective EHR data, but also [for] the subjective data… that would be more relevant to something of a solution."
Alan Pitt, MD
Traditionally, healthcare has relied on objective data collected about the patient through a claim or an EHR report rather than through self-reported data from the patient report, Pitt says. "Subjective data is patient-reported data, 'How do you feel about that surgery you had three weeks ago? Are you back to walking? What is your pain level?''
This type of data could be key to getting a broader, more accurate picture of how the patient is doing and what interventions he or she may need. "The piece missing is the subjective data that goes beyond the hospital, beyond the clinic, [and] all the way to the home, to figure out value and outcome." Pitt says.
When providers connect with patients at the home and community levels, they also have the opportunity to identify risk-factors that prevent patients from achieving their optimal level of health. Barriers to care play a large role in determining whether a patient becomes a high-risk individual.
"If you drill down, you see that a lot of [risk factors] are social barriers to access," says Frank C. Astor, MD, MBA, FACS, chief medical officer NCH Healthcare System Inc. "There's transportation, there's domestic violence. There's a whole bunch of other issues that are difficult to deal, with but you're going to have to deal with no matter what."
Frank C. Astor, MD, MBA, FACS
The New Frontier
The same could be said about population health management.
It's something healthcare systems will have to deal with no matter what. Healthcare is not going to stay static any longer and the shift from receiving care in acute, hospital settings has begun. Clinical transformation has begun and new care models are beginning to take shape. According to the HealthLeaders Media October 2014 Population Health Intelligence Report, healthcare reform is focusing on value, and population health management is one model to provide fiscally responsible, effective care.
The new model will move beyond the walls of the hospital, linking all points of care and all healthcare disciplines.
Research finds that Magnet designation correctly identifies a hospital's level of nursing excellence, but that earning the recognition does not improve surgical patient outcomes.
Hospitals that meet the Magnet Recognition Program's criteria for "quality patient care, nursing excellence, and innovations in professional nursing practice," are considered to be facilities that provide the gold standard in nursing care.
And because they incorporate Magnet Model Components such as transformational leadership and structural empowerment into their nursing practice, Magnet facilities also attract highly skilled RNs and improve patient care, safety, and satisfaction says the ANCC.
That may sound like a ringing endorsement for Magnet recognition. However, it's important to note that Magnet designation is not a panacea for all that ails your hospital. Just 7% of U.S. hospitals have been designated as Magnet facilities by the American Nurses Credentialing Center.
"Professionally, I think what you see are high degrees of professional competence and confidence because Magnet organizations invest in education, training and development," says Barbara R. Medvec, RN, MSN, MSA, NEA-BC, senior vice president and chief nursing officer for the Oakwood Healthcare System in Dearborn, MI.
Medvec says Oakwood Hospital has been incorporating Magnet standards into its nursing practice environment since 2002, but began its official journey towards Magnet designation in 2008.
Christopher R. Friese,
PhD, RN, AOCN, FAAN
"The foundations of excellence of continuing to improve practice and the foundations around nurses managing and controlling their professional practice are values that Oakwood has believed in for a long, long time," she says. "We've built the foundations around the Magnet principles because we know it builds a stronger nursing professional practice within the organization."
Why did Oakwood decide to go down the Magnet designation path when it already had incorporated principles of excellence into its nursing practice?
"When you're on the journey, it helps you inspire staff to move forward," Medvec says. "For us to go that next level is really recognizing the excellence that we have and that we built within our program."
A study in the June issue of Health Affairs supports the idea that the Magnet Recognition Program is, in fact, excellent at identifying excellence. But while researchers found the program to be an accurate tool in identifying high-performing hospitals, they also uncovered some surprising nuances about Magnet facilities' surgical outcomes—namely, Magnet recognition alone does not improve surgical patient outcomes.
Study Specifics
"Many of us in the nursing community know that Magnet recognition confers a great deal of benefit to the staff nurses and the nursing leadership that are in those institutions," says Christopher R. Friese, PhD, RN, AOCN, FAAN, assistant professor at the University of Michigan School of Nursing in Ann Arbor.
But "there's been a question as to whether Magnet recognition was also associated with improved patient outcomes."
Friese says through the study, titled "Hospitals In 'Magnet' Program Show Better Patient Outcomes on Mortality Measures Compared to Non-'Magnet' Hospitals," he hoped to delve into how Magnet recognition was related to surgical patient outcomes.
For the published paper, he and his colleagues looked at 13 years-worth of national Medicare data for 1.9 million surgical patients hospitalized from 1998 to 2010 for coronary artery bypass graft surgery, colectomy, or lower extremity bypass. The anonymous data came from 1,000 hospitals across the country and the study was funded by the National Institute of Nursing Research.
According to the study findings, surgical patients treated in Magnet hospitals were "7.7% less likely to die within 30 days of their operation, and 8.6% less likely to die after a post-operative complication, compared with patients in non-Magnet hospitals."
"From the patient point of view, if I have to pick a place to go, I want to pick a Magnet," Friese says.
The Big But
"In this study… what we find is yes, Magnets are better," he says, "but Magnets were better to begin with. They were better many years before they were a Magnet and then during and after their Magnet recognition their [surgical] outcomes don't change."
To help me better understand the findings, Friese gave an example of hospital that first received Magnet designation in 2005.
"The patients treated in that hospital in 1998 and 1999 still had better outcomes than their peers," he says. "So the outcomes were better than their peer institutions way before they had Magnet status, on average." Once the hospital officially embarked on its Magnet journey and then after it received Magnet recognition, surgical outcomes did not continue to improve.
"A patient [at the same facility] in 2007 or 2008, those outcomes were not better than they were in 2005 or 1998," he says, though to be clear, the quality of the outcomes did not decline either.
Advice for Nurse Leaders
Based on his findings, Friese has some words of wisdom for nurse leaders: "They should be encouraged that Magnet does successfully identify high-performing hospitals."
It's important, however, to be cognizant of what goals and outcomes you hope to achieve when you consider taking the Magnet journey.
"If the goal is to improve engagement, satisfaction, and staff retention, Magnet is a very well-established way to do that," Friese says. "If your motivation is, 'We have a problem with our patient outcomes [or] with our care delivery,' pursuing Magnet recognition… may not be the best use of your resources."
A better tactic to help improve patient outcomes would be to create partnerships with institutions that have good outcomes to find out the keys to their successes, Friese says. "I think what we really want to do is create that community where nurse leaders are sharing what they've done to improve outcomes so that everyone benefits from it."
Concern for the hospital's bottom line has traditionally been outside the realm of RNs, but understanding healthcare costs gives them an advantage in improving patient care and insight into leadership challenges.
From the time we enter school, nurses are taught to be advocates who champion our patients' needs regardless of their diagnosis, social standing, or access to resources.
"When I was a student nurse the mantra was, 'We give care regardless of cost,'" 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.
Times have changed in the years since Penner and I went to nursing school. Today, often to the chagrin of those providing bedside care, there is a much greater emphasis on healthcare costs and financial outcomes than there were just a few decades ago. I've heard many nurses imply that "bean counters," administrators, and for-profit companies value financial outcomes more than doing what's right for patients and that this mindset is detrimental to patient care.
But after talking with Penner, it became clear to me that nurses don't have to let financial goals determine how they provide care to their patients. In fact, hospital finances usually benefit when nurse-driven improvements to care delivery are made.
Susan J. Penner
Quality Nursing Care is Cost-effective Care
"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."
She gives as an example, the push by CMS to reduce preventable readmissions."The people in the hospital who are among the most crucial in doing that are the nurses," she says.
Nursing care is also instrumental in preventing hospital-acquired conditions, such as CAUTIs and DVTs after certain orthopedic procedures. HACs are about to start negatively affecting hospital reimbursements.
Additionally, nurses can help contain costs by reducing the waste of resources. This means not filling your pockets or the patient's room with IVs or wound care supplies that the patient may never end up using.
Nurses need to be educated on how their actions can positively or negatively affect the hospital's bottom line. "If we don't teach them how their practice is linked up with costs and revenues, they're never going to know and they're never going to see why waste is a problem," Penner says.
Nurses Don't Say the 'F' Word
Historically, nursing has shied away from discussions about finance in both the academic and clinical settings. "Something I've see in the literature is that not only do nurses not get this [exposure to finance] in school, but they don't learn this on the job," Penner says. "Even when nurses are promoted into management, they don't always get this kind of training."
Based on her own experience as both a bedside nurse and nurse leader, San Francisco General's Chief Nursing Officer, Terry Dentoni, MSN, RN, CNL, agrees.
"What I knew about cost was when that yellow sticker was on the door, someone was going to get charged for that IV," Dentoni says. "When I pulled six IVs out and put them in my pocket, I didn't understand that I was costing the organization money."
When she went into management, she gained financial knowledge through drills with her then CNO, but she describes her understanding of finance at that time as more of a rote, "check-the-box" mentality. It wasn't until 2007 when she took Penner's course on healthcare financial management that she understood the power that bedside nurses have to improve financial outcomes as well as patient care.
"If they knew what the cost-benefit ratios were," she says, "they could come up with business cases to support what goes on at the bedside to enhance hospital flow and hospital bottom line."
Bedside Business Sense Makes Cents
While she covers concepts like Medicare and insurance reimbursement, healthcare costs and revenue, and creating nursing budgets, a major focus of Penner's master's-level course at USF is on how-to create a business plan to support bedside care improvements.
Students work in teams to come up with an improvement project, write either a business plan or grant proposal, and perform a financial analysis of costs and savings to show the idea is cost effective.
She's seen projects ranging from proposals to purchase a robot that disinfects hospital rooms with ultraviolet rays to creation of a mobile diabetic foot care clinic. And though many of her students are experienced nurses like Dentoni, Penner says creative and cost-effective problem solving isn't something that should be left strictly to nurse managers and nurse leaders.
"Nurses across-the-board need to have some kind of insight on costs and benefits and making a business case," Penner says. "Another thing that I think would help is for hospitals to take a more bottom-up approach around budgeting rather than top-down."
By this she means, leaders should share budgetary concerns with front-line staff, involve bedside nursing staff on budget committees, and be open to hearing ideas for improvement from those performing direct care.
Dentoni has taken this approach at San Francisco General and says the more involved front-line staff in processes that contribute to cost-savings efforts, the more successful those efforts will be. "As executive leaders, we tell them what the metrics are and they tell us how they're going to do it," she says.
She saw this first-hand when trying to decrease operating room turnover time to 30 minutes or less. When the goal was first set by management success was sporadic, but once the staff decided this was a metric they wanted to improve, turnaround times were consistently 32 minutes or below.
"You've got to have them own it," Dentoni says. "It's all about giving information and letting them understand the business."
Dentoni points out nurses don't have to choose between being fiscally responsible or providing quality nursing care. They can do both. "It doesn't have to define us," she says, "but it does have to be considered to do the greater good for the greater amount of patients."