Provide one example, with supporting evidence, of clinical autonomy that demonstrates the authority and freedom of nurses to make nursing care decisions (within the full scope of their practice) in the clinical care of patients.
AND Provide one example, with supporting evidence, of organizational autonomy that demonstrates the authority and freedom of nurses to be involved in broader unit, service line, organization, or system decision-making processes pertaining to patient care, policies and procedures, or work environment.
Example One
The initial focus on decreasing CAUTI's began in 2011, but this has been an ongoing effort. It was realized that we were decreasing Foley days with our original efforts going forward, but CAUTI's were not decreasing on our surgical unit, 3E. Because we were continuing to see CAUTI's on 3E, a Lean team began to meet April 2013, consisting of nursing staff from 3E. Lean concepts and CAUTI numbers from each unit were shared with the group and the 3E staff were inspired to make changes being that the CAUTI numbers were highest on 3E. We developed laminated forms for "Reminders for Hygiene with Foley Catheter Care" for each room with a patient with a Foley catheter. The plan was to use a new basin and cloths with soap and water at least daily for peri care, cleansing perineum and catheter from body outward each time it was done, to assure catheter was secure on leg and to partner with someone to assist and to hold each other accountable. Reminders for insertion were also posted on 3E, to assure perineum was cleansed with soap and water prior to catheterization, to seek assistance of second person and to assure a culture is sent with every Foley insertion. Though we were unable to have ED presence at these meetings, 2 ED champions were named and they were kept informed of plans. As of 10/2/2013, there were no CAUTI's on 3E from May through August and one in ICU in June. These changes were then rolled out to the other units by means of daily rounding, assuring appropriate Foley care, ongoing education and posting the laminated reminders for rooms. CAUTI prevention education is done annually during May as a monthly education component, with hands-on demonstration of Foley catheter insertion and data to show our current rates of CAUTI's.
Exhibit EP16.1 4-26-13 meeting
Exhibit EP16.2 Slides for MEC CAUTI 6-14 +May data+DI
This continues as an ongoing effort with daily rounds to assure timely removal of Foley catheters, appropriate care for Foley catheters, and ongoing on-the-spot education with new nursing staff.
Example Two Background/Problem Background At F. F. Thompson patients come through our surgical center for minor procedures. These patients could technically be treated in a "clinic" or "clinical" setting as opposed to a formal operating room (OR). The only suitable available space at Thompson is within the OR. Problem "Clinic" patients are admitted to the OR by a completely different process than patients coming for other types of surgery. Patient profiles were not being completed as these patients were not going through Pre-Admission Testing (PATC). The prior electronic medical record (EMR) allowed clinic patients to be designated as such and they appeared in the OR roster. When the EMR changed from Meditech to McKesson, the clinic patient was not "seen" in the electronic roster as a surgical patient. This put the patients at an increased risk for errors in admission and led to a decrease in OR efficiency. Goal Accurate and complete documentation of vital signs, medications, allergies and past medical history for clinic patients.
• Standardize surgical patient process for admission to the OR with
○ 100% proper booking of clinic cases by MD offices
○ 100% SCC registration as clinic patient
• Capture the clinic patient profile in the Electronic Medical Record with
○ 100% clinic patients interviewed by PATC Registered Nurse
○ 100% patient profiles completed, including current medications, medical history, allergies and vital signs
• Assure compliant and consistent documentation of intraoperative times
• Improve discharge of clinic patients from SCC
○ SCC Registered Nurse captures patient discharge times
□ Improve charge capture
Description of the Intervention A Do it Group (DIG) was created in November 2012. This interdisciplinary team included OR schedulers, Nurses from pre-admission testing, OR, Surgical Care nurses and an informatics nurse. The first step was to define the current process, and a flow diagram was developed to visually describe the current steps. Admission Process for Clinic Patients 2012
At the second meeting the interdisciplinary team developed a new "ideal state" process (see below). In addition the team created a form to track "key" issues including:
Having mapped out the new process the team presented the ideas to the key stakeholders: leadership , MD office staff, OR schedulers and nurses working in pre-admission testing, the surgical care center and the OR. All associates involved in the operationalization of the change received information and education with respect to their role in the smooth and safe transition of clinic patients using the new process. As depicted above, the process starts with the booking slip. On the booking slip the" clinical" patient type is checked by the physician's office and then the OR scheduler annotates "CLINICAL" in the comment section which shows up on the schedule. Also, to further alert the SCC and OR Associates of the patient's status, the patient's paper chart is placed in a "clinical" binder which is color-coded blue with a "CLINICAL" sticker affixed to the front cover.
The new process was operationalized in January 2013 and the results were tracked from January through June 2013. Participants DIG Chair- Catherine Habberfield RN, CNOR , Clinical Nurse, Operating Room DIG member Vickii Bement, RN, BSN, CNOR, Charge Nurse, Operating Room DIG member Kathy Cooley, RN, BSN, CNOR, Informatics Nurse, Operating Room DIG Member Kim Hyde, LPN, OR scheduler, Operating Room DIG Member Tammy Jeffrey, RN, Clinical Nurse, Operating Room DIG Member Kelly Hennessy, RN Clinical Nurse, Pre Admission Testing Center DIG Member Louise McGuire, RN Clinical Nurse, Surgical Care Center DIG Sponsor Janet Kerr Director of Performance, Improvement Finance Department Results/Data Outcome The graph demonstrates that that the goal of 100% compliance with required data elements (vital signs, past medical history, home medications and allergies) was met from the second month of implementation of the new process. The new process is hardwired in the system and we have consistently achieved our goal of 100% compliance with required patient safety information in our electronic medical record. The results were shared with the organization during the "QTIPS" quality fair and this DIG was recognized during Associate Recognition month as the DIG of the Year for its contribution to patient safety in the OR. Exhibit EP16.3 OR Dig of the Year Board