The process(es) that enable the CNO to influence organization-wide change beyond the scope of nursing

Provide one example, with supporting evidence, of a CNO-influenced positive change that had organization-wide impact beyond the scope of nursing services. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data

Problem

Pharmacy coverage for the Emergency Department (ED) is achieved by a pharmacist remotely reviewing orders.  There is not a pharmacist physically in the department to assist with medication related issues.  Medication reconciliation for the admitted patients and medication education for  patients discharged from the ED falls to the Registered Nurses.  The implementation of the  Electronic Health Record (EHR), McKesson Paragon, has resulted in a change in workflow in the ED which makes the entering of home medications  more time consuming. There is a need for a greater pharmacy presence within the department.

Background Information

Hazel Robertshaw, PhD, RN, CENP is ideally placed to effect change within and beyond the scope of nursing. As the Vice President of Patient Care Services/CNO she is an integral part of the Executive Team and is a member of a number of system wide committees and work groups. As the VP of Patient Care Services, she has non nursing departments that report to her (see exhibit TL3EO.1- organizational structure).

Exhibit TL3EO.1 Organizational Structure

Exhibit TL3EO.1 Organizational Structure.pdf

In 2012, a new Director of Pharmacy, Christopher Dailey, Pharm D, was appointed following the retirement of the previous post holder. The CNO identified  an opportunity to improve patient safety and associate satisfaction by increasing the clinical pharmacists' interventions at the bedside . The change required an additional pharmacy position and a new role for all pharmacy department associates. The changes to the pharmacist's role resulted in the need for the technicians to assume some of the pharmacist tasks. This required additional training for the techs.  Hazel collaborated with Chris to advocate at the Board level for the additional FTE. Initially the program was implemented  on the inpatient units and the success of the program is highlighted in the 2013 Annual report. (see exhibit TL3EO.2- 2013 Thompson Health Annual Report).

Exhibit TL3EO.2

Exhibit TL3EO.2 2013 Annual Report.pdf

The Emergency Department was not a part of the initial program. Further discussions at Medication Safety Committee regarding medication reconciliation prompted Hazel and Chris to review and revise the clinical pharmacy program.  A pilot program for the ED was created, in conjunction with the Director of Emergency Medicine, Vijay Bansal,  and the Director of Critical Care Nursing, Joshua Kulp, BSN, RN,. The ED generates 80% of hospital  admissions. The need for a comprehensive home medication list is essential in the electronic world to facilitate provider medication reconciliation activities on admission.  Pharmacists are experts in this field and the location of a pharmacist in the emergency department during the hours of 7am-3pm was initiated to improve accurate capture of home medications prior to  admission. In addition, the pharmacist would be available to provide education to patients going home on new medications.

Goal Statements

The goal of the program was to:

1. Increase pharmacist interventions surrounding medication reconciliation activities for all patients admitted through the Emergency Department between 7am and 3pm.
2. Increase ED patient satisfaction as measured by the Press Ganey question "information about home care" to above the 50th percentile, benchmarked against Magnet hospitals.

To achieve these goals,  Aviva Bodek,  PharmD, BCPS, offered to act as the primary pharmacist for the Emergency Department.  Aviva agreed to work in the ED  from 7am to 3pm, Monday -Friday,  and consult with as many patients as possible.

Empirical Outcomes

Empirical outcomes of the program are presented in the following tables.

1. ED Medication Reconciliation activities. Each change to a medication name, dose, or route, was captured on an Excel spreadsheet.  Other medication interventions, e.g., education about discharge medications, or advice on antibiotic usage to ensure consistency with core measures, were also collected . 
2. This question was chosen as a surrogate measure for both the pharmacist involvement in medication teaching and for the increased nursing time available for providing home care education as a result of spending less time documenting home medications.

GOAL 1-Increase pharmacist interventions surrounding medication reconciliation activities for all patients admitted through the Emergency Department between 7am and3pm.

The data demonstrates the successful implementation of this program and the resultant number of clinical pharmacy interventions achieved in the initial three months.

GOAL 2- Increase ED patient satisfaction as measured by the Press Ganey question  "information about home care" to above the 50th percentile compared to Magnet Hospitals.

The graph demonstrates that this goal was exceeded within the first month post intervention and was sustained throughout the data collection period. This is the busiest time of year for the Emergency Department.

The hospitalist team is  advocating for expansion of this service into the afternoon and evening hours, as it allows for a more timely completion of their admission medication reconciliation process.

The hospital is investigating this implementation.

Participants

Hazel Robertshaw, PhD, RN, CENP VP Patient Care Services/CNO  Hospital Administration

Aviva Bodek, PharmD, BCPS, Clinical Pharmacist, Pharmacy, Patient Care Services

Christopher Dailey, PharmD, Director of Pharmacy, Pharmacy, Patient Care Services

Joshua Kulp, BSN, RN Director of Critical Care Nursing, Patient Care Services

Vijay Bansal, MD, Director of Emergency Medicine, Department of Emergency Medicine