Provide one example, with supporting evidence, of clinical nurse communication with a nurse leader that influenced a change in the nurse practice environment. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. OR Provide one example, with supporting evidence, of clinical nurse communication with a nurse leader that influenced a change in the patient experience. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data. OR Provide one example, with supporting evidence, of clinical nurse communication with a nurse leader that influenced a change in nursing practice. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
Example One: Change in patient experience- direct bedding in the emergency department
Background/Problem Customer Satisfaction is a priority of the nursing staff at Thompson. Despite numerous interventions, and direct feedback from patients, our scores for Emergency Department were significantly under the Magnet Mean and Thompson Health's goal of the 90th Percentile. When reviewing the Press Ganey patient satisfaction tools, the priority index identified patient dissatisfaction with waiting time as one area of opportunity. In June 2013, the Greater Rochester Quality Council (GRQC) award for quality was presented to Unity Hospital (a local facility) for their work around improvement in Emergency room patient flow. An opportunity arose for members of the Emergency Department, Quality and Executive Team to attend a presentation at Unity hospital detailing the work they had done to achieve their results. Attendees were: Hazel Robertshaw PhD, RN,CENP, Vice President of Patient Care Services/CNO Vijay Bansal, MD, Emergency Services Medical Director Josh Kulp, BSN, RN Director of Critical Care Services Heather Forkum, BSN, RN, Clinical Nurse Emergency Gina Smith, RN, CEN, Clinical Nurse Emergency Following the presentation, Heather and Josh discussed the operationalizing one of the strategies presented. The strategy involved "direct bedding/in room triage" when there is an open staffed room in the ED. This strategy was discussed at a staff meeting and the team agreed to pilot this on the day shift (7a-3p). Participants Sarah Boyce, BSN, RN, CEN, Clinical Nurse Emergency Department, Department of Nursing Danielle Choate, AAS, RN, SANE, Clinical Nurse Emergency Department, Department of Nursing Megan Didas, BSN, RN, Clinical Nurse Emergency Department, Department of Nursing Mark Marchase, BSN, RN, Clinical Nurse Emergency Department, Department of Nursing Wendy Miller, BSN, RN, SANE, Clinical Nurse Emergency Department, Department of Nursing Christine Perry, BSN, RN, CEN, Clinical Nurse Emergency Department, Department of Nursing Patti VanAuker, MSN, RN, CEN, Clinical Nurse Emergency Department, Department of Nursing Patty Trickey, RN, CCRN, Clinical Nurse Float pool, Patient Care Services Kelly Newton, AAS, RN, Clinical Nurse Emergency Department, Department of Nursing Heather Forkum, BSN, RN, Clinical Nurse Emergency Department, Department of Nursing Jonathan Fulmer, AAS, RN, Clinical Nurse Emergency Department, Department of Nursing David Garnar-Allsopp, AAS, RN, Clinical Nurse Emergency Department, Department of Nursing Marc Herbert, MSN, RN, Clinical Nurse Emergency Department, Department of Nursing Cassidy Mincer, BSN, RN, Clinical Nurse Emergency Department, Department of Nursing Stephanie Williamee, RN, Clinical Nurse Emergency Department, Department of Nursing Goal Statements Improve patient satisfaction with waiting during the 7a-3p timeframe to above the 75th percentile compared to all Press Ganey database for the following questions: 1. Waiting time to treatment area 2. Waiting time to see doctor 3. Overall rating of ER care Intervention A team of Emergency Room personnel attended the presentation at Unity hospital regarding patient flow (Exhibit TLEO9.1) The process for in room triage was discussed at a staff meeting (Exhibit TLEO9.2) regarding the direct bedding procedure (TL9EO.3). The date for implementation was set for Monday June 16th. Exhibit TL9EO.1- notes from Unity Presentation
TL9EO.1 Example 1 Unity Presentation.pdf
Exhibit TL9EO.2 Staff meeting minutes 6.12.14 TL9EO.2 Example 1 2014-06-12-MINUTES.pdf
Exhibit TL9EO.3 Direct Bedding Procedure TL9EO.3 Example 1 Direct Bed Procedure.pdf
Data Requirements The team decided to review the Press Ganey Patient Satisfaction data for the identified goal statements related to the following questions every two weeks to assess the impact of the change: Graph TL9EO.1 Percentile ranking for Press Ganey question "Waiting time to treatment area" compared to all Press Ganey database.
The above graph demonstrates that the outcome was achieved over time. The final data point exceeded the goal set.
Graph TL9EO.2 Percentile ranking for Press Ganey question "Waiting time to see doctor" compared to all Press Ganey database.
The graph above demonstrates that the outcome was achieved over time. The final data point exceeded the goal set.
Graph TL9EO.2 Percentile ranking for Press Ganey question "overall rating of ER care" compared to all Press Ganey database
The graph above demonstrates that the outcome was achieved over time. The goal was achieved in the third week and was sustained through the data collection period. Outcomes The implementation of this change in practice achieved the desired goal by the 3rd post intervention data point on all the measures chosen. This was significant as June and July are historically some of the emergency departments' busiest months of the year. The ED staff were initially skeptical that this change would make a difference to patient satisfaction. The first post-intervention results were disappointing, as there was some confusion amongst the team about the new process. Josh reinforced the new process and drove the bedside triage forward, discussing with members of the team constantly about the impact this change can have on patients. As evidenced by the graphs above, the results have been astounding with the full implementation of the new triage plan. Example Two - Provide one example, with supporting evidence, of clinical nurse communication with a nurse leader that influenced a change in nursing practice.
Background/Problem Patient falls are an area of concern throughout the hospital system. In alignment with the hospital’s strategic goals and objectives to sustain and advance a culture of safety, quality, and compliance throughout the system, the nursing staff were aware of the safety concerns around patient falls, and were instrumental in identifying ways to help decrease the number of falls with injury during all shifts and communicated these concerns with nursing leadership. Goal Statement Increase patient safety while decreasing patient falls with injury from the current trended data on all medical surgical units and ICU by 5%. Interventions At the September 2013 Nursing Practice Council Meeting, the trended fall data was reviewed and discussed with Diana Ellison, MSN, CNL, Fall Meeting Coordinator, to alert council members and nursing in general to the number of falls with injury and discuss FF Thompson’s current fall assessment tool, the Hendrich II (Exhibit TL9EO-2.1). This tool is used in all medical and surgical units, as well as ICU. Another tool with very similar sensitivity and specificity, the Morse Assessment Tool, was also reviewed. There is an annual fee for the Hendrich II model and the Morse assessment tool is available at no charge. In the cost conscious environment of health care, and considering the trending of our falls, after the Nursing Practice Council reviewed the Morse Assessment Tool, it was agreed to move forward with the implementation of the new tool to see if the fall trend would reverse. Fall events are reported through the Medkinetics event reporting system. Spreadsheets and graphs are developed using this data. These graphs compare the data within each unit and ICU month to month, and all units combined. In response to feedback from clinical nurses at the Nursing Practice Council, and clinical nurses during regular rounding, education was developed utilizing three sources:
Documentation changes were made to accommodate the new assessment tool and to enhance use of the nursing process in the nursing plan of care by documenting interventions to prevent patient falls in the electronic care plan. Education was then developed to communicate this change to the nursing staff. The most recent Educational Opportunity Survey (See OO6) identified that clinical nurses prefer online education with post-tests. The education regarding the Morse scale and the changes in electronic documentation was provided to nursing staff via mandatory Power Point presentations from December 2013 through April 2014. (Exhibits TL9EO-2.2, TL9EO-2.3). Use of the Morse Fall Scale began May 1st, 2014, with utilization of the new nursing process/documentation of interventions of the fall scale assessment for each patient.
Exhibit TL9EO-2.1
TL9EO Example 2 September Practice Council minutes.pdf
Exhibit TL9EO-2.2
TL9EO Example 2 Morse Fall Scale 12-6.pdf
Exhibit TL9EO-2.3
TL9EO Example 2 Morse Fall Scale Part II (documentation) 2-11.pdf
Screen shots of the Morse Falls scale and the use of the nursing care plan are included in the power point education above.
Participants
Diana Ellison, MSN, RN, CNL Clinical Nurse Leader, Nursing Administration, Patient Care Services
Members of the Nursing Practice Council:
Adrian Hordon, MSN RN Clinical Nurse Educator and Magnet Program Director, Nursing Administration, Patient Care Services
Cathy Crosby, MSN, RN, CNL, Clinical Nurse Leader, Diagnostic Imaging Department,
Debra Bott, RN, Post Anesthesia Care Unit, Perioperative Services, Department of Nursing
Elizabeth Alexander, MSN, RN, C-NE Director Medical Surgical Nursing, Patient Care Services
Hazel Robertshaw, PhD,RN, CENP, Vice President Patient Care Services/CNO, Hospital Administration
Kathleen Mancini, RN, Birthing Center, Department of Nursing
Kathy Roeland, RN, Cardiac Rehabilitation, Department of Nursing
Kathy Wethington, RN, CMSRN, 3 West, Medical Surgical Nursing, Department of Nursing,
Lisa Maier,RN, 3 East, Medical Surgical Nursing, Department of Nursing,
Nancy Moore, CMSRN, 2 West, Medical Surgical Nursing, Department of Nursing,
Paula Shoff, RN, CEN, Emergency Department, Department of Nursing
Ragan Stevens, RN, SANE, 3 East /3 West, Medical Surgical Nursing, Department of Nursing,
Sarah Clayson, MSHA, BSN, RN, Nursing Supervisor, ICU Acting Nurse Leader, Nursing Administration, Patient Care Services
Kyla Popielarczyk, BSN, RN, Operating Room, Perioperative Services,Department of Nursing
Christine Lyon, RN, 3 East, Medical Surgical Nursing, Department of Nursing,
Mary Kate Corey, BSN, RN, Intensive Care Unit, Department of Nursing
Data requirements
Outcome
As evidenced above, upon implementation of the new Morse Tool on May 1st, 2014, the number of falls with injury across all units has decreased, with two months having zero injury. After intervention, the number of “Severe Injury” cases reported, in which a patient has suffered an injury that has required: surgery, cast, traction, neurology consult, etc, has been zero. The two injuries shown above after intervention are minimal; the June injury being a skin tear requiring a dressing, and the August injury being reported from the patient as having “pain” in affected limb, with no bruising or fracture. Due to the clinical nurse communication with a nurse leader, falls with injury across all units have decreased from an average of 1.42 to 0.92; which reflects a decrease of 35% respectively. This change can be attributed to better identification of falls risk with the implementation of this new tool.