CNL Summit
2014
ABSTRACT
PRESENTATIONS
January 17, 2014
To read the full abstracts, visit: XXXX
CNL Summit
Hyatt Regency Orange County
Abstract Presentation Schedule- by Room
Friday, January 17, 2014
HARBOR ROOM (2ND
FLOOR)
2:45 p.m.
Developing a Clinical Nurse Leader Practice Model: An Interpretive Synthesis
Miriam Bender, PhD RN CNL
Outcomes Research Institute, Sharp Healthcare
San Diego, CA
Primary Contact Email: [email protected]
3:15 p.m.
CNL Impact and Outcomes on a Psychiatric Medical Unit
Kevin Hengeveld MSN RN CNL
Mercy Health Saint Mary's Campus
Grand Rapids MI
Primary Contact Email: [email protected]
3:45 p.m.
Implementing a Clinical Nurse Leader Program: We can't afford not to!
Mary Irvin, MSN, MBA, NEA-BC & Kathy Oliphant, MSN, RN
TriHealth
Cincinnati, Ohio
Primary Contact Email: [email protected]
4:15 p.m.
Toward a More Patient Centered Plan of Care
Jo Ellen Inman-Puckett, RN, MBA, MSN, CNL. CMSRN
Carolinas Medical Center
Charlotte, NC
Primary Contact Email: [email protected]
GARDEN 1
2:45 p.m.
A Clinical Nurse Leader led multidisciplinary Heart Failure Program: Integrating best practice
across the care continuum to reduce avoidable 30 day readmissions.
Jan Broniec MS, RN, CNL
St. Luke's University Health Network
Bethlehem, PA
Primary Contact Email: [email protected]
2
3:15 p.m.
Dedicated Purposeful Rounding: A Novel Approach to Hourly Rounding
Cynthia Cohen RN, MSN, CNL, CCRN, RN-C
Elliot Health System
Manchester, NH
Primary Contact Email: [email protected]
3:45 p.m.
Too hip to be square… and too hip for surgical site infections
Michael Culver, MSN, RN, CNL
Texas Health Harris Methodist Hospital: Hurst-Euless-Bedford
Bedford, TX
Primary Contact Email: [email protected]
4:15 p.m.
Screen and Intervene: Improved Outcomes from a Nurse-Initiated Sepsis Protocol
Kristin Drager MSN RN CNL CEN
William S. Middleton Memorial Veterans Hospital
Madison, WI
Primary Contact Email: [email protected]
GARDEN 2
2:45 p.m.
Application of The Integrative Clinical Concepts of Physical Assessment, Pathophysiology and
Pharmacology within a CNL Graduate Clinical Course
Dr. Grace Buttriss DNP, RN, FNP-BC, CNL
Queens University of Charlotte CNL Coordinator and Faculty
Charlotte, NC
Primary Contact Email: [email protected]
3:15 p.m.
Implementing the CNL Role with Clinical Partners
Beth-Anne Christopher, MS, RN, CNL
Rush University College of Nursing
Chicago, IL 60612
Primary Contact Email: [email protected]
3:45 p.m.
Incorporating the CNL within a Health Plan: The Possibilities and Potentials are Limitless
Rose L. Hoffmann PhD, RN, CNL
University of Pittsburgh
Pittsburgh PA
Primary Contact Email: [email protected]
3
4:15 p.m.
Using a brochure assignment to market Model A & Model C CNL graduate roles
Keevia Porter, DNP, NP-C
University of Tennessee Health Science Center
Memphis, TN
Primary Contact Email: [email protected]
GARDEN 3
2:45 p.m.
Early indicators of success in the implementation of Primary Team Nursing in a
comprehensive cancer center
Jeremy Morris, MS, BSN, RN, CNL, PCCN
The University of Texas MD Anderson Cancer Center
Houston, TX 77030
Primary Contact Email: [email protected]
3:15 p.m.
Implementing an Evidence-Based Guideline specific to the care of Latino Adult Type 2
Diabetes Mellitus (AT2DM) patients in a community health center.
Marilisa Ferrer, BSN, RN, (CNL student)
Alivio Medical Center
Chicago, IL
Primary Contact Email: [email protected]
3:45 p.m.
CNL driven discharge process improvement: How a microsystem assessment helped improve
the discharge process on a medical surgical unit.
Cory Franks RN MSN CNL
Texas Health Resources
Fort Worth , Texas
Primary Contact Email: [email protected]
4:15 p.m.
Interventions to Improve Staff Responsiveness and Patient Satisfaction through Call Light
Management and Purposeful Hourly Rounding.
Esther Gosdin MSN, RN
Texas Health Southwest Harris Hospital
Ft. Worth, Texas
Primary Contact Email: [email protected]
GARDEN 4
2:45 p.m.
Enhancing Medication Safety for Patients Regarding Side Effects of Newly Prescribed
Medications
Bethel S. Guk-Ong, MS, RN-BC, CNL, OCN
4
MD Anderson Cancer Center
Houston, Texas
Primary Contact Email: [email protected]
3:15 p.m.
Building And Leading A Team To Decrease t-PA Usage for PICC Line Clots
Joe Hafley MSN, RN, CCRN, CNL
Texas Health Resources
Ft. Worth, TX
Primary Contact Email: [email protected]
3:45 p.m.
Performance Improvement for Surgical Care Improvement Project with Incorporation of PostOperative Daily Rounding Tool
Brandon Hunter, RN, MSN, CNL
Carolinas Medical Center
Charlotte, NC
Primary Contact Email: [email protected]
4:15 p.m.
Evolution of CNL Workgroup for a 14-Hospital System
Diane Thomas, MSN, RN, CNL; Holly Haddad, MHS, MSN, RN, CNL
Texas Health Resources
Ft. Worth, TX
Primary Contact Email: [email protected]
GRAND BALLROOM A
2:45 p.m.
Cost Benefit Analysis of Employing a CNL on a Medical Surgical Unit in Arkansas
Kerry Jordan RN, MSN, CNL: Laura Hall RN, MSN, CNL
University of Central Arkansas
Conway, Arkansas
Primary Contact Email: [email protected]
3:15 p.m.
Examining the application of the CNL skill set in diverse practice roles
Kristen Noles, MSN, RN,CNL; Emily Simmons, MSN, RN, CNL; Velinda Block, DNP, RN;
David James, DNP, RN, CCRN, CCNS; Angela Jukkala, PhD, RN
University of Alabama at Birmingham Hospital and UAB School of Nursing
Birmingham, Alabama
Primary Contact Email: [email protected]
3:45 p.m.
Continuity of Care: A Community Collaborative
Catherine Lauridsen BSN, RN, CNL student
Shawnee Mission Medical Center
5
Shawnee Mission, KS, 66204
Primary Contact Email: [email protected]
4:15 p.m.
Resilience and Transition to Practice in Model C CNL Graduates
Geralyn Meyer, PHD, RN, CNE, CNL & Bobbi Shatto, MSN, RN, CNL
Saint Louis University School of Nursing
St. Louis, MO 63104
Primary Contact Email: [email protected]
GRAND BALLROOM B
2:45 p.m.
Evolving CNL role: Exemplars from CNLs and Nurse Executive
Linda Roussel, DSN, RN, CNL, NEA-BC
University of Alabama Birmingham School of Nursing
Birmingham, AL
Primary Contact Email: [email protected]
3:15 p.m.
Readying the Practice Envirorment for the CNL: Perspective from Nurse Leaders
Patricia Thomas PhD, RN, FACHE, NEA-BC, ACNS-BC, CNL
Catholic Health East-Trinity Health
Livonia, MI
Primary Contact Email: [email protected]
3:45 p.m.
Improving Model A and Model C Clinical Nurse Leader (CNL) Students Certification Pass
Rates
Sherry Webb, DNSc, CNL & Alise Farrell, MSN, CNL
University of Tennessee Health Science Center
Memphis, TN
Primary Contact Email: [email protected]
4:15 p.m.
NO SESSION
GRAND BALLROOM E
2:45 p.m.
Meeting the needs of a geriatric-specific, acute care CNL cohort
Katie Lutz MSN, RN, CNL, PHN
Veterans Administration
Palo Alo, CA
Primary Contact Email: [email protected]
6
3:15 p.m.
CNL Led Implementation of a Comfort Care Order Set
Debbie Newman RN, MSN, CNL
Central Texas Veterans Health Care System
Temple, Texas
Primary Contact Email: [email protected]
3:45 p.m.
Good, Better, Best: Enhancing Team Perception in the Wake of Change
Yvette Ong, MS, BSN, RN, OCN, NE-BC
MD Anderson Cancer Center
Houston, TX
Primary Contact Email: [email protected]
4:15 p.m.
Discharge Planning to Prevent Readmissions and Improve Patient Satisfaction
Ginu Philip, MSN, RN, CNL
Texas Health Dallas
Dallas/Texas
Primary Contact Email: [email protected]
GRAND BALLROOM D
2:45 p.m.
Implementation and Development of a NICHE unit led by Clinical Nurse Leaders
Kasia Qutermous MSN, RN-BC, CMSRN, CNL & Veronica Rankin MSN, RN-BC, CMSRN,
CNL
Carolinas Medical Center
Charlotte, NC
Primary Contact Email: [email protected]
3:15 p.m.
How a CNL and Pharmacy Collaboration Project saved over $8000 within 2 months
Veronica Rankin MSN, RN-BC, CMSRN, CNL
Carolinas Healthcare System
Charlotte/NC
Primary Contact Email: [email protected]
3:45 p.m.
Financial Readiness: Building a Business Case for the Clinical Nurse Leader Role
Penny Moore Ph.D., RN, CNL
Texas Christian University
Ft. Worth, TX
Primary Contact Email: [email protected]
4:15 p.m.
The Role of the CNL in Creating a Culture of Certification and Professional Development
Danell Stengem, MSN, RN-BC, CNL
Texas Health Harris Methodist Hospital - Fort Worth
7
Fort Worth, TX
Primary Contact Email: [email protected]
GRAND BALLROOM F
2:45 p.m.
CNL Impact Cross-Continuum: Pre-Operative Pain Medications
Elizabeth Triezenberg MSN, RN, CNL, CNRN
Mercy Health Saint Mary's
Grand Rapids MI
Primary Contact Email: [email protected]
3:15 p.m.
A Clinical Nurse Leader's Role in Advancing Quality Stroke Care at a Micro, Meso and Macro
Systems Level.
Flame Uytico, MSN,RN, CNL,CEN
Texas Health Dallas
Dallas, TX
Primary Contact Email: [email protected]
3:45 p.m.
The Road to Advanced Heart Failure Certification: A Cross-Continuum Approach
Rebecca Valko MSN, RN, CNL & Kristy Todd MSN, FNP-BC, RN-BC
Mercy Health- Saint Mary's
Grand Rapids, MI
Primary Contact Email: [email protected]
4:15 p.m.
Implementing the Clinical Nurse Leader Role to Improve Outcomes: A Leadership Model
Centered on Innovation, Efficiency, and Excellence
Denise M. Wienand MEd, MSN, RN, CNL; Prachi Shah MSN, RN, CNL; Brandy Hatcher MSN,
RN, CNL; Alison Jordan MSN, RN, CNL, Jen Grenier MSN, RN-BC; Angela Cooper MSN,
RN,CNL; Rachel Start MSN, RN
Rush Oak Park Hospital
Oak Park IL
Primary Contact Email: [email protected]
8
CNL Summit
Hyatt Regency Orange County
Abstract Presentation Schedule - By Session
Friday, January 17, 2014
2:45 p.m.
Harbor Room (2nd Floor)
Developing a Clinical Nurse Leader Practice Model: An Interpretive Synthesis
Miriam Bender, PhD RN CNL
Outcomes Research Institute, Sharp Healthcare
San Diego, CA
Primary Contact Email: [email protected]
Garden Room 1
A Clinical Nurse Leader led multidisciplinary Heart Failure Program: Integrating best practice
across the care continuum to reduce avoidable 30 day readmissions.
Jan Broniec MS, RN, CNL
St. Luke's University Health Network
Bethlehem, PA
Primary Contact Email: [email protected]
Garden Room 2
Application of The Integrative Clinical Concepts of Physical Assessment, Pathophysiology and
Pharmacology within a CNL Graduate Clinical Course
Dr. Grace Buttriss DNP, RN, FNP-BC, CNL
Queens University of Charlotte CNL Coordinator and Faculty
Charlotte, NC
Primary Contact Email: [email protected]
Garden Room 3
Early indicators of success in the implementation of Primary Team Nursing in a
comprehensive cancer center
Jeremy Morris, MS, BSN, RN, CNL, PCCN
The University of Texas MD Anderson Cancer Center
Houston, TX 77030
Primary Contact Email: [email protected]
Garden Room 4
Enhancing Medication Safety for Patients Regarding Side Effects of Newly Prescribed
Medications
Bethel S. Guk-Ong, MS, RN-BC, CNL, OCN
MD Anderson Cancer Center
Houston, Texas
Primary Contact Email: [email protected]
9
Grand Ballroom A
Cost Benefit Analysis of Employing a CNL on a Medical Surgical Unit in Arkansas
Kerry Jordan RN, MSN, CNL: Laura Hall RN, MSN, CNL
University of Central Arkansas
Conway, Arkansas
Primary Contact Email: [email protected]
Grand Ballroom B
Evolving CNL role: Exemplars from CNLs and Nurse Executive
Linda Roussel, DSN, RN, CNL, NEA-BC
University of Alabama Birmingham School of Nursing
Birmingham, AL
Primary Contact Email: [email protected]
Grand Ballroom E
Meeting the needs of a geriatric-specific, acute care CNL cohort
Katie Lutz MSN, RN, CNL, PHN
Veterans Administration
Palo Alo, CA
Primary Contact Email: [email protected]
Grand Ballroom D
Implementation and Development of a NICHE unit led by Clinical Nurse Leaders
Kasia Qutermous MSN, RN-BC, CMSRN, CNL & Veronica Rankin MSN, RN-BC, CMSRN,
CNL
Carolinas Medical Center
Charlotte, NC
Primary Contact Email: [email protected]
Grand Ballroom F
CNL Impact Cross-Continuum: Pre-Operative Pain Medications
Elizabeth Triezenberg MSN, RN, CNL, CNRN
Mercy Health Saint Mary's
Grand Rapids MI
Primary Contact Email: [email protected]
3:15 p.m.
Harbor Room (2nd Floor)
CNL Impact and Outcomes on a Psychiatric Medical Unit
Kevin Hengeveld MSN RN CNL
10
Mercy Health Saint Mary's Campus
Grand Rapids MI
Primary Contact Email: [email protected]
Garden 1
Dedicated Purposeful Rounding: A Novel Approach to Hourly Rounding
Cynthia Cohen RN, MSN, CNL, CCRN, RN-C
Elliot Health System
Manchester, NH
Primary Contact Email: [email protected]
Garden 2
Implementing the CNL Role with Clinical Partners
Beth-Anne Christopher, MS, RN, CNL
Rush University College of Nursing
Chicago, IL 60612
Primary Contact Email: [email protected]
Garden 3
Implementing an Evidence-Based Guideline specific to the care of Latino Adult Type 2
Diabetes Mellitus (AT2DM) patients in a community health center.
Marilisa Ferrer, BSN, RN, (CNL student)
Alivio Medical Center
Chicago, IL
Primary Contact Email: [email protected]
Garden 4
Building And Leading A Team To Decrease t-PA Usage for PICC Line Clots
Joe Hafley MSN, RN, CCRN, CNL
Texas Health Resources
Ft. Worth, TX
Primary Contact Email: [email protected]
Grand Ballroom A
Examining the application of the CNL skill set in diverse practice roles
Kristen Noles, MSN, RN,CNL; Emily Simmons, MSN, RN, CNL; Velinda Block, DNP, RN;
David James, DNP, RN, CCRN, CCNS; Angela Jukkala, PhD, RN
University of Alabama at Birmingham Hospital and UAB School of Nursing
Birmingham, Alabama
Primary Contact Email: [email protected]
Grand Ballroom B
Readying the Practice Envirorment for the CNL: Perspective from Nurse Leaders
Patricia Thomas PhD, RN, FACHE, NEA-BC, ACNS-BC, CNL
Catholic Health East-Trinity Health
Livonia, MI
Primary Contact Email: [email protected]
11
Grand Ballroom E
CNL Led Implementation of a Comfort Care Order Set
Debbie Newman RN, MSN, CNL
Central Texas Veterans Health Care System
Temple, Texas
Primary Contact Email: [email protected]
Grand Ballroom D
How a CNL and Pharmacy Collaboration Project saved over $8000 within 2 months
Veronica Rankin MSN, RN-BC, CMSRN, CNL
Carolinas Healthcare System
Charlotte/NC
Primary Contact Email: [email protected]
Grand Ballroom F
A Clinical Nurse Leader's Role in Advancing Quality Stroke Care at a Micro, Meso and Macro
Systems Level.
Flame Uytico, MSN,RN, CNL,CEN
Texas Health Dallas
Dallas, TX
Primary Contact Email: [email protected]
3:45 p.m.
Harbor Room (2nd Floor)
Implementing a Clinical Nurse Leader Program: We can't afford not to!
Mary Irvin, MSN, MBA, NEA-BC & Kathy Oliphant, MSN, RN
TriHealth
Cincinnati, Ohio
Primary Contact Email: [email protected]
Garden 1
Too hip to be square… and too hip for surgical site infections
Michael Culver, MSN, RN, CNL
Texas Health Harris Methodist Hospital: Hurst-Euless-Bedford
Bedford, TX
Primary Contact Email: [email protected]
Garden 2
Incorporating the CNL within a Health Plan: The Possibilities and Potentials are Limitless
Rose L. Hoffmann PhD, RN, CNL
University of Pittsburgh
Pittsburgh PA
Primary Contact Email: [email protected]
12
Garden 3
CNL driven discharge process improvement: How a microsystem assessment helped improve
the discharge process on a medical surgical unit.
Cory Franks RN MSN CNL
Texas Health Resources
Fort Worth , Texas
Primary Contact Email: [email protected]
Garden 4
Performance Improvement for Surgical Care Improvement Project with Incorporation of PostOperative Daily Rounding Tool
Brandon Hunter, RN, MSN, CNL
Carolinas Medical Center
Charlotte, NC
Primary Contact Email: [email protected]
Grand Ballroom A
Continuity of Care: A Community Collaborative
Catherine Lauridsen BSN, RN, CNL student
Shawnee Mission Medical Center
Shawnee Mission, KS, 66204
Primary Contact Email: [email protected]
Grand Ballroom B
Improving Model A and Model C Clinical Nurse Leader (CNL) Students Certification Pass
Rates
Sherry Webb, DNSc, CNL & Alise Farrell, MSN, CNL
University of Tennessee Health Science Center
Memphis, TN
Primary Contact Email: [email protected]
Grand Ballroom E
Good, Better, Best: Enhancing Team Perception in the Wake of Change
Yvette Ong, MS, BSN, RN, OCN, NE-BC
MD Anderson Cancer Center
Houston, TX
Primary Contact Email: [email protected]
Grand Ballroom D
Financial Readiness: Building a Business Case for the Clinical Nurse Leader Role
Penny Moore Ph.D., RN, CNL
Texas Christian University
Ft. Worth, TX
Primary Contact Email: [email protected]
13
Grand Ballroom F
The Road to Advanced Heart Failure Certification: A Cross-Continuum Approach
Rebecca Valko MSN, RN, CNL & Kristy Todd MSN, FNP-BC, RN-BC
Mercy Health- Saint Mary's
Grand Rapids, MI
Primary Contact Email: [email protected]
4:15 p.m.
Harbor Room (2nd Floor)
Toward a More Patient Centered Plan of Care
Jo Ellen Inman-Puckett, RN, MBA, MSN, CNL. CMSRN
Carolinas Medical Center
Charlotte, NC
Primary Contact Email: [email protected]
Garden 1
Screen and Intervene: Improved Outcomes from a Nurse-Initiated Sepsis Protocol
Kristin Drager MSN RN CNL CEN
William S. Middleton Memorial Veterans Hospital
Madison, WI
Primary Contact Email: [email protected]
Garden 2
Using a brochure assignment to market Model A & Model C CNL graduate roles
Keevia Porter, DNP, NP-C
University of Tennessee Health Science Center
Memphis, TN
Primary Contact Email: [email protected]
Garden 3
Interventions to Improve Staff Responsiveness and Patient Satisfaction through Call Light
Management and Purposeful Hourly Rounding.
Esther Gosdin MSN, RN
Texas Health Southwest Harris Hospital
Ft. Worth, Texas
Primary Contact Email: [email protected]
Garden 4
Evolution of CNL Workgroup for a 14-Hospital System
Diane Thomas, MSN, RN, CNL; Holly Haddad, MHS, MSN, RN, CNL
Texas Health Resources
Ft. Worth, TX
14
Primary Contact Email: [email protected]
Grand Ballroom A
Resilience and Transition to Practice in Model C CNL Graduates
Geralyn Meyer, PHD, RN, CNE, CNL & Bobbi Shatto, MSN, RN, CNL
Saint Louis University School of Nursing
St. Louis, MO 63104
Primary Contact Email: [email protected]
Grand Ballroom B
NO SESSION
Grand Ballroom E
Discharge Planning to Prevent Readmissions and Improve Patient Satisfaction
Ginu Philip, MSN, RN, CNL
Texas Health Dallas
Dallas/Texas
Primary Contact Email: [email protected]
Grand Ballroom D
The Role of the CNL in Creating a Culture of Certification and Professional Development
Danell Stengem, MSN, RN-BC, CNL
Texas Health Harris Methodist Hospital - Fort Worth
Fort Worth, TX
Primary Contact Email: [email protected]
Grand Ballroom F
Implementing the Clinical Nurse Leader Role to Improve Outcomes: A Leadership Model
Centered on Innovation, Efficiency, and Excellence
Denise M. Wienand MEd, MSN, RN, CNL; Prachi Shah MSN, RN, CNL; Brandy Hatcher MSN,
RN, CNL; Alison Jordan MSN, RN, CNL, Jen Grenier MSN, RN-BC; Angela Cooper MSN,
RN,CNL; Rachel Start MSN, RN
Rush Oak Park Hospital
Oak Park IL
Primary Contact Email: [email protected]
15
CNL Summit
Hyatt Regency Orange County
Abstracts in Alphabetical Order By Last Name
Friday, January 17, 2014
Abstract title: Developing a Clinical Nurse Leader Practice Model: An Interpretive Synthesis
Author Name & Credentials: Miriam Bender, PhD RN CNL
Institution: Outcomes Research Institute, Sharp Healthcare
City/State: San Diego, CA
Primary Contact Email: [email protected]
Background Information:
The Institute of Medicine’s Future of Nursing report identifies the Clinical Nurse Leader (CNL)
as an innovative and necessary new role for meeting higher healthcare quality standards. The
AACN CNL White Paper provides a concise model for CNL educational curriculum and end-ofprogram competencies. However, a review of the literature found the CNL is not yet clearly
defined in terms of fundamental activities and responsibilities necessary to produce outcomes.
Lack of practice clarity limits the ability to articulate, implement, and measure CNL-specific
practice and outcomes.
Aim:
The purpose of this study was to clarify fundamental CNL practice structures and processes
contributing to expected care quality outcomes.
Methods/Programs/Practices:
While the extant CNL literature provides a resource to help clarify CNL practice, the
heterogeneous nature of the evidence is ill suited to traditional methodologies for systematic
review. Interpretive synthesis offers a unique approach towards integration of a body of literature,
involving reinterpretation and reanalysis of various text-based forms of evidence. Interpretive
synthesis design and grounded theory analysis was used to integrate the extant CNL literature into
a coherent understanding of CNL practice. Purposeful sampling of the literature was used to
identify reports describing CNL practice. The search was performed in CINAHL, Pubmed, and
Dissertations & Theses, using the term “clinical nurse leader”. A grey search was also performed
in Google to identify additional sources of CNL practice reports. The searches were conducted in
November 2011 with a follow-up in September 2012 to capture any newly published CNL
reports. Results were reviewed and included if they described actual CNL practices. Thirty
implementation/case study reports, eight qualitative/mixed methods studies, three quantitative
studies, and 254 conference abstracts were included in the synthesis.
Outcome Data:
CNL practice encompasses five domains: (1) Preparation for CNL Practice; (2) the Structure of
CNL Practice; (3) the Core Phenomenon of CNL Practice - Continuous Clinical Leadership; (4)
Acceptance; and (5) Outcomes of CNL Practice. Preparation for CNL Practice components
include: clear understanding of current care delivery deficits; strong leadership support; and an
effective change management strategy. Structure of CNL Practice components include:
microsystem care delivery redesign; competency-based CNL workflow; and accountability for a
defined set of outcomes. Continuous Clinical Leadership components include: source of constant
communication/information; strengthening inter-professional relationships; team creation;
16
supporting staff engagement; and shifting focus from person to process. Acceptance components
include: initial buy-in; exposure; and understanding. Outcomes of CNL Practice components
include: improved care environment; improved care quality; and nursing brought to the forefront
of healthcare redesign.
Conclusion:
This study advances understanding of the relatively new CNL role by synthesizing an empirically
derived model for practice. The CNL Practice Model describes five domains that interact to
produce the structure, function, and outcomes of CNL practice. It clarifies CNL practices,
differentiates them from existing nursing roles and practices, and proposes mechanisms by which
a CNL-integrated care delivery system can improve healthcare quality. The core phenomenon of
CNL practice involves developing multidisciplinary relationships to promote and sustain
information exchange, shared decision-making and effective care processes. The model highlights
the importance of a systematic approach to CNL practice development and implementation,
including macro and microsystem involvement, care delivery redesign, CNLs functioning at their
full scope of practice, and allotting time for practice acceptance. The model can be beneficial to
organizations contemplating CNL implementation, helping to frame an implementation strategy
that addresses all five domains of CNL practice, and providing a preliminary roadmap of
necessary steps for CNL practice success. The model may also be helpful to current and future
CNLs as a framework for articulating their practice to their microsystem team, macrosystem
leadership, and healthcare community at large.
Abstract title: A Clinical Nurse Leader led multidisciplinary Heart Failure Program: Integrating
best practice across the care continuum to reduce avoidable 30 day readmissions.
Author Name & Credentials: Jan Broniec MS, RN, CNL
Institution: St. Luke's University Health Network
City/State: Bethlehem, PA
Primary Contact Email: [email protected]
Background Information:
Nationally heart failure (HF) continues to be a growing problem. It is the leading cause of
Medicare admissions with 6.6 million Americans burdened by this disease. Thirty-day
readmissions have reached striking figures with one in four patients being readmitted nationally
and similar results in Pennsylvania. Costs of these readmissions have prompted Medicare to
initiate penalties to hospitals with higher than expected rates. In 2011, our network readmission
rates were higher than expected, highlighting an opportunity to improve our current HF Program.
In response, our administration formed a multidisciplinary team to evaluate current practices,
identify gaps, and develop strategies to redesign the HF program and improve outcomes. Our goal
was to reach top quartile performance. This multidisciplinary team conducted a thorough review
of current literature to identify best practices. Several models were identified that demonstrated
success at improving outcomes and reducing readmissions. All emphasized the importance of
17
improving care transitions, outpatient follow up and care coordination. Next, a needs assessment
was performed and revealed multiple opportunities for improvement including: knowledge gaps
regarding best practices for patients with HF among physicians, nurses and post discharge facility
health care providers; no consistent process for following patients after discharge; inconsistent
communication between health care settings; and a need for addressing the needs of more
advanced HF patients with regards to symptom management at home. Based on the findings of
our literature review and needs assessment, we chose initiatives from several studies for designing
a new HF program.
Aim:
To decrease all cause HF readmission rates to achieve top quartile performance as defined by
Premier® data base within 15 months of implementing a redesigned HF program.
Methods/Programs/Practices:
A new model for the HF program was piloted using the framework of the PDCA methodology in
order to integrate best practices into our care for patients with HF. The new HF program was
patient centered and focused on a coordinated outpatient approach. The program was led by two
dedicated Heart Failure Care Coordinators/Clinical Nurse Leaders (HFCC/CNL). Other additional
resources included two midlevel providers who alternate between the inpatient and outpatient
settings dedicated to the HF population throughout the care continuum. The key components that
were initiated included: timely follow-up appointments with health care provider within 3-7 days
after discharge from the hospital; follow-up phone calls 24-48 hours post-discharge; home health
care referrals, tele-health monitoring, palliative care and improved communication between health
care settings including assisted living and skilled nursing facilities. Throughout the
implementation we continuously reviewed readmission data, evaluated results, identified barriers
and realigned our interventions. Based on the observed success at our main campus, the model
was expanded network-wide.
Outcome Data:
From the inception of our redesigned HF program, in November of 2011 through January 2013,
we have seen an overall 42.7% reduction in HF readmissions at our main campus (from 26.62%
to15.26%) and a 33.1% reduction for the network (from 22.9% to 15.38%) and realized our goal
of top quartile performance at 0.69 based on Premier, Inc. data comparison. Since then, we have
seen sustained improvements both at the main campus and at the network level. For FY 2013 our
overall readmission rate was 14.9%.Our ability to sustain continued success in reducing
readmissions suggests that this program can be utilized as a model for other institutions looking to
decrease HF readmissions.The factors that were crucial for the success of our HF program in
reducing 30 day readmissions across our network were several-fold and include: commitment of
administration and nursing leadership to champion a HFCC/CNL nurse driven HF program; a
focus on the outpatient process and care coordination after discharge; real time drill downs of 30
day readmissions daily with feedback; engagement of medical and nursing staff to promote and
sustain best practices.
Conclusion:
Recent changes from the Affordable Care Act have challenged hospitals to reduce 30 day
readmissions for several diagnoses including HF or suffer significant penalties. Attention to care
transitions and implementation of chronic disease management programs have been suggested as
first step to improving outcomes. The HFCC/CNL role is well aligned to address these challenges
to reduce 30 day readmissions and improve the quality of care our patients with HF receive. This
CNL led HF Program required an initial investment of two cardiology mid-level providers and
18
two CNLs. The cost of these resources is estimated at $367,463 per year. Financial data was
analyzed for our Network and identified that one HF admission costs on average $9,552 including
direct and indirect costs. Network data for FY2013 demonstrates 59 fewer HF readmissions than
last year and represents a cost savings of approximately $563,568. Additional savings are
expected as we further implement these interventions across our Network. Additionally, $11,000
was invested in the purchase of 10 tele-health monitoring systems for use by our home health care
agency.
For many hospitals and networks, penalties incurred will well exceed the cost of these additional
resources. The success of this program in reducing 30 day readmissions well below expected
values combined with penalties from Medicare for those hospitals with a higher than the expected
rate make an excellent case for initiating this program at other hospitals.
Abstract title: Application of The Integrative Clinical Concepts of Physical Assessment,
Pathophysiology and Pharmacology within a CNL Graduate Clinical Course
Author Name & Credentials: Dr. Grace Buttriss DNP, RN, FNP-BC, CNL
Institution: Queens University of Charlotte CNL Coordinator and Faculty
City/State: Charlotte, NC
Primary Contact Email: [email protected]
Background Information:
A goal of the Clinical Nurse Leader Nursing Program at Queens University of Charlotte is to
enhance a student’s Advanced Physical Assessment, Pathophysiology and Pharmacology
proficiency through integrative course and practicum experiences. The course was designed as an
innovative process for presenting the "3 P" content through the use of Clinical Exemplars,
Clinical Application and student conducted Case Presentations. This new course offering is a
novel method implemented to promote the "3 P" application in the student CNL role.
Aim:
The purpose or aim of the "3 P" course is to introduce the principles of Advanced Physical
Assessment, Pathophysiology and Pharmacology to Clinical Nurse Leader students to enhance
their knowledge level and application during required clinical experiences.
Methods/Programs/Practices:
The new CNL course offering is titled "Integratice Clinical Concepts" and includes 75 application
clinical hours. This course was developed to integrate the concepts of Physical Assessment,
Pathophysiology and Pharmacology into one integrated Graduate CNL Nursing Course. The
clinical component provides the student with opportunity to apply the "3P" classroom content
with an assigned Preceptor in the clinical setting.
Students submit weekly logs highlighting their aplication of the "3P's" during their clinical
experiences, are tested based on the content and present a final integrative patient case
presentation at the completion of the course.
19
Outcome Data:
This presentation will discuss the outcomes from the initial offering of the "3 P" course for CNL
students and the preparation for transitioning the nursing curriculum to include the course as a
new requirement for all Graduate Nursing students at Queens University of Charlotte.
Furthermore, the presentation will discuss the advantages and challenges in executing the
integrative nursing course within the CNL curriculum.
Conclusion:
Clinical Nurse Leader Nursing curriculums are designed to provide the foundation for the
graduate nurse to lead and coordinate care in the CLN role. The innovative "3P" course presents
the content necessary to support the student during their clinical experiences, attainment of CNL
certification and management of complex systems of care as a CNL graduate.
The content and design of this course will be illustrated, while the benefits and the challenges of
offering the innovative course in the Graduate Nursing CNL Program will be discussed,
Abstract title: Implementing the CNL Role with Clinical Partners
Author Name & Credentials: Beth-Anne Christopher, MS, RN, CNL
Institution: Rush University College of Nursing
City/State: Chicago, IL 60612
Primary Contact Email: [email protected]
Background Information:
AACN requires 360 hours in the last term for CNL development. Rush College of Nursing
(RCON) faculty designed an innovative approach to the use of these hours to best meet the CNL
objectives. The goal of leadership development is facilitated by a unique distribution of residency
hours between direct care hours and indirect hours.
Aim:
The purpose of this presentation is to provide examples of quality learning leadership
experiences in partnership with clinical agencies that enable Model C students to meet CNL
objectives during their residency term using a unique distribution of residency hours.
AACN states that in the “Expectations for Clinical/Practice Partners” that organizations ‘design
learning opportunities, in conjunction with the school of nursing, which allow the
CNL student to successfully complete the required clinical experiences and to practice in the CNL
role’. RCON has taken this approach one step further as one of the leadership learning
experiences for the CNL student. The CNL students are required to have an immersion clinical
experience which demonstrates all of their learning/preparation and how they are able to apply the
previous learning in an intensive clinical experience. RCON faculty experimented with having
the students demonstrate to the clinical partners that they have the knowledge and skills to build
20
and lead teams to achieve better patient/client outcomes through the negotiation of their clinical
residency experience. Although cultivating partnerships with some of the clinical partner sites
were faculty driven, other sites were developed by the students themselves. Faculty members
were instrumental in making contacts on behalf of students but the students were the persons who
negotiated with the clinical partner for the clinical residency experience.
Methods/Programs/Practices:
Part of the residency clinical experience (indirect hours) requires the student to take an
independent leadership role to improve cost, quality and service outcomes. The student is
expected to contribute to the mission of the partner organization. To accomplish this goal, clinical
partners work with faculty to identify potential projects based on the organization’s mission to
which students can contribute.. These projects are posted in a central location for student
review. Each project requires an application to the agency. Based on the application submitted,
the student is interviewed by the organization's contact person to determine fit and commitment to
the project. Students gain experience in organizational fit determination for future use when
seeking employment. Examples of indirect hour experiences will be presented including an
example of the application process.
Outcome Data:
Specific project outcomes will be discussed within the context of projects examples provided.
The types of outcomes achieved address the three stated focus areas of cost and quality
improvements (clinical ladder, intellectual disabilities, and vaccinations) and service (stroke,
school based clinics).
Conclusion:
While other colleges of nursing have a similar clinical course for CNL students, the outcomes
achieved demonstrate that dividing the residency hours between direct and indirect allows the
CNL student to fully develop the leadership role in regard to improving cost, quality and service
outcomes.
Abstract title: Dedicated Purposeful Rounding: A Novel Approach to Hourly Rounding
Author Name & Credentials: Cynthia Cohen RN, MSN, CNL, CCRN, RN-C
Institution: Elliot Health System
City/State: Manchester, NH
Primary Contact Email: [email protected]
Background Information:
Providing exceptional customer service , patient centered care, and ensuring patient safety are
important goals of our healthcare delivery system. Hourly rounding has been identified in nursing
research as a means of reducing patient falls and hospital acquired pressure ulcers (Woodard,
2009; Halm, 2009). Additionally research has shown that patient satisfaction scores as measured
21
by Press Ganey (PG) and Hospital Consumer Assessment of Health Plans Survey (HCAHPS)
improve with the successful implementation of hourly rounding (Meade, 2006; Gardner, Woolett,
Daly, & Richardson, 2009). Hourly rounding is an evidence-based approach to ensure essential
care is delivered to every patient in a timely manner.
Many acute care hospitals have attempted to implement the use of hourly rounding.
Translating this evidence into practice at the bedside has proven to be challenging (Deitrick,
Baker, Pacton, Flores, & Swavely, 2012). Barriers to successful implementation include, lack of
clarity about the process, an inability to incorporate hourly rounding into the current workflow of
nurses and licensed nursing assistants (LNA), and lack of accountability (Deitrick et al., 2012).
This project follows the creation and implementation of an additional specialized LNA role of
Designated Purposeful Rounder (DPR) added to the current staffing matrix. The DPR is
responsible for rounding on the entire unit with a focus on patient safety, exceptional customer
service, and increasing patient mobility and function.
Resources:
Deitrick, L. M., Baker, K., Pacton, H., Flores, M., & Swavely, D. (2012, January-March). Hourly
Rounding: Challenges with implementation of an evidence-based process. Journal of Nursing
Care Quality, 27(1), 13-19. http://dx.doi.org/10.1097/NCQ.0b013e18227d7dd
Halm, M. A. (2009, November). Hourly rounding: What does the evidence indicate? American
Journal of Critical Care, 18(6), 581-584. http://dx.doi.org/10.4037/ajcc2009350
Gardner, G., Woolett, D., Daly, N., & Richardson, B. (2009). Measuring the effect of patient
comfort rounds on practice environment and patient satisfaction. International Journal of Nursing
Practice, 15, 287-293. http://dx.doi.org/10.111/j.1440-172X.2009.01753.x
Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds on patients’ call
light use, satisfaction, and safety. American Journal of Nursing, 106(9), 58-70. Retrieved from
http://journals.lww.com/ajnonline/pages/default.aspx
Woodard, J. L. (2009). Effects of rounding on patient satisfaction and patient safety on a
medical-surgical unit. Clinical Nurse Specialist, 23(4), 200-206. Retrieved from
http://journals.lww.com/cns-journal/pages/default.aspx
Aim:
*Increase patient satisfaction
The following are questions from the HCAHPS and Press- Ganey survey that will be utilized for
comparison pre/post implementation. The goal is an increase the Top Box score of each question
by 1.5%. The baseline data is representative of a time period from March 1, 2013 through July 31,
2013. Evaluation of our success is over a six-month period post-intervention.
HCAHPS Questions:
•During this hospital stay, how often were your room and bathroom kept clean?
•How often did you get help in getting to the bathroom or in using a bedpan as soon as you
wanted?
•During this hospital stay, how often did the hospital staff do everything they could to help you
with your pain?
•Press Ganey Question:
Amount of attention paid to your special or personal needs.
22
*Increase staff satisfaction:
Statistical improvement from Pre/Post survey questions comparing original hourly
rounding process with use of the DPR. A Qualitative analysis will also be used to further
understand the new role as it pertains to evaluation of job satisfaction, ability to spend time with
patients, impact on patient safety, and development and education/support.
*Decrease patient falls:
Decrease patient falls to the designated Magnet median rate of 2.86 per 1,000 patient days.
The combined median fall rate for our Adult-Medical Surgical floors for the first quarter for the
year 2013 is 4.45. The Cardiac Intermediate Care Unit (CICU) for the same time period had a fall
rate of 4.67 per 1,000 patient days.
Methods/Programs/Practices:
This presentation documents the evolution, implementation, and evaluation of the effectiveness of
an additional designated Licensed Nursing Assistant assigned to complete purposeful, hourly
rounding on all patients in a telemetry unit and two medical surgical units. The Purposeful Hourly
Rounder is utilized 7 days a week between the hours of 0700-2300. Metrics focus on
the impact of this intervention on patient safety, patient/family centered care, and patient and staff
satisfaction. In addition to performing hourly rounds, a hydration cart providing tea, fruited water,
and snacks is offered to all appropriate patients at 1400, and 2000. The cart provides exemplary
customer service while promoting hydration. The Designated Hourly Rounder is an addition to
the staffing matrix. This role is not considered expendable to fill gaps in LNA coverage on any
particular shift or unit, or to provide 1:1 coverage.
Go-live date for the DPR was September 23, 2013. All LNA's (all units, all shifts) received three
layers of training. Initial completion of a self-paced PowerPoint presentation and quiz. A twohour face-to-face session with CNLs (10 students/2 CNLs) incorporating videos, discussion and
role scenarios. Finally, 3 hours of 1:1 mentoring with a CNL was completed as each LNA began
their initial shift as the DPR.
All RN's completed the self-paced PowerPoint presentation and quiz. Managers attended a
presentation on the role of DPR.
Two theories provided the framework for development of this program, Rogers' Diffusion of
Innovation, and Kolcaba's Theory of Comfort. The principles of the Theory of Comfort were
presented to the LNA's in the face-to-face training, including the model and taxonomic structure.
Outcome Data:
Data collection prior to implementation included a survey of RNs and LNAs assessing the
rounding system prior to implementation as well as patient surveys inquiring into their
identification and personal thoughts of the rounding process. These surveys will be repeated at 3
months and 6 months.
Staff tracking of the reason for call light activation began October 15th and will be ongoing.
Outcome data from December (3 months) will be incorporated into the presentation in addition to
continuous tracking of patient falls, pressure ulcers, HCAHPS and Press- Ganey survey results.
Conclusion:
This project was driven by a dedicated group of CNLs from inception to implementation.
Initially, PDSA cycles were implemented on a single med/surg floor during the evening shift.
LNA's were integral to the process changes of subsequent PDSA cycles as the role was
developed. Improvement in fall rates and Press-Ganey scores were vital in building the business
case within the organization to add the DPR to the staffing matrix.
23
Nursing literature that describes difficulty in successfully implementing hourly rounding is
abundant. No studies were found that examine a similar addition to the staffing matrix to focus
the attention of one LNA on anticipating and fulfilling the needs of patients. The development
and implementation of this role illuminates the valuable role of the CNL in identifying system
process problems and developing interventions that empower RNs and LNAs to embrace change
and bring EBP into their practice.
Abstract title: Too hip to be square… and too hip for surgical site infections
Author Name & Credentials: Michael Culver, MSN, RN, CNL
Institution: Texas Health Harris Methodist Hospital: Hurst-Euless-Bedford
City/State: Bedford, TX
Primary Contact Email: [email protected]
Background Information:
A CNL Microsystem Assessment uncovered that hip surgeries, when combined, comprise the
largest pool of DRGs on the surgical unit. Surgical site infection (SSI) is the 7th most frequent
DRG. The 2012 SSI rate specific to fractured-hip arthroplasty was 5.2% (6.25% first quarter); the
national mean rate is 1.44%.
Perioperative cleansing of the skin with CHG-impregnated towelettes has demonstrated a
reduction in SSIs. Continued daily cleansing of the skin has been shown to sustain low microbial
density on the skin. Additionally, prophylactic treatment of patients colonized with SA has been
linked to lowering SSI rates. Patients who suffer SSI have a longer hospital stay while the
infection is treated or are readmitted for the treatment and the average cost of an SSI admission is
$25,546. Additionally, it is difficult to treat a SA infected prosthesis with antibiotics alone,
requiring long-duration therapy. If antibiotics fail to eradicate the infection, the patient will
require a staged exchange of the prosthesis consisting of two subsequent operations: 1) removal
of the infected prosthesis and placement of antibiotic-impregnated interim spacers and 2) removal
of the spacers and implantation of a new prosthesis.
Aim:
The purpose of this process improvement is to realize a decrease in surgical site infections (SSIs)
in the population of fractured-hip arthroplasty patients on a surgical unit by specifically screening
for Staphylococcus aureus (SA) colonization, treating colonized surgical patients
prophylactically, and ensuring that the entire population receives a total of three chlorhexidine
gluconate (CHG) baths prior to surgery. This represents an augmentation of the current practice
of providing two CHG baths preoperatively.
Methods/Programs/Practices:
The CNL formed and led a multidisciplinary team to accomplish this process improvement
including infection prevention, surgeon, information & technology, laboratory, materials
24
management, product manufacturer, surgical unit manager, surgical unit RN, surgical unit PCT,
and partner CNL.
All patients admitted to the surgical unit with a hip fracture are included in this process
improvement at the outset by assumption and are given an initial CHG bath on, or very soon after,
admission. Patients are verified as a part of the process improvement when the orthopedic
surgeon orders an arthroplasty procedure. (All other forms of hip surgery are exclusionary.) The
surgeon implements, or is recommended to implement an order set created by the process
improvement team that includes 3 preoperative CHG baths, nasal SA screening via polymerase
chain reaction (PCR) technology (results in < 60 minutes), and a conditional order, based on the
result of the culture, for a nasal antibiotic ointment regime to begin prior to surgery.
Outcome Data:
The rate of SSI in the target population for the first quarter of 2013 was 0% (n=22). This
compares with 6.25% (n=32) for the first quarter of 2012. This represents an estimated savings of
$51,092. The surgical unit staff has expressed satisfaction in receiving real-time feedback
regarding the effect of their interventions on the quality of care being provided to their clients.
Finally, the Unit Based Council brought forth a new resolution: “We will continue this process
improvement as well as investigate and incorporate other strategies that will enable us to be
experts in the care of all of our hip surgery patients.”
Conclusion:
Patients with end-stage osteoarthritis develop a plan for arthroplasty with their Orthopedist. They
have the opportunity to set a date for the procedure and plan for it, gather information about the
pending procedure, get surgical clearance from their own cardiologist, get lab work done in
advance, get several days during which to take antimicrobial baths, and get a clear understanding
about which medications should and should not be taken in the days and hours leading to surgery.
Patients that require arthroplasty subsequent to traumatic fracture enjoy none of these benefits.
Ultimately, the task of this CNL-led multidisciplinary team was to mitigate the disparity between
these two sides of the same coin. The CNL identified the area of concern through an assessment
of the microsystem and brought together an array of disciplines to determine solutions. This
process improvement included a compressed time-frame for 3 preoperative antimicrobial baths
and foreknowledge of SA colinization status. The future plan of the surgical unit is to create of a
multi-formatted pre-operative educational program that includes a detailed introduction to patientcontrolled analgesia, incentive spirometry, and rehabilitative therapy.
25
Abstract title: Screen and Intervene: Improved Outcomes from a Nurse-Initiated Sepsis
Protocol
Author Name & Credentials: Kristin Drager MSN RN CNL CEN
Institution: William S. Middleton Memorial Veterans Hospital
City/State: Madison, WI
Primary Contact Email: [email protected]
Background Information:
Sepsis is a serious medical problem. The overall mortality rate from severe sepsis or septic shock
ranges from 30-60% and it is the 10th leading cause of death in the United States with costs
nearing 17 billion dollars. Studies indicate early identification of sepsis, coupled with an
evidence-based sepsis treatment protocol improve patient outcomes. The William S. Middleton
Memorial Veterans Hospital did not utilize a sepsis protocol. A Clinical Nurse Leader (CNL)
identified this gap and formed an interdisciplinary group of vested stakeholders to create a sepsis
committee to initially focus programming in the Emergency Department (ED) microsystem.
Aim:
Develop and implement a nursing sepsis educational program and new nurse-initiated evidencebased sepsis protocol to facilitate early recognition of patients meeting sepsis criteria and deliver
evidence-based interventions to improve patient outcomes and reduce hospital resource utilization
and costs by June 2013.
Methods/Programs/Practices:
A CNL performed a comprehensive literature review of sepsis-related research and clinical
guidelines. With Institutional Review Board (IRB)-approval, the CNL performed a two-year
retrospective medical record review of patients with sepsis-related medical diagnoses. This
analyses provided baseline data that were utilized to develop a new sepsis program, performance
measures, and staff education. In June 2012, an ED nursing sepsis education program using
didactic and simulation teaching modalities was taught by the CNL and a Nurse-Initiated Sepsis
Protocol was implemented in the ED. Data collection was performed by the CNL for one-year
post-sepsis protocol initiation. Statistical analyses of pre- and post-ED sepsis intervention
variables provided outcome data. Since implementation of the ED sepsis protocol, the CNL-led
sepsis programming has expanded organizationally to include the intensive care units (ICU) and
hospital inpatient acute care units. In an effort to standardize sepsis care throughout the
organization, the nurse-initiated ED sepsis protocol has expanded to include the ICU staff. Acute
care nurses received sepsis education and a newly-developed sepsis guideline to facilitate early
recognition of sepsis with corresponding SBAR scripting that is utilized when communicating
concerns to the provider. The sepsis committee continues to meet quarterly to evaluate
programming, review new evidence, identify and resolve barriers.
Outcome Data:
Statistical analyses of pre- and one year post- ED sepsis nursing education and protocol
implementation reveal: improvements in compliance of 6 of 6 ED sepsis protocol performance
measures, a reduction in the progressive worsening of stages of sepsis in ED patients treated with
the protocol (from 35% reduced to 5.9%), a decrease in mortality rate of patients treated with the
sepsis protocol in the ED (from 12% reduced to 6%), and an average reduction of four bed-daysof-care per patient treated with the sepsis protocol in the ED. This results in an overall cost
26
savings of $6310 per patient. Of the 85 post-ED sepsis protocol patients identified in this study,
hospital costs were reduced by $536,000 from June 2012-June 2013.
Conclusion:
CNL-driven programming provides nurses with the education and tools to recognize sepsis early
and, in collaboration with the provider, initiate evidence-based diagnostic and treatment
interventions that improve patient outcomes and reduce hospital resource utilization and costs.
Abstract title: Early indicators of success in the implementation of Primary Team Nursing in a
comprehensive cancer center
Author Name & Credentials: Jeremy Morris, MS, BSN, RN, CNL, PCCN
Institution: The University of Texas MD Anderson Cancer Center
City/State: Houston, TX 77030
Primary Contact Email: [email protected]
Background Information:
In response to the need for improved quality, service, and outcomes, a Primary Team Nursing
(PTN) model was developed and implemented on several units at a large teaching institution. The
model was created to achieve patient focused quality care and service; and to support and develop
nursing staff. The Clinical Nurse Leader (CNL) role has been a key role in leading and building
teams to deliver care that is effective and efficient. In PTN, teams sized to care for a cohort of
patients vary depending on unit geography. On the unit highlighted in this abstract, staff members
on a 48-bed unit were divided into four teams, each with a CNL responsible for a cohort of 12
patients and the staff taking care of those patients, including nurses, nursing assistants and patient
services coordinators.
Aim:
The aim of the PTN is to enhance the delivery of quality and reliable care and achieve positive
patient outcomes measured by nurse sensitive outcomes including, but not limited to fall rates,
pressure ulcer prevalence, CAUTI and CLABSI rates and patient and staff satisfaction scores.
Methods/Programs/Practices:
Staff members were introduced to PTN and the role of the CNL through in-service education,
staff meetings, and an Experiential Day during the year prior to implementation. CNLs provide
the day to day continuity for patients and ensure that nurses who work two or three days a week
are kept apprised of the overall assessment and plan of care for the patients. They are also
instrumental in communicating about the patients in the cohort with other disciplines. Since
implementation of PTN, pharmacy, case management and mid-level providers have chosen to be
assigned to a specific cohort of patients, staff and CNL as a means of focusing the delivery of
their care and services. CNLs guide the care of the patients, the multi-professional practice and
the development of staff assigned to their team. Bedside Shift Report (BSSR) is practiced and the
27
TeamSTEPPS process has been utilized to enhance communication and mutual support among
caregivers. A morning Brief is held by each team with all team members after BSSR to share
information about all of the patients with the whole team.
Outcome Data:
Outcomes of PTN implementation on the unit have surpassed expectations. From November,
2011, to November, 2012, there were a total of 56 falls with an average of 6.5 days between falls
as compared to a total of five falls with 30 days between falls from January, 2013, through May,
2013. 41% of the previous year’s falls involved injury and just 20% involved injury from
January, 2013, to May, 2013. All patients on the unit are surveyed quarterly for unit acquired
pressure ulcers. There has been a steady downward trend in unit acquired pressure ulcers from
4.35% and 2.33% in the third and fourth quarters of 2012, to 0% in both the 1st and 2nd quarters
of 2013. Press Ganey HCAHPS results have shown that when we are compared to all databases
the unit is above the 50th percentile in all but two domains. Staff perception of the process has
been measured using the TeamSTEPPS T-TPQ survey tool which measures perceptions of all
aspects covered in the TeamSTEPPS process. This tool was administered prior to implementation
and at three months and six months since implementation. Scores have showed maintenance or an
increase in all areas which include Team Structure, Leadership Situational Monitoring, Mutual
Support and Communication.
Conclusion:
The implementation of Primary Team Nursing has proved to be successful over the first year. Key
quality indicators have improved. Opportunities to continue to focus on other areas in need of
improvement are being pursued at the unit level with collaboration of staff, unit leadership and
CNLs. Staff report that they appreciate working with a smaller, more consistent group of team
members as they are able to know and supplement each other’s strengths and weaknesses.
Positive patient comments regarding the model have included comments such as: “Team Nursing
experience was amazing. This is truly a model of how it should work. Every nurse who cared for
me was engaged in helping whether it was the nurse assigned to me or not." and “The staff
worked together like a well-oiled machine - with caring and concern”.
Abstract title: Implementing an Evidence-Based Guideline specific to the care of Latino Adult
Type 2 Diabetes Mellitus (AT2DM) patients in a community health center.
Author Name & Credentials: Marilisa Ferrer, BSN, RN, (CNL student)
Institution: Alivio Medical Center
City/State: Chicago, IL
Primary Contact Email: [email protected]
Background Information:
The U. S. Census data from 2008 estimates that approximately 11% or 3.3 million Latino
American adults age 18 or older had diabetes. Hispanic Americans with type 2 diabetes have a
28
prevalence rate of 11% compared to 6.4% of non-Hispanic whites, a higher incidence of diabetes
related complications and poorer access to healthcare (U.S. Census Bureau, 2008). Latinos are
1.6 times more likely to die of diabetes-related complications as whites due to poor management
of their diabetes. Diabetes is associated with increased morbidity and mortality due to
complications arising from cardiovascular disease and kidney failure (CDC, 2011).
Landmark diabetes trials have shown the advantages of regulating blood glucose, blood pressure
and blood lipids as well as the need for annual eye, foot and kidney exams in reducing
microvascular and macrovascular complications. However, a substantial gap still exists between
national evidence based recommendations for diabetes and current clinical practice (Welch, et al
2011). A strengths, weaknesses, opportunities and threats (SWOT) analysis revealed a lack of
knowledge and standardization regarding evidence-based practice for Latino AT2DM patients in
the clinic.
Aim:
The objectives of this project are to: 1) educate the clinical staff, patients and families on the
value and use of an evidence-based guideline specific to the treatment of Latino AT2DM patients,
2) develop and implement an evidence-based guideline specific to the treatment of Latino
AT2DM patients, 3) create a clinician point of care reminder incorporating the new evidencebased guideline, 4) increase and measure clinical application of the evidence-based interventions
for Latino AT2DM patients, and 5) evaluate clinician pre- and post- implementation compliance
rates.
Methods/Programs/Practices:
A strengths, weaknesses, opportunities and threats (SWOT) analysis was completed by the CNL
student in order to assess the microsystem need for implementing an evidence-based guideline for
Latino AT2DM patients. The CNL student and lead team reviewed the results of the analysis and
identified a need to improve clinical application of evidence-based interventions for Latino
AT2DM patients. The CNL student distributed a pre-assessment questionnaire regarding
clinician knowledge and attitudes towards adopting evidence-based guidelines into patient care.
A literature search regarding interventions for AT2DM patients was conducted by the CNL
student and analyzed by the clinicians. Search terms included adult Type 2 diabetes
recommendations, treatment of Type 2 diabetes, clinical practice guidelines for Type 2 diabetes
and management of Type 2 diabetes. From this review, the CNL student developed a guideline
and created a new diabetic flow sheet. The CNL student educated the lead team regarding care of
this patient population and the diabetic flow sheet. The lead team will provide staff education
concerning the new guideline and incorporate the diabetic flow sheet into each adult diabetic
medical record by October, 23, 2013. Clinicians will adopt the new guideline into their care of
Latino AT2DM patients and utilize the new diabetic flow sheet by October 31, 2013. The
bilingual health educators will provide culturally sensitive patient and family education regarding
the new guideline by November 30, 2013.
Outcome Data:
The finalized guideline was approved by the medical director and approved for organization-wide
implementation on October, 11, 2013. Primary outcome measures will include clinician attitudes
pre- and post- implementation, staff participation in educational in-services, evaluation of staff
and patient knowledge regarding the new guideline, and pre- and post- clinician compliance rates
regarding adherence to the new guideline and diabetic flow sheet.
Conclusion:
29
Clinical Nurse Leaders working within microsystems will play an instrumental role in bridging
the existing gap between research evidence and clinical practice. Evidence-Based practice
contributes to the science of nursing, results in better patient outcomes, keeps practices current
and relevant, increases confidence in making decisions, supports standards from regulatory
agencies, and is vital for high-quality patient care (Beyea & Slattery, 2006).
Abstract title: CNL driven discharge process improvement: How a microsystem assessment
helped improve the discharge process on a medical surgical unit.
Author Name & Credentials: Cory Franks RN MSN CNL
Institution: Texas Health Resources
City/State: Fort Worth , Texas
Primary Contact Email: [email protected]
Background Information:
A 24 bed medical surgical unit team discovered an opportunity to improve their discharge process
after reviewing the unit Press Ganey scores. Patient Discharge Information scores had been low
and were trending downward. The unit CNL assembled a team of staff RNs and performed an
assessment of the discharge process. The data collected revealed several barriers to an efficient
discharge process. After analyzing the data the team decided to focus on two primary issues to
bring improvements to the unit discharge process; unclear responsibilities of the unit team
members, and inconsistent team coordination of the discharge process.
Aim:
To promote the outcome of an organized and efficient discharge process for the patient, the
medical surgical unit team members aimed to:
1. Define or clarify team member roles and responsibilities in the discharge process, and
2. Develop a communication pathway for the team members to follow to coordinate continuity
and reduce time lapses in discharge steps.
Methods/Programs/Practices:
Initial data collection included:
1. Team Development of a process map to detail what the assumed process of discharge looks
like.
2. Direct observation of the discharge process by the CNL and two charge nurses to discover
the actual performance of the care team during discharge.
3. Phone call follow up to previous patients to collect feedback on their personal discharge
experience. Phone sample included all patients who provided any negative feedback on Press
Ganey survey.
30
Team analysis of the data identified two primary areas needing change. The team focused their
efforts to:
1. define the individual role responsibilities of the team members participating in
the discharge process; the primary RN, Charge Nurse, and the patient care technician (PCT)
and
2. develop a communication pathway process among the discharge team members to coordinate
efforts during discharge.
Practices:
The team produced two interventions to address the focus areas.
The first intervention was to define the roles of the charge nurse, the primary RN, and the PCT for
discharge processes. The second intervention was to create and implement a communication
pathway for the team members to follow during the discharge that helped coordinate the team and
produce an organized, efficient process.
The roll-out of the new interventions was carried out through staff education at staff meetings and
one-on-one in-services for the unit RNs and PCT. Charge nurses were introduced to the new
process separately so additional time could be invested in an effort to support the compliance of
the unit staff.
Outcome Data:
1.Post intervention patient follow-up calls were performed using the same inclusion criteria
utilized during the initial data collection. A reduction of patients who provided negative feedback
on Press Ganey surveys was noted. Overall an increase in patient satisfaction was noted on
follow-up calls.
2.Team members were surveyed via email and directly at staff meetings. The team members
provided positive feedback as to the new processes ease of use and the overall organization of the
new discharge process.
3.The post-intervention Press Ganey scores for Patient Discharge Information increased to meet
the unit target goals.
Conclusion:
The CNL skill set and role implementation supported unique methods of evaluating the medical
surgical unit microsystem discharge processes, analyzing the collected data, and implementing
interventions to directly address the identified needs. Discharge quality processes were improved.
The low Press Ganey scores that triggered this team to act have improved to meet unit goals. The
CNL facilitated improvements in a quick and efficient manner that involved all team members.
The project success and the medical surgical team's ability to maintain quality patient discharge
information outcomes over time is strengthened by the CNL's understanding of the microsystem
and ability to coordinate team efforts to improve patient care.
Abstract title: Interventions to Improve Staff Responsiveness and Patient Satisfaction through
Call Light Management and Purposeful Hourly Rounding.
Author Name & Credentials: Esther Gosdin MSN, RN
Institution: Texas Health Southwest Harris Hospital
31
City/ State: Ft. Worth, Texas
Primary Contact Email: [email protected]
Background Information
When patients are placed in a hospital bed there is one piece of equipment they feel is their
lifeline, the call light. As care providers, we even say things such as, ''If you need anything, just
press this button and we will be there,'' or ''If you start feeling worse, I want you to call me right
away!'' It is generally reported as a patient-satisfaction issue because it is one of the questions
most patient satisfaction surveys ask. Most nurses realize it is most definitely a quality-of-care
issue as well.
The number of patient call lights was calculated at on busy med-surg-telemetry unit for a one
week period and the results were that there were 1,750 calls. This averages to be 250 calls per
day. The highest volume of calls were received for reasons including request for repositioning,
proximity of frequently used items, request for restroom assistance, pain medication, RN/PCT,
and Intravenous pump alarm.
AIM
This project examines the effects of specific nursing strategies that affect patients’ perception of
staff responsiveness. Efforts were made to improve the Hospital Consumer Assessment of
Healthcare Providers and Systems Survey (HCAHPS) patient satisfaction scores related to staff
responsiveness.
The HCAHPS survey questions “During this hospital stay, after you pressed the call button, how
often did you get help as soon as you wanted it?” was identified by the hospital as the top
HCAHPS priority index items for improvement. The staff responsive questions that are asked by
HCAHPS include “During this hospital stay, after you pressed the call button, how often did you
get help as soon as you wanted it?” Choices to choose from include Always, Usually, Sometimes,
and Never. The term “Top box” is the most positive response to HCAHPS survey questions and
correlates with the response of "Always”. Performance targets at or above the 50th percentile is
average. The goal is at or above the 90th percentile. At THSW staff responsiveness measured
well below the desired level.
Methods/Programs/Practices
Implementation of staffing interventions include focused hourly rounding applying the 4 P’s
(pain, positioning, personal needs, placement) and AIDET (acknowledge, introduce, duration,
explanation, thank). Patients receive hourly rounds by the nurses and patient care technicians
(PCTs). The visits would be hourly unless more frequent visits are necessary. During the visit
the patient will be assessed for well-being; monitored for pain and comfort level; assisted to
reposition and/or to the bathroom if necessary, and checked to make sure the patient has easy
access to frequently used item. Staff members were instructed to perform specific behaviors,
using the acronym AIDET: Acknowledge the patient; Introduce and identify their role; Duration –
provide accurate time expectation for tests, physician visits, and tray delivery; Explain what will
occur throughout the day and leave contact information on the care boards that are in each
patient's room; and Thank the patient for choosing our hospital. The patients would be reminded
that visits will be hourly.
Volunteers assist during the busy times of the day to help with patient care issues such as
answering the telephone and/or letting the patient know that the nurse is aware of their request.
To endorse patient-centered care effectiveness of patient-initiated call light use and the efficiency
32
of staff’s responsiveness to call lights will be promoted. Regular on-the-job training of patient
safety-first practices with a focus on addressing patients’ call lights are recommended to raise
consensus and awareness of the importance of call light response among staff members.
Outcomes Data
Purposeful hourly rounding reduced the number of patient call lights and increased patient
satisfaction. Accidental calls decreased by 50 percent; request repositioning decreased by 97
percent; proximity decreased by 40 percent; request for bathroom assistance decreased by 31
percent; Request for RN/PCT decreased by 5 percent; request for pain med decreased by 15
percent; and IV assistance decreased by 21 percent. After calculating the number of patient call
lights it was found that the number of call lights was reduced by 18.7 percent. The number of
falls decreased from eight per quarter to two per quarter.
According to the Press Ganey survey question “During this hospital stay, after you pressed the
call button, how often did you get help as soon as you wanted it? the average percentage that
answered “always”s was 14.7 percent before implementing. After implementing the project the
percentage that answered always increased to 63.2 percent in a two month period.
Conclusion
Call Light Management that includes purposeful hourly rounding and AIDET is an effective tool
that will improve patient satisfaction and decrease patient calls. While falls have a tremendous
impact on the patient, they also directly affect a healthcare organization’s cost per case and length
of stay. The average hospital stay for patients who fall is 12.3 days longer, and injuries from falls
lead to a 61% increase in patient-care costs (Leyden, & Singleton, 2011).
Reference
Leyden, B. & Singleton, D. (2011). Introduction to supplement - Meeting the challenge of falls
reduction. American Nurse Today, 6(2).
Abstract title: Enhancing Medication Safety for Patients Regarding Side Effects of Newly
Prescribed Medications
Author Name & Credentials: Bethel S. Guk-Ong, MS, RN-BC, CNL, OCN
Institution: MD Anderson Cancer Center
City/State: Houston, Texas
Primary Contact Email: [email protected]
Background Information:
Providing consistent, patient centered education on medications can contribute to enhanced
patient safety and satisfaction. An opportunity was identified to improve the process of patient
33
education for new medications on an inpatient surgical urology and orthopedic unit. The process
of hardwiring nurse practice to consistently educate and document new medication teaching was
identified as an opportunity for improvement. High patient turnover rate as well as differing
communication styles and practices among the nursing staff contributed to inconsistencies in
patient education and documentation. Additionally, there was an opportunity for improvement in
Press Ganey patient satisfaction scores related to new medication teaching, as reflected in the
question: “Before giving you any new medicine, how often did hospital staff tell you what the
medicine was for?” A quality improvement initiative was implemented by the Clinical Nurse
Leaders (CNL) to address this practice gap and to improve patient satisfaction scores.
Aim:
The aim of this CNL-led quality improvement initiative was to improve consistency in nursing
practice, increase nurses’ knowledge and ability to educate patients and document new
medications teaching. A further aim was to improve patient satisfaction scores related to
medication teaching to the 90 percentile.
Methods/Programs/Practices:
The CNL developed and implemented a quality improvement initiative to hardwire consistent
practice related to new medication side effect teaching and documentation. The project began by
re-educating nurses’ about practice expectations and the resources available to support that
practice, as well as through demonstration of effective patient education by the CNL. Nurses
were mentored at the bedside by the CNL and direct observation was used to ensure consistent
practice. Nurses’ documentation of new medication teaching was monitored through a monthly
medical record audit for completion of the institution’s Inpatient Plan of Care Teaching Record
(IPOCTR). The CNL engaged nurse champions from the staff to assist in with these audits.
Inconsistencies in practice were addressed both individually with the nurse involved, as well as
through constructive dialogue with unit staff about barriers to successful practice. To address
reported staff barriers to successful practice the CNL developed enhanced education related to
overcoming these barriers and streamlined processes related to documentation that made the
process more accessible for nurses. Patient satisfaction scores were tracked through patient
responses to the Press Ganey survey question related to new medication teaching.
Outcome Data:
Although we were unable to achieve our patient satisfaction goal of 90% with new medication
teaching, the scores improved by 12% following implementation of this initiative. The medical
record audits for nurse documentation of patient teaching for new medication improved
significantly. The CNL identified a potential correlation between the medical record audit and
patient’s satisfaction scores. Nurses were successful in improving the consistency of their
documentation during the project implementation without requiring direct observation by the
CNL. The goal is to hardwire this practice on our surgical unit by continued monitoring for
compliance. There is evidenced that hardwiring of practice changes can take significant time, and
require continued reinforcement that may contribute to long-term success.
Conclusion:
Providing consistent education for patients regarding new medications may influence patient
satisfaction scores and safety in medication administration. CNLs are integral in hardwiring
practice through ongoing oversight and collaboration with nursing team. Acknowledging and
celebrating team successes is essential to reinforce and hardwire nursing practice, though it may
take time. This practice change can be adopted in any clinical setting.
34
Abstract title: Building And Leading A Team To Decrease t-PA Usage for PICC Line Clots
Author Name & Credentials: Joe Hafley MSN, RN, CCRN, CNL
Institution: Texas Health Resources
City/State: Ft. Worth, TX
Primary Contact Email: [email protected]
Background Information:
On September 1, 2012, Texas Health Resources (THR) Harris Methodist Fort Worth Hospital
(HMFW), a 731 bed Magnet award winning medical service facility, stopped using heparin
flushes due to the increased risk of Heparin Induced Thrombocytopenia. In the eight months
prior, Harris 6 (H6), an Acute Medical unit, administered only 33 doses of Alteplase (t-PA) to declot patient's Peripherally Inserted Central Catheter (PICC), an average of only 4.1 doses/month,
costing the unit approximately $418/month. During the month of September 2012, once heparin
flushes were no longer used, H6 administered 20 doses of t-PA to de-clot patient's PICC lines, a
400% increase. This was an increased cost of $1632 for this month alone. A clotted port is not
only expensive to treat, it also increases a patient's risk for infection, decreases patient
satisfaction, delays treatment times (i.e. IV anti-biotics, IV fluids, IV pain meds), and is
frustrating to the bedside RN.
Aim:
The initial aim of this project was to decrease the number of clots in the CNL's microsystem by
educating the staff, using evidence-based practices, on appropriate care of a PICC. However,
upon further assessment, several more problems surfaced. It was discovered that the
manufacturer of the brand of PICC currently being used at HMFW required flushes with Normal
Saline (NS) AND heparin. Therefore, when the hospital stopped using heparin flushes in
September 2012, the number of PICC clots increased dramatically. An additional problem
existed with HMFW's Central Line Policy; it lacked specific step-by-step instructions for the front
line nurses on the maintenance and care of a PICC. This policy was also confusing in regards to
the procedure of de-clotting a PICC when using t-PA. This presented a barrier for nursing staff,
therefore ports remained clotted. Many RNs expressed apprehension in the use of t-PA because
they believed it would thin their patient's blood and cause them to bleed. It was also ascertained
that this issue was not just a problem on H6, but also an issue throughout the entire hospital.
Methods/Programs/Practices:
In October 2012, key front line and managerial stakeholders were assembled by the CNL to form
an interdisciplinary team. The team members that were recruited included: two PICC RNs,
Director of Patient Safety, two Pharmacists, VP Chief Medical Officer, Manager of H6, two
Clinical Nurse Leaders, Nursing Educator, Nursing Informatics Specialist, and Director of
Nursing Med/Surg. An initial team meeting was held to discuss the problem of increased clots in
PICC lines, as evidenced by data collected by the CNL and Pharmacists. The interdisciplinary
35
team decided to discontinue use of the current PICC line and change to a catheter that required
only saline flushes. It was also decided that hospital wide education would be needed to instruct
the RNs on proper maintenance and care of the new PICC. A representative from the PICC
company was asked to give in-services to the RN staff on each unit for the new PICC. The CNL
and PICC Team revised HMFW's Central Line Policy utilizing evidence-based practice (EBP)
guidelines and a step-by-step format that was more user friendly for the RN staff.
Outcome Data:
A new PICC was ordered that required only NS flushes. In-services were provided by the
manufacturer representative on proper maintenance and care, which the CNL also reinforced to
the H6 staff over the next several months. The representative explained to the CNL not to expect
a decrease in clots over the next three to four months, due to the change in practice of flushing
technique and the new valved catheter. In the first four months of using the new catheter, t-PA
usage increased by 45%. It was surmised that this was due to the new found comfort level of RNs
on the de-clotting procedure, the CNL mentorship at the bedside with the t-PA procedure, the RN
staff's knowledge of the importance of de-clotting ports, and the new valved catheter. In the fifth
and sixth months, t-PA usage decreased by almost 50%.
THR began working on system wide policies for their 15 entities shortly after HMFW's policy
was updated by the CNL. The Central Line Policy that was revised by the CNL and PICC Team
was presented to the Professional Practice Council by the CNL. The THR Policy Administrator
requested assistance from the CNL on the system wide Central Line Policy due to the CNL's work
on implementing EBP into HMFW's policy. The THR system wide Central Line Policy was
revised at the corporate level in collaboration with the H6 CNL, based off of the CNL's revisions
made at the facility level.
Conclusion:
The CNL role impacts frontline nursing care not only at the microsystem level, but also at the
macrosystem level. Frontline caregivers experience problems with patient care processes every
day that often go unresolved. The CNL who is observant and diligent can dive deep to determine
the root cause of problems and facilitate change. A CNL who is resourceful knows who the key
stakeholders are to drive those changes, then builds the team to tackle those problems and
facilitates change to improve patient care at the point of care and beyond.
Abstract title: CNL Impact and Outcomes on a Psychiatric Medical Unit
Author Name & Credentials: Kevin Hengeveld MSN RN CNL
Institution: Mercy Health Saint Mary's Campus
City/State: Grand Rapids MI
Primary Contact Email: [email protected]
36
Background Information:
The Psychiatric Medical Unit is unique in the country as one of very few who care for patients
with acute psychiatric needs that also have acute medical needs up to a medical surgical level of
care. In 2010 the CNL role was introduced as part of a care model re-design. At that time the unit
had a high fall and restrictive measure rates and low patient satisfaction outcomes. It had
numerous transfers to higher level of care. Staff did not feel empowered and the culture was a top
down paternalistic approach.
Aim:
To demonstrate the impact of integrating the CNL role within the Triple Aim concepts - reduce
or maintain cost, improve clinical outcomes and improve service to patients.
Methods/Programs/Practices:
The care model changed in 2010 with the introduction of the CNL role. The nursing leadership
for the PMU now had a manager, shared a MSN prepared educator and CNL. Each role was
aligned to the new care model and to a vision of improving patient outcomes through evidenced
based practice. Using principles from the recovery model and concept of resilience were used to
reshape practice on the PMU. Just in time teaching, staff meetings and yearly competencies were
some of the vehicles for transmission. The focus became how to collaborate with patients, skill
building and emphasizing verbal de-escalation techniques.
Communication amongst the care team was improved through interdisciplinary rounds. The entire
team would discuss each patient answering questions as to why they were admitted, what
interventions were needed and where would they go when ready. Potential problems or power
struggles were also discussed and plans were made proactively.
Empowerment of the nursing staff was accomplished through emphasizing shared leadership
through the unit based council and self-scheduling. Through these avenues nursing leadership
sought to have frontline staff be involved and influence decisions on the unit
Outcome Data:
We have made significant movement in falls, restrictive measure. Falls decreased by 60% from
FY 2010 to FY 2013. Restrictive measures decreased 90% from FY 2010 to FY2013. Acute
medical transfers reduced by 77%. Culture of Safety overall score increased by 28%.
Patient satisfication results have improved over all. One specific question regarding feeling
included in decisions in care has improved 3.8% in one year and 7% in past 3 years.
Conclusion:
Having a nursing leadership team comprised of educator, manager and CNL provided the driver
to change the culture on the PMU. The CNL added a systems point of view along with leadership
dynamics to move culture and barriers. This model would be applicable in any setting. We are
still on the journey to include our patients better. We are learning different skills to accomplish
this then ones used in the past.
Abstract title: Incorporating the CNL within a Health Plan: The Possibilities and Potentials are
Limitless
Author Name & Credentials: Rose L. Hoffmann PhD, RN, CNL
Institution: University of Pittsburgh
City/State: Pittsburgh PA
Primary Contact Email: [email protected]
37
Background Information:
The CNL is a leader within the healthcare team and functions across all systems, not specifically
acute care. This individual assumes accountability for healthcare outcomes and coordinates care
by the health care team. Although the majority of CNLs practice in an acute care setting, the need
for clinical opportunities in nontraditional healthcare settings that showcase the role functions of
the CNL and their impact on safety, quality and improved patient outcomes is needed.
Aim:
The aim of the clinical practicum is to provide nontraditional opportunities for CNL students that
complement the role functions as described in the White Paper on the Education and Role of the
CNL. In addition, CNL students work alongside stakeholders in a health plan to showcase the
role, knowledge and career opportunities where a CNL may function.
Methods/Programs/Practices:
Working with stakeholders within an integrated global health enterprise, a four week rotation in a
health plan network was created. Students who reside within the metropolitan area of the health
plan complete this rotation during the course Contemporary Issues in Nursing and the CNL role
seminar. This 60 hour clinical practicum included hands on experiences in telephonic counseling
and care coordination for a specific cohort of outpatients. Students participate in interprofessional
team meetings that focus on optional discharge planning for acute care patients. In addition each
CNL student participates in a systems review for a cohort of patients within the health plan to
identify risks and develops strategies that improve specific healthcare outcomes within one of the
following areas (1) decrease readmissions (2) improve access or (3) promote continuity of care.
This data is shared with students in subsequent terms to enhance continuation of research
findings.
Outcome Data:
Qualitative data from both students and stakeholders within the health plan reveal the following
themes: (1) information manager in relation to identification of specific populations served by the
health plan that could benefit from outreach strategies (2) team manager to augment
interprofessional communication between the various healthteam members in the health plan, (3)
outcome manager to incorporate evidence-based practice strategies that improve patient outcomes
and satisfaction post discharge and (4) educator for patients and stakeholders. Furthermore,
information gleamed from the clinical practicum, such as reimbursement and financial incentives
for health team members can be transferred to future employment opportunities upon graduation.
Conclusion:
This non traditional clinical practicum experience proved beneficial for both CNL students and
stakeholders in a health plan. This experience will become a standard clinical practicum for
students residing in the metropolitan area. Projects which extend over several terms will be
created that share student learning in subsequent terms, provide continuity of care for patients
served by the health plan and reinforce the shared roles between stakeholders employed by the
health plan and the CNL.
38
Abstract title: Performance Improvement for Surgical Care Improvement Project with
Incorporation of Post-Operative Daily Rounding Tool
Author Name & Credentials: Brandon Hunter, RN, MSN, CNL
Institution: Carolinas Medical Center
City/State: Charlotte, NC
Primary Contact Email: [email protected]
Background Information:
The Surgical Care Improvement Project (SCIP) is a core measure that effects institutional
reimbursement from Centers for Medicare & Medicaid Services (CMS). It is comprised of nine
quality indicators for specific adult surgical populations that must be met in order to be compliant
to government regulations and thus retain full reimbursement per Value Based Purchasing. In
2012, Carolinas Medical Center (CMC) had demonstrated weak performance for SCIP with an
overall 2012 Appropriate Care Score of 89.54%. In 2013, the goal was set at 97% in order to
break even for Value Base Purchasing. Difficulties in CMC's performance have been related to
the deployment of Computerized Physcian Order Entry, being an academic medical center which
requires educating of new residents, and higher acuity patients with more complex procedures.
Fragmented interventions had been attempted by various departments, but no processes were
effective to help increase scores.
Aim:
Increase Appropriate Care Score for SCIP to an annual average of 97% using a standardized of
daily rounding tool to identify appropriate general surgery patient populations and track specific
quality indicators for improvement. Bring awareness of the SCIP initiative to physicians and
nurses regarding quality indicators and documentation requirements of CMS.
Methods/Programs/Practices:
A rounding tool was created for a post-operative surgical floor to track specific quality indicators
pertinent to SCIP, including foley catheter discontinuation, antibiotic discontinuation, beta
blocker administration, and VTE prophylaxis administration. This tool was developed to bring
about a systematic approach to managing patients on a daily basis, including patients that transfer
from higher acuity units. The tool assisted the Clinical Nurse Leaders in following these specific
patients through post-operative day one and day two. Beginning in early February 2013, each
new surgical patient's chart was reviewed and quality indicators for SCIP were documented to a
flow sheet that could be reviewed through the first two post-operative days for improved
performance to CMS guidelines. The primary nurse was made aware of any specific indicators
that could be considered a fallout if not addressed in a timely manner. Physcians were notified
about patients that were not currently meeting the SCIP measure due to improper documentation
regarding foley catheter or extended antibiotic infusion, exclusion of beta blockers or proper
prophylaxis, and re-ordering of antibiotics within 48 hours of surgery. Communication to the
primary nurse and physician was vital to make sure orders and documentation were completed to
be consistent with CMS guidelines.
Outcome Data:
Currently, the SCIP Appropriate Care Score for 2013 is at 94.83%. The rounding tool assisted in
narrowing variation in month to month scores. Post operative general surgery SCIP fallouts,
39
excluding operating room and pre-operative specific measures, totaled 24 over a six month span
for 2012, comapred to 9 for the same time frame in 2013; a 63% improvement. The most
significant improvement has been with VTE prophylaxis and urinary catheters. VTE 2012
fallouts totaled 13 compared to current 2013 fallout of 2; an 85% improvement. Foley catheter
2012 fallout totaled 7 compared to current 2013 fallout of 4; a 43% improvement. Beta blocker
improved by 50%, but the percentage is due to only 2 fallouts for 2012 and 1 for 2013 in the
months of February - July. Antibiotic extension is currently at a zero change with 2 fallouts for
2012 and 2013.
Conclusion:
The daily rounding tool is a standardized approach that makes tracking post-operative patients
effective and simple when monitoring quality indicators for SCIP core measures. This serves as a
model for utilizing mastered prepared nursing to educate and empower nurses for quality
improvement processes. Improved performance in quality indicators for SCIP in the general
surgery population provides evidence that a post-operative rounding tool would be effective for
other units that encounter surgical patients. Increased reliability in meeting these measures along
with continued education will assist CMC in achieving a 97% Appropriate Care Score on a
consistent basis. Further enhancements can be made in this process with the incorporation of an
electronic-based program that can assist in tracking quality indicators for SCIP.
Abstract title: Toward a More Patient Centered Plan of Care
Author Name & Credentials: Jo Ellen Inman-Puckett, RN, MBA, MSN, CNL. CMSRN
Institution: Carolinas Medical Center
City/State: Charlotte, NC
Primary Contact Email: [email protected]
Background Information:
A patient-centered model of nursing care is a component of what the quality health care, according to the
Institute of Medicine (IOM, 2001). The IOM included patient preferences, values, and needs for
information as critical factors in guiding care. In 1984 the World Health Organization (WHO) stated that
there is a ‘need to reinforce the values of solidarity, equity and human rights, while recognizing the rights
of individuals to freedom of choice, participation and dignity’ (World Health Organization [WHO], 1984,
para. 13). These fundamental rights lead to the importance of the right of each individual, healthy or
unhealthy, to participate in care on his or her own terms. WHO states that patients should receive
information and that patient. The international code of ethics for nurses outlines nurses’ duty to provide
individuals with adequate information on which to base consent for care, as well as promoting an
environment in which human rights are respected (The International Council of Nurses [ICN],2000.
Patient-centered care (PCC) involves a widespread approach in which patient care is personalized in an
effort to meet the patient’s preferences, values, and information needs. Attree 2001, and Larrabee &
Bolden, 2001 reported that patients believe their care to be of high quality if it considered their needs and
values. Possible benefits due to increased PCC include increased patient satisfaction with care and
improved functioning (Staniszewska & Ahmed, 1999).
40
Aim:
Clinical Nurse Leaders (CNLs) are uniquely situated to successfully improve patient participation in their
Interdisciplinary Plan of Care (IPOC) due to their advanced education in physiological sciences and
leadership in initiating, developing, and maintaining change in practice. The purpose of this practice
change project was to determine the extent to which the CNL can improve PCC by increasing the
participation and awareness of the patient in the IPOC process. The goal was the improvement of the
quality of the IPOC and thus, the quality of care for the patient being cared for on a post-surgical acute
care unit.
Methods/Programs/Practices:
Interdisciplinary care planning is both a mandated clinical process and a mandated written document.
Complex acute patient needs require the coordination and problem-solving approach from an
interdisciplinary process involving patient assessment, planning, intervention implementation, and
evaluation of the intervention. This method of planning and delivering care has been historically known as
the nursing process (American Nurses’ Association, 2004). Not only is there a mandate to plan and
document the IPOC, but the patient and the family are to be included in the process. If documentation and
use of the IPOC is less than optimal, actual patient and family involvement is even more dismal. An
informal questioning of nurses on our post-surgical unit revealed less than 5% compliance regarding
inclusion of the patient or family with the IPOC process. Audited compliance with IPOC documentation
on the same unit recently revealed 46% utilization of IPOC on patient charts
Watson’s theory of caring provides the theoretical framework for this proposed practice change. The
theory of caring science focuses on the benefits of an authentic relationship between the nurse and the
patient. The interaction between the nurse and the patient during the nursing process provides an
opportunity to translate caring in a sacred and non-judgmental manner, while promoting healing and
wholeness. In an environment where love and caring are the most sacred values, any interaction put forth
out of love and involving caring, such as the transpersonal relationship created during the IPOC process,
will also be sacred.
Outcome Data:
The mean rating on nursing communication with the patient was tabulated for the patients in the first four
weeks (the control group) and the second four weeks (the intervention group). The same mean rating was
computed for satisfaction of nursing care for both groups. An independent t-test was used to compare the
pre and post intervention scores. The data revealed a mean score of 4.89 (+ or -1.49) for the group polled
in June, without the IPOC supplied to the patient. The mean score for the July patients was 5.31 (+ or 1.76). The t-value for a one tailed test was -2.31 (p < .05), indicating a statistically significant difference
between the mean scores of the two groups. This supports the rejection of the null hypothesis that the
different scores were by chance; indeed the intervention, the IPOC at bedside, was a likely cause for the
rise in patient satisfaction with nursing quality and communication. Providing a copy of a patient’s IPOC
to the patient involves the patient with their own plan of care. It brings the patient into an active role with
their care plan. The result is an increased satisfaction with nursing communication and an increased
perceived quality of nursing care. By providing the patient with the current documentation, a dialogue with
shared accountability is initiated. Bedside CNLs should consider reviewing this information during their
rounding with the patients in their microsystems.
Conclusion:
Respect for a patient’s beliefs and values are a basis for obtaining patient participation in planning and
performing nursing care. "Respect encompasses communication, whereby information is provided not only
as a basis for decision making, but also because it is an important factor in trust between health care
professionals and patients" (Ehnfors et al., 2006, p. 511). Ehnfors and colleagues added that patients with
confidence and trust in their providers are more likely to have higher levels of satisfaction with their
healthcare providers. The interaction between the patient and the nurse is an opportunity not only to
provide education, but to earn trust and collaborate in a sacred environment.
41
References
:
American Nurses’ Association. (2004). Nursing: Scope and standards of practice (White Paper).
Washington, DC: American Nurses’ Association.
Attree, M. (2001). Patients’ and relatives’ experiences and perspectives of “good” and “not so good”
quality care. Journal of Advanced Nursing, 33(4), 456-466.
Bernsten, K. J. (2006). Implementation of patient centeredness to enhance patient safety. Journal of
Nursing Care Quality, 21(1), 15 - 19.
Ehnfors, M., Ekman, I., & Eldh, A. C. (2006, September). Conditions for Patient Participation and NonParticipation in Health Care. Nursing Ethics, 13(), 503 -514. doi: Retrieved from
Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academy Press.
Jansson, I., Pilhammar-Andersson, E., & Forsberg, A. (2009, March 24). Evaluation of documented
nursing care plans by the use of nursing-sensitive outcome indicators. Journal of Evaluation in
Clinical Practice, 16, 611 - 618. doi: 10.1111/j.1365-2753.2009.01233x
Larabee, J. H., & Bolden, L. V. (2001). Developing patient-perceived quality of nursing care. Journal of
Nursing Care Quality, 16(1), 34-60.
Lauver, D. R., Ward, S. E., Heidrich, S. M., Keller, M. L., Bowers, B. J., Brennen, P. F., Wells, T. J.
(2002). Patient-centered interventions. Research in Nursing & Health, 25, 246 - 255.
Mead, N., & Bower, P. (2000). Patient centeredness: A conceptual framework and review of the empirical
literature. Social Science & Medicine, 51, 1087-1110.
Schoot, T., Proot, I., Ter Meulen, R., & De Witte, L. (2005). Actual interaction and client centeredness in
home care. Clinical Nursing Research, 14(4), 370-393. doi: 10.11771054773805280093
Shea, H. L. (1986). A conceptual framework to study the use of nursing care plans. International Journal
of Nursing Studies, 23, 147-157.
Staniszewska, S., & Ahmed, L. (1999). The concepts of expectation and satisfaction: do they capture the
way patients evaluate their care?. Journal of Advanced Nursing, 29(2), 364-372.
Stewart, M., Brown, J. B., Meredith, L., & Galajda, J. (2000). The impact of patient-centered care on
outcomes. Journal of Family Practice, 49(9), 796-804.
The International Council of Nurses. (2000). The ICN code of ethics for nurses (Policy brief). Retrieved
from http://www.icn.ch/icncode.pdf:
Wensing, M., & Grol, R. (2000). Patients’ view on health care: A driving force for improvement in disease
management. Disease Management & Health Outcomes, 7, 117-126.
Abstract title: Implementing a Clinical Nurse Leader Program: We can't afford not to!
Author Name & Credentials: Mary Irvin, MSN, MBA, NEA-BC & Kathy Oliphant, MSN, RN
Institution: TriHealth
City/State: Cincinnati, Ohio
Primary Contact Email: [email protected]
Background Information:
42
The timing is right to improve the value of care by improving patient outcomes which will then
lead to lower overall costs. With healthcare reimbursement based on performance of quality of
care indicators and core measures, there is a need for more effective clinical problem solving and
better coordination and continuity at the point of care. The Clinical Nurse Leader (CNL) role is
designed to eliminate fragmentation of care and to rapidly implement best practices.
Aim:
The goal of integrating a CNL on all inpatient nursing units is to positively impact patient
outcomes as evidenced by improvements in quality and satisfaction scores and decreasing cost
within an appropriate length of stay (LOS). The CNL should promote nursing staff development,
enhance physician-nurse relationships, and improve patient satisfaction. Role integration with
care managers and social workers was crucial to create a team approach concerning coordination
of care for patients at all levels of complexity and risk. Collaboration and communication with
nurse navigators assures continuity of care across the continuum.
Methods/Programs/Practices:
Pre-Implementation:
• Create organizational charter to present the business case for CNL role.
• Communicate change to leadership (utilized existing FTEs for pilot CNL positions).
• Obtain approval for care delivery model change.
• Analyze key interfacing roles such as nurse manager, staff nurse, clinical nurse
specialist, and charge nurse.
• Assemble interdisciplinary team for the macrosystem education and strategic planning.
• Identify pilot units.
• Hire pilot CNL positions (at two hospitals in 8/2012).
• Orient CNL to framework of new role: develop strategies to implement evidenced based
practices and determine outcomes related to quality, satisfaction, innovation, and cost
avoidance.
• Create dashboard to monitor trends on each unit.
• Define cohort of patients for specific units.
• Determine reporting structure.
• Complete microsystem assessment.
Implementation:
• Implement day to day processes and arrange ongoing meetings with leadership to
further refine the details of the role.
• Engage tracking and dashboard utilization to facilitate ongoing improvement processes
with physicians and team.
• Disseminate results of CNL implementation to microsystem team.
• Modify practices and protocols according to desired outcomes.
• Communicate outcomes at executive leadership meetings.
Outcome Data:
Following a successful CNL pilot program, there were not enough qualified CNLs available to
roll out the program to all nursing units, so a cohort program was designed with a local college.
15 new positions were created with similar CNL job responsibilities titled "Clinical Outcomes
Nurse" for candidates in the MSN-CNL cohort program; these FTEs will be transitioned to CNL
positions following graduation and certification.
Conclusion:
43
The CNL puts best practices into action by collaborating with nurses, providers, and the entire
healthcare team to improve patient outcomes. This proactive, integrative approach utilizes data
trends and evidenced-based practices to engage bedside nurses to improve care.
Abstract title: Cost Benefit Analysis of Employing a CNL on a Medical Surgical Unit in
Arkansas
Author Name & Credentials: Kerry Jordan RN, MSN, CNL: Laura Hall RN, MSN, CNL
Institution: University of Central Arkansas
City/State: Conway, Arkansas
Primary Contact Email: [email protected]
Instructions: Please complete each of the following sections, when applicable. Each section
should contain between 50 and 250 words, using Times New Roman, 12 point font.
Background Information:
Growing numbers of Clinical Nurse Leaders (CNLs) across the United States are impacting safety
and quality of healthcare systems. However, because of the small number of CNLs in Arkansas,
their value is not well known.
Aim:
The purpose of this limited cost benefit analysis was to apprise Arkansas stakeholders of the
financial value of employing a CNL on a medical surgical unit in an Arkansas hospital.
Methods/Programs/Practices:
Researchers collected and analyzed data from an 18 bed medical surgical unit in a non-profit
hospital in Arkansas. Costs and benefits were calculated based on the data.
Costs: After reviewing current role description of unit personnel it was determined that the
Admission/Discharge RN position on the unit overlapped with the CNL role. Consequently
researchers recommended that the Admission/Discharge RN position be converted to a CNL
position. Calculated costs for converting the role included: 1) Tuition and book fees for two years
of CNL education at a local university totaling $13,054 over a two year period. 2) A salary
increase of $10,400/annum for the position over a five-year period. Salary costs included a 1.7%
annual cost of living increase and an annual discounted rate of 3%.
Benefits: Unit data revealed higher than average rates for falls and CAUTIs for 2012. Benefits
were calculated based on potential reduction of those rates, along with potential savings from
decreased RN turnover rates. The unit experienced 20 falls in 2012 (rate 3.91/1000 patient days).
Research indicates that CNL initiatives can result in a 50% decline in fall rates. This would
decrease fall rates on the unit by 10 falls/ann. On average, 30% of falls result in injury (Reid &
Dennison, 2011) and falls with injury cost $13,316/fall (Wong, Bolini & Dunagan, 2011).
Consequently, CNLs could save the unit 3 (number of estimated falls with injury prevented) x
$13,316/ann or $39,948/ann. The unit experienced 5 CAUTIs (rate .978/1000 patient days) in
44
2012, which was higher than hospital and national rates. Using data from two previous studies,
Scott (2009) estimated 2007 CAUTI costs, to be on average $935 per incident. Based on outcome
data from several hospitals, it is estimated that employing a CNL on the unit could decrease
CAUTI incidence to 0, which represents a savings of 5 X $935 per year or $4673/ann. RN
turnover rates on the unit for 2012 averaged 1.33/ann. The financial cost of losing a single nurse
has been calculated to equal twice the nurse’s annual salary (Atencio, Cohen, & Gorenberg,
2003). Average RN nursing salary at the study hospital is approximately $46,800. It is estimated
that the cost of losing one RN would be $46,800X2 or $93,600. Studies have documented
decreased staff turnover rates of 10% after CNL implementation (Stanley, Gannon, & Gabuat,
2008). Based on these outcomes, a decrease in nursing staff turnover rate by 10% would mean a
$12,448/ann savings to the unit. Cost benefits of decreased falls, CAUTIS, and RN turnover rate,
were summed for years 3-5 using a discount rate of 3%.
Outcome Data:
Total cost of CNL education and employment on the unit over a five year period equaled
$42,200. Total benefits of employing a CNL equaled $152,092. Calculated benefits only included
a limited number of benefits described above. The resultant cost/benefit ratio was 3.6.
Conclusion:
CNLs are contributing to improved quality of care across the country. This limited cost/benefit
analysis on a mediical/surgical unit in Arkansas demonstrates that employing a CNL would be
well worth the investment
Abstract title: Examining the application of the CNL skill set in diverse practice roles
Author Name & Credentials: Kristen Noles, MSN, RN,CNL; Emily Simmons, MSN, RN,
CNL; Velinda Block, DNP, RN; David James, DNP, RN, CCRN, CCNS; Angela Jukkala, PhD,
RN
Institution: University of Alabama at Birmingham Hospital and UAB School of Nursing
City/State: Birmingham, Alabama
Primary Contact Email: [email protected]
Background Information:
Ten years ago, in response to the growing concern over patient safety, quality, and health care
outcomes, the American Association of Colleges of Nursing (AACN), created the role of the
Clinical Nurse Leader (CNL). However a recent survey indicates that quality and safety problems
persist despite focused efforts. Though the CNL role was developed to improve care within the
microsystem, the pilot implementation within our organization’s (large academic health center)
resulted in role ambiguity, increased cost, and lack of quantifiable measures of influence. As a
result, nurse leaders examined how the CNL skill set could be utilized in non-traditional CNL
roles across the macrosystem to positively impact quality and safety. Through utilizing the CNL
45
at the macrosystem and microsystem levels, the benefit of the CNL in the practice setting is now
being recognized.
Aim:
The aim of this project is to demonstrate how the CNL skill set is utilized in various practice roles
at the macrosystem and microsystem level to improve organizational outcomes.
Methods/Programs/Practices:
Macrosystem: Two key roles within the organization highlight the impact of the CNL skill set at
the macrosystem level. The leader of our organization’s shared governance model (Nursing
Practice Congress) and the coordinator for organization’s Geriatric Scholar Program are both
certified as CNLs. As the chair of the Nursing Practice Congress, one CNL utilized expertise in
communication; information and healthcare technologies; ethics; healthcare systems and policies
to build effective interprofessional teams to improve quality and safety. These nurse driven teams
identified, examined, and improved nursing practice across the 1,000+ bed hospital. As
coordinator for the Geriatric Scholar Program, the CNL utilized key CNL competencies such as
critical thinking; assessment; and health promotion to identify and implement evidenced base
practices mentorship of unit based interprofessional teams.
Microsystem: By working at the macrosystem both the NPC chair and GSP coordinator were able
to assess various microsystems throughout the organization to determine readiness for practice
change. With these insights, the CNLs were able to mentor their respective microsystem based
teams to address anticipated barriers to their projects. Highlighted projects include the
implementation and standardization of turning schedules for pressure ulcer prevention;
standardization for room cleanliness audits for compliance with CDC guidelines; and the
development and implementation for functional assessments for geriatric patients across the
organization. All projects valued from the unique , connections and knowledge of the greater
healthcare system gained from the CNLs working at the macrosystem level.
Diverse Practice Roles: Within our organization, the diverse skill set of the CNL has supported
their successful practice in diverse roles across the organization including Advanced Nursing
Coordinator; Assistant Nurse Manager, Case Manager, Unit Educator, and Nurse Manager.
Within our region, CNLs are practicing in diverse roles providing professional services to ensure
lateral and vertical integration of care for at risk populations.
Outcome Data:
The outcomes of the CNLs are realized in microsystems across the organization. For example,
during its first three years the NPC has addressed 47 practice issues; chartered 44 work teams,
and spearheaded 31 house-wide clinical practice changes with over 35 different disciplines
involved. Over the past two years, the GSP has implemented 9 quality improvement projects
across 17 clinical microsystems. A total of 27 scholars have been mentored in both the geriatric
care and the science of quality improvement. To date, 4 projects have been presented at national
conferences and 2 have been implemented as house wide initiatives.
Conclusion:
The outcomes of the CNLs are realized in microsystems across the organization. For example,
during its first three years the NPC has addressed 47 practice issues; chartered 44 work teams,
and spearheaded 31 house-wide clinical practice changes with over 35 different disciplines
involved. Over the past two years, the GSP has implemented 9 quality improvement projects
across 17 clinical microsystems. A total of 27 scholars have been mentored in both the geriatric
46
care and the science of quality improvement. To date, 4 projects have been presented at national
conferences and 2 have been implemented as house wide initiatives.
Abstract title: Continuity of Care: A Community Collaborative
Author Name & Credentials: Catherine Lauridsen BSN, RN, CNL student
Institution: Shawnee Mission Medical Center
City/State: Shawnee Mission, KS, 66204
Primary Contact Email: [email protected]
Background Information:
Community collaboration that includes patient engagement is a priority in the redesigned health
care system. Reducing avoidable hospital readmissions and improving the efficiency and
effectiveness of patient care across the health care continuum requires a focused effort between
health care providers. Initiated by Shawnee Mission Medical Center, a Continuity of Care
Collaborative was formed using the Triple Aim. This community collaboration along with
implementing the role of the Transition Care Coordinator brought value to health care for
patients, hospitals, and communities by increasing patient engagement, improving transitions in
care and reducing 30-day hospital readmission rates.
Aim:
To better coordinate health care and improve patient engagement by forming a Continuity of Care
Collaborative along with implementing the role of Transition Care Coordinator, adding value to
health care for the patient, hospital and our community by reducing 30-day hospital readmission
rates.
Methods/Programs/Practices:
1.
A Continuity of Care Collaboration was established in 2011, along with instituting the role
of the Transition Care Coordinator. The Transition Care Coordinator's responsibilities include:
identification of patients that are at high risk for hospital readmissions; membership on the
multidisciplinary patient care team within the hospital; coordination of patient care with postdischarge health care providers; health care coach and care coordinator for patients and families;
and educator for hospital staff and area care facilities regarding patient care. The Transition Care
Coordinator follows patients between 30 to 45 days after discharge and works closely with
multidisciplinary health care providers to deliver quality outcomes in care, as well as maintaining
a coaching relationship to increase patient engagement.
2.
A Continuity of Care Collaborative was created among a wide range of area care
providers, including skilled nursing, hospice, private duty agencies, long term care, long term
acute, and rehab hospitals, as well as emergency service providers. This collaborative meets
47
monthly, breaking down barriers between health care providers and works to reduce avoidable
hospital readmissions while improving patient transitions in care.
Outcome Data:
From 2011 to 2012, 30-day all cause Medicare readmission rates dropped for CHF 22.91% to
16.5% (28% decrease), PNA 16.5% to 13.1% (21% decrease) and AMI 19.8% to 10.1% (49%
decrease). January through July 2013 Medicare 30-day all cause readmission rates for patients 65
years and older are: CHF 12%, PNA 11% and AMI 9%. CMS readmission penalties dropped
from .43% in 2013 to .22% in 2014.
Conclusion:
With the coordination of care initiatives enacted by the Continuity of Care Collaborative along
with the implementation of the Transition Care Coordinator, Shawnee Mission Medical reduced
the 30-day all cause readmission rates for Medicare patients with congestive heart failure,
pneumonia and acute myocardial infarction in the year 2012. This model enhances lateral
integration of care for patients, with the aim of improving efficiency and effectiveness across the
health care continuum. Our community's collaborative efforts continue to expand, with a focus
on finding innovative approaches to enhance patient engagement and improve transitions in care,
adding value for patients, hospitals and communities.
Abstract title: Meeting the needs of a geriatric-specific, acute care CNL cohort
Author Name & Credentials: Katie Lutz MSN, RN, CNL, PHN
Institution: Veterans Administration
City/State: Palo Alo, CA
Primary Contact Email: [email protected]
Background Information:
What began as an inquiry into the use of physical restraints on a medicine-oncology-telemetry
unit led to the identification of a high risk acute care population: patients over the age of 65 at
high risk for the development of negative patient outcomes such as the development of geriatric
syndromes (delirium, falls, incontinence, frailty), readmission, and institutionalization. Initial data
showed 72% of patients placed in restraints had a diagnosis of dementia, delirium, or delirium
superimposed on dementia. Other observations led to interventions focused on long term
hospitalization related to conservatorship and readmissions due to end of life or delirium-related
behavioral symptoms.
Aim:
48
To prevent functional and cognitive decline throughout hospitalization, provide health literate
discharge instructions, and promote advance care planning strategies for patients meeting CNL
cohort criteria.
Methods/Programs/Practices:
-Using Hartford Institute for Geriatric Nursing's evidenced-based assessment tools, each patient in
the cohort receives a thorough assessment. Based on applicability, the assessment consists of a
Katz Index of ADL, Lawton IADL scale, Mini-Cog, MMSE, Geriatric Depression Scale,
Confusion Assessment Method, Falls Risk Assessment, Hospital Admission Risk Profile, and
Transitional Care Model. Ordered medications are verified against the BEERS criteria for
appropriateness.
-Once assessed, the CNL participates in care coordination and lateral integration with the
following services: Medicine, Case Management, Social Work, Neuropsychology, Intermediate
Intensive Care Unit, and the Geriatric Research Education Clinical Center (GRECC).
-A CNL templated note was created with all of the assessments above including a palliative care
assessment.
-An After Hospital Care Plan- a Project Red readmission tool for health literacy- is created and
delivered to the patient and family
-A therapeutic activities cart was created to provide diversional activities for hospitalized
dementia patients
-An interdisciplinary task force was brought together for the creation of a delirium protocol. The
protocol will consist of an order set, EBP interventions, SBAR communication during transitions
of care, and, documentation on the problem list (In progress).
-Altogether seven staff nurses were identified and currently are working towards the ANCC's
gerontological certification. In collaboration with the healthcare system's extended care service,
the acute care staff nurses will attend a two-day educational program which prepares the student
for the exam.
Future endeavors to enhance the delivery of care for our geriatric population:
-Conversion of term and concept of "sitter" to caregiver based on a dementia/delirium protocol
-Music in medicine
-CNL committee to link cohorts between microsystems
Outcome Data:
-Though in its infancy (2.5 months), the cohort consists of 25 patients, only one of which has
been readmitted.
Conclusion:
What began as an observation of a geriatric and often frail, elderly patient population and the
increasing incidence of physical restraint use, delirium, and falls has evolved a structured,
evidence-based intervention for the purpose of enhancing patient safety, quality of life, staff
knowledge base, and hospital resources. The CNL cohort comes at a time when the issue of an
aging population is gaining national and global attention. With this attention, our geriatric patients
will be recognized for what they represent- a patient population with complex needs. By virtue of
preventing and reducing the incidence of geriatric syndromes and ensuring a safe discharge home,
the intervention has the potential to reduce morbidity and mortality.
49
Abstract title: Resilience and Transition to Practice in Model C CNL Graduates
Author Name & Credentials: Geralyn Meyer, PHD, RN, CNE, CNL & Bobbi Shatto, MSN,
RN, CNL
Institution: Saint Louis University School of Nursing
City/State: St. Louis, MO 63104
Primary Contact Email: [email protected]
Background Information:
The health care environment has been described as chaotic; complicated by staff nurse reports of
short staffing, heavy workloads and compromised quality of care (Roberts, Jones & Lynn, 2004),
The literature states that the most stressful and challenging time for new nursing graduates is the
first few months of practice when they are transitioning from the student role to that of registered
nurse. In 2004, Casey, Fink, Krugman & Propst found that the median turnover rates for graduate
nurses during their first year of employment ranges from 38%-61%. With the cost of orientation
for a graduate nurse being $44,000 to $80,000 (American Association of Nurse Executives, 2010)
it is critical that factors of successful transition be addressed.
It may be that resilience is a factor that can facilitate successful transition. Resilience is defined
as the “ability of an individual to adjust to adversity, maintain equilibrium, retain some sense of
control over their environment and continue to move on in a positive manner” (Jackson, Firtko &
Edenborough, 2007, p. 3). In studies of baccalaureate prepared acute care nurses (Hodges,
Keeley & Troyan, 2008; Hodges, Troyan & Keeley, 2009), operating room nurses (Gillespie,
Chaboyer, Wallis, & Grimbee, 2007; Gillespie, Chaboyer, & Wallis, 2009) and psychiatric
nurses (Matos, Neushotz, Griffin, and Fitzpatrick, 2010), resilience has been shown to impact job
satisfaction and career persistence. No studies were found that looked at the resilience of new
graduate nurses and how this characteristic related to their transition to practice
Aim:
The aim of this study is to examine the relationship between resilience and transition to practice
in three cohorts of Model C CNL graduates from a Midwestern university. Data obtained from
the initial cohort will be presented.
Specific research questions were:
•What factors are associated with differences in the resilience level of new nursing graduates?
•Is increased resiliency associated with a more positive transition to practice?
•Does positive transition to practice increase resiliency?
Methods/Programs/Practices:
An e-mailed survey was used in a repeated measures design. Participants were surveyed at
graduation and 3, 6 and 12 months post graduation. The 25 item Resilience Scale (Wagnild &
50
Young, 1993) was used to measure resilience. The Casey-Fink Graduate Nurse Experience
Survey (1999) was used to obtain data on transition to practice.
Outcome Data:
The initial cohort of Model C CNL graduates consisted of 22 people, 20 of whom were female.
The average age was 29.71 years (SD 9.03). Initial data analysis indicates that this first cohort of
Model C CNL graduates had moderately high resilience at graduation. Further analysis of data is
on-going and will examine factors associated with resilience and transition to practice.
Conclusion:
An impetus for the CNL movement was the need for nursing leadership at the bedside. If CNL
education for Model C students is to fulfill this promise it will be necessary to assist these
graduates in developing the tools that will enable them to positively transition to practice so that
they are more inclined to stay at the bedside. Resilience may be one such tool.
Abstract title: Financial Readiness: Building a Business Case for the Clinical Nurse Leader Role
Author Name & Credentials: Penny Moore Ph.D., RN, CNL
Institution: Texas Christian University
City/State: Ft. Worth, TX
Primary Contact Email: [email protected]
Background Information:
McGlynn, Asch, Adams et al.(2003) suggest the absence of a business case is a significant reason
health care organizations do not implement quality projects despite research documenting their
effectiveness. Those charged with maintaining the financial health of an entity are most
concerned about the monetary impact of a new program in the current budget year ((United States
Department of Veterans Affairs, 2004). The business case will be one tool to develop
implementation readiness. Leadership readiness at all levels was found to potentially present a
gap and requires careful planning to address all pertinent issues and questions (Giniat, Benton,
Biegansky, & Grossman, 2012).
Aim:
The purpose of this presentation is to provide specific steps to be followed when developing a
business case
Methods/Programs/Practices:
The essential components of a solid business case for implementing the Clinical Nurse Leader
role is the center of this poster. A checklist is offered to provide content and organization that can
facilitate your presentation to financial stakeholders. Specific examples of Clinical Nurse Leader
initiated projects with financial implications such as reduced length of stay, decreased
readmission rates, increased patient satisfaction, and fewer adverse events are shared. Costs and
51
benefits, in both the short and long term, are explored. Be prepared to answer the question, “Does
implementing the Clinical Nurse Leader role yield a return on investment?” Specific methods to
be prepare to have this conversation are included. A well prepared nurse could increase the
probability of successful implementation. The technique (steps) presented can be easily adapted
to the implementation of other projects that nursing champions.
Outcome Data:
This is not a research study. The business case suggestions provided here were used successfully
by a 14 entity healthcare system in north central Texas.
Conclusion:
Nurses no longer have an option, they need to know the business. The ability to sell an
innovative plan or idea to those who hold the purse strings require special talents that can be
developed. Learning to write and present a business case is a valuable skill especially when
developing leadership readiness for an innovation.
References
Giniat, E., Benton, B., Biegansky,E, & Grossman, R. (2012). People and change management in
an uncertain environment. Journal of Healthcare Financial Management Association, 60(10),
84.
McGlynn, E. A., Asch, S. M., Adams, J. et al. (2003) The quality of health care delivered to
adults in the United States. N Engl J Med. 348, 2635-2645.
United States Department of Veterans Affairs, Health Economics Resource Center. (2004).
Health Services Research and Development Service: QUERI economic analysis
guidelines. Retrieved from http://www.herc.research.va.gov/files/MPDF_303.pdf.
Abstract title: CNL Led Implementation of a Comfort Care Order Set
Author Name & Credentials: Debbie Newman RN, MSN, CNL
Institution: Central Texas Veterans Health Care System
City/State: Temple, Texas
Primary Contact Email: [email protected]
Background Information:
Central Texas Veterans Health Care System (CTVHCS) is an integrated health care system
providing inpatient and outpatient care to veterans across a large and diverse geographic area
comprised of thirty-eight counties in the center of Texas. CTVHCS is a major provider of health
care for combat veterans from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom
(OEF) with close proximity to Ft. Hood. Within CTVHCS, patients die in all areas such as acute
care and intensive care. Both doctors and nurses in areas outside of Hospice identify a lack of
confidence or comfort in taking care of dying patients. The focus outside of hospice tends to be
on helping patients get better or recover rather than making their last days or hours comfortable.
52
Aim:
To ensure that the needs of the dying patient and the family are consistently met throughout the
entire facility a “comfort care protocol” was deemed necessary. A CNL led multidisciplinary
team of qualified individuals was assembled to undertake the task of creating the protocol. The
intent of this protocol is to assist the healthcare team, in a variety of settings, to provide
exceptional end of life care.
Methods/Programs/Practices:
Once the protocol, which included a comfort care order set (CCOS) was developed the CNL
group took on the task of implementation. The order set was sent out to a select group of
physicians and physician’s assistants to pilot on a test patient. Once the pilot was completed,
changes were made to the order set based on the recommendations. An education framework was
then developed. The CNLs educated providers throughout the facility on the benefits of using the
CCOS when writing orders on a patient at end of life. The CNLs also educated nurses on the
order set and taught them insertion and maintenance of subcutaneous infusion lines, which is new
to the facility.
Outcome Data:
The providers were receptive to education provided and many have used the CCOS when writing
orders for patients at end of life. The nurses were also receptive to the education and were excited
about the benefits of using a subcutaneous site for patients at end of life. Many patients in the
Hospice Unit have benefited from having a subcutaneous site placed. As the order set is used
throughout the facility anticipated outcome data will include improved scores on the "Bereaved
Family Survey" as a result of:
•Optimal pain/symptom management
•Emotional, social, and spiritual support for patients and families
•Decrease in unnecessary procedures/tests
•Individualized care
•Improved quality of life
•Increased staff knowledge, skill and confidence in providing end of life care in the non-hospice
setting
Conclusion:
To improve quality of care at end of life across all settings a CNL led multidisciplinary team
developed a comfort care protocol and adapted a CCOS. Once developed the CNL group took on
the task of implementation throughout the facility. An education framework was developed and
implemented hospital wide. The providers and nurses alike were receptive to the order set that
increases comfort and confidence by offering guidance in caring for patients at the end of life.
Abstract title: Good, Better, Best: Enhancing Team Perception in the Wake of Change
Author Name & Credentials: Yvette Ong, MS, BSN, RN, OCN, NE-BC
Institution: MD Anderson Cancer Center
City/State: Houston, TX
Primary Contact Email: [email protected]
Background Information:
53
A 32-bed medical unit within a Comprehensive Cancer Center implemented a new nursing care
delivery model, primary team nursing (PTN). In PTN a stable, assigned group of professional
nurses and support staff are collectively accountable and responsible for the outcomes of care for
a cohort of patients. Each of the two teams on the unit has a master’s prepared Clinical Nurse
Leader (CNL) overseeing care delivery at the microsystem level. With any organizational change
there are many responses that staff may experience as they make the transition to the new state.
The unit leadership team and CNLs assessed the teams’ needs, prepared them for the transition,
and continuously implemented action plans that assisted the team in managing change and
shaping a positive perception of the change.
Aim:
To describe leadership action plans that contributed to supporting staff as they made the transition
and developed an ultimately positive perception of the change.
Methods/Programs/Practices:
Multiple interactive sessions were held to introduce the teams to the concept of primary team
nursing and to answer questions about the model. Prior to implementation, a TeamSTEPPS™
Teamwork Perceptions Questionnaire (T-TPQ) and Teamwork Attitudes Questionnaire (T-TAQ)
was administered involving all the team members, including nurses, nursing assistants and patient
service coordinators, to gather baseline data regarding team members’ perceptions and attitudes
about team work, leadership and communication. A post-implementation T-TPQ was conducted
at 3 and 6 months. Opportunities for improvement were identified and discussed during open door
sessions that were held with both teams. Opportunities for improvement emerged regarding team
members providing and receiving feedback in a positive manner; team members resolving
conflicts successfully; leader involving staff in decision making; and leader providing staff
opportunities to discuss unit's performance after an event. Several interventions were put into
action including briefs led by the CNLs after bedside shift report; post-event debriefings led by
the CNLs or charge nurses; conflict management and communication educational sessions, which
included role playing to get staff out of their comfort zone; and the revitalization of the charge
nurse, unit nursing assistant, and patient service coordinator councils to provide an avenue to
explore concerns, resolve conflicts, and move forward with action items.
Outcome Data:
The team of nurses, nursing assistants and patient services coordinators has expressed confidence
in the value of PTN and has experienced their respective cohorts develop into high-functioning
teams. The unit's Team STEPPS survey scores have improved in all the areas, including the key
areas identified as opportunities for improvement in the perceptions questionnaire. For instance,
the scores for positive exchange of feedback increased from 3.56 to 4.02 at the 6-month mark and
staff resolve their conflicts from 3.36 to 3.83 at the 6-month mark with the focus on
communication and conflict management.
Conclusion:
As a profession, nursing is always called upon to lead and participate in change. Nurse leaders
and CNLs play a key role in establishing direction, motivating, and inspiring their teams as they
make transitions in care delivery designed to improve patient outcomes and ultimately staff
satisfaction.
54
Abstract title: Discharge Planning to Prevent Readmissions and Improve Patient Satisfaction
Author Name & Credentials: Ginu Philip, MSN, RN, CNL
Institution: Texas Health Dallas
City/State: Dallas/Texas
Primary Contact Email: [email protected]
Background Information:
According to VBP started by CMS, hospitals across the country will be paid for inpatient acute
care services based on care quality, not just the quantity of the services they provide. Readmission
rates are often directly related to poor quality of care provided to patients during their transition
from the hospital to home or other care settings. Discharge instructions are not properly
communicated to the patient, hospital and ambulatory care health records are not reconciled, and
arrangements for follow-up care are not made. This can result in readmission to the hospital in
forms of infection or pneumonia. Evidence suggests that comprehensive discharge planning
prevents readmissions.
•
Patient’s perception on “discharge information” is one of the low rated scores in the
HCAHPS survey on Main 4 West (M4W).
•
The targeted score on “discharge information” is 87%.
•
At Texas Health Dallas(THD), the average cost of stay for a patient diagnosed with
pneumonia is $48,512 and readmission average cost is $29,535.
•
Pneumonia readmission rate is 12.93% and general readmission rate is 8.75% (data
compiled from May 2012 to January 2013) in M4W. The target pneumonia readmission rate goal
is 9.24-10.63%.
Aim:
The goal of this project is to improve patient satisfaction scores on “discharge information” and
maintain the scores at 87% or above. This is the target percentage on HCAHPS. Another goal is
to reduce readmission rates to the target rate of 9.24-10.63% and reducing the readmission costs
by $29,535 per admission.
Methods/Programs/Practices:
•
The CNL comprised a lead team consisting of RNs, CNL, case manager, pharmacists, unit
secretary, unit supervisor and members of the quality department.
•
The CNL led education sessions to educate nurses about discharge planning.
•
The discharge planning project focused on scheduling follow up appointments, filling up
prescriptions at the time of discharge and detailed discharge instructions. “Retail Pharmacy”
services were utilized to fill discharge prescriptions to ensure availability of medications at the
time of discharge.
•
Detailed follow up information were provided to patients and families including name of
the physician, service provided by the physician (cardiologist, oncologist, etc.), telephone
number, address to the physician’s clinic, time frame to follow up, and date of follow up
appointment if the appointment was scheduled by the staff. All these information were printed on
the “Patient Follow-up Information” sheet for easy reference and handed to patients at the time of
discharge.
55
•
Discharge nurses and CNL focused on detailed discharge education emphasizing on “sign
and symptoms to watch for” after patients leave the hospital. Patients were instructed when to call
the physician and when to call 911 or go to the emergency room.
•
HCAHPS survey scores related to “discharge information” were gathered at the beginning
and end of project implementation.
•
Overall and pneumonia readmission rates of patients discharged from M4W were
collected before and after project implementation.
Outcome Data:
•
HCAHPS question response to “Did doctors, nurses or other hospital staff talk with you
about whether you would have the help you needed when you left the hospital?” improved from
78.6% (n=14) in September 2012 to 88.2% (n=17) in August 2013.
•
HCAHPS question response to “Did you get information in writing about what symptoms
or health problems to look out for after you left hospital?” improved from 78.6% (n=14) in
September 2012 to 94.1% (n=17) in August 2013.
•
The overall score on “discharge information” increased from 78.6% (n=14) to 91.2%
(n=17).
•
Pneumonia readmission rates decreased from 12.93% (May 2012 to January 2013) to
10.26% (February 2013 to April 2013). Overall readmission rates decreased from 8.75% (May
2012 to January 2013)to 7.72% (February 2013 to April 2013). Potential cost savings for
preventing one readmission is $29,535.
Conclusion:
•
At the end of project implementation, the HCAHPS scores went beyond the target score of
87%.
•
Pneumonia readmission rates reached the target goal of 9.24-10.63%.
•
Results indicate that enhanced discharge planning process impacts patient satisfaction
scores and readmission rates.
•
Even though the number of patient responses after project implementation were
comparatively low, the results indicate improvement in patient satisfaction scores.
•
Discharge planning that focused on follow up appointments, discharge medications, and
detailed discharge instructions resulted in better financial outcomes for the hospital. While
readmission rates decreased, patient satisfaction scores related to “discharge information”
improved.
•
Enhanced discharge planning has remarkably affected readmission rates and patient
satisfaction scores.
Abstract title: Using a brochure assignment to market Model A & Model C CNL graduate
roles
Author Name & Credentials: Keevia Porter, DNP, NP-C
Institution: University of Tennessee Health Science Center
City/State: Memphis, TN
Primary Contact Email: [email protected]
56
Background Information:
Students graduating from a Model A and Model C Clinical Nurse Leader (CNL) program will
seek employment after graduation as registered nurses (RNs) and/or Clinical Nurse Leaders
(CNLs). Our graduates face challenges when seeking employment as CNLs because few
hospitals have a job description for the CNL role. To be a potential candidate for a CNL, the job
requirements as it is described by one hospital’s job description, the candidate must have at least 2
years of clinical experience. Our Model C students lack this experience as new RN graduates. Our
Model A students, experienced RNs, rarely see employment postings for CNL roles except at the
one hospital within their system. Other hospitals in the region are still learning about our CNL
program and our graduates.
In preparation for initiating and sustaining a future CNL role, students must be able to articulate
to potential employers how they are able to deliver and improve patient care with the unique
skillset they will possess. Model A and Model C students are required to complete an assignment
to prepare them to advocate for, establish, and maintain a CNL role by creating a marketing
brochure for use within select care environments. The brochure will be added to their
professional portfolios, to be presented during job interviews.
Aim:
The aim of this presentation is to describe an assignment developed to prepare Model A and
Model C CNL students for articulating and marketing the CNL role to potential employers before,
upon, and after graduation. By completing a CNL marketing brochure, students will be able to
build the business case for future CNL practice at health care organizations of their choice.
Methods/Programs/Practices:
In the Professional Roles course, Model A and Model C students are to design a 6-panel brochure
using Microsoft Office products. Students are provided with a copy of the assignment
instructions, and required and recommended preparatory reading assignments. They will
highlight: a) their personal vision and mission statements as future CNLs, b) relevant background
information on the CNL role, c) unique qualities of the CNL role, d) costs and benefits of hiring a
CNL, and e) their personal skills that enhance the CNL role. After submitting the brochures for
grading, students will be evaluated using a rubric created specifically for the assignment. The
rubric evaluates their individual brochures on overall significance to the CNL role, organization
and flow, grammar/ spelling, creativity, clarity, accuracy of data provided, clarity, design, and
completeness. Students will be provided feedback for improvement as needed.
Outcome Data:
At the end of the course, students will add the marketing brochure to their professional portfolios
to present in support of their experience and training as they seek employment upon and after
graduation.
Conclusion:
In progress
57
Abstract title: Implementation and Development of a NICHE unit led by Clinical Nurse Leaders
Authors/credentials: Kasia Qutermous MSN, RN-BC, CMSRN, CNL & Veronica Rankin MSN,
RN-BC, CMSRN, CNL
Institution: Carolinas Medical Center
City/State: Charlotte, NC
Primary Contact Email: [email protected]
Background Information: Patients aged 65 years and older make up greater than 30% of the 3
Tower medical-surgical unit population at Carolinas Medical Center (CMC). This statistic led the
Chief Nurse Officer of CMC to seek out available resources aimed at improving outcomes of this
population. Extensive research in evidence-based practice pinpointed the Nurses Improving the
Care for Healthsystem Elders (NICHE) organization as an answer in this quest. The NICHE
organization specializes in equipping healthcare providers with the tools, education, and training
to improve outcomes of elderly patients. This organization additionally provides a training
program, education curriculum, an annual conference, weekly webinars, online Geriatric
Resource Nurse Consultants, and evidence-based resources for its members. A 2013 goal to
obtain NICHE designation was set and the Clinical Nurse Leaders (CNLs) rose to the challenge.
A review of the unit’s Professional Research Consultants (PRC) scores identified the need for
improvement in geriatric care. Data showed poor scores from geriatric patients specifically
concerning communication, the decision making process and overall quality of care. By
assuming the role of coordinator, disseminating education on the initiative, organizing
multidisciplinary efforts, and recruiting Leadership Training volunteers, the CNLs led the unit’s
NICHE journey in a structured manner. The unit was designated as the first and only NICHE site
at CMC on April 10, 2013. The CNL’s on this unit have taken a variety of steps in order to obtain
this designation and continue to work effortlessly in collaboration with interdisciplinary team
members to ensure the success of improved geriatric care.
Aim: The aim of this journey is to improve the quality of care for the geriatric population by
increasing staff’s knowledge of geriatric issues, increasing competence in geriatric care, and
developing as well as implementing hospital geriatric protocols. The vision for the hospital
system is to transform the delivery of geriatric care by providing a comprehensive, safe, and
individualized plan of care using evidence-based principles and a multidisciplinary holistic
approach to achieve optimal psychosocial, spiritual and functional patient outcomes.
Methods/Programs/Practices: The process of improving geriatric care and developing as a
NICHE unit is ongoing and evolving. The CNL’s of 3 Tower have taken many steps to ensure the
success of this initiative. In order to obtain unit designation, the CNL’s along with several
leadership team members and a few staff members participated in a Leadership Training Program
(LTP) provided by the NICHE organization. Through this training a shared vision was developed
by for the unit. This shared vision was later revised by a multidisciplinary NICHE Steering
Committee. The leadership team members also conducted a SWOT analysis which evaluated the
unit’s strengths, weaknesses, opportunities and threats. From this long range goals and an action
plan was developed. A Geriatric Institutional Assessment Profile (GIAP) survey was conducted
on all nursing staff in order to help identify baseline unit data on geriatric care provision. As
previously mentioned the NICHE steering committee which includes more than 8 disciplines and
the hospital’s CNO meets monthly and reviews goals and action items. The CNLs are currently
forming multidisciplinary geriatric rounds to review high risk geriatric patients on the unit
weekly. Long term goals include pursuing grant funding for our NICHE journey and eventually
expanding this initiative to our emergency department.
58
Outcome Data: One hundred percent of the nursing staff completed the GIAP survey. This
survey identified staff-reported needs of increased geriatric education and resources. Eleven
nurses have completed the LTP training including all of the 3 Tower CNLs, the CNO, Nurse
Manager and Clinical Nurse Specialist (CNS). Furthermore, the 3 Tower CNL’s have obtained
Gerontology Certification.
The CNLs of 3 Tower recently implemented a geriatric pharmacy pilot which resulted in a
unit stationed pharmacist for the duration of two months. The pharmacist reviewed all geriatric
patient medication profiles and communicated with both nursing staff and physicians about
potential opportunities. Within a two month period this pilot resulted in a cost savings of over
$8,000. Pharmacy was also able to provide weekly unit in-services regarding medications and
their effects on the geriatric population.
Outcome improvements specifically affecting the geriatric population has been
multifaceted for the unit. The unit has experienced an increase in mobility to an average of 74%
for 2013 year to date. This was a 40% increase when compared to 2012. Additionally, patient falls
are on pace to decrease by 10%. Quality of care for the geriatric population has also increased by
12%, overall level of safety has increased by 8% and nurses’ communication with patient/family
has increased by 5% since the initiation of our NICHE journey.
Conclusion: Of our total inpatient days 32% consists of total Medicare inpatient days. As the
population ages it is expected that these percentages will increase as well as the healthcare
expenditures required to properly care for this population. It is our goal to continue to improve the
knowledge deficit regarding geriatric care and monitor outcomes specific to this population.
Abstract title: How a CNL and Pharmacy Collaboration Project saved over $8000 within 2
months
Author Name & Credentials: Veronica Rankin MSN, RN-BC, CMSRN, CNL
Institution: Carolinas Healthcare System
City/State: Charlotte/NC
Primary Contact Email: [email protected]
Background Information:
Pharmacy collaboration is a vital component in addressing the pharmaceutical needs which can be
a barrier to providing safe geriatric care. Issues such as Poly-pharmacy, Beer’s list
contraindications, and side effects can lead to dementia, falls, and potentially death. Clinical
Nurse Leaders (CNLs) are needed now more than ever to serve as the interlink to patient safety.
Current literature provided by the Institute of Healthcare Improvement (2009) stresses the risks
associated with poly-pharmacy in the elderly and calls for action to rectify the safety risk. Nobili,
Garattini, & Mannuccio (2011) recommends reducing unnecessary medication usage and ensuring
compliance with medications of necessity. Although current pharmacists are available to the unit,
each pharmacist covers multiple units per shift. This extended coverage monopolizes the impact
one pharmacist can have on each unit. Pharmacists are required to multitask and prioritize needs.
59
This inturn often leads to lack of time for activities such as patient and staff education, med
reconciliation alterations and troubleshooting, and profile reviews. CNLs are educated and
prepared to tackle issues such as these through conducting failure mode analysis, microsystem
assessments, and anticipating risks within the patient population.
Aim:
The aim for this initiative was to improve clinical care delivery through a collaboration with
pharmacy for population focused medication interventions, teaching, and clinical support for
staff. The essential element for this initiative was to make a pharmacy resource readily available
to staff by being stationed on the unit.
Methods/Programs/Practices:
In February 2013 CNLs on 3 Tower at Carolinas Medical Center initiated collaboration with
pharmacy directly focusing on geriatric care. A pilot study was conducted from April until June
that supplied a stationary geriatric pharmacist and pharmacy students for the unit. Pharmacy inservices were provided two to three times weekly for dayshift and nightshift staff. These inservices included pain medications to avoid in the elderly, medications that contribute to falls,
enteral nutrition, etc. The pharmacy students provided medication counseling for patients and
their families at the bedside. Massive medication reconciliation and profile reviews were
conducted leading to many improvements of polypharmacy within the geriatic patient population.
Pharmacy attended the bi-weekly multidisciplinary rounds that includes the unit’s CNLs, clinical
case managers, social worker, nutritionist, pastoral care liaison, and physical therapy personnel.
This participation led to discussion and medication changes directly related to the patient’s health
status, behavior, and level of consciousness. Staff quickly acclimated to the clinical resource
provided by this pilot study and was appreciative.
Outcome Data:
An actual cost savings of over $8000.00 was calculated from actions taken by pharmacy during
this 2 month pilot study. A potential cost savings of over $10,000.00 was calculated from the
estimated costs associated with each intervention. Althought the financial return on investment is
very important and quantifiable, clinical knowledge, team building, and patient safety is priceless
and oftentimes more difficult to measure. As a result of this initiative the Professional Research
Consultants (PRC) patient satisfaction scores for consistency with medication education provided
to patients improved from 87.2% in 2012 to 98.5% for 2013. PRC scores for side effects
education improved from 67.8% in 2012 to 100% in 2013. PRC scores for teamwork between
doctors, nurses and staff consistently improved annually from 63.1% in 2011 to 90% in 2013.
PRC scores measuring patient's satisfaction with discharge instructions improved from 32% in
April 2013 to 98.9% in May and 99.6% in June during this pilot. Other results including Quality
of Care has steadily improved annually from 50.5% in 2011 to 85.7% for 2013. Staff has
reported satisfaction and requested the resumption of this collaboration pilot study. Ultimately a
change in culture for staff concerning medicinal effects, administration, and teaching has
drastically occurred amongst the staff. This is evident by the drastic improvement in patient
satisfaction.
Conclusion:
Clinical Nurse Leaders are needed now more than ever to lead the multidisciplinary team in
efforts that will improve outcomes for all patients especially the vulnerable elderly population.
Collaborations with various disciplines should be fostered and coordinated by the CNL in order to
improve quality of care. Continued collaboration efforts will ensue to ensure the continued
progress with this initiative that is expected to resume in the Spring of 2014.
60
Abstract title: Evolving CNL role: Exemplars from CNLs and Nurse Executive
Author Name & Credentials: Linda Roussel, DSN, RN, CNL, NEA-BC
Institution: University of Alabama Birmingham School of Nursing
City/State: Birmingham, AL
Primary Contact Email: [email protected]
Background Information:
The CNL role was created as the nursing profession requires quality graduates who are prepared
for clinical leadership in a variety of healthcare settings, and across health care continuums. CNLs
must be prepared to implement outcomes-based practice and quality improvement strategies as
well as remaining in and contributing to the profession, practicing at their full scope of education
and ability. CNLs are educated and socialized to develop and manage microsystems of care
sensitive to the health care needs of individuals and families.
Aim:
The aim of this presentation is to provide exemplars of how CNLs function through role and skill
set development has evolved since inception of the degree and how Nurse Executives have
embedded CNL work into systems and health care delivery models. Exemplars will be presented
linking specific areas of competencies..
Methods/Programs/Practices:
The authors gained extensive knowledge of how CNLs are working within their various
microsystems contributing value-based care in the updating of CNL role development in their
update of CNL curriculum content (through analysis of microsystem's project work. The authors
will provide dynamic exemplars and themes related to CNLs broad areas of competencies
including (but not limited to) Clinician, Outcomes Manager, Client Advocate, Educator, Systems
Analyst, Risk Anticipator, and Team Manager. Additionally, the Nurse Executive perspective
(through 1:1 interviews) will be described cross walking with CNL competencies and embedded
in clinical microsystems for sustainability.
Outcome Data:
Review of exemplars from CNL program graduates throughout the country reveal alignment of
CNL skill set with impressive outcomes, specifically related to the Institute of Medicine (IOM)
Aims for Quality (safe, effective, efficient, equitable, timely, and patient-centered). Additionally,
Nurse Executive 1:1 interviews revealed the importance of preparing the enviroment for the CNL
role, as well as embedding the role into the work environment. Outcomes related to staff
satisfaction and retention, as well as selected patient outcomes will be described.
Conclusion:
CNLs and Nurse Executive alignment are essential to the success of the CNL role and
sustainability of the role. Nurse Executive support goes beyond an understanding of the role to the
successful integration and engagement of CNLs in the microsystem work environment This will
be presented, along with future recommendations for CNL role development..
61
Abstract title: The Role of the CNL in Creating a Culture of Certification and Professional
Development
Author Name & Credentials: Danell Stengem, MSN, RN-BC, CNL
Institution: Texas Health Harris Methodist Hospital - Fort Worth
City/State: Fort Worth, TX
Primary Contact Email: [email protected]
Background Information:
Texas Health Resources (THR) has offered a Nurse Career Advancement Program (NCAP)
throughout their large healthcare system for many years. NCAP offers challenge and opportunity
to professional direct care registered nurses at THR by delineating and recognizing the various
knowledge and skill levels of nurse clinicians. The goal of this program is to allow nurses to
advance professionally without leaving the bedside and improve the satisfaction they receive
through responsibility, achievement, professional growth, and recognition. NCAP has various
levels of clinical nursing practice reflective of Benner's model of skill acquisition from novice to
expert (Benner, 1984). Four of the six levels have activity requirements that are beyond the basic
job description of a bedside nurse. Levels IV thru VI (Expert - Virtuoso) require specialty
nursing certification. A majority of studies on nursing certification have shown that it has
intrinsic value, increases nurses’ sense of empowerment, and enhances collaboration with other
healthcare team members (Wade, 2009).
A microsystem assessment was performed by the Clinical Nurse Leader (CNL). Participation in
NCAP and the number of certified medical/surgical nurses within the microsystem was noted to
be considerably less in comparison to other units at Texas Health Fort Worth (THFW). CNLs are
expected to guide the clinical team by encouraging professional development, provide continuing
education, and promote clinical excellence and collegiality (Sherman & Pross, 2010). A plan was
formed to promote and coach/mentor the nursing staff to increase participation in NCAP and their
attainment of national certification in medical-surgical nursing.
Aim:
The aim of this project was twofold: to increase nurse participation in NCAP and to increase the
number of medical-surgical certified nurses within the CNLs Acute Medical microsystem.
Methods/Programs/Practices:
A "Get Certified" campaign was initiated in September, 2012 by the CNL. All nurses within the
microsystem were emailed a daily “Medical-Surgical Certification Question of the Day”.
Certification questions were obtained from Medical-Surgical Nursing Certification Exam Review
publications. Multiple-choice questions included the answer and rationales for both correct and
incorrect answers. Publication references were included with each question. Unit managers of 4
microsystems within the Med/Surg Division expressed an interest in receiving Certification
Questions of the Day for their nurses. Those units were added to the email distribution list. All
nurses who received daily questions were asked to complete a survey one year post
implementation to measure their satisfaction with the daily questions.
An informational bulletin board was created in the nursing staff area to provide information about
this project. The bulletin board included the following items: side by side comparison of the two
nationally recognized Medical-Surgical Certifications, information about bonus money & exam
reimbursement funds availability from THFW upon successful achievement of certification, and
62
information about the daily "Medical-Surgical Certification Question of the Day" email being
delivered to their email inbox.
All front line nurses within the microsystem were recruited with an informational email and in
person by the Clinical Nurse Leader and Nurse Manager to participate in NCAP. Nurses who
expressed an interest were coached and mentored by the CNL in how to prepare their NCAP
portfolio.
Outcome Data:
Survey results revealed that 65% of the nurses who responded were planning to take the
Med/Surg certification exam in the future. Nurses indicated that the daily questions increased
their awareness of certification in general (94.5%), the questions enhanced their confidence in
their knowledge of Med/Surg nursing (88.9%), and the rationales for answers and incorrect
answers were beneficial (96.4%). Current certified nurses indicated that they still utilized the
Med/Surg certification question of the day to reinforce their knowledge base (98%).
Nurse achievement of either NCAP level III or IV has increased by 300% over the past 12 months
and Med/Surg nurse certification attainment increased 100% over that same time period on the
CNLs microsystem alone. Several other nurses are planning to or have already applied for NCAP
and several nurses are planning to or have applied for Med/Surg certification. Survey data
included all microsystems within the Med/Surg division that received Certification Question of
the Day emails.
NCAP and certified nurses are recognized publically on a wall located in the lobby of their
microsystem. The wall displays individual NCAP nurse’s achievement plaques and a MedicalSurgical Nursing Certification plaque listing each certified nurse’s name. The nurse manager has
approved funds for name badges that include each certified nurse’s credentials. The plaques and
name badges serve to publically recognize the nurse’s professional achievement. Additionally,
first-time NCAP recipients receive a pin from the THFW NCAP Review Board designating level
achievement and are invited to attend a system-wide NCAP recognition banquet.
Conclusion:
CNLs foster a close connection between professional development of individuals and
development of quality and high standards in the microsystem. Many barriers exist for direct care
nurses to elevate their professional practice: lack of time, fear of failure, lack of motivation, cost
of certification exams, and feelings of being overwhelmed with the entire process. The CNL role
is in a unique position within the microsystem to break down barriers and provide coaching &
mentoring of elevated professional development behaviors. The culture within a microsystem can
change and gain momentum through role modeling of professional accountability by the CNL.
63
Abstract title: Evolution of CNL Workgroup for a 14-Hospital System
Author Name & Credentials: Diane Thomas, MSN, RN, CNL; Holly Haddad, MHS, MSN, RN,
CNL
Institution: Texas Health Resources
City/State: Ft. Worth, TX
Primary Contact Email: [email protected]
Background Information:
In 2008, Joan Shinkus Clark, Senior Vice President and Chief Nurse Executive at Texas
Health Resources (THR), a 14 entity healthcare system in the Dallas/Fort Worth Metroplex,
introduced the Clinical Nurse Leader (CNL) role in response to the changing healthcare
environment. After developing a strategy with THR executives and partnering with Texas
Christian University, the first nurses were hired into the Patient Care Facilitator (PCF) role, a
precursor/student role to the Clinical Nurse Leader. Joan Clark created the THR CNL Advisory
Board consisting of CNOs, nursing leadership, and PCFs to facilitate development and
implementation of the role across THR.
The inaugural PCFs began meeting outside of the Advisory Board to support one another
while learning the role. As the vision for the role developed from a corporate perspective, this
group focused on consistency and standardization throughout THR. Within the first few months,
the group recognized a need to meet monthly to develop and implement the foundational structure
and work plans to address the Advisory Board’s strategic plan. The PCFs became known as the
Workgroup and have evolved over the last four years following the trajectory of Patricia Benner's
Novice to Expert theory. The Workgroup now consists of representatives from 14 hospital
entities within THR.
Aim:
Initially, the aim of THR’s CNL/PCF Workgroup was to provide support for those involved
in the newly created role. The group investigated available literature related to the CNL role to
determine structural elements and tools to support the work. In collaboration with THR Advisory
Board members, the Workgroup created job descriptions for the CNL and PCF, expectations and
competencies in collaboration with nurse educators, and workflow tools and reports to support
data collection. Once the initial foundation was in place, the Workgroup formalized its structure,
adopted a work plan with annual goals, and selected a chairperson and co-chairperson. Each year
the Workgroup has matured, as evidenced by improved quality and cost outcomes at the
microsystem level
Methods/Programs/Practices:
The CNL/PCF Workgroup has become a vital venue for individual practitioners to discuss
ideas and clinical projects. As PCFs and CNLs matured in their individual roles, the Workgroup
matured in developing more complex tools and measurements. The Workgroup began to
standardize clinical practices at each hospital entity by creating an introduction to the role for
hospital administration and staff, PCF orientation, a mentorship program, system metrics,
admission and discharge workflow tools, rounding tools, discharge follow-up, and patient
education tools.
The Workgroup is now co-led by a CNL program director and CNL chairperson who lead in
strategic planning and system standardization. Subcommittee task forces create standard practices
for documentation, rounding, PCF orientation, and daily routines. During each monthly meeting,
small group discussions allow for mentoring of newer members.
A CNL/PCF online SharePoint was developed as a resource to facilitate communication for the
Workgroup and Advisory Board. The SharePoint is a repository for members to communicate
64
microsystem wins in a journal or Impact Report format, job descriptions, education and
orientation materials, project ideas, school resources, workflow documents, and CNL research
articles.
Outcome Data:
The Workgroup began in 2009 with six PCFs and grown to include 32 PCF and CNL
members. The Workgroup members have created numerous tools that guide clinical care
throughout the system. These tools include PCF and CNL job descriptions, competency
validations, EHR clinical reports, CNL program standards, CNL sharepoint, patient education
tools, portfolio development, and an outcomes dashboard. The dashboard reflects outcome
improvements and is indivualized for each entity. Collected data includes patient safety
measures, readmission rates, patient length of stay, patient satisfaction, and cost per case per
entity microsystem. Each microsystem also measures outcomes according to individual
microsystem assessments.
The Workgroup provides clinical expertise and collaborates with THR system councils and
departments to improve patient outcomes. For example, the group works with the Education
Council to create standardized patient education materials to improve continuity of care,
Information Technology to enhance clinical documentation, and Nursing Finance to link patient
outcomes to financial benefits.
Conclusion:
The THR CNL/PCF Workgroup began in 2009 and has evolved into a dynamic, creative team
that demonstrates the vital role of the CNL in today’s healthcare environment. Each year the
workgroup takes on new goals to ensure role consistency, improve patient outcomes, demonstrate
effectiveness of the CNL role on a system level, provide mentoring for new members, and
provide peer support and networking. At this time, the CNL/PCF Workgroup has grown six-fold
in four years and is maturing to an expert team. Microsystem outcomes indicate a considerable
positive impact of the CNL role on quality and cost efficiency. Due to this positive impact, THR
plans to increase the number of CNL clinicians to 85 by the end of 2014.
Abstract title: Readying the Practice Envirorment for the CNL: Perspective from Nurse Leaders
Author Name & Credentials: Patricia Thomas PhD, RN, FACHE, NEA-BC, ACNS-BC, CNL
Institution: Catholic Health East-Trinity Health
City/State: Livonia, MI
Primary Contact Email: [email protected]
Background Information:
While great attention has been paid to what CNLs can do in a healthcare setting, little has been
written about what nurse leaders need to do to ready the practice envirorment for the inclusion of
CNLs in the practice setting. Based on discussions with Chief Nursing Officers and practical
65
experience with implementing the role in two health systems in Michigan, this presentation will
offer pragmatic advice about successful CNL integration in care delivery systems.
Aim:
The aim of this presentation is to highlight and describe how Chief Nursing Officers can cross the
organizational hurdles in introducing the CNL role into the organization. Emphasis will be placed
on the tactical steps nurse leaders can implement to prepare the workplace and workforce for role
changes, relationships changes, and role accountability across clinical specialties within and
outside the acute care setting.
Methods/Programs/Practices:
Strategies to clarify where roles were distinct and where they were different when considering the
CNL role was undertaken. Two meetings with CNOs, CNLs, representatives from human
resources, nurse educators, clinical directors, Clinical Nurse Specialists, nurse managers, and case
managers were facilitated by the system CNO. After those meetings, the CNO at each hospital
held meetings with CNL students (graduating within the year), case managers, CNSs, and nurse
educators. When different positions became open, the decision to fill the position was evaluated
by the nursing leadership team. If the position was not filled, a plan was developed to establish
how the role functions would be done prior to the CNLs graduating. Upon graduation, each CNL
was moved from their unit of origin based on unit needs and the strengths each CNL had
demonstrated. Each CNL was oriented to their new unit and each completed clinical orientation
that newly hired staff nurses would receive. About 6 months after graduation and placement on
the nursing unit, the CNLs were charged by the CNO to establish 2 unit goals using the A3 format
that was part of the Lean/Quality philosophy of the organization. One goal needed to focus on
patients and a clinical concern and one on staff. Before approving the unit specific problem to be
addressed, each CNL had to collaborate with the unit manager, CNS, and staff. The CNLs met
with the department director, unit manager, and CNs every two weeks. Monthly meetings were
held with the CNO and all the CNLs in the organization to discuss progress.
Outcome Data:
Improvement in organizataional outcomes have been demonstrated over a 2 year period since the
implementation of the CNL role. These indicators had been stagnent in terms of improvement in
the 2 year period prior to CNL implementation. Improvement in outcomes were seen in Falls,
patient satisfaction, staff turnover/retention, NDNQI staff satisfaction indicators, core measures
and immunization rates. Additionally, there was a financial impact in values-based purchasing of
$1.4 million dollars. With these successes, physicians, pharmacists, and nurses across clinical
speciality and practice settings seek CNLs when facing either stagnant metrics or practice changes
that extend beyond a single department.
Conclusion:
Preparing the organization for the implementation of the CNL role is important to achieving the
change and outcomes that can be facilitated by the CNL role. For the CNL to enact their role, they
need the support of the interdisciplinary team and to be seen as a support to their unit and the
nursing leaders in accomplishing the work of nursing. This does not come without deliberate
attention and intervention by nurse leaders in preparing all nursing staff who will experience role
change. By brining all the nursing professionals together for initial discussions and then
identifying small deliberate steps leading up to and after implementation of the CNL role,
organizations can plan for success.
66
Abstract title: CNL Impact Cross-Continuum: Pre-Operative Pain Medications
Author Name & Credentials: Elizabeth Triezenberg MSN, RN, CNL, CNRN
Institution: Mercy Health Saint Mary's
City/State: Grand Rapids MI
Primary Contact Email: [email protected]
Background Information:
Medicating patients for pain prior to orthopedic surgery has been documented in the literature to
help with pain management post-operatively. A few of our orthopedic surgeons had attempted to
use a pain 'cocktail' prior to surgery but often found the patient ready for surgery and the
medications not given. The lack of a process for preoperative medication ordering as well as no
surgeon standardization of practice resulted in the variability of medication being given. As a
result preoperative medications were not being used or valued by several of the other orthopedic
surgeons.
Aim:
Develop a sustainable process in which patients would receive 100% of prescribed pre-operative
medications prior to surgery.
Methods/Programs/Practices:
A cross-continuum focus group was pulled together for a short meeting to identify gaps/barriers
and opportunities. Utilizing LEAN process improvement methodology several gemba walks were
done to identify the current state and map out the desired outcome. Rounding on project
champions across the continuum was used for the remainder of the project as well as email
communication. Several stake-holder units were involved in the development and decision of the
final process. When the pilot process was clearly identified the surgeon champion began utilizing
the process to evaluate the success. Success of the process led to the surgeon champion
collaborating with his partners to determine a standardized medication list which was then
implemented into the process steps
Outcome Data:
Sample size utilization of preoperative pain medications in patients having total joint replacement
went from 50% to 90% with the implementation of this process. On the orthopedic inpatient unit
HCAHPS patient satisfaction scores of pain well controlled have increased from below 50%
benchmark in Q1 FY2013 to the 90% benchmark in the Q4 of FY2013. The process used for
ordering the medication has steadily increased since implementation and shows 100% of surgeon
completion for each of the last three months. With the implementation of the process all but one
of the total joint surgeons are utilizing preoperative pain medications and the length of stay for
total joint patients has decreased. Qualitative data from patient rounding has a theme of patient
responses asking "What has been done differently since my last surgery? I feel so good." Data
extraction will be completed prior to presentation to show the number of intravenous pain
medication use by patient after arrival to the inpatient unit by sample pre and post preoperative
medication implementation.
Conclusion:
The role of the Clinical Nurse Leader (CNL) in developing and impacting processes across the
system which impact ultimately at the microsystem and impact the Triple Aim – cost, quality, and
service, need to be highlighted. This project was successful because of the vested interest and
systems thinking across the continuum. The surgeons and others in the cross-continuum identified
67
a frustration in lack of a process and committed to collaborate in identification and implement of
a sustainable path for preoperative medications. Each department evaluated their microsystem for
implementation and reported to the CNL who linked the microsystem processes together crosscontinuum. The result was a cross-continuum supported sustainable process to improve the pain
experience for our total joint patients.
Abstract title: A Clinical Nurse Leader's Role in Advancing Quality Stroke Care at a Micro,
Meso and Macro Systems Level.
Author Name & Credentials: Flame Uytico, MSN,RN, CNL,CEN
Institution: Texas Health Dallas
City/State: Dallas, TX
Primary Contact Email: [email protected]
Background Information:
A Clinical Nurse Leader (CNL) is responsible for provision and management of care in and
across all health care settings. The integrative function of the CNL in interdisciplinary
collaboration, supervision and care outcomes advances stroke care for Texas Health Dallas
(THD),a primary stroke center (PSC) in North Texas. Stroke is the fourth leading cause of death
and the leading cause of serious long-term disability in the U.S. Texas Health Dallas has been a
designated PSC since 2008 and is now in process for becoming a comprehensive stroke center.
The Clinical Nurse Leader in THD plays a pivotal role in advancing and promoting quality stroke
care in alignment with the hospital's mission. The CNL implements significant interventions for
continuity of care to assist stroke patients in the microsystem. The CNL also plans and
collaborates with neuroscience services to assess and improve overall stroke hospital care and
recommend changes at a micor,macro and mesosystem level. The CNL focus on interventions to
improve stroke care at the bedside and hospital wide, even going outside the boundaries of the
workplace reaching out to the communities that the hospital serve through
health promotion, secondary prevention and stroke risk reduction by conducting community
stroke screenings and prevention education at a macrosystem level.
Aim:
The purpose of this study is to assess the impact of the Clinical Nurse Leader role in advancing
quality stroke care at all levels of healthcare, meaning at a microsystem, macrosystem and
mesosystem level. Integrating the CNL role with the hospital system's neuroscience services
creates a collaborative environment to deliver effective and quality stroke care at Texas Health
Dallas, a primary stroke center that is advancing towards a comprehensive level stroke
certification.
Methods/Programs/Practices:
I. Microsystem Level - the CNL forms a stroke team at the unit level to advance stroke care
including designation of a stroke champion from one of the bedside RNs. Collaborates with the
68
clinical supervisors (CSs) and charge nurses (CNs) in taking the lead for ensuring all core
measures are met in a timely manner. The CNL makes a visual tool called "The Stroke Journey"
and ensures that each stroke patient has this reminder inside the room to alert the nurses that there
is a checklist to be followed to ensure that no stroke core measure is left out. A CNL-led inservice regarding use of the electronic stroke checklist was also conducted to encourage nurses to
utilize this tool for stroke patients. The Stroke Rounds weekly assist primary RNs to gather
pertinent information about their patient's stroke including the type, risk factors and plan of care.
Lastly, the CNL promotes stroke education through staff compliance with the 2013 stroke
education requirements. An online stroke education curriculum was set up by the Stroke
Coordinator and staff is reminded to complete this education requirements at a designated time.
The CNL validates that education requirements are met.
II. Mesosystem Level - The CNL is an active member of the hospital's Stroke Operations
Committee or SOC. This committee meets once a month and is composed of interdisciplinary
neuroscience services such as the ED, Laboratory, Radiology, Rehab, Pharmacy, Education, and
all hospital units that serve stroke patients. There is also an extensive doctor representation from
neuro, interventional, radiology and rehab physicians. The SOC team discuss unit and hospital
metrics, cases, analyze events and establish plans to advance the hospital's comprehensive stroke
program. The CNL takes responsibility in making the hospital's stroke discharge phone calls for
stroke patients to evaluate patient understanding of their care, to validate patient education and
evaluate compliance with discharge instructions. All data gathered from the stroke DC calls gets
presented in the SOC monthly meeting and any scores that needs improvement based on the core
measure compliance gets acted upon. Information from the SOC meetings gets disseminated to
the unit level via staff meetings and at the THD Coordinating Council, a hospital shared
governance model that involves staff decision making.
III. Macrosytem Level - The CNL goes further in disease prevention and promoting health on a
bigger scale. Living by the hospital's mission: "to improve the health of the people in the
communities that we serve." Going beyond the hospital's walls, the CNL collaborates with the
hospital's Stroke Coordinator in promoting health by conducting community stroke screenings
inside the hospital, and outside. The CNL volunteers and participates at the Hamilton Park and
YMCA Community Health Fairs in screening visitors for stroke risk and providing free BP and
cholesterol checks. The CNL educates and hands out flyers to promote stroke awareness during
stroke month in May at the hospital. As a lifelong learner, the CNL enhances professional
development by attending different stroke conferences and educational opportunities throughout
the year. Last year, the CNL was able to present posters on stroke at the CNL Summit 2013 New
Orleans and at the 19th National Nursing Research Conference in Dallas. This also ensures that
the CNL is updated on the latest evidence-based information about stroke. This is a great
opportunity for the CNL to showcase stroke process improvements beyond the hospital walls, at
the macrosystem level.
Outcome Data:
Data was collected and compared on the microsystem's score for stroke core measure compliance
at Hamon 4 North. Prior to the CNL-led process interventions, the stroke core measure
compliance was at 82% percentile from July 2012 - December 2012 (n = 35) and post comparison
showed 100% compliance on core measures for stroke (dysphagia, NIHSS screen, DVT
prophylaxis and patient education) from January 2013 to October 2013 ( n = 79). Patient's
understanding of stroke education provided by staff nurses was evaluated through the post DC
calls and prior to the interventions, only 65% of patients understood their instructions from June
2012- Dec. 2012 (n=52). After CNL interventions, the patient's understanding increased to 98%
from Jan. 2013- Oct. 2013 (n = 83). The overall average for post-discharge calls on stroke patients
69
for 2013 increased above 90th percentile on all aspects and significantly on stroke education, EMS
activation, instructions of follow-up care and instructions on medications.
Staff compliance in regards to stroke education requirements also increased 80% from June 2012Dec. 2012 (n= 25) to 100% from Jan. 2013-Oct. 2013 (n=23). Baseline Press Ganey scores on
stroke category were at 52.8 % as of 3rd quarter 2012 and 84% for the 4th quarter. As of 2013, the
Press Ganey scores were at 89.6% and 92.6 for the 1st and 2nd quarter respectively. The stroke
readmission rate for this microsystem started with an average of 1.83 for the first quarter and has
remained at zero for the rest of 2013.
Conclusion:
A stroke system of care comprises of a comprehensive and diverse approach that address all
aspects of stroke. The CNL role is part of a comprehensive interdisciplinary collaboration that
impacts stroke patients and streamlines nursing care at THD. Along with this role comes
leadership and competency skills to integrate and coordinate care so that stroke patients can
receive positive outcomes. Through a comprehensive and integrated approach, debilitative effects
of strokes are minimized and understanding of the disease process is maximized so patient's level
of understanding is increased for better health management. As this study has shown, the CNL
takes the lead in ensuring that process changes from bedside to hospital to community is
sustainable to deliver the best stroke evidence-based care to patients and families that is being
served. Clearly, overall stroke care has improved at Texas Health Dallas due to the efforts of an
interdisciplinary collaboration of which a Clinical Nurse Leader is a part of, as the journey for
Comprehensive Stroke Center (CSC) certification continues.
Abstract title: The Road to Advanced Heart Failure Certification: A Cross-Continuum Approach
Author Name & Credentials: Rebecca Valko MSN, RN, CNL & Kristy Todd MSN, FNP-BC,
RN-BC
Institution: Mercy Health- Saint Mary's
City/State: Grand Rapids, MI
Primary Contact Email: [email protected]
Background Information:
Heart Failure (HF) is one of the main chronic diseases currently targetted by The Joint
Commission (TJC), Centers for Medicare & Medicaid Services (CMS) and many value-based
payment initiatives. The average total lifetime cost of treating a heart failure patient is
$109,541—but 76% (nearly $84,000) is due to inpatient costs. Heart Failure accounts for more
than 700,000 hospitalizations every year and is associated with high rates of mortality and
morbidity. With changes in reimbursement for readmissions and quality of care, hospitals will see
decreasing payment from CMS and private payers if they do not address this complex disease.
The mission of the Heart Failure Collaborative at Mercy Health-Saint Mary's is to achieve
positive outcomes by implementing evidenced-based practices to improve the care and
coordination of services across inpatient and outpatient settings. The efforts of this program
70
focuses on adult heart failure patients including inpatient and outpatient services, and transitions
of care with coordination across the continuum.
Aim:
The goals of the collaborative are to address all three components of the Triple Aim: decrease cost
by decreasing length of stay and re-admissions, and provide superior quality and service.
Additionally, standardization of heart failure management and patient education using evidence
based practices across the continuum were addressed and improved.
Methods/Programs/Practices:
The Mercy Health-Saint Mary's Heart Failure Collaborative started meeting monthly in early
2012. The inter-disciplinary team is comprised of physicians (primary care providers,
hospitalists, emergency physicians and specialists such as palliative care and cardiology), nurses
(Clinical Nurse Leaders (CNLs), advanced practice and staff nurses), pharmacist, dietician,
transition coordinators, clinical documentation specialists, ambulatory practice nurses and home
health care.
The program consists of utilizing evidence-based practice and collaborating with staff across the
continuum. The following components have been addressed: follow up appointments are made
prior to discharge, post discharge phone calls made to patients within 72 hours and again as 2-3
weeks post discharge, HF algorithm for outpatient use, and implementation of MIPCT (Michigan
Primary Care Transformation) care managers at outpatient offices. The cross-continuum team met
separately to map out the navigation of the HF patient across the care continuum to gain a greater
understanding of all of the roles and responsibilities.
Inpatient care of the patient with HF was improved by: clustering of HF patients on specific units,
involvement of case management to ensure all eligible patients received home health
care/telemonitoring after discharge, collaboration with transition coordinators to have post
discharge appointments made prior to discharge, revision of HF patient education (stoplight tool
added), and development of Power Plans for the ED and inpatient. Additionally, RNs and
physicians received updated education on the care of the HF patient.
Outcome Data:
Mercy Health-Saint Mary's received Bronze Achievement Award for “Get with the Guidelines”
Heart Failure from the American Heart Association (AHA) in December 2012. Then received
Silver Achievement Award for “Get with the Guidelines” Heart Failure from the AHA in August
2013.
Most importantly, Advanced Heart Failure Certification was achieved after The Joint
Commission visit in August of 2013-Pending award presentation in near future. Mercy HealthSaint Mary's will be the second hospital in Michigan to be awarded this honor.
Additionally, there has been decreases in length of stay and increases in the percentage of follow
up appointments being scheduled, follow up discharge phone calls and patients being discharged
with home health when they have a diagnosis of heart failure. The integration of palliative care
has been another core element of this program to allow early intervention and understanding for
patients and families as the disease progresses in later stages.
Conclusion:
71
Our cross-continuum approach was essential to the success of our receiving Advanced Heart
Failure Certification in August 2013. The strength of our relationship with Palliative Care, Home
Care, MiPCT and Transition Coordinators were highlights of our program. Additionally, CNLs
and CNSs have important roles to facilitate teams and use process improvement strategies to
achieve excellent outcomes for our patients with heart failure.
72
Abstract title: Implementing the Clinical Nurse Leader Role to Improve Outcomes: A
Leadership Model Centered on Innovation, Efficiency, and Excellence
Author Name & Credentials: Denise M. Wienand MEd, MSN, RN, CNL; Prachi Shah MSN,
RN, CNL; Brandy Hatcher MSN, RN, CNL; Alison Jordan MSN, RN, CNL, Jen Grenier MSN,
RN-BC; Angela Cooper MSN, RN,CNL; Rachel Start MSN, RN
Institution: Rush Oak Park Hospital
City/State: Oak Park IL
Primary Contact Email: [email protected]
Background Information:
The Clinical Nurse Leader (CNL) role at ROPH is a new nursing leaderhsip role that has been
implemented to improve the delivery of health care across the continuum. There is a great need
for utilizing the Clinical Nurse Leader (CNL) as part of a microsystem as part of an innovative
73
care delivery model which utilizes evidence in order to address patients' needs and demonstrate
measurable improvement in patient satisfaction and quality outcomes. The implementation and
pilot of the new care model utilizing the CNL was put in place using best practices to drive care
for improved patient outcomes and staff satisfaction. The CNL role has been proven at ROPH to
help provide for improved staff and patient outcomes and quality as well as providing a more
cost-effective approach to healthcare using best practices.
Aim:
Current literature regarding current uses of the Clinical Nurse Leader as part of a microsystem
was reviewed to determine use of the CNL as a leadership role involved in decision making.
Goals and interventions to be described are based on current evidence based practices to decrease
length of stay and readmissions for heart failure patients. The presentation will aim for the
learners understanding of how strategies were created, the actual implementation, strategies for
review and change, and what the development of the CNL role to go hospital wide. Further, the
presentation will discuss the implementation of the Innovation Unit and use of the CNL as the
interdisciplinary coordinator. Presenters will aim for comprehension of how the CNL role was
successfully integrated and implemented throughout the hospital as well as data and outcomes.
Methods/Programs/Practices:
Strategies which include CNL led interdisciplinary rounding, CHF focused patient education,
TeachBack, and increased staff education regarding meeting Core Measures will be presented.
New patient educational folders were implemented and used for all teaching of heart failure
patients; patient specific education using TeachBack methods implemented as well, and staff
education regarding Core Measures provided at change of shift to all staff. CNL Interdisciplinary
Rounds were implemented to encourage increased collaboration among all members of the
interdisciplinary team. Using the PDSA cycle, after the initial six month Innovation Unit trial
period, changes were made to scheduled times for the CNL to be present, the addition of
additional disease specific patient educational materials, the implementation of TeachBack for all
patients, and the use of the CNL's to follow all CMS Core Measures.
Outcome Data:
Quarterly data collection from October, 2012 through current time will be provided. Graphs and
charts will be used to display the outcomes of specific data. Explanation of goals, interventions,
and measurements for data collection will be discussed. Innovation Unit goals are: to increase
collaboration and satisfaction among all members of the multidisciplinary team, enhance patient
education, decrease average length of stay (ALOS), decrease 30-day readmission rates, improve
HCAHPS scores, and CMS Core Measures. Data collection has been completed pre-innovation
unit and is currently being continued.
Some significant data includes, HCAHPS "Rating of the Telemetry Unit (from 0 to 10)" has gone
up to 76% (August 2013) and is currently at 100% (September 2013) from an average score of
73.0% (July to September 2012) pre-innovation unit. Overall length of stay of the innovation unit
decreased from 4.3 days (September 2012) pre-innovation unit, to 4.0 days (January 2013), and
further decreased to 2.67 days (August 2013). Also, a tremendous drop has been witnessed in the
readmission rate for the heart failure patients which was our initial disease specific group that the
CNL focused on. The rate has dropped from 29.4% (November 2012) to 12.5% (December
2012), and more recently to9.0% (April 2013).
Conclusion:
Positive outcomes have been shown to date since the initial go-live date of October 1, 2012.
Through the implementation of the CNL role, data collected has shown decreased ALOS and
improvements in outcomes such as CMS Core Measures, quality indicators specified (such as
74
falls, pressure ulcers, central line infections, and UTI’s), and HCAHPS scores. Subjective data
has shown an increase in overall staff satisfaction and increased knowledge base of staff.
Implications for the future include further development of the CNL role into ROPH’s patient care
model hospital-wide.
75

アメリカにおける救急看護の現状と将来 M.M.McMahon, RN,CEN,NP

Career Spotlight Interview with Hollee

MEDIA RELEASE - Leicestershire Partnership NHS Trust

Recruitment of Staff Nurse in Palliative Care under JIVDAYA Project

Nurses for Nursing Homes throughout the United Kingdom

RE: Contact via Florida | Board of Nursing - Nursing

turnberry cnl sensor

Tuition Fees - Passaic County Technical Institute

Get back to everyday life after your cancer treatment. Listen to

GUAM COMMUNITY COLLEGE LPN – Quarterly Report April – June