implementing the clinical nurse leader role: a care model ... · implementing the clinical nurse...

8
August 2015 78 Nurse Leader Implementing the Clinical Nurse Leader Role: A Care Model Centered on Innovation, Efficiency, and Excellence N urses must become full partners with other healthcare disciplines to become involved and take responsibility for identifying system problems. Nurses devise and implement improve- ment plans, track improve- ments over time, and make necessary adjustments as lead- ers who implement change and help improve the healthcare sys- tem. 1 We are facing the dilemma of fragmented healthcare that can only be improved through “new inno- vative care delivery models…that address patient needs and wants, span sites of care, result in more efficient use of resources, and demonstrate measurable improvement in patient satisfaction and quality outcomes over time.” 2 With the implementation of the clinical nurse leader (CNL) role, the innovation unit as developed at Rush Oak Park Hospital (ROPH) addresses current healthcare system concerns, such as the creation of more effective interdiscipli- nary care, point-of-care coordination, and the implementation of evidence-based practice findings. 3 Denise M.Wienand, MEd, MSN, RN, CNL, Prachi R. Shah, MSN, RN, CNL, Brandy Hatcher, MSN, RN, CNL, Alison Jordan, MSN, RN, CNL, Jennifer M. Grenier, MSN, RN-BC, Angela M. Cooper, RN, MSN, CNL, Rachel Start, MSN, RN, and Karen Mayer, MSN, MHA, RN, NEA-BC, FACHE R OPH in Oak Park, Illinois, is a 176-bed, not-for-profit, general medical and surgical community hospital that is a clinical partner of Rush University Medical Center in Chicago. The initial innovation unit was implemented on ROPH’s 24- bed telemetry unit in September 2012.The general population is a diverse, mainly elderly population with patient conditions including congestive heart failure, chronic renal failure, compli- cations of diabetes, sepsis, and pneumonia. The CNL role has been defined as a nurse who is a confi- dent clinician, a leader within a microsystem, and a quality manager. The CNL seeks evidence-based practices and has the ability to analyze system outcomes. 4 Research shows that the use of the CNL as a clinical decision-maker and active member of the interdisciplinary team helps to drive the design and direction of cost-effective, evidence-based care within a microsystem. 5 The CNL role is being explored

Upload: others

Post on 20-May-2020

3 views

Category:

Documents


0 download

TRANSCRIPT

August 201578 Nurse Leader

Implementing the ClinicalNurse Leader Role: A Care Model Centered onInnovation, Efficiency, and Excellence

Nurses must become

full partners with

other healthcare disciplines to

become involved and take

responsibility for identifying

system problems. Nurses

devise and implement improve-

ment plans, track improve-

ments over time, and make

necessary adjustments as lead-

ers who implement change and

help improve the healthcare sys-

tem.1 We are facing the dilemma

of fragmented healthcare that can

only be improved through “new inno-

vative care delivery models…that address patient needs and wants, span sites of care, result in more efficient use of

resources, and demonstrate measurable improvement in patient satisfaction and quality outcomes over time.”2 With

the implementation of the clinical nurse leader (CNL) role, the innovation unit as developed at Rush Oak Park

Hospital (ROPH) addresses current healthcare system concerns, such as the creation of more effective interdiscipli-

nary care, point-of-care coordination, and the implementation of evidence-based practice findings.3

Denise M. Wienand, MEd, MSN, RN, CNL, Prachi R. Shah, MSN, RN, CNL, Brandy Hatcher, MSN,RN, CNL, Alison Jordan, MSN, RN, CNL, Jennifer M. Grenier, MSN, RN-BC, Angela M. Cooper, RN,MSN, CNL, Rachel Start, MSN, RN, and Karen Mayer, MSN, MHA, RN, NEA-BC, FACHE

ROPH in Oak Park, Illinois, is a 176-bed, not-for-profit,general medical and surgical community hospital that is a

clinical partner of Rush University Medical Center in Chicago.The initial innovation unit was implemented on ROPH’s 24-bed telemetry unit in September 2012. The general populationis a diverse, mainly elderly population with patient conditionsincluding congestive heart failure, chronic renal failure, compli-cations of diabetes, sepsis, and pneumonia.

The CNL role has been defined as a nurse who is a confi-dent clinician, a leader within a microsystem, and a qualitymanager. The CNL seeks evidence-based practices and hasthe ability to analyze system outcomes.4 Research shows thatthe use of the CNL as a clinical decision-maker and activemember of the interdisciplinary team helps to drive thedesign and direction of cost-effective, evidence-based carewithin a microsystem.5 The CNL role is being explored

www.nurseleader.com Nurse Leader 79

today by many practice institutions and employers. O’Gradyand VanGraafeiland6 demonstrated that various uses of theCNL role since its development have helped to reduce thefragmented care in many institutions today. The reduction infragmentation seen in ROPH since the implementation ofthe CNL role has led to improvements in care coordination,quality outcomes, patient satisfaction, and interdisciplinaryrelationships. The role of CNL is unique as compared withthat of the registered nurse (RN) in that CNLs have theknowledge of a bedside nurse combined with the leadershipskills to focus on patient- and family-centered care.6

BACKGROUNDThe innovation unit was developed with the ROPH visionand mission in mind to promote patient- and family-focusedhealth, support, and education throughout a patient’s lifes-pan.7 The Rush Oak Park nursing care delivery model is ateam-based, primary care nursing model for providinghumanistic and focused patient-centered care based on JeanWatson’s Theory on Human Caring.7 The intended missionof the innovation unit is to develop processes for improvingefficiency through the introduction of the CNL role.Processes for improvement were coordinated with all mem-bers of the interdisciplinary team utilizing the latestevidence-based practices. These processes promote theenhancement of patient safety, quality care, and patient andteam satisfaction.

After designating certified CNLs from within the hospitalto lead the innovation unit, hospital outcomes were reviewed.Information analyzed before setting goals included patientand RN satisfaction scores, nurse-sensitive indicators, and thelatest evidence-based information. The innovation unit goalsset were to increase collaboration and satisfaction amongmembers of the interdisciplinary team, enhance patient edu-cation, decrease average length of stay (ALOS), decreasepatient 30-day readmission rates, improve quality indicators(such as falls, pressure ulcers, and central line infections), andsuccessfully implement the CNL role. With these goals inmind, specific interventions were created for the implementa-tion of the innovation unit. The interventions chosen weredaily, CNL-led interdisciplinary rounds, a unit status board,teach-back for heart failure patients, and post-discharge fol-low-up phone calls.

INTERVENTIONSThe admission process initiates the introduction of theCNL to patients and their families to help facilitate thepatient’s progress through the healthcare environment. TheCNL is a critical member of the interdisciplinary team whohelps guide patients through today’s complex healthcaresystem and acts as a resource for solving complex nursing-related problems.4 As new admissions occur, the CNL makescontact with the patient and family to explain his or herrole. Contact information is supplied to patients throughbusiness cards and a pamphlet (Figure 1). The CNLs monitorand help facilitate all patients’ progress toward dischargewhile they are on the unit.

Interdisciplinary RoundsThe interdisciplinary rounds intervention is a collaborative,interdisciplinary, team-based patient rounding process.Rounds are completed at the patient’s bedside and used toshare information and discuss the plan of care with inputencouraged from the patient or family. Patients help identi-fy their preferences related to their goals, care needs, dis-charge planning, and any transition barriers.8 The CNLleads interdisciplinary rounds for all admitted patients on adaily basis (Monday through Friday) and is responsible forreviewing the patient plan of care established by the teamthrough any previous interdisciplinary rounds meetings.The CNL documents the outcome of rounds using theinterdisciplinary rounds note (Figure 2). If the newly admit-ted patient has a diagnosis of heart failure, the CNL alsocompletes the heart failure assessment note to documentwhether heart failure core measures have been met (Figure

Figure 1. CNL Patient Pamphlet

August 201580 Nurse Leader

3). A CNL-developed tool called the Heart Failure Journey(Figure 4) is placed in the patient’s room as a visualreminder for all nurses caring for the patient to ensure thatall heart failure core measures are met before discharge.Journey “reminder” signs were also developed for stroke,surgical care improvement process, acute myocardial infarc-tion, venous thromboembolism, and falls.

During rounds, the RN is responsible for updating theteam about the patient’s diagnosis, morning assessment, andprogress; reviews with the team the patient’s plan of care forthe day; and updates the patient’s information board in theirroom. The pharmacist reviews scheduled medications (indi-cations and side effects) with the patient during rounds andthe case manager reviews discharge plans and any potentialdischarge barriers. The CNL is responsible for facilitatingthe resolution of any issues discovered in rounds regardingthe patient’s plan of care and then obtains an estimateddischarge date.

UNIT STATUS BOARDDuring the unit’s change of shift, the charge RN uses theunit status board (Figure 5) to facilitate a brief discussionregarding patient code status, behavioral or safety risks, pro-cedures, falls, and other indicators being followed. RNs andpatient care technicians (PCTs) use the board to give otherson the unit a subjective look at any status changes in theirworkload throughout their shift. With the use of a coloredmagnet system (red � “I’m swamped,” yellow � “I’m

almost there, just give me another hour,” and green � “I’mgood”), the RN or PCT may update the unit status boardwith any changes. The charge RN or unit clerk is responsi-ble for frequently updating the unit status board with thenumber of anticipated discharges, admissions, transfers, andany changes in patient information. The charge RN is alsoresponsible for coordinating the breaks and buddies (ie, theRNs and PCTs who cover for each other when off theunit) for the shift along with their estimated break times.The unit status board provides staff with a global picture ofwhat is occurring on the unit. The unit status board, whenupdated at the beginning of each shift, is a shared processand visual indicator for managing breaks, staff workloads,patient flow, and patient status.9

HEART FAILURE TEACH-BACKAt the time of admission, the CNL will have identifiedpatients who have been admitted with a diagnosis of heartfailure.10 The CNL educates those patients about the heartfailure teach-back intervention and reviews informationcontained in patient education folders developed specificallyfor heart failure patients.

During focused heart failure education, the patient maybe asked questions to ensure the teaching has been under-stood. The CNL asks the patient 4 specific heart failureteach-back questions daily to reinforce learning and assesspatient understanding of what has been taught regardingheart failure.11 In teach-back, patients are asked to teach

Interdisciplinary Rounds Note (CNLROUNDS) Comments:

CNL confirmed all team members have introduced themselves by name and role?

CNL/RN: Is patient 30 day readmit? Patient's reason for admit, plan of care, progress towards discharge. Isolation? Fall risk? DM/Stroke/HF education points added?

CNL/RN: Lines that could be removed (Foley, PICC, Central Line).

CNL: Any nutritional issues? A1c>=7.0? Dietician consult ordered?

CNL/RN: reviewed/verified patient's immunizations/injections.

CNL: PT/OT needed? Order placed? PM&R consult necessary?

Pharmacist reviewed the patient's scheduled medications for today. Any medication issues?

CM reviewed where the patient will likely go after discharge/who will be helping with care, needs, and possible discharge barriers.

RN communicated the patient's daily goal(s) and updated the patient's white board.

RN communicated the patient's greatest safety risk.

CNL asked patient/family: any concerns, questions? Has the staff cared for your mental, emotional, and spiritual health?

CNL: Any ethical issues/concerns?

Figure 2. Interdisciplinary Rounds Note

www.nurseleader.com Nurse Leader 81

back the information that has been taught to them, in theirown words, in response to the questions asked. This allowsthe person teaching to understand whether the patient hascomprehended the information and also gives the teacherinsight into whether there is a need for the use of addition-al teaching methods to help aid in comprehension. Heartfailure teach-back is a process designed to focus onimproving patient care and safety by increasing communi-cation. This process allows for assessment of the patients’understanding of information provided by using specificopen-ended disease-related questions.11 The CNL rein-forces heart failure education at admission, at discharge, andagain during a post-discharge follow-up telephone callusing the heart failure teach-back process. The CNL docu-

ments the ability of the patient to answer teach-back ques-tions through the completion of the heart failure teach-back note (Figure 6).

TRANSITIONS ADVOCATEAs a patient advocate, the CNL helps patients make asmooth transition from hospital to home. In addition, theCNL keeps the patient processes moving along post-dis-charge. The CNL role allows better facilitation of progressthrough the continuum of care with the coordination ofkey activities.12 The CNL acts as a partner with thepatient’s attending physician to determine the necessity offollow-up appointments and then schedules a follow-upappointment with the patient’s primary care physician or

Heart Failure Assessment Note (CNLHFASSESS) Comments:

Patient specific discharge instructions for diet and activity ordered?

LVS function assessment completed?

If LVS function assessment is not required, has the reason been documented?

For patients with LVEF < 40%, ACE-Inhibitor/ARB prescribed at discharge?

If ACE/ARB is not prescribed on discharge, is contraindication documented?

Figure 3. Heart Failure Assessment Note

Figure 4. Heart Failure Journey

August 201582 Nurse Leader

physician’s office if necessary. The CNL is responsible forcontacting all heart failure patients post-discharge to assesspatient satisfaction and understanding of their diagnosis,education, and self-care. With the use of an outpatientelectronic medical record charting system made availableto the CNL, telephone follow-up phone calls are complet-

ed and documented through the CNL discharge phonecall note (Figure 7). Calls are made weekly until 30 dayspost-discharge. Furthermore, the CNL has the ability tofollow up with the attending physician through e-mail tocommunicate any questions or concerns that the patientmay have post-discharge.

Figure 5. Unit Status Board

Heart Failure Teach Back Note (CNLHFTB) Comments:

What is the name of your water pill?

How much weight gain would you want to report to your healthcare provider?

What high-salt foods do you need to avoid/be aware of?

Can you name 3 to 4 symptoms in the yellow zone (warning signs of when you want to call your healthcare provider)?

Time Spent Teaching

Patient Orientation

Score

Figure 6. Heart Failure Teach-Back Note

PROJECT MEASURESTo determine the success of the innovation unit, specific meas-ures were defined to determine whether the interventions haveled to positive outcomes. Project-wide measures include deter-mining whether there is an increase in collaboration and satis-faction among all members of the multidisciplinary team.Collaboration and satisfaction was measured with the use ofthe Healthcare Team Vitality Instrument tool,13 which wasadministered before the implementation of the innovation unitand 1 year post-implementation.14 Other project-wide meas-ures to be used in determining positive outcomes that indicatesuccessful implementation of the CNL role were measuressuch as HCAHPS scores, core measures, ALOS, and 30-dayheart failure readmission rates provided by the Rush Oak ParkQuality department. Measures are used to determine whetherthe innovation unit helped to enhance patient education,

decrease the ALOS, improve specific quality indicators, andimprove overall satisfaction.

OUTCOMESThe care model change was implemented October 1, 2012,on our telemetry unit. Through the implementation of theCNL role, data collected have shown improvements in alloutcomes: decreased ALOS and improved CMS core meas-ures, reduced quality indicators (falls, pressure ulcers, cen-tral line infections, and urinary tract infections), andincreased HCAHPS scores (Figure 8). Subjective data haveshown an increase in overall staff satisfaction and anincrease in the knowledge base of staff. On the initial unit(telemetry), the readmission rate for heart failure patients(Figure 9) dropped from 23.5% (October 2012) to 7.1%(February 2014). On our medical-surgical unit, where the

www.nurseleader.com Nurse Leader 83

Discharge Phone Call Note (CNLDCCALL) Comments:

Have you experienced any new symptoms or have previous symptoms worsened?

Did you receive a discharge summary and have you reviewed it?

Do you have an appointment with your primary care physician for follow-up? Have you had your follow-up appointments?

Are you waiting for any follow-up tests?

Are you receiving any type of home care?

Has your home health provider contacted or visited you yet?

Has your transition back to home been difficult?

Do you have questions about your medications?

Were you able to fill all of your prescriptions?

Are you having any problems with your medications (headaches, dizziness, nausea)?

Are you weighing yourself daily?

What is the name of your water pill?

How much weight gain would you want to report to your healthcare provider?

What high-salt foods do you need to avoid/be aware of?

Can you name 3 to 4 symptoms in the yellow zone (warning signs when you want to call your healthcare provider)?

Is the patient advised to call PCP or specialist physician?

Is the patient advised to go to the ED?

Need to call MD and call patient back?

Need to call outpatient pharmacy and call patient back?

Figure 7. Transitions Advocate Discharge Phone Call Note

CNL role was initiated in October 2013, data have shown adecrease in ALOS (Figure 10) from 5.73 days (October2013) to 4.85 days (May 2014). Data collection has beenongoing for both the telemetry and medical-surgical unitswith consistent improvements on both units being realized.This was a cost-effective strategy because the care model

was designed without adding any additional full-timeequivalent personnel.

DISCUSSIONWith the implementation of the CNL role, the innovation unitdeveloped at ROPH helps to address current healthcare system

August 201584 Nurse Leader

60

65

70

75

80

85

90

95

100

HCAHPS Telemetry-Communication with RN's

Communicationw/t RNs

Linear(Communicationw/t RNs)

Figure 8. HCAHPS Telemetry-Communication With RNs

23.5

45.4

9.0

7.1

8.3

22.2

9.1

19.0

13.3

21.4

9.0

8.0 10

.0

7.1

0

5

10

15

20

25

30

35

40

45

50

Oct

-12

Nov

-12

Dec-

12

Jan-

13

Feb-

13

Mar

-13

Apr-

13

May

-13

Jun-

13

Jul-1

3

Aug-

13

Sep-

13

Oct

-13

Nov

-13

Dec-

13

Jan-

14

Feb-

14Telemetry Heart Failure Readmission Rate

Rate (%)

Linear (Rate (%))

Figure 9. Telemetry Heart Failure Readmission Rate

www.nurseleader.com Nurse Leader 85

concerns through the interventions implemented. Throughoutthe implementation process, a learning process has occurred andchallenges have been encountered and addressed. Overall, theimplementation of the CNL role has led to improved outcomes.Precise data collection and review continue to help in under-standing how to further develop and fully integrate the CNLrole hospital-wide so that nursing can continue to use the latestevidence-based care while coordinating with all members of theinterdisciplinary team, promoting the enhancement of safety andquality patient care, and improving patient and team satisfaction.Using the CNL role to meet today’s healthcare challengesshould be synonymous with becoming a pivotal leader inchange in an ever-changing, complex healthcare system. NL

References1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing

Health. Washington, DC: National Academies Press; 2011.2. Kimball B, Joynt J, Cherner D, O’Neil E. The quest for new innovative care

delivery models. J Nurs Adm. 2007;37:392-398. 3. Buerhaus P, Ulrich B, Donelan K, DesRoches C. Registered nurses’ perspec-

tives on health care and the 2008 presidential election. Nurs Econ.2008;26:227-235.

4. Smith SL. Application of the clinical nurse leader role in an acute caredelivery model. J Nurs Adm. 2006;36(1):29-33.

5. Lammon CA, Stanton MP, Blakney JL. Innovative partnerships: the clinicalnurse leader role in diverse clinical settings. J Prof Nurs. 2010;26:258-263.

6. O’Grady EL, VanGraafeiland B. Bridging the gap in care for children throughthe clinical nurse leader. Pediatr Nurs. 2012;38:155-158, 167.

7. Rush Oak Park Hospital. Mission, Vision and Values. 2012.http://roph.org/about/mission.html. Accessed August 1, 2012.

8. Institute for Healthcare Improvement. How-to guide: multidisciplinaryrounds. Available at: http://www.ihi.org/resources/Pages/Tools/HowtoGuideMultidisciplinaryRounds.aspx. Accessed July 8, 2012.

9. Lee B, Shannon D, Rutherford P, Peck C. Transforming care at the bedsidehow-to guide: optimizing communication and teamwork. Available at:http://www.ihi.org/resources/Pages/Tools/ TCABHowToGuideOptimizingCommunicationTeamwork.aspx. Accessed July 8, 2012.

10. Institute for Healthcare Improvement. How-to guide: improved care for patientswith congestive heart failure. Available at: http://www.ihi.org/resources/Pages/Tools/HowtoGuideImprovedCareforPatientswithCongestiveHeartFailure.aspx.Accessed July 8, 2012.

11. White M, Garbez R, Carroll M, Brinker E, Howie Esquivel J. Is "teach-back"associated with knowledge retention and hospital readmission in hospitalizedheart failure patients? J Cardiovasc Nurs. 2013;28:137-146.

12. Agency for Healthcare Research and Quality, Boston University. An overviewof the reengineered discharge (RED) toolkit. 2011. Available at:https://www.bu.edu/fammed/projectred/newtoolkit/1.%20An%20Overview%20of%20the%20RED%20toolkit%203.2.11.pdf. Accessed July 2, 2012.

13. Lee B, Upenieks V. Healthcare Team Vitality Instrument. 2011.http://www.ihi.org/knowledge/Pages/Tools/HealthcareTeamVitalityInstrument.aspx. Accessed August 8, 2012.

14. Upenieks VV, Lee EA, Flanagan ME, Doebbeling BN. Healthcare team vitalityinstrument (HTVI): developing a tool assessing healthcare team functioning.J Adv Nurs. 2010;66:168-176

Denise M. Wienand, MEd, MSN, RN, CNL, is Clinical NurseLeader Liason at Rush Oak Park Hospital in Oak Park, Illinois.She can be reached at [email protected]. Prachi R.Shah, MSN, RN, CNL, is Performance Improvement Specialist atRush Health in Chicago, Illinois. Brandy Hatcher, MSN, RN,CNL, is Clinical Nurse Leader at Rush Oak Park Hospital inOak Park, Illinois. Alison Jordan, MSN, RN, CNL, is ClinicalNurse Leader at Rush Oak Park Hospital in Oak Park, Illinois.Jennifer M. Grenier, MSN, RN-BC, is Unit Director, Telemetry atRush Oak Park Hospital in Oak Park, Illinois. Angela M. Cooper,RN, MSN, CNL, is Unit Director, Intensive Care Unit at RushOak Park Hospital in Oak Park, Illinois. Rachel Start, MSN, RN,is Magnet Program Coordinator at Rush Oak Park Hospital inOak Park, Illinois. Karen Mayer, MSN, MHA, RN, NEA-BC,FACHE, is Vice President, Patient Care Services at Rush OakPark Hospital in Oak Park, Illinois.

1541-4612/2014/ $ See front matterCopyright 2015 by Elsevier Inc.All rights reserved.http://dx.doi.org/10.1016/j.mnl.2014.11.011

5.38 5.4

5.73

5.53

4.9

5.6

4.88 4.78

4.91 4.85 4.85

4.2

4.4

4.6

4.8

5

5.2

5.4

5.6

5.8

6

Jul - 13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14

Medical-Surgical Unit: Average Length of Stay (Days)

5.535.535.6

CNL Role Implemented

Figure 10. Medical-Surgical Unit: Average Length of Stay in Days