improving quality of hospital care using clinical nurse leaders grace sotomayor, mba, msn, rn,...
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Improving Quality of Hospital Care using Clinical Nurse Leaders
Grace Sotomayor, MBA, MSN, RN, FACHE, NEA-BC, CNL
Chief Nurse Executive, Carolinas Medical Center Nov 02, 2012
Content
• Background
• Process
• Goals
• Current Deployment of CNLs
• Results to Goals
• Other Results
• Questions
CHS
• >10.5m patient encounters /year in >800 care sites across the Carolinas
• 2,800 Physicians and ACPs• Primary Care Network with 3m active patients• 60,000 employees
Mission: To create and operate a comprehensive
system to provide healthcare and related services,
including education and research opportunities, for the
benefit of the people it serves.
Carolinas Medical Center
CMC
• 893 beds
• Level 1 Trauma Academic teaching facility
• Multiple Hallmarks designated units
• Multiple TJC DSC designations
• Council structure for Nursing Shared Governance since 2003
• Magnet submission entered Aug 01, 2012
CMC Nursing Practice Model
7
CNL
• Masters prepared generalist nurse
• Preparation Foci:• Practice is at the microsystems level
• Client care outcomes are the measure of quality practice
• Practice guidelines are based on evidence
• Client centered practice is intra and interdisciplinary
• Information will maximize self care and client decision making
• Nursing assessment is the basis for theory and knowledge development
• Good fiscal stewardship is a condition of quality care
• Social justice is an essential nursing value
• Communication technology will facilitate the continuity and comprehensiveness of care
• The CNL must assume guardianship for the nursing profession
CNL
• Role areas• Clinician
• Outcomes Manager
• Client Advocate
• Educator
• Information Manager
• Systems Analyst/Risk anticipator
• Team Manager
• Member of a profession
• Lifelong learner
• Programs in NC: UNC, Queens University
Why CNL?
• Linkage between education and outcomes
• Performance on Nurse Sensitive Indicators critical for patient quality/safety and reimbursement
• Nursing Leadership philosophy• Direct care nurses need to be well educated
• Direct care nurses know best how to improve nursing care
Implications for Nursing
• IOM Report on Future of Nursing
Implications for Nursing
• IOM Report on Future of Nursing
Implications for Nursing
• IOM Report on Future of Nursing
CNL Role
Planning
• 3 year Duke Endowment matching grant funds: 36 CNLs for adult Medical Surgical units at CMC
• Partnered with Queens University, Charlotte for curriculum development• 38 credits
• Created PCL course to jump start process• 2 days: Health Care Reform, Finance, Quality, Change Management,
Case Management, CNL Role
• PCLs take course at CMC in final year of school
• Candidates selected carefully, must want to work in direct care
PI Goals
By Dec 2012:
•Quality• Zero falls with injury
• Zero HAPU
•Cost• Turnover- annual rate 12% or less in med-surg units
•Satisfaction• Inpatient satisfaction: overall Quality of Care 90th%ile
• NDNQI RN Job satisfaction >60
Implementation
• Information sessions for staff and managers
• AACN White Paper on CNL role
• Visited USF and Baycare: Morton Plant Mease
• Attended annual CNL meetings co-sponsored by VA and AACN
• Changed care delivery model on targeted units to be budget neutral
• Implemented 8 hr /5 days/week model on day shift as “ Attending Nurse “ in ~ “12 bed hospital”
• Partnered with Dartmouth for Micro system learning
Budget Neutrality
Key Points
•Did not want role to be additive exposing it to potential deletion in the future
•Work of CNL to be part of the nursing workflow at the bedside
•The CNL is a direct care nurse with advanced skills
•Assignments restructured by direct care staff on each unit to accommodate the CNL
•Transitioned from Action OI as benchmarking vendor to Premier in 2011
9.08
9.59 9.73 9.66 9.79
10.47
9.9310.14
10.77
9.559.77
10.86
10.039.71
10.26
9.399.69
11.45
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
3T 4T 5T 9T 11T 11A
Bu
dg
eted
WH
PP
D
2009 2010 2011
Current CNL Deployment Total 22 YTD 2012
• 3T 1 year 36 beds; Full complement of 3 CNLs since August, 2011
• 4T 2 months 36 beds ; Full complement of 3 CNLs since August, 2012
• 5T 1 year 36 beds ; 2 CNLs since December, 2011; Full complement of 3 CNLs since April 2012
• APC 2 years 13 beds ; Full complement of 2 CNLs since August, 2010. One CNL working in Women’s meso- system and one in HROB
• 9T 1 year 36 beds ; Full complement of 3 CNLs since August, 2011
• 10A 0 36 beds. 3 PCLs
• 10T 10 months 36 beds; 1 CNL on evening shift since January 2012; 1 CNL since Aug 2012; remainder 2 PCLs
• 11A 1 year 24 beds; 2 CNLs since August, 2011; Full complement of 3 CNLs since August, 2012
• 11T 1 year 36 beds; 1 CNL since August, 2010; Full complement of 3 CNLs since December, 2011
CNL Process
• Ensure EBP at bedside
• Bedside report
• Hourly rounding
• Pain management
• Teaching on the spot
• Galvanize the inter professional team
• 5P Assessment
• Care planning
• Physician rounding
• Lean huddles
• Lead PI
• Teaching strategies, clinical care, Throughput
• PI team participation e.g IPE, Transitions, ADOD
Template for 5P AssessmentThe 5Ps: Purpose, Patients, Patterns, Processes , Professionals
Results
Falls/1000 Patient Days
1st cohort graduated
Falls/1000 Patient DaysAll CNL units
4.91
5.63 5.485.76
5.08 4.994.36 4.32 4.22
3.843.58
4.08
2.192.47
2.8
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
1Q09 2Q09 3Q09 4Q09 1Q10 2Q10 3Q10 4Q10 1Q11 2Q11 3Q11 4Q11 1Q12 2Q12 3Q12
CNL Only units Goal
Favorable
N
2nd cohort graduated
3rd cohort graduated
Falls with Injury/1000 Patient Days
1st cohort graduated
2nd cohort graduated
3rd cohort graduated
Hospital Acquired Pressure Ulcers
Hospital Acquired Pressure Ulcers
RN Turnover - 2009
3 Units at or better than goal
RN Turnover - 2010
5 Units at or better than goal
RN Turnover - 2011
5 Units at or better than goal
RN Turnover – 2QYTD Annualized
6 Units at or better than goal
Patient Satisfaction
1st cohort graduated
2nd cohort graduated
3rd cohort graduated
RN Job Satisfaction ( Enjoyment)
Other Indicators
D/C to Home < 120 min of MD Order
Baseline Collected Pre-Canopy Implementation
Data Source: Unit Admission/Discharge Log | Manually entered by Unit Secretary
D/C to Home before 12:00 Noon
Baseline Collected Pre-Canopy Implementation
Data Source: Unit Admission/Discharge Log | Manually entered by Unit Secretary
Next steps
• Complete model on evenings and weekends
• Ongoing education for CNLs: value based purchasing; performance improvement; micro system learning
• Develop novice to expert competencies
• Institute a CNL preceptor program
• Institute a CNL Practice Council
• Develop the CNL as coach
The CNLs – second cohort pinning
Questions?