March, 2012 - Update
Notable Nursing: Update - March, 2012
Peds Patient Education Study Finds RNs Want to Teach, Need Tools
Patient education is an important part of nursing care, particularly in the field of pediatrics. However, the quality of teaching among all specialties can differ from one nurse to the next reflecting the individual’s knowledge and expertise. These are important care considerations since research shows that patient teaching effects patient outcomes.M
To test a theoretical patient education model, nurses at Cleveland Clinic explored the potential impact of knowledge, expertise and confidence in the knowledge of patient-education content, and their teaching strategies using a descriptive design and a sample of pediatric nurses.
“Our discharge satisfaction surveys were showing a deficiency in getting adequate information to our parents about why their child was admitted or home-going care for their illness,” says Meredith Lahl, MSN, PCNS-BC, PNP-BC, CPON, Senior Director of Advanced Practice Nursing at Cleveland Clinic. “In addition, we don’t always have specialized nursing areas available. You could see a surgical patient and two chronically ill children one day and the next be caring for a child with cancer and one with heart disease.”
Trying to make RNs expert in these areas, and helping them become comfortable teaching what families needed to know, was challenging. To address these concerns, a survey of the nursing staff was completed to assess teaching comfort level across multiple diagnoses.
“At Cleveland Clinic we have some pretty sick kids coming our way,” says Sandra L. Siedlecki, PhD, RN, CNS, Senior Nurse Researcher in the Department of Nursing Research & Innovation at Cleveland Clinic’s main campus. “Our patients have needs that are more complicated. We don’t know what we don’t know, which is the reason this study was undertaken.”
Surveying Nursing Needs
The survey of RNs at Cleveland Clinic’s main campus and Children’s Hospital included most of the diagnoses that are seen on Cleveland Clinic pediatric units. Those responding were asked to rate how comfortable they felt doing the required teaching for each of these diagnoses. They were also asked about where they felt the problems were.
“We found our nurses were comfortable with common disorders such as asthma or pneumonia,” notes Siedlecki. “The problem is that we are no longer admitting children with asthma and pneumonia as often as we used to. The conditions that are now putting children into the hospital are diseases such as cancer and heart disease. These very special and complex diagnoses were those the nurses felt least comfortable teaching.”
The survey results suggested the need for more specialized training of the nurses. Among the other findings was that there was a critical lack of teaching resources to help with the process.
Continuing Education & Teaching Resource Needs
One early decision was to make changes in the continuing education programs offered to nurses. Working with this information, nurse educators were in a better position to address knowledge deficits. Using the experts available at Cleveland Clinic, in-services were made available to help nurses become familiar with the patient-teaching needs of more complicated patients.
“Nurses can complete the physical tasks with no problem,” says Lahl. “But, communicating that to the parents takes another skill set altogether. You can know it in your head, but communicating that to another person isn’t easy.”
It was also recognized early in the process that there was a need to develop a wider variety of patient teaching resources.
“We spent a significant amount of time creating and/or updating handouts, videos, brochures, and other education components to give our parents,” explains Lahl. “We felt this could be completed very quickly and would really help our nursing staff. There was not a lot available before we identified the need.”
The results also showed that RNs were taking these concerns seriously. As a group, their responses found that nurses believed patient education was their responsibility and that they should be held accountable for outcomes.
“What effects teaching potential are the available resources and also the expertise and knowledge of the nurses,” says Siedlecki. “The more we do to improve our teaching potential, to increase the quality of what we teach, and how we teach, the better our patient outcomes become. That is the bottom line.”
Notable Nursing: Update - March, 2012
Nursing Helps Find $10 Million in Supply Chain Savings
It was a daunting task when they got their marching orders.
“Two years ago we were challenged to carve $100 million from Cleveland Clinic’s supply chain,” says John Cicero, Director of Clinical Sourcing & Supply Chain Management for Cleveland Clinic. “If we were successful, it would dramatically affect costs going forward.”
To find the savings, a Product Evaluation Committee was formed involving the main campus and all of Cleveland Clinic’s regional hospitals. An integral part of this effort are representatives from nursing.
“This touches so much of our patients’ lives,” says committee member James Bryant, MSN, RN, CEN, CCRN, NEA-BC, Associate Chief Nursing Officer, Clinical Practice/Emergency Medicine at Cleveland Clinic. “Everything from gauze sponges to complex drainage systems for post-surgical wound management falls within the supply chain.”
It soon became apparent to the committee that there was little unified purchasing. Each hospital had pockets of people looking at supply issues. This often meant some hospitals used a certain product line while the rest used another.
“We assembled a group from many different areas, both inside and outside nursing, to form a single point for making supply-related decisions,” notes Cicero. “By codifying an integrated approach, once products are endorsed, we only have to talk to the vendor about price.”
The committee meets the second Tuesday of every month. Nursing representatives from each hospital throughout the system are included from areas such as infection control, wound care, or education departments to augment the core as needed.
Before the meeting, a packet is sent out containing the meeting agenda and other support information. They also include sample products the members can test, such as when the committee spilled milk to check the absorbency of different gauze sponges.
Committee members communicate their work and get feedback from the nursing units. If they find a concern, it is brought back to the main group for consideration.
After research is complete, and the committee reaches a consensus that a product or products will be useful, the next step is meeting with vendors to talk price. In some cases, only one product is acceptable. In others, there may be multiple versions approved and the vendors participate in spirited bidding to get the contract.
Clinical Use as Important as Savings
“The last thing we want to do is make a change only for the savings,” stresses Bryant. “We also want a product that is best for our patients and does the job clinically.”
The duties of the committee do not stop at product approval. New products will often be piloted on the main campus and in the community. If needed, the group works with nursing educators to meet those needs.
There have already been major successes resulting in over $10 million in savings during the first two years. The committee’s look at admission packets resulted in savings of $261,000, mostly by deciding some items were not needed. Gloves are another area where the initiative saved nearly $500,000, in this instance, because many makers were acceptable, vendors were forced to compete for the business on price.
Standard Supplies, Standard Policies
As the committee’s mission has evolved, nursing has found that standardizing supplies also allows for standardization of policies and procedures. This makes it easier to move staff around and opens up opportunities for nurses to move between the hospitals with a much smoother transition.
“This has been an opportunity to partner with groups nursing has not always worked with in the past,” says Bryant. “Nurses gain insight into the sheer volume of purchasing done by Cleveland Clinic and the supply chain people get a look at the concerns seen at the bedside.”
Notable Nursing: Update - March, 2012
New Roles, New Opportunities for Advance Practice Nurses
As the Director of Community Outreach at Langston Hughes Community Health Center, Michelle Berkley Brown, MSN, CNP, views her role as fundamental in breaking down barriers with a community that has historically had difficulty accessing optimal health care. You can feel her excitement as she tells you about her role.
"I look at my role and the health center as the entrance to our healthcare system," she says. "For so many years, healthcare has been intimidating to the population we are serving, especially the minority population." Berkley-Brown completed her advanced nursing degree in 1999, and for more than a decade she has been involved in start-up healthcare programs in Cleveland’s minority communities. After graduation, Berkley-Brown worked in an HIV/AIDS program, jointly developed between Cleveland Clinic and Antioch Baptist Church.
"The program was one of the first faith-based programs in the country targeting HIV/AIDS under President Clinton," she continues. Berkley-Brown shines as she describes her role in getting the program running. As a result of her efforts, after three years the program became a national model for others to follow.
Next, she was hired to start up Cleveland Clinic Youth Wellness Center, which she managed alone. "My learning curve went right up." And this prepared her for the development and start up of the Langston Hughes Community Health Center that she currently manages. Asked where she sees her most important contribution as an advanced practice nurse, she says: "The biggest impact is in empowering the underserved to take better care of themselves. I am in a unique position to do that."
Berkley-Brown takes time to point out how essential this work is. "I am very passionate about it. There is so much more than just the clinical aspect." She considers a focus on wellbeing, prevention and patient empowerment as high priorities for at-risk, underserved communities. In her role at the Wellness Center, she makes concerted efforts to break down fears about the healthcare system and also teaching patients how to navigate it. "Disparities exist because there's a lack of knowledge of how to access the services," she explains.
Support of Berkley-Brown and her APN colleagues through continuing education courses is an effort that Cleveland Clinic takes seriously. In February, the first Endocrinology Education Day for Nurses Review Program took place and an APN Education Day is scheduled in March.
"Cleveland Clinic gives us the opportunity to continually learn, and makes it easy and convenient to earn our CEUs by bringing it to us," Berkley Brown adds. “By attending, we meet our colleagues that we can learn from."
Sara Omidi, MSN, RN, C-ANP, Education Committee Chair, at Cleveland Clinic’s Endocrinology Metabolism Institute (EMI) talks about February's APN Annual Endocrine Review Day. "We noticed the lack of a workshop that specifically addressed endocrine disorders and wanted to provide APNs with high-quality evidence-based information so that they could provide better state-of-the-art patient care." Omidi organized efforts to make the 2012 Endocrine Review Day a success.
"It took a year of careful planning, several meetings, and discussions to get this going," she says. "We invited leading experts to present new findings in patient care and research." Omidi was thrilled by the overwhelming response. Looking ahead, she says: "We are hoping to build on our experience from this year's event and open our educational workshop to all APNs at other healthcare facilities as well."
Notable Nursing: Update - March, 2012
Nurse Communication: The Key to Improving HCAHPS Scores
The message has been clear since the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey in 2006: nurses are the gateway for improving the patient’s overall hospital experience. This imperative has not gone unnoticed by Cleveland Clinic’s Nursing Institute as it began numerous nursing initiatives in 2010 to address patients’ needs.
First and foremost of the HCAHPS survey’s 18 core questions about critical aspects of patients’ perception of their hospital experiences are queries regarding the nurses and doctors overall effectiveness of communication and responsiveness. To address this, nurse managers and their nursing staff throughout Cleveland Clinic’s system were trained on the four key hourly rounding behaviors and language including: introduction (tell the patient your name and your role); explaining the purpose of rounding (for the first visit); assessing the “four Ps” – pain, position, potty (toileting needs); and possessions/personal items. While similar to others’ efforts nationally, Cleveland Clinic is setting itself apart due to its committed attention to making rounding “purposeful” each and every time it is done.
“There is something called rounding that isn’t,” says Christine Rogen, MPH, RN, Patient Experience Specialist at Cleveland Clinic’s Office of Patient Experience. “It’s one thing to go into a room to see a patient, but it’s having the connecting moment and making yourself available to the patient that is key. Spending the time to ask the patient what else can be done for them and consistently addressing the four Ps makes the rounding purposeful and helps alleviate a patient’s anxiety.”
Not just an isolated unit-by-unit prerogative, Cleveland Clinic’s purposeful hourly rounding initiative is supported and invigorated enterprise wide through executive leadership committed to making improvements daily. A primary driver behind this ongoing initiative is the Enterprise Responsiveness Steering Committee consisting of chief nursing officers, nursing directors and nurse managers throughout the system. The monthly teleconference meetings set goals for the committee to continue improving the patient experience through staff responsiveness and nurse communication and, most importantly, the steering committee has revised and implemented a validation tool that ensures the key behaviors and language for Purposeful Hourly Rounding are taking place.
“By participating on the Responsiveness Committee, we can share key strategies and learn new information from hospitals within our system,” says Kerry Major, MSN, RN, Chief Nursing Officer, Cleveland Clinic Florida.
“We’re all facing similar challenges, and it takes a lot of time and effort to make sure our staff is committed to the ongoing efforts related to rounding with a purpose,” says Major who oversees 400 nurses at Cleveland Clinic Florida. “The validation piece is really about getting out there and observing that the tools and appropriate behaviors are being used correctly.”
Dedication from Cleveland Clinic’s nurses to overall improved patient care is making a difference. Rounding efforts implemented in the Spring/Summer of 2010 at Cleveland Clinic’s main campus have shown to have significant impact on nursing-related HCAHPS scores, with results first showing traction in the second quarter of 2011 based on the Nurse and Staff Response scores. As the patient reported ‘Rounding Frequency’ increased, so too did the HCAHPS Nurse and Staff Responsiveness Scores, according to Carmen Kestranek, Senior Director, Experience Intelligence for Cleveland Clinic’s Office of Patient Experience.
“Long before we saw the movement of scores at the overall hospital level, we identified the strong relationship between regular and purposeful hourly rounding with the nursing HCAHPS scores,” says Kestranek. “The small but upward movement of patient reporting ‘Rounding Frequency’ scores – a custom question added to all of our surveys – was further shown to be significant by the simultaneous increase in our HCAHPS scores and national percentile rankings.”
From developing a patient-centered script used by all nurses to enhance purposeful rounding to setting a system-wide standard and utilizing a validation tool for the 11,000-plus nursing staff, Cleveland Clinic is setting a premium standard on patient experience.
“Purposeful hourly rounding, timely response to call lights and meeting our patients’ needs quickly are all part of our plan that is continually setting an agenda and offering direction to the entire enterprise. Our focus on excellence in responsiveness holds all caregivers accountable,” says Rogen.