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									The Clinical Nurse Leader:
   Its Time Has Come

            Presentation to:
           2010 CNL Summit
    The CNL: On the Leading Edge
        of Healthcare Reform
             San Diego, CA
            January 21, 2010
        Rosemary Gibson, M.Sc.
       Author, The Treatment Trap
           and Wall of Silence
Overview of Presentation

    Discuss how the work of clinical
     nurse leaders is timely in the context
     of health reform

    Explore ideas for how clinical nurse
     leaders can multiply their impact

    Highlight what the work of clinical
     nurse leaders means for patients and
     reflect on the goodness of it.
The Timeliness of CNLs:
     Health Reform
   Health reform: unlike 1994 health reform
    which was about insurance coverage, now,
    coverage and quality are on the table

   Quality matters at high levels President
    Obama mentioned HAIs, medical mistakes,
    and overuse in speeches and interviews

   This dialogue is responsive to a public that
    is expressing its concern about quality and
The Timeliness of CNLs:
   Public Reporting
 Public reporting of health care
  indicators, including nursing
  sensitive measures, is here now and
  will continue
 It’s not a matter of if, but when
 Still learning how to do public
  reporting in a way that meets the
  needs of providers and also the
The Timeliness of CNLs:
   Payment Reform
   Health care reform is calling for
    payment reforms that move toward
    accountable care organizations and
    paying for bundles of care rather
    than individual care processes

   We cannot continue with “1,000
    measures in 1,000 days” approach
Policy Voice for Nursing
       on Quality
 Nursing Quality and Safety Alliance
  being established at George
  Washington University Nursing as
  neutral convener and facilitator
 Its purpose is to support a collective
  voice for nursing on national policy
  especially CMS actions on public
  reporting and payment reform, and
  the work of the National Quality
  Forum among others
Policy Voice for Nursing
       on Quality
   NQF is the go-to place for obtaining consensus
    around future measures that CMS will use for public
    reporting and payment reform

   CMS will continue to ask for comments in the
    Federal Register on proposed measures for public
    reporting and nursing needs a clear and sustained

   What if: mini public policy internships for nurses
    with NQSA to bridge the worlds of policy and
    clinical care
What CNLs Do For Quality

    What caught my attention about the role of
     the CNL:

    “Outcome-based decision making,
     implementation of evidence-based
     strategies within a microsystem…

    “The CNL evaluates patient outcomes,
     assesses cohort risk, and has the decision
     making authority to change care plans
     when necessary….”
    CNLs and TCAB

 An arranged marriage with TCAB?
 Improve quality and safety of patient
  care (in and beyond med-surg)
 Increase vitality and retention of
 Engage and improve patient and
  family experience of care
 Improve the effectiveness of the
  entire team
Power of Discovery vs.
Someone Told Me To Do It
A  narrative from Dr. Paul Miles,
  VP American Board of

A  case of overuse of a surgery
  for sinusitis and what his
  practice did to discover the
  reasons for it
The Power of Discovery vs.
Someone Told Me To Do It
    He began to rigorously examine the care he was
     providing to his patients. One of his first efforts
     was to reduce the number of children who were
     having a new surgical procedure that he and the
     physicians in his practice believed was being
     performed unnecessarily by surgeons in their
    A group of ear, nose and throat (ENT)
     physicians had discovered a new procedure,
     endoscopic sinus surgery, to treat chronic
     sinusitis. The ENT doctors convinced the health
     insurance company to pay them $12,000 for
     performing it…
The Power of Discovery vs.
Someone Told Me To Do It
    After that, the rural Idaho community had one
     of the highest rates of this procedure in the
     nation. Dr. Miles and his colleagues believed
     that the surgery was expensive, potentially
     dangerous, and of questionable efficacy. More
     than 100 children a year in their small
     community had had this operation.

    Dr. Miles says, “The CT scans for some of the
     kids looked pretty normal and our pediatric
     group was upset that they were having surgery.”
The Power of Discovery vs.
Someone Told Me To Do It
    “The five of us pediatricians in our practice
     looked at our referral pattern to the ENTs for
     this surgery and how we defined, diagnosed and
     treated chronic sinusitis. What we found
     surprised us. In a three-month period we
     diagnosed chronic sinusitis in 150 children. One
     physician in our practice diagnosed it 96 times
     and referred the patients for surgery, while
     another doctor diagnosed it only twice and
     recommended surgery…
The Power of Discovery vs.
Someone Told Me To Do It
    …With this huge difference, we asked ourselves
     how each of us defined chronic sinusitis and
     learned that we had six different definitions. We
     also asked how each of us examined the
     children, and it turns out that we examined
     them differently. To our surprise, we learned
     that we were part of the problem of the increase
     number of surgeries because we were
     inappropriately diagnosing children with
     chronic sinusitis, which led parents to seek relief
     with the new surgical procedure…
…While we were indignant with the
ENT physicians performing these
operations for what we considered
‘an acute remunerative procedure,’
the finger of blame came back at us.
We developed a practice guideline
and were successful in reducing the
number of children in our
community who had the surgery…
…Now, we ask ourselves 3

- Why do you do what you do
- How do you know what works?
- How can you improve what you
Article From ‘Fast Company’
   Toyota’s Approach
       to Quality

“Typically, the Big Three auto makers
 take an all too American approach to
 the idea of improvement. It’s
 episodic, it’s goal-oriented, it’s
 something special. It’s a pale imitation
 of the approach at the Georgetown
 (Kentucky) Toyota plant…”
“…If you go to the Big Three, you’d find
improvement projects just like you’d find at
Georgetown. But they would be led by some
kind of engineering group, or a Six Sigma
black belt, or a lean-manufacturing guru of
some kind. They might even do as good a job
as they did at Georgetown. They might say,
‘Look what we did…’
“In a year, that happens a couple of times in a
whole plant for the Big Three. And it would
get all kinds of publicity in the company.
Toyota is doing it in every single department,
every single day. They’re doing it on their
own, no black belts, and they’re doing it
regularly, not just once.”
Swim Upstream?

Can CNLs multiply their
impact by swimming
A Case of an 8-Year Old Boy on
 Oxygen at a Midwest Hospital

 Patient has asthma, pneumonia
 On oxygen, bronchodilators, antibiotics
 Transported for a chest x-ray and on oxygen
  at 15 l / minute
 Upon return to the floor, oxygen tank was
 Patient was cyanotic, admitted to intensive
Investigation/Process Improvement:
Oxygen Cylinder Hand-off

Patient is being transported, intubated, ventilated with ambu bag
at 8 liters per minute of oxygen supplied by this tank.
Please fill out questionnaire.
 Question: How Long Before
    the Tank is Empty?

 1650    psi

8     Liters/minute

 Ifthe trip to radiology and back
  may take an hour, do you have
  enough oxygen for the trip?
Investigation findings & source
of process improvements
 Profound  lack of knowledge re: oxygen
  cylinders except for respiratory
  therapists and anesthesiologists
 Inadequate hand-offs between med-surg
  units and diagnostic areas
 Need for standardized reliable
  methodology regardless of training,
Oxygen Tank Assessment Tool

   Is it possible for CNLs to identify a
    known hazard and work together
    with manufacturers and purchasing
    organizations to engineer the hazard
    out of the health care system?

   It would be broadly analogous to the
    actions anesthesiologists took in the
    early 1980s to improve anesthesia
    patient safety…
            What Your Work
            Means to Patients

   Have you ever thought about what your
    work means to patients?

   Let’s step back for a minute.

   Think about the totality of your work on
    improving outcomes…
            What Your Work
            Means to Patients

   Has your work reduced harm from falls?
    Pressure ulcers? Failure to rescue?

   Every data point is a person
   Your work prevents these events

   Reflect for a moment on the good of it all…

   Back home, take time to honor the
    goodness of it

   Elderly confused woman recently admitted
    to the hospital; family present in the unit

   Patient was missing during the night

   Nurse supervisor informed the CNO

 “… It was a Sunday morning and I was
 having breakfast with the night staff. It was
 Nurse Recognition Week. A new nurse
 supervisor came up to me and said that a
 patient had been missing during the night…

 …The family was angry, blaming the
 hospital. I said, ‘Let’s go talk with the
 family.’ We walked to the patient’s room.
 The supervisor was a big guy and he was
 very shaken. I was frightened…
Benevolent Gestures

… I went into the room, sat down and
introduced myself and said, ‘I am so, so
sorry. I came to apologize on behalf of the

The daughter started crying and I held her
hand. I realized the family was blaming
themselves in part because they were there
the whole time.
More Benevolent Gestures

  …I said, ‘There is not going to be any
 blaming in this room.’

 …After searching the hospital, we did find
 the patient…
More Benevolent Gestures

… We had the patient thoroughly checked
in the Emergency Department; they went
over every inch of her whole body, and the
family saw that we took great care in
making sure their mother was alright. I
stopped in to see the woman and her family
every day…
Restoring Trust

… The family thanked me for coming to see
them -- they were stunned. We restored the
family’s trust in us.

 I said to them, ‘If you have lost faith in the
 unit where your mother went missing, we
 can move her to another unit.’ The family
 did not want that – because their trust had
 been restored…
Role Modeling for Nursing
… The nursing staff were in the room and
standing in the hallway as I was talking to
the family and holding the daughters’
… They had never seen someone take
ownership. I was stunned to hear the next
day how many people knew about this.
People came up to me in the halls and said,
‘I heard about what happened and what you
Breaking the Cycle

… I remember as a 25-year old nurse being
publicly ridiculed for a mistake. There was
a surgeon I trusted. The patient’s hand was
swelling after surgery. He said to cut the
back of the dressing. I should have asked
more questions. He screamed at me in the
middle of the nursing station.
Breaking the Cycle

… Now, years later in my role at the hospital,
 nothing punitive is going to happen if
 someone makes an unintentional
“Drive out fear so that everyone may work

“A patient is the most important visitor on
our premises. He is not dependent on us.
We are dependent on him. He is not an
interruption in our work. He is the purpose
of it. He is not an outsider in our business.
He is part of it. We are not doing him a
favor by serving him. He is doing us a
favor by giving us an opportunity to serve
him.” Gandhi
“Be the change you want to see.”
You are the change you want to see.

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