VIEWS: 9 PAGES: 47 POSTED ON: 8/10/2012
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 safety. 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 public 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 voice 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 nurses 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 Pediatrics 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 community. 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 questions: - Why do you do what you do - How do you know what works? - How can you improve what you do?” 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 upstream? 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 empty Patient was cyanotic, admitted to intensive care 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, experience Oxygen Tank Assessment Tool Opportunity? 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? Infections? 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 Narrative Elderly confused woman recently admitted to the hospital; family present in the unit Patient was missing during the night Nurse supervisor informed the CNO Narrative “… 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… Narrative …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 hospital.’ 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 Staff … The nursing staff were in the room and standing in the hallway as I was talking to the family and holding the daughters’ hands. … 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 did…’ 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 mistake…. “Drive out fear so that everyone may work effectively….” Deming “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.
Pages to are hidden for
"Gibson"Please download to view full document