Motivate staff to achieve peak performance without increasing pay

Transcription

1 Vol. 4 No. 8 August 2004 Patient safety INSIDE Read these ideas for getting your staff excited about patient safety initiatives on p. 3. Interdisciplinary care corner Read how one hospital created a new documentation process to improve interdisciplinary communication on p. 4. Management skills Read tips and suggestions on how to navigate through the various groups within a healthcare facility on p. 6. Nursing shortage Read how one veteran OR nurse is working to stem the nursing shortage on p. 7. Training Looking for ways to engage resistant learners? Learn how to get through to unmotivated staff on p. 8. Time management Are you working hard but not getting much accomplished? Read how efficient nurse managers work smart on p. 12. Enclosed: Check out this special report on verifying nurse credentials. Buy more and save! Call 800/ to learn how you can save more than $100 per subscriptions when you order multiple copies of Strategies for Nurse Managers. Leadership Motivate staff to achieve peak performance without increasing pay Managers believe that money is a top motivator, but it really doesn t encourage employees to put forth their best efforts. Research shows that pay will achieve two objectives: it will ensure that employees come to work and that they stay with your facility. That s certainly nothing to complain about, however, increased pay is clearly not inspiring peak performance. Follow these rules to achieve peak performance from your staff: Communication Blanket orders, such as resume all medications, are dangerous because physicians could forget to include previous vital medications, or nurses and pharmacists may misinterpret the order. For example, a physician could discontinue an antiarrythmic drug before a procedure, says Michael Hoying, RPh, MS, pharmacy director at Fairview and Lutheran hospitals in Cleveland. After the procedure, the physician may issue a blanket resume all Rule #1: Tie rewards to performance: What you reward is what you get. For example, if you want high performance, your high performers should be rewarded differently from your low performers. And if you want teamwork then you must reward team players. Rule #2: Tie rewards to individual preferences: Because every employee has different needs and wants, it s important to know your employees and what motivates them. Ask them what their interests are and what gets > p. 2 How to combat dangerous blanket medication orders in your facility medications order because he or she intends for the patient to begin retaking the antiarrythmic. But because the physician discontinued the order rather than holding it, the patient may not be told to take the antiarrythmic. This could have harmful effects if the patient needs the drug. The physician is the only one who knows what he or she means, say Sarah Moake, RN, nurse manager of the medical-surgical unit at Henderson (TX) Memorial Hospital. > p. 2

2 Leadership Motivate staff < p. 1 them excited. Rule #3: Reward employees in public: Whenever possible recognize team members in front of their colleagues. You should always punish in private and reward in public. Rule #4: Reward staff in a timely manner: Receiving a reward or recognition six months after a nurse has gone the extra mile loses its impact. So do it now. And don t worry if not all employees are present. It s far better to get the recognition one-onone, instead of not at all. Rule #5: Be specific: When recognizing team members in public, be very clear about what is being rewarded or recognized. That level of specificity allows other team members to emulate the right behavior and increases the probability that similar actions will be repeated. Rule #6: Reward at random times: You are violating this rule if employees get upset every time you are not rewarding them. Recognizing team members randomly causes the desired behaviors to be more likely repeated and reduces the WIIFM what s in it for me effect. Rule #7: Tell stories: Get extra mileage out of your rewards and recognitions by becoming a storyteller. Telling stories about how a nurse went the extra mile to ensure that the patient received the best possible care helps staff internalize what s important, and begins to shape behavior and performance more effectively than policies or statistics. Source: Don t Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness. Rinke, W. J. McGraw-Hill, New York, Communication Medication orders < p. 1 It s important to train nursing staff to automatically call the physician if they receive a vague order. Such phone calls lead to better communication among caregivers and can prevent potential errors from blanket orders. If a physician gives an order to continue home meds, have staff find a list of the patient s home medications and have that present when they call to confirm the order, says Sandra Fly, RN, Henderson Memorial s director of performance improvement, quality, and JCAHO accreditation. It just comes down to being as professional as possible and having as much information as possible, Fly says. Tips for staff to communicate efficiently with a physician about a blanket order: Make sure you have enough information about the patient s medications when you call a physician to clarify an order. Write a clarification in the patient s chart when you receive an order interpretation from the physician so another nurse doesn t have to call the physician again. Source: Hospital Pharmacy Regulation Report, June 2004, HCPro, Inc. Page HCPro, Inc. Strategies for Nurse Managers August 2004

3 Patient safety Three creative ideas to get your staff excited and committed to patient safety initiatives Are you stumped for ways to get staff excited about your facility s patient safety initiatives? The following are three inspiring suggestions that have worked in facilities across the country. 1. Design a patient safety related crossword puzzle and give prizes out to the first five or 10 staffers who complete it correctly. (See sample puzzle on p. 5.) Consider distributing the puzzle at staff meetings or in nurses mailboxes. 2. Sponsor a slogan contest. Award prizes for the person who comes up with the catchiest phrase to promote your latest patient-safety project, suggests Debra Molnar, a patient ombudsman at Wadsworth- Rittman (OH) Hospital. Print the winning slogan on pens, t-shirts, or balloons. Winning slogans at Wadsworth-Rittman have included, Patient Safety: Caring Without Compromise, and the acronym THINK, which stands for: Take your time Handle with care Inform others of concerns Notice your surroundings Know your limits 3. Ask staff to sign a Commitment to Patients in which they pledge to not use certain abbreviations or to pause for a time out before surgery. Post the contract prominently throughout the unit. Nurse leaders should be Barbara Organ, RN some of the first in the hospital to sign the contract and should consider posting their signed copy prominently throughout each unit, says Barbara Organ, RN, director of licensure, certification, and accreditation for Memorial Regional Hospital in Hollywood, FL. [The contract] provides a level of accountability. If I sign on that I m going to do this, then I m going to work really hard to make it happen. It provides a level of accountability, says Organ, whose hospital asks medical and nursing staff to sign such contracts. If I sign on that I m going to do this, then I m going to work really hard to make it happen. Source: Briefings on Patient Safety, July 2004, HCPro, Inc. SNM Subscriber Services Coupon Start my subscription to SNM immediately. Options: No. of issues Cost Shipping Total Print 12 issues $179 (SFNMP) $18.00 Electronic 12 issues $179 (SFNME) N/A Print & Electronic 12 issues of each $224 (SFNMPE) $18.00 Order online at and save 10% Be sure to enter source code N0001 at checkout! Sales tax (see tax information below)* Grand total *Tax Information Please include applicable sales tax. Electronic subscriptions are exempt. States that tax products and shipping and handling: CA, IL, MA, MD, NJ, VA, VT, FL, CT, GA, IN, MI, NC, NY, OH, PA, SC, TX, WI. States that tax products only: AZ, TN. Please include $21.95 for shipping to AK, HI, or PR. Your source code: N0001 Name Title Organization Address City State ZIP Phone Fax address (Required for electronic subscriptions) Payment enclosed. Please bill me. Please bill my organization using PO # Charge my: AmEx MasterCard VISA Signature (Required for authorization) Card # (Your credit card bill will reflect a charge to HCPro, the publisher of SNM.) Expires Mail to: HCPro, P.O. Box 1168, Marblehead, MA Tel: 800/ Fax: 800/ customerservice@hcpro.com Web: Strategies for Nurse Managers August HCPro, Inc. Page 3

4 Interdisciplinary care corner Improving interdisciplinary communication: How one hospital revamped its documentation During the JCAHO survey at Halifax Regional Medical Center in Roanoke Rapids, NC, the surveyor took a close look at patient records and noticed that clinicians didn t document how specialists from various disciplines communicated with one another about their patients care plans. However, nurses, physicians, and therapists did communicate with one other daily they simply didn t document it. The surveyor wanted us to have one place in the patient record where everyone could see what each discipline s goals were for the patient, says Margaret Rose, the performance improvement director and hospital risk manager. Each discipline needed to be able to look at the big picture of the patient s care. Problem #1: Some disciplines, such as nursing, entered their notes for patients into electronic medical records. Others, such as respiratory therapy, wrote their notes longhand and placed them into the patient s hard-copy file. Surveyors wanted more consistency so that all disciplines could open a patient s chart and with one glance, know what each clinician s goals were for the patient. Problem #2: The electronic documentation system was cumbersome. It required nurses to pass through several screens before they reached the appropriate screen allowing them to enter plan-of-care information. In addition, other caregivers, including physicians, were unable to access the information if someone else was working on one of the unit s available computers. Problem #3: Surveyors wanted to see that specialists communicated with physicians, nurses, discharge planners, and case managers consistently to learn about each patient s care plan and any changes to it. Those meetings occurred for patients with complicated needs or who had extended hospital stays, but not for all patients, says Rose. Brainstorming solutions The hospital formed a task force that included 17 people from various disciplines. The team split into two groups that brainstormed ways to improve the hospital s documentation process for communication among disciplines. The teams gathered together at the end of the five weeks to compare ideas and select the best solutions. Solution #1: The teams decided to create a simple two-page form that nurses must insert at the front of each hardcopy patient file. The form contains a designated section for each discipline to enter basic information, such as the patient s diagnosis, goals, expected length of stay, medications, special needs, and goals. Providers from each discipline must fill out their corresponding section of the form. If a provider from a particular discipline doesn t provide care for the patient, a nurse must check off N/A, for nonapplicable, in the space reserved for that discipline s notes. We didn t want to leave anything blank, says Rose. We wanted to have some way to document that the patient wasn't receiving certain care so that it wouldn t look as if it had been left blank due to an oversight. Solution #2: The task force also developed a 10- page handbook with care-planning language to tutor providers who don t document patient goals regularly. The handbook explains what care planning is and how to create and use an interdisciplinary plan of care. Care planning has been an integral part of the nursing process for a long time, but not with other Page HCPro, Inc. Strategies for Nurse Managers August 2004

5 disciplines, such as respiratory therapy, says Rose. Solution #3: In 2004, the hospital plans to move to a fully electronic documentation system that will make it easier to enter and share patient information within the organization. It will integrate the interdisciplinary information contained on the two-page form. Reaction Some nurses didn t like the new form and regarded it as duplicate documentation because they already entered each patient s goals into an electronic record. The task force emphasized that nurses merely needed to write their major goal for the patient on the form and then check a box marked, see documentation. They didn't know that they didn t have to put all of their detailed documentation on there, says Rose. It's just an overview. If you would like a copy of the two-page form that Halifax Regional Medical Center developed contact Rebecca Delaney at 781/ , Ext or rdelaney@hcpro.com. Source: Briefings on JCAHO, April 2004, HCPro, Inc. Patient safety puzzle Note: Find the answers on p. 11. Across: 1. Team participation in the development of a patient s plan of care should be. 3. You must use two of these when taking blood samples or administering medications or blood products. 9. An infant abduction or patient suicide would be a event. 12. on medical machinery should be audible, never silenced, and attended to promptly. 16.This is an absolute must while mixing or preparing medications. 17.Morphine 2 5 mg IV every hour is an example of a order. 18.This should be part of your preop verification process. 20.These are high-alert medications. 21.Do this to help identify failure points in high-risk processes. Down: 2. Acute Myocardial Infarction, Pneumonia, and Congestive Heart Failure are three such measures. 3. This should have free-flow protection. 4. Number of nurses or licensed staff required to verify a patient s identification during blood administration. 5. Post-operative complications, wrong-site surgery, and medication errors are a few examples of this. 6. U, IU, Q.D., Q.O.D. 7. This requires a definitive marking. Source: Baylor Medical Center. Reprinted with permission. 8. The JCAHO s preferred mode of survey readiness. 10.Errors rarely occur in this manner. 11.This happens after a verbal or telephone order has been written down. 13. The culprit behind medical errors. 14.MS, MSO4, and MgSO4 are often with one another. 15. Passé expression for hospital-acquired infections. 19. Staff should always wash their hands before entering a patient s. Strategies for Nurse Managers August HCPro, Inc. Page 5

6 Management skills Managing the masses: How to navigate through the various groups in a healthcare organization In any organization there are different tribes or groups of people who have their own culture and their way of thinking and communicating. No where is this more evident than in a healthcare facility, said Peg Neuhauser, MA, in her presentation, Orchestrating Healthcare Teams during the Case Management Society of America s annual meeting in Nashville, TN, in June. Neuhauser gave four tips on managing various groups within a facility to better lead staff and serve patients. 1. Watch out for tribal warfare. The first step to successful communication with various groups is recognizing the groups that exist in your facility and what has historically has been a sticking point between you and the people in this group. If there s a group with which you have a history of bad feelings or confrontation, prepare before you meet with them. Try brainstorming all of things they could say to you that could frustrate you, so that you re not caught off guard during the meeting, says Neuhauser. If you re prepared you can stay on focus and on message, she said. Also, if you use a word or phrase that usually irritates this group try to avoid repeating it when speaking with them. You have a huge vocabulary, use it, advises Neuhauser. Don t let language interfere with your message. 2. Informal connections are as important as formal connections. Take a look at the different connectors between groups. Neuhauser said there is always a go-to person who connects various groups through informal relationships. You can get more accomplished by going to this person than through formal channels. Seek these people out; they re incredibly valuable people to tap into, she said. 3. Develop the habit of connecting. When speaking with staff or other nurse leaders make a habit of asking questions that link groups. Some questions that are good to work into conversation include the following: What do you think? Who else might be affected by this? Who else needs to know about this? Also, Neuhauser advises nurse leaders to bypass and call people or, even better, meet with colleagues face-to-face. The more electronic the communication, the less personal and the harder it gets to make connections, she said. 4. Create the sweep effect. According to Neuhauser, a leader only needs 25% of staff to buy into ideas for change after you influence this segment most likely the rest will follow. Identify the movers and shakers in your organization, these are the people who will help get the momentum going and help you get things done, she says. Source: Orchestrating Healthcare Teams: The Case Manager as Leader, Peg C. Neuhauser, MA, Case Management Society of America annual meeting, Nashville, TN. Questions? Comments? Ideas? Contact Associate Editor Rebecca Delaney Telephone: 781/ , Ext rdelaney@hcpro.com Page HCPro, Inc. Strategies for Nurse Managers August 2004

7 Nursing shortage Veteran OR nurse works to stem nursing shortage Louise DeChesser, RN, CNOR, MS, is worried. As a 54-year-old babyboomer she knows as she grows older and her health fails the dearth of qualified perioperative nurses will mean less quality care in the OR. DeChesser, who is the president of Surgical Solutions, a healthcare consulting company, knows firsthand how serious the current shortage of OR nurses is, and she says it will only get worse. There are so few OR nurses that many facilities are using technicians to circulate through the OR and administer medications, she says. The OR nurse is on the decline and we re using more ancillary staff as a Band Aid TM, but it s not a permanent solution. Before going into ambulatory care administration and nurse education, DeChesser worked as an OR nurse for 35 years. Today she teaches a unique, hands-on course to educate experienced RNs how to work in the operating room. Most nurses today don t get that hands-on experience during their nursing education, according to DeChesser. In the 60s and 70s students had a rotation in the OR for three months, and you could spend more time there for an elective, explains DeChesser. Now nursing students get one day of observation and that s their whole experience in the OR. Because of that lack of education nurses are not attracted to OR nursing, says DeChesser, and those who are interested in working in the OR are faced with a dilemma. It s a double-edged sword, she says. You can t begin working in the OR without experience, yet how can you gain experience without working in an OR? The course, developed by the American Organization of Perioperative Nurses, is geared toward veteran nurses and provides hands-on, practical training. It also provides college credit and continuing education credits if the nurse completes the semester. For more information, visit Stress management Quick tips to reduce stress in your day Unfortunately, stress is a fact of life for both nurses and nurse leaders. Christine Dumas, DDS, and Kevin Soden, MD, MPH, two national medical reporters, provide tips on dealing with stress to help you handle the demands of your day: Put your coffee cup down. After drinking four or five cups of coffee during the day, your body has an elevated level of stress hormones all the way into the evening, making you feel more stressed out than you actually are. Reduce your stress on the spot. Find a buddy to confide in, advises Dumas. Whether it s a glance at a meeting to convey your frustration or a quick phone call to let off steam, sharing the cause of your stress with a friend as soon as possible will lessen the effect it has on your work. Take a mini-vacation every day. Go outside for a few minutes and walk around. You need to get away from work to refresh yourself, says Soden. Stop working when you leave work. The average person thinks about work for two hours after they leave, says Dumas. It may be difficult, but try to leave the problems your dealing with on your unit when you walk out the door. Source: Improving American Health Through Case Management, Christine Dumas, DDS, and Kevin Soden, MD, MPH, Case Management Society of America annual meeting, Nashville, TN. Reprinted with permission. Strategies for Nurse Managers August HCPro, Inc. Page 7

8 Training How to get through to change-resistant learners The one constant in the healthcare industry is change. Whether you have to train staff on the JCAHO s Patient Safety Goals, a new piece of equipment, or a new unit policy, introducing change can be challenging especially when staff members are not receptive to learning about the change. One principle of adult learning is that adults are selfdirected learners. But what happens when adults direct themselves not to learn? Resistant learners are restless, sometimes rebellious, and often sullen. Their negative body language and verbal remarks clearly communicate that they do not want to participate, regardless of the topic or the learning environment. Their attitudes influence other staff, making it difficult to establish and maintain a positive atmosphere. How can you deal with this problem and maintain your own positive attitude? If your staff don t always see change as an opportunity for professional or personal growth, use this quick exercise to show them that mastering new concepts and skills benefits their organization and affects their performance reviews. Discuss these questions at an upcoming staff meeting to ease the transition from the familiar to the unknown. What trends and forces of change currently affect nursing? What are your strengths? Which of these strengths will continue to make you successful in the future? What new skills do you need to learn to stay valuable in the healthcare industry? What have you learned in the past six months? What do you expect to learn in the next six months? What do you need to unlearn? Which skills are becoming obsolete? What practices (e.g., attitudes, behaviors, work routines, etc.) that worked for you in the past are no longer valid? This technique could help resistant staff adjust to new concepts by offering a broader perspective on change. It encourages employees to reevaluate their individual contributions to the organization s culture, and to consider how their attitudes and skills affect hospitalwide patient satisfaction and quality improvement. Source: Healthcare Training Weekly, HCPro, Inc. Subscriber news Your continuing education credits are now ready! Follow these four simple instructions to receive your FREE contact hours: 1. Access our online learning Web site at 2. Enter your username. 3. Enter your password (your username and password were mailed to you in March). 4. Complete the free quarterly online course found in my courses on the left navigation bar. We are thrilled to continue to provide you with the highest quality of healthcare information while fulfilling your continuing education needs. Please do not hesitate to call us at 800/ or us at customerservice@hcpro.com if you have any questions regarding this exciting new benefit. We thank you for your business. HCPro, Inc., is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. Page HCPro, Inc. Strategies for Nurse Managers August 2004

9 JCAHO Reduce risk: Steps your facility can take to avoid patient falls during hospitalization Nothing is more counterproductive and frustrating for patients, their families, and caregivers than an injury sustained in a fall during hospitalization. A new study conducted by the Washington University School of Medicine in St. Louis found that most patient falls resulting in an injury occurred when the patient was either in the bathroom, on the way to the bathroom, or while using a bedside commode. The JCAHO targeted patient falls in its proposed National Patient Safety Goals for Patient falls are the second mostfrequent cause of harm for patients, topped only by medication errors, says Amanda Borgshdorf, MHSA, coordinator of the Madison (WI) Patient Safety Collaborative. The following are suggestions to help reduce patient falls in your unit: Expand the use of regularly scheduled, assisted trips to the bathroom for patients at risk for falling. Ask patients whether they use a walker or cane outside of the hospital. Ensure that canes, walkers, and other assistive devices are available for patients who need them. Many falls documented in the study occurred when patients who normally used a walker or a cane outside of the hospital were not using one when they fell. Avoid sleeping pills. Certain medications, such as those that aid sleep, increase the risk of falls. A group called the Madison Collaborative, composed of three medical groups and four hospitals started a fall prevention program in The collaborative focused on reducing the use of sleeping aids, offering natural sleep inducers, such as warm herbal tea, ear Patient falls are the second most-frequent cause of arm for patients, topped only by medication errors. plugs, a warm blanket, or a brief massage. If the patient was still awake and requesting assistance 30 minutes later, caregivers offered an over-the-counter medication to relieve minor pain that might interfere with sleep. If another 30 minutes pass, they provided a low dose of sleep medication that is not generally associated with falls. The collaborative found that 44% of patients fell asleep after receiving warm tea or other intervention. Another 44% fell asleep after receiving a nonprescription pain killer. Another factor in patient falls was the confused or disoriented patient who doesn t understand that he or she should not walk without assistance. Patients need to be reminded that they re on a number of medications, in an unfamiliar environment, and being put through a routine of tests, procedures, and bed rest, all of which can make them weaker and more susceptible to falling, says Melissa Krauss, a researcher coordinator at Washington Medical University Center. Amanda Borgshdorf, MHSA According to Borgshdorf, the Madison collaborative also implemented a safe-room setup, which includes placing bedside tables on the nonexit side of the bed, locking bed wheels, tucking away electric cords, and installing bed-exit alarms. The collaborative provided continual fall-prevention education with a half-day inservice training program involving a nurse known as a unit champion from each unit. Source: Hospital Falls Study Suggests Ways to Reduce Risk, Washington University in St. Louis, School of Medicine and Briefings on Patient Safety, May 2004, HCPro, Inc. Strategies for Nurse Managers August HCPro, Inc. Page 9

10 Legal matters Nurse supervision: Understand your responsibilities Editor s note: The following is an excerpt from Managing Documentation Risk: A Guide for Nurse Managers, written by Patricia A. Duclos-Miller, MS, RN, CNA, and published by HCPro, Inc. As a director, nurse manager, or supervisor, you must ensure that patients have appropriate care and that staff members providing care have sufficient supervision. If a patient is injured and suspects that your staff were not adequately supervised, he or she could allege that your supervision was negligent. Your liability will be based upon the following: Your delegation of patient care to a nurse who was unable to perform the care Your failure to personally supervise the nurse when you knew or should have known that supervision was necessary Your failure to take the necessary steps to avoid patient injury when you were present and able to intervene Inadequate staffing, which can be perceived as negligent judgment by the nurse manager Ask yourself the following questions after an adverse event to manage your risk: Did my staff follow organization policies, procedures, and practices? If not, did I adopt changes as soon as possible after the event occurred to prevent another adverse event? Was the nursing documentation reviewed for accuracy and completeness? Were the necessary departments notified about the event? Was an intensive investigation or root-cause analysis with staff completed as close to the event as possible? Were the necessary changes adapted as soon as possible? Were staff informed of the possible root causes of the event? Was education provided based on any changes to policies, procedures and practices? Nursing in the news Pointing the finger: Nurses blamed for most errors Although only about 8% of physicians consider nurses part of the decision-making team when it comes to patient care, nurses are held accountable for the majority of medical errors, according to a study from the University of Montana, published in the June issue of American Journal of Nursing. Researchers surveyed nurses, physicians, pharmacists, and hospital administrators at 29 rural hospitals for three years. Ninety percent of hospital administrators surveyed said patient safety is primarily the responsibility of nurses. The study s authors tie their statistics to the nurse recruitment and retention problem afflicting countless hospitals, stating their findings, make it clear that the processes used to identify errors, assign responsibility for them, and resolve patient safety issues may have unintended, unfavorable effects on nurse recruitment and retention. Source: An Error by Any Other Name, Ann Freeman Cook, PhD, Helena Hoas, PhD, Katarina Guttmannova, MA, and Jane Clare Joyner, JD, RN, American Journal of Nursing, June Page HCPro, Inc. Strategies for Nurse Managers August 2004

11 Celebrating Nurses Tune in, breaking news: The first nursefocused radio show launches on Web The first radio program solely devoted to nurses recently aired its inaugural broadcast in May featuring interviews with nurses from across the country. Nurseradio.org, operated by the New England School of Whole Health Education and the American Holistic Nurses Association, profiles nurses with inspirational stories, such as a nurse who worked with victims of the Chernobyl nuclear disaster and a nurse who served a tour of duty in Vietnam in the 1960s in the business of nursing and public jealth nursing. I think nurses are feeling somewhat unsupported in their efforts to provide the best patient care possible, says Mary-Anne Benedict, MSN, RN, chair of the Nurse Radio advisory board. This radio program provides them an opportunity to hear from nurse leaders and to grow professionally. With the seemingly permanent nursing shortage and increased complexities and needs of patients, nurses are at high risk for burnout. Georgianna Donadio, PhD, producer and host of the program, says she hopes her show provides inspiration and motivation for nurses to continue working in their field. Nursing is experiencing a tremendous crisis right now, says Donadio. Nurses are dissatisfied with the work environment and they re dropping out of the profession. We want them to know they re appreciated. To listen to the radio program, visit org. Puzzle answers (from p. 5) Across: Down: 1. Multidisciplinary 2. Core 3. Patient 3. Pump identification 4. Two 9. Sentinel 5. Sentinel event 12. Alarms 6. Do not use 16. Focus 7. Site 17. Range 8. Continuous 18. Time out 10. Isolation 20. Electrolytes 11. Read back 21. FMEA 13. Root cause 14. Confused 15. Nosocomial 19. Room AUG/SEPT Audioconferences: Upcoming events 8/3/2004: Effective Competency Assessment: How To Build Performance-Based Job Descriptions That Comply With JCAHO HR Standards 8/17/2004: Redesigning The Patient Care Work Environment: How To Improve Patient Flow, Staff Satisfaction And Patient Safety 8/25/2004: How To Identify And Respond To Resident Falls 9/16/2004: Preparing Nursing/Clinical Teams To Adopt New Technologies For more information call our Customer Services Department at 800/ to register. Strategies for Nurse Managers August HCPro, Inc. Page 11

12 Time management Working smart: How to accomplish more in your day without working more hours What is the difference between working hard and working smart? Many people work lots of hours and feel they have really worked hard, yet they may not have been working smart. With all the demands on a nurse manager s time, it is often difficult to prioritize and work efficiently and effectively. When you are exhausted at the end of the day and feel like you ve been spinning your wheels and didn t accomplished much, it s time to ask, was I working hard or smart? The following are tips from managers who work smart: Determine before the day begins the most important task that needs to get accomplished that day and don t let yourself get distracted from completing that goal. Don t let staff decide priorities for you. A staff member s emergency doesn t always have to replace the first item on your to do list. Maybe the nurse s emergency can go to your #3 or #4 item. Ask yourself, what can I do today that will have the most effect? Realize that sometimes smart work is working with staff, helping them with tasks and procedures. You may not be getting to the pile of paper on your desk, but you are getting more done by gaining trust and input from staff. Source: Adapted from the Manager Tip of the Month by Shelley Cohen, RN, BS, CEN, HEalth Resources Unlimited. Strategies for Nurse Managers Editorial Advisory Board Shelley Cohen, RN, BS, CEN President Health Resources Unlimited Hohenwald, TN Sue Fitzsimons Senior Vice President Patient Services Yale-New Haven Hospital New Haven, CT David Moon Executive Vice President Modern Management, Inc. Lake Bluff, IL Bob Nelson, PhD President Nelson Motivation, Inc. San Diego, CA Tim Porter-O Grady, EdD, RN, CS, CNAA, FAAN Senior Partner Tim Porter-O Grady Associates, Inc. Otto, North Carolina Dennis Sherrod, EdD, RN Forsyth Medical Center Distinguished Chair of Recruitment and Retention Winston-Salem State University Winston-Salem, North Carolina We want to hear from you For news and story ideas: Contact Associate Editor Rebecca Delaney Phone: 781/ , Ext Mail: 200 Hoods Lane, Marblehead, MA rdelaney@hcpro.com Fax: 781/ Publisher/Vice President: Suzanne Perney Group publisher: Kathryn Levesque Executive Editor: Emily Sheahan Online resources: Web site: Visit HCPro s Nursing site at Subscriber services and back issues: New subscriptions, renewals, changes of address, back issues, billing questions, or permission to reproduce any part of Strategies for Nurse Managers, please call our Customer Service Department at 800/ Strategies for Nurse Managers (ISSN X) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA Subscription rate: $179 per year. Postmaster: Send address changes to Strategies for Nurse Managers, P.O. Box 1168, Marblehead, MA Copyright 2004 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978/ Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call 781/ or fax 781/ For renewal or subscription information, call customer service at 800/ , fax 800/ , or customerservice@hcpro.com. Visit our Web site at Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. Opinions expressed are not necessarily those of Strategies for Nurse Managers. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Page HCPro, Inc. Strategies for Nurse Managers August 2004

13 Verifying Nurse Credentials: Methods to reduce risk and ensure patient safety A supplement to HCPro publications

14 Verifying Nurse Credentials: Methods to reduce risk and ensure patient safety Background Throughout his 15-year nursing career, Charles Cullen, RN, worked at nine hospitals and one nursing home and murdered 13 patients. As he moved from hospital to hospital, Cullen s employers say they never knew of his checkered past, which included an investigation into his nursing care, an accusation that he had stolen drugs, and a conviction of criminal trespassing and harassment after he broke into a nurse s home in In 2004, Cullen pleaded guilty to 13 murders and two attempted murders of patients in his care. Investigators in the case learned that when Cullen applied to various hospitals, human resources representatives called his former employers who only disclosed the dates of his employment. This was the case at Somerset Medical Center in Somerville, NJ, where Cullen worked for 13 months, killed 13 patients, and tried to kill two more. When he came under criminal investigation for patient overdoses, Somerset Medical fired Cullen, and he applied for a new nursing position at another New Jersey hospital. He lied on his application, stating he was fired from his previous nursing job for obtaining a nursing license under false pretenses, when in fact he was under criminal investigation. Cullen also lied on his New Jersey nursing license renewal form in When asked whether any licensed healthcare facility had taken action against him that affected his employment between 1997 and 1999, Cullen answered no. In reality, he had been fired by the Liberty Nursing and Rehabilitation Center in Allentown, PA, for improperly administering medications in Although less extreme, the story of Susan Ann Robertson in Louisiana is still alarming because of the serious threat posed to patient safety. 2 Verifying Nurse Credentials

15 Robertson applied for a nursing job at Gambro Healthcare in Gonzales, LA, filled out an application, and told a hospital supervisor she was a RN licensed in New York state. She said she applied for a Louisiana license, but didn t have it with her during the interview. Gambro hired Robertson, and she worked at the facility for three months until the administrators caught on, called the state boards in Louisiana and New York, and found out she was not and had never been a licensed nurse in either state. Why would you let a nurse, who underwent less scrutiny than a physician, work in your critical care unit? asks Hugh Greeley, founder of The Greeley Company in Marblehead, MA, and medical credentialing expert. Accounts of nurses and impostors such as Cullen and Robertson send a chill through the healthcare community, not only because of the horrific breach of trust between caregiver and patient, but also because healthcare administrators know that they too could have nurses who are hiding a shady past working on units and caring for patients. Stories of nurses faking credentials, hopping from job to job in various states, and harming patients are a reminder that you must be diligent in verifying nursing applicants licensure, criminal background, and education before hiring them to work on your units. When hiring Cullen, Somerset Medical Center followed its own verification procedure and called his previous employers. Unfortunately these former employers did not provide critical information that ultimately could have prevented the deaths of 13 patients. Although even the most rigorous verification process may not expose every inconsistency in a nurse s past, the more stringent the process, the more capable your facility will be to find discrepancies in applicants backgrounds. Unfortunately, the nurse-credentialing process in many facilities is inadequate allowing nurses who may have had action taken against them by another state nursing board, a criminal history, or incomplete education onto the unit making patients vulnerable and the Verifying Nurse Credentials 3

16 facility liable. Most facilities verify nursing credentials in a process different from physician credentialing. However, considering how closely nurses work with patients, subjecting nursing applicants to a less stringent credentialing process may not be in your facility s or patients best interest. Applicants hiding their pasts It is a sad reality that it is no longer reasonable to assume your nursing applicants are telling the truth on their applications and in their interviews. Raymond Jacobs, a vice president at Kroll Background America in Nashville, TN, a background-screening company, estimates that 13% of applicants for hospital positions have a criminal past. Also, one out of every three job applications has an intentional error, according to CBSMarketwatch.com. Human resources compliance The Management of Human Resources chapter of the JCAHO s Comprehensive Accreditation Manual for Hospitals states that hospitals must have a process to ensure an applicant s qualifications are consistent with the position s responsibilities. Under standard HR.1.20, the hospital must verify the applicants licensure, education, experience, competency, and criminal background according to the law, the facility s policy, and regulations. Verifying licensure and credentialing nurses can be a confusing process. Today, more nurses move from state-to-state throughout their careers, and different states have different requirements for licensure. Twenty-three state boards do not conduct criminal background checks on applicants for nurse licensure they rely on the applicant to disclose such information on the license application. Unfortunately, applicants can t always be trusted when answering these questions, and their past could come back to haunt the institution when the truth eventually comes out. If the nurse isn t competent, that will be realized quickly because each nurse is under supervision of a dedicated, highly skilled nurse manager, says Greeley. However, a nursing applicant s criminal past isn t as obvious, he says. 4 Verifying Nurse Credentials

17 Although your facility may be compliant under JCAHO because it follows policies and regulations when hiring nurses, current policies may not adequately spell out how to scrutinize a nurse s background. Examine your facility s bylaws or human resources (HR) policy and procedures to see whether they protect your patients and sufficiently screen applicants for dangerous nurses or impostors. Proposed legislation After the Cullen murders came to light, there was a groundswell of calls for reform. New Jersey Senators Jon Corzine (D) and Frank Lautenberg (D) proposed legislation earlier this year to expand the National Practitioner Data Bank (NPDB) to include nurses and other healthcare professionals. The NPDB is a federally funded clearinghouse for information on physicians, dentists, and other healthcare practitioners. Facilities can find information about medical malpractice payments, adverse licensure actions, adverse clinical-privilege actions, and adverse professional society-membership actions. If passed, Corzine s and Lautenberg s legislation would require hospitals to report to state nursing boards and to the NPDB when they take any adverse action against a nurse. They would also have to report a nurse if he or she violates a federal or state law, including state health professional standards, such as drug diversion, falsification of documents, or repeated medication errors. When hiring nurses, facilities would be required to first check the NPDB for information on the applicant s background. If a facility did not report information to the database or did not check the NPDB before hiring a nurse, they could be fined up to $50,000 per violation. The senators legislation also provides protection to healthcare whistleblowers, or employees who report activities that violate standards of care to the NPDB. Currently, there is no similar central repository for disciplinary information on nurses. The National Council of State Boards of Nursing Verifying Nurse Credentials 5

18 maintains NURSYS, a database of nurse license and license discipline information provided by participating state boards of nursing. Currently 27 states provide license information to the NURSYS database. The New Jersey state assembly also reacted to the Cullen case by drafting a bill that would allow hospitals to share more detailed information about a former employee when contacted by another medical facility looking to hire that individual. An amendment was added to the bill to allow the state board of nursing to double-check information provided by license applicants and nurses applying for renewal. A centralized credentialing process Credentialing nurses usually falls to the HR department in most institutions, while the medical staff office handles physician and advancepractice RN credentialing. Because of this split, the credentialing process is often different for nurses than it is for the medical staff. This should not be the case, says Laura Harrington, RN, MHA, CPHQ, practice director of external peer review, credentialing, and national seminars at The Greeley Company. It doesn t matter whether they re an employee or part of the medical staff, facilities should use the same procedure to verify licenses during the initial application, she says. Harrington says creating a consistent credentialing process will ensure that everyone who has contact with patients has been properly vetted. This is common sense considering how much time nurses spend oneon-one with patients. Current practices In a recent HCPro survey on nurse credentialing, 98% of respondents said their facility did have a process in place to verify nurse credentials. However, credentialing processes are laden with weaknesses of which a fraudulent applicant could easily take advantage. For example, when asked how they verify a nurse s credentials, 78% of respondents said they photocopy the nurse s license. It s not good 6 Verifying Nurse Credentials

19 enough to photocopy a license and stick it in the file, says Harrington. With today s technology, visual verification of a license is not sufficient. Someone can easily forge a license and use it to obtain a nursing position if the facility does not verify the license with the state board. Several respondents said they verify credentials merely by looking at the nurse s license, and only 38% of respondents said they contact nursing applicants previous employers during the hiring process. Best practices Take the following critical steps to verify nurses credentials and to ensure your patients safety and your facility s integrity: Step 1: Gather applicant s information The application for employment should be thorough and should obtain the information needed to ensure patient safety in your facility. If this first step isn t well done, then the entire decision process is compromised, says Greeley. Ask for the following information on your application: The applicant s name as well as other names they have used (e.g., a maiden name) Education, degree obtained, and name and location of educational institution Professional licensure, state where the license was issued, date issued, license number, and expiration date Specialty certifications Employment history Disciplinary actions on their license Verifying Nurse Credentials 7

20 Also be sure to ask whether the applicant has ever been convicted or pleaded guilty or no contest to any criminal charges (other than speeding violations). If the answer is yes, ask the applicant to specify the charges and the dates they occurred. Also inquire whether the applicant has ever been convicted or pleaded guilty or no contest to a drug or alcohol-related offense and ask whether he or she has ever been suspended, sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance program (e.g., Medicare or Medicaid), or similar federal, state, or health agency. Step 2: Verify applicant s information After asking the applicant the questions above, it s imperative to verify this information to the best of your ability. Document each verification step, even if you don t find anything, to further reduce your institution s liability. Some facilities hire a third party to verify applicants information, but most often the HR department completes this task. Either way, make sure there s a specific, established process for verification. Primary verification is the best method to check an applicant s qualifications, including education, licensure, and past employment. Most state nursing boards post licensure information on their Web sites. However, one state nursing board head recommends that facilities call their state board for the most up-to-date information. Our Web site is up-to-date, but if something happened in the past few days, although it may not be up on the site, we would still know about it, says Dorothy Fulton, RN, MA, executive administrator for the Alaska State Board of Nursing. Also check the state board in every state where the nurse has worked. Also, consider running criminal background checks on all applicants, even if your state nursing board runs a check of its own. The nurse may have committed a crime after receiving his or her license. In most states, the responsibility is on nurses to notify the state board if they are convicted of a crime which they may or may not do, putting your facility at risk. 8 Verifying Nurse Credentials