Structural Empowerment

Structural Empowerment

Professional Development SE1EO Clinical nurses are involved in interprofessional decision-making groups at the organizational level. Provide two examples of improvements resulting from the contribution of clinical nurses in interprofessional decision-making groups at the organizational level. Example #1 Critical Illness Clinical Excellence Team: Pneumonia Vaccine Eligible Patients BACKGROUND/PROBLEM: According to the Centers for Disease Control (CDC), pneumonia is the leading cause of vaccine-preventable illness and death in the United States. One in 20 people who contract the disease die. Some bacterial strains of pneumonia have become resistant to traditional antibiotics making vaccination that much more important. Those at greatest risk of developing pneumonia are people age 65 and older, the very young and people with a weakened immune system related to disease. While SJO s goal was to vaccinate 100% of appropriate patients who met vaccination criteria, we were consistently missing about 6% of patients who should have been vaccinated while hospitalized. GOAL STATEMENT: Decrease failure rate of the number eligible patients to receive pneumonia vaccine. DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES): The Critical Illness Clinical Excellence Team (CET) is a multidisciplinary interprofessional performance improvement team. Nursing is represented by members from Critical Care, Definitive Step-Down Unit, Quality Management, Case Management, Cardiac Services, Emergency Care Center, Infection Prevention, Clinical Education, Women s Services, Clinical Informatics, Medical Telemetry and the chief nursing officer. Non-nursing members include intensivists, Anesthesia, Pathology, Oncology/General Surgery, Hematology/Oncology, Blood Bank, Clinical Outcome Data Analyst, Respiratory Therapy and hospitalists. The scope of this team includes pneumonia vaccine administration to adult inpatients since SJO experienced inconsistent failure rates. Barriers to consistent pneumonia vaccine administration and the potential reasons for the barriers were identified. In 2011 the standardized procedure for the pneumonia vaccine was revised to accommodate patients discharged on hospital day 1, renal transplant patients and teen moms. In 2012, the screening tool was added to electronic nursing documentation with a prompt to order the vaccine if the criteria indicates such. In 2013 the standardized procedure was revised to no longer require an order and this was built into the electronic pneumonia vaccine assessment. Clinical nurses Augie Maggio, MSN, RN,, from Medical Telemetry, and Song Lee, BSN, RN, CMSRN, from General Surgery, talked about the difficulty of knowing which patients needed the

vaccine. They suggested that an electronic reminder be developed. The team hypothesized that if the clinical nursing staff was flagged with information regarding which patients needed the pneumonia vaccine, then failure to provide the vaccine to eligible patients would decrease. This interprofessional decision-making group decided that pneumonia vaccine eligibility would be electronically communicated to all clinical coordinators, relief charge nurses and managers by Clinical Outcome coordinators. After input from clinical nurses Augie Maggio; Song Lee; Jaimie Browne, BA, AD, RN, CMSRN; Roxanne Hainey, BSN, RN, ; and Ronnel Diaz, BSN, RN, and after multiple revisions to the electronic template, the final template was implemented in June and July 2014 as illustrated below. SE1EO Figure 1 Template for pneumococcal vaccine communication Please do a Pneumococcal Vaccine Screen for the following patient(s): ADMISSION DATE PATIENT NAME AA ROOM# ATTENDING MD Reminder: Please reassess the following patient(s) for Pneumococcal Vaccine as per stated in initial assessment: ADMISSION DATE PATIENT NAME AA ROOM# ATTENDING MD The following patient(s) meet criteria for the Pneumococcal Vaccine. Please document administration or contraindication/refusal of patient: ADMISSION DATE PATIENT NAME AA ROOM# ATTENDING MD SE1EO PARTICIPANTS: Name Credential Title-Specialty Department Soudi Bogert BSN, RN, Clinical Outcome Critical Care CCRN Manager Linda Boose-Shutes BSN, RN, Manager DSU CCRN Elaine Cervantes BSN, RN Clinical Nurse III Critical Care Sothary Chhoeung Quality Analyst Quality Management

Nancy Christiansen MSN, RN, Clinical Nurse Critical Care CNS, CCRN Specialist Ray Ann Chung BSN, RN Clinical Nurse II Critical Care Jaimie Browne BA, AD, RN, Clinical Coordinator General Surgery CMSRN Roxanne Hainey BSN, RN, Clinical Coordinator Medical Telemetry Augie Maggio MSN, RN, Clinical Nurse III Medical Telemetry Song Lee BSN, RN, Clinical Nurse II General Surgery CMSRN Ronnel Diaz BSN, RN Interim Clinical Medical Telemetry Coordinator Barbara Compean BSN, RN Case Manager Case Management Trish Cruz BSN, RN Manager Evidenced Quality Management Based Care Lisa Evans ACNP, MSN, Nurse Practitioner Cardiac Services RN Diana Feres BSN, RN Clinical Outcomes Quality Management Coordinator Mary Gonzales MSN, RN, Infection Infection Prevention CIC Preventionist Val Grinenko MBA, MT, Director Blood Bank CLS Patricia Nguyen Pharm.D Manager Pharmacy Susan Parke DNP,NP, RN Director Infection Prevention FNP-BC, CPHQ, CIC Kim Rossillo BSN, RN, Manager Medical Telemetry James Roum MD Intensivist Critical Care Katie Skelton MSN, MBA, CNO Administration RN, NEA-BC Patrick Smith RT Manager Respiratory Therapy Jennifer Sturm BSN, RN, Clinical Nurse IV Critical Care CCRN Frank Sweeney MD Anesthesia Surgery Qunicy Almond MD Hospitalist Pulmonary Kang Hsu MD Hospitalist Pulmonary Thomas D. Kim MD Hospitalist Pulmonary

OUTCOME(s): Clinical nurses prompted the Critical Illness Clinical Excellence Team to develop an electronic reminder regarding vaccine eligibility for patients. The graph demonstrates that prior to introduction of the electronic reminder to clinical staff there was a greater than 6% failure rate. Following implementation of the electronic reminder, the failure rate decreased to 0%. SE1EO Figure 2 Eligible Patients Failing to Receive Pneumonia Vaccine

Example #2 Heart Failure Clinical Excellence Team: Heart Failure Readmission BACKGROUND/PROBLEM: Heart failure is one of the most common conditions in the nation that results in hospital readmission. However, evidence shows that readmission rates decrease when heart failure patients receive adequate education about managing their disease. SJO s long-standing outpatient Heart Failure Clinic is 100% education-based and is offered at zero cost to patients and insurance. The education provided allows patients to play an active role in managing their own health, which reduces the probability of readmission. The Heart Failure Clinic is operated by Sue Henke, BSN, RN, CHFN, a seasoned nurse with extensive clinical experience in working with heart failure patients. Sue combines her expertise with a compassionate understanding of the challenges faced by heart failure patients who represent different backgrounds, ages and education levels, as well as psychological and socioeconomic stressors. Patients who attend the clinic are managed by their own physicians via two-way communication initiated by Sue. During a Heart Failure Clinic visit Sue performs a brief physical examination followed by education, including (but not limited to) pathophysiology, medication, diet, sodium restriction, fluid restriction, activity, smoking, daily weight, exacerbation of symptoms, and when to call the physician. Sue is also available to patients via phone and follow-up educational sessions at the clinic. In 2013, Sue and Aileen Ingles, BSN, RN,, CN IV, Heart Failure Clinical Excellence Team (CET) co-chair, concluded that SJO heart failure patients who were discharged from the acute care setting were not being consistently referred to the Heart Failure Clinic for education and follow up. Based on evidence they knew that if more patients were referred to the clinic the number of heart failure readmissions would decrease. SE1EO Figure 3 Heart Failure Clinic referrals prior to practice change 2013 June July Aug # of Referrals 28 16 17 GOAL STATEMENT: Increase the number of Heart Failure Clinic education visits in order to decrease allcause, risk-adjusted heart failure readmission rates. DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES): The Heart Failure CET is a multidisciplinary interprofessional performance improvement team co-chaired by Aileen from Medical Telemetry, and Maged Azer, MD, cardiologist, with nursing members from the Pulmonary Renal unit, Medical Telemetry unit, Case

Management, Home Health, Observation unit, Emergency Care Center, Clinical Education, Clinical Information Services, Quality Management, the Heart Failure Clinic and Case Management. In addition, there is hospitalist attendance, a member of the Patient Family Advisor Council, a clinical analyst, and the chief nursing officer as Executive Management Team sponsor. The team has access to documentation specialists, pharmacy, registered dietitians, hospice and coders as needed. Sue and Aileen outlined the current Heart Failure Clinic referral process and learned that it was physician dependent. They presented their findings to the Heart Failure CET. To remind the physician to order the referral, they recommended that a note be placed on the chart front requesting clinical follow up post discharge. After developing and implementing this strategy, they soon learned that the outcome was dependent on the clinical nurse pointing out the note on the chart front. Sue then recommended that the team consider removing the physician s order since the Heart Failure Clinic is education-based and an order is not needed for patient education. The team agreed in September 2013. Sue and Aileen worked with cardiologist Thomas C. Kim, MD, to establish a process for an acute care patient with the primary diagnosis of heart failure to have an automatic referral by the physician or clinical nurse to the Heart Failure Clinic. This also increased the number of referrals. In September/October 2013 Sue and Aileen provided education to clinical nurses via Power Minutes, staff meetings, one-on-ones, skills days, new graduate orientation and rounds. This direct education increased number of referrals to the Heart Failure Clinic. SE1EO Figure 4 Heart Failure Clinic referrals after practice change 2013 Sept Oct Nov Dec # of Referrals 6 57 74 77 2014 Jan Feb Mar Apr May June # of Referrals 83 89 29 103 79 43 SE1EO PARTICIPANTS: Name Discipline Title Department Aileen Ingles BSN, RN, Clinical Nurse IV Medical Telemetry Co-Chair Maged Azer MD, Co-Chair Cardiologist Trish Cruz BSN, RN Manager, Evidence- Quality Management Based Care and Clinical Outcomes Gail Denham AD, RN RN Analyst Clinical Informatics Peter Fuerst Patient Patient Family Advisor Community Member Monica Gonzalez BSN, RN, CEN Clinical Nurse II Emergency Care Center

Roxanne Hainey BSN, RN, Clinical Coordinator Medical Telemetry Sue Henke BSN, RN, Program Coordinator Heart Failure Clinic CHFN Norina Aquino BSN, RN, Clinical Coordinator Pulmonary Renal Pauline Njuguna BSN, RN Clinical Nurse II Medical Telemetry Vivian Norman MSN, RN, Clinical Educator Clinical Education CCRN Carla Peeples BSN, RN Clinical Outcomes Quality Management Coordinator Lupe Ramos MSN, RN, ACNP Nurse Practitioner Cardio-Vascular Services Kim Rossillo BSN, RN, Nurse Manager Medical Telemetry Katie Skelton MSN, MBA, RN, NEA-BC Vice President Patient Care Services, CNO Executive Management Team Sponsor Pulmonary Renal Observation Unit Cheryl Welp MSN, RN, CNML Nurse Manager Mary Williams AD, RN-BC Clinical Nurse II Pulmonary Renal Doris Wrather AD, RN Registered Nurse St. Joseph Home Health Kathy Yezarski BSN, RN, ACM Nurse Manager Johnson Chui MD Hospitalist Pulmonary Tony Pham MD Hospitalist Pulmonary Case Management Social Services OUTCOME(s): Through education provided to nursing staff in September and October 2013, the Heart Failure Clinical Excellence Team clinical nurses were able to remove barriers and increase the number of patients being seen in the clinic. In the clinic, patients received education on their condition and learned ways to avoid problems, complications and readmissions. Through nursing s effort to increase clinic visits the clinical nurses of the Heart Failure CET were able to decrease all-cause risk adjusted heart failure readmission rates.

SE1EO Figure 5 All-Cause Risk-Adjusted Heart Failure Readmission Ratio Return to SE home page