Reprinted with permission,
Courtesy, Merion Publications.
BY Anne R. McDarby |
- If you ask hospital nurses
to identify their greatest source of job satisfaction, they are
likely to respond it is their ability to improve patients' lives
and health. While that is reason enough to love their chosen
profession, nurses also should take credit for the critical roles
they are playing in reshaping healthcare.
Just look to the nurses at Clara Maass Medical Center, Belleville,
NJ; Monmouth (NJ) Medical Center and Newark (NJ) Beth Israel
Medical Center. These three New Jersey hospitals, all affiliates
of the Saint Barnabas Health Care System, recently were selected
for the 2005 Solucient 100 Top Hospitals: Performance Improvement
(PI) Leaders Award for achieving consistent improvement in clinical
outcomes, patient safety, hospital efficiency, financial stability
and growth during a 5-year period (1999-2005).
At the bedside and in management roles, nursing staff at all
three hospitals were instrumental in driving the changes that
led to such positive results.
A culture of excellence spans the Saint Barnabas Health Care
System, and the collective focus from staff on all levels at
the three hospitals has paid off in numerous ways. Among them:
- new ICU protocols improved patient outcomes and reduced
length of stay;
- successful efforts to curb length of stay resulted
in greater efficiencies and more financial stability; and
- new
standardized orders and the introduction of rapid response
teams improved patient safety.
The list goes on, and the progress continues. Following are
examples of how nurses at Clara Maass, Monmouth and Newark Beth
Israel are helping shape a new healthcare environment within
their facilities.
In March, Clara Maass Medical Center celebrated a milestone.
The hospital's average length of stay of was 5.3 days — its
lowest ever.
"This truly is one of Clara Maass's great success stories," said
Mary Ellen Clyne, MSN, RN, CNAA, vice president of patient care
services. But back in 1999 — Clyne's first year at Clara
Maass — the average length of stay was 12.2 days. It was
among the hospital's greatest opportunities for improvement.
"With length of stay, we took the bull by the horns and formed
a multidisciplinary committee that meets daily to review the
status of every inpatient that has been here 4 days or longer," said
Sharon McEvoy, RN, nurse manager of the 2 North Annex medical
unit at Clara Maass. The committee, which is comprised of nurses,
physicians, case managers/social workers and representatives
of the lab, radiology, dietary, pharmacy, infection control and
rehab, works together to seek opportunities and break down barriers.
Then there are the instances when a creative approach helps
to resolve an individual patient's dilemma. McEvoy described
a recent occurrence involving an elderly man on her unit whose
condition was no longer acute. He required subacute care or nursing
home placement, but McEvoy and her staff could not locate any
family, and the patient was confused at times and could not provide
them with information.
"With the patient's permission, because we had to respect his
confidentiality, we took a road trip to his home hoping we would
find information or phone numbers in a prominent place, like
on his refrigerator," McEvoy said.
The trip was an effective solution. McEvoy said they found information
about a family member, and the patient ultimately was discharged
from the hospital and placed in a safe environment.
When Monmouth Medical Center introduced clinical resource nurses
to the night shift in October 2005, staff nurses responded enthusiastically
to the added level of support.
The two clinical resource nurses — Jodi Imperato, RN,
CCRN, and Sue Clemens, RN, CCRN — are ICU-trained and work
three 12-hour shifts per week, serving adult patient care units
throughout the hospital (the seventh night is covered by an ICU
nurse). They serve as adjuncts to the nursing supervisor, rounding
on all patient care units in order to talk to staff nurses about
their educational and equipment needs.
"This nurse serves as a liaison who can speak right away to
the appropriate department. For example, if a unit nurse has
a medication question, the resource nurse will address it with
the pharmacy," said Patricia Zweier, BSN, RN, CPHQ, director
of nursing and PI standards.
Imperato, who was an ICU nurse at Monmouth before stepping into
her new role, said she sees herself now as a mentor and teacher.
Her most important responsibility is to develop the skills of
RNs on the night shift. She described a recent interaction with
a staff nurse on the hospital's orthopedic unit as an example.
"The nurse had a patient with a colostomy, which was something
she hadn't seen since nursing school. She needed a review and
called me. I went to the patient's room and demonstrated colostomy
care with her," she said. Imperato documented the instruction
in her notes and returned to visit the nurse a week later.
"I asked how she would manage a colostomy and she was able to
tell me perfectly," Imperato said.
The resource nurse also is a key member of another important
initiative improving patient outcomes and safety at Monmouth.
During her shifts she is on-call for the hospital's new Rapid
Response Team. Introduced last fall, the team is comprised of
the resource nurse, a third-year medical resident and a respiratory
therapist. If a unit nurse feels immediate intervention is needed
with a patient (e.g., change of blood pressure, mental status),
she can summon the team with one phone call.
"We are there to help and to provide a higher level of care
in their setting," Imperato said. "If an ICU transfer is required,
we'll do it, but if we can intervene and prevent that, we will." Since
its introduction, the team is credited with helping to decrease
the number of cardiac arrest codes and produce better patient
outcomes.
Dorothy Beauliere, BSN, RN, CCRN, said she has seen a lot of
changes during her 17 years as an adult ICU nurse at Newark Beth
Israel Medical Center. But she described a new ventilator weaning
protocol introduced on her unit in 2003 as one of the best things
that's ever happened there.
"Patients are weaned quicker and discharged earlier," she said.
As a result of the new protocol, Newark Beth Israel's ICU has
had no cases of vent-related pneumonia for the past 18 months.
In the past, initiating the process of weaning a patient from
the vent required waiting for the physician to come in during
his rounds.
"But sometimes they didn't come until late at night, and that
would delay the patient's discharge," Beauliere said. With the
new protocol, if the patient is awake and stable in the morning,
a staff nurse and a respiratory therapist can initiate the weaning
process.
"We first call the physician with the patient's status and say
he or she is ready for extubation. Sometimes the physician participates,
especially if he is in-house. The process generally goes very
smoothly," she said.
There are other important outcomes as well.
"With change there is always some resistance. At first some
physicians were unsure, but now they're all on board," Beauliere
said. "The patient goes home sooner, families can get back to
normal life, and nurses feel a great sense of satisfaction. We
all benefit."
These and many other PI initiatives at the three hospitals are
ongoing.
At Newark Beth Israel, staff nurses are now represented on the
hospital's PI Council, where they share their perspectives and
take ownership of challenges.
"Building a culture of excellence clearly starts with front-line
staff. As a management team, we need to make sure they feel empowered
and have the resources they need to get the job done," said Nancy
Shendell-Falik, MS, RN, vice president of patient care services
at Newark Beth Israel. "Even if you have the best management
team, consistent level of performance can only occur if it is
carried by the frontline staff."
Maintaining communication and sharing common goals are imperative,
Clyne added.
"You've got to be out there, be responsive and follow through," Clyne
said. "As a result of our transformation, we have further fostered
our relationships with each other and demonstrated tangible outcomes.
Everyone understands the vital roles they play."
Another key factor in sustaining quality is the system's increased
use of evidence-based protocols.
"From a nursing standpoint, these protocols have really helped
our staff nurses to facilitate quality care for their patients," said
Maureen Swick, PhD, RN, CNAA, vice president of patient care
services at Monmouth Medical Center.
What continues to drive her — and nursing staff at all
three hospitals — is the potential for even better outcomes.
"The challenges never stop, so you can never be comfortable
and never be satisfied," she said. We must be constantly striving
to sustain and improve."
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