Nurses Lead Quality Improvement and Innovation

January-February 2016
By: Ann Hendrich, Ph.D., RN, FAAN

The United States health care system is undergoing a profound transformation. Accelerated by the 2010 Patient Protection and Affordable Care Act, the movement to fee-for-value is propelling us as health care leaders to fundamentally rethink our models for how we care for the persons and families we serve. At Ascension Health, this era of change prompts us to renew our focus on our mission as a Catholic health care system, to provide "spiritually centered, personalized care that sustains and improves the health of individuals and communities."1

What this means in practice is that we are building teams, redesigning processes and breaking down silos so that we can meet the needs of persons from all walks of life through all stages of their lives, especially those who are struggling. Our quadruple aim is to provide the highest quality of care at a lower cost, while offering exceptional experiences to the persons we serve and the providers who make up our care communities.

A vital component of this approach to care is that it is an interdisciplinary team effort, with physicians, nurses, pharmacists, social workers, physical and occupational therapists, among others, collaborating with each other and with patients across the continuum of care.

This teamwork ethic produces an environment that cultivates the leadership potential of nurses and the care team. The Institute of Medicine's 2011 report, The Future of Nursing: Leading Change, Advancing Health, made the case that the nursing profession was poised to take on an expanded role in a redesigned health care system, in part because nurses have expertise in areas that are central to health care transformation, such as care management, health promotion and designing care models across the continuum. The report offered recommendations for how the nursing profession could be strengthened to take on emerging challenges by ensuring that nurses have the scope to practice to the full extent of their education and training and to act as full partners with physicians and other health professionals in leading health care innovation.2

The stories of three nurses in Ascension health ministries offer case studies of how nursing leaders build teams, foster collaboration and champion innovation.

COMMUNICATION IS THE KEY
Beginning in 2003, Ascension Health implemented evidence-based interventions to reduce the rate of facility-acquired pressure ulcers (FAPUs) across the health ministries and to systematically measure performance.3 These efforts have produced and sustained outstanding results; FAPU prevalence for acute care sites is 0.65 per 1,000 patient days for FY15 (July 1, 2014 – June 30, 2015), 94 percent lower than the national average. Nurses such as Jennifer Gengo, MSN, RN, CWOCN, have been leaders on the ground where their day-to-day efforts have produced these results and whose dedication continues the drive toward zero FAPU.

In 2002, Gengo was a clinical nurse specialist at St. Vincent's Medical Center in Bridgeport, Connecticut. Pressure ulcers were just beginning to come into focus as a patient safety priority, and in 2003, the Joint Commission issued national patient safety goals that included reducing the incidence of pressure ulcers.

Gengo earned certification as a wound care, ostomy and continence care nurse specialist (WOCN) in 2007.

"The more I learned, the more I became convinced that we could prevent harm to patients by changing how we look at pressure ulcers," she said. "The key is to build a team where everybody has a sense of responsibility for the patient's outcome."

She decided to bring an interdisciplinary approach to the problem of device-related pressure ulcers. "We had a high incidence of patients with new tracheostomies who developed tracheal pressure ulcers," she said. However, focusing the care team on that problem meant she needed to facilitate shifts in perspective.

For example, the ear, nose and throat physician group tended to view the respirator as a lifesaving device, period. She wanted to communicate the idea to them that while protecting the airway comes first, it also is important not to cause harm and that there were steps the care team could take to reduce harm. The most effective approach, she found, was to discuss the issue with physicians on a patient-by-patient basis during consults. "It's all about back-and-forth communication," she said.

Effective communication also helped respiratory therapists recognize they could play a role in addressing the problem of tracheal pressure ulcers.

"Just like you need to turn and position patients to prevent pressure ulcers, you need to look under their devices," Gengo said. "Respiratory therapists were well positioned to do this."

The purchasing department proved to be another partner in patient care. "The tracheostomy tubes we were using were hard and rigid," she said. "We found another company with a softer one, which was a better choice for some patients."

Gengo recently transitioned from serving in an inpatient setting to an outpatient setting, but she affirmed that "wound care has become my passion." She said she finds great satisfaction in mentoring other nurses in the practice of wound care and in improving their comfort in communicating effectively with other members of the care team — a leadership skill.

COLLABORATIVE NETWORKS
In February 2014, St. Vincent's HealthCare in Jacksonville, Florida, selected Amy Svensson, RN, CCRN-K, to be a clinical ambassador for Ascension Health's Hospital Engagement Network (HEN), part of the Centers for Medicare and Medicaid Services' Partnership for Patients initiative. During her 12 months in the role, Svensson facilitated implementation of best practices to reduce patient harm at St. Vincent's three acute care hospitals in Jacksonville.

Reducing catheter-associated urinary tract infections (CAUTIs), a hospital-onset infection, is a Partnership for Patients national priority as well as a systemwide priority for Ascension Health. One of the challenges Svensson faced was how to spur improvement in this area at St. Vincent's Medical Center Riverside in Jacksonville. The hospital had reached a plateau in its performance in reducing CAUTIs and did not see a path forward.

She found her solution by tapping into the power of collaborative networks.

"In my nursing career up to this point," Svensson said, "I was always asking myself, 'Why aren't we all working together better?' When I linked into the Ascension Health System and the HEN network, I was really energized."

Within the network, she looked for available models and resources, starting with St. Vincent's Medical Center Southside, one of the Jacksonville health ministry's other acute care hospitals. The Southside hospital was making good progress in CAUTI reduction and had hardwired many practices that it could share with St. Vincent's Riverside. Svensson also looked to the infectious diseases team, which was coordinating the HEN work at Ascension Health. This team had developed a CAUTI bundle, an online CAUTI education module for caregivers, articles describing research and interventions supporting best practices, and a template for root cause analysis of events. The infectious diseases team also was able to connect Svensson with subject matter experts and to facilitate dialogue with other Ascension Health hospitals. What's more, Svensson had access to the nationwide HEN learning collaborative in which CAUTI reduction was a core focus area.

Svensson encouraged the St. Vincent's Riverside care teams to look beyond their current routines and processes and to embrace the evidence-based and innovative practices she gathered through her network research. She facilitated the establishment of simplified, uniform processes across units. She engaged nursing staff to discuss breakdowns in practice and to come to a consensus on how to standardize processes. St. Vincent's Riverside already had nurse-driven protocols for catheter removal, for example, but many staff members didn't know about them. To address that issue, the protocol was incorporated into the order sets in the electronic health record, and nurses received training on its use. 

Also, the care team engaged physicians and nurses continuously with performance updates and case reviews. Svensson knew that physicians would support the effort if they looked at the evidence and the data supporting the adoption of interventions to reduce CAUTI, and she knew that the Ascension Health HEN had developed these resources.

"Sustained change is never accomplished alone but happens with the combined efforts of all front-line staff," Svensson said. "The top priority of all caregivers is to provide safe care to our patients. My job was to engage our team in the continuous effort to provide the highest quality of care possible." 

St. Vincent's Riverside is beginning to see the fruits of its efforts: In 2015, its CAUTI rate has been dropping in critical care units. Svensson has transitioned to a new role as system quality program manager and is applying and extending what she learned from the HEN work to direct quality and safety initiatives such as reducing C. difficile infections and sepsis. She also plans to pursue a doctorate of nursing practice degree.

"I find great joy in knowing that my work makes a difference in patients' lives," she said, "even though I may not be the person physically providing their care."

TRANSFORMED PERINATAL CARE
The problem that Debra Keith, MS, CNM, set out to solve was that women at her OB-GYN clinic had long wait times before being able to see a provider. This was the mid-2000s, and Providence Hospital in Washington, D.C., had a large volume of patients. Most came from underserved areas of the city where they had few other options for perinatal care.

"Women were spending two or three hours in the waiting room, with nothing to do but watch television," Keith said.

While her initial motivation was to create "positive health care experiences" for these women, Keith ended up transforming perinatal care at her clinic, improving health outcomes for mothers and babies. Keith and other nurse midwives at her clinic had heard about a new model of group perinatal care called CenteringPregnancy. With this model, eight to 12 women with similar due dates form a group that meets regularly throughout pregnancy and early postpartum.

At the heart of these sessions is group discussion and learning. A nurse midwife helps guide the discussion, but the women lead it themselves by sharing their questions and concerns as well as their knowledge and experiences. In the group format, women talk about topics such as nutrition and breast-feeding while they prepare for the experience of childbirth. By taking their own blood pressure and weight at each session, the women begin to take charge of their own health. They support one another and develop a relationship with their nurse midwife that is not common in traditional care, where they may not always see the same provider from visit to visit.

"We get attached to our patients in group," Keith said. "We get to know them well."

Keith, who is director of nurse-midwifery services, championed the effort to bring CenteringPregnancy to Providence. She was able to gain executive support for the program because she was able to show that the clinic could bill group care in the same way as a traditional prenatal visit would be billed and that each nurse midwife would still see the same volume of patients as in traditional care.

One of the biggest obstacles to implementing the program was structural: Traditional clinics do not have space where nearly a dozen women can meet, much less accommodate any family members or other support people who might accompany them. Also, there had to be private space available for a table or cot where the nurse midwife could conduct physical exams.

For Keith, improving perinatal care for underserved women is a personal calling. Earlier in her career, she spent time in Paraguay and Nicaragua serving as a labor and delivery nurse and educator in rural areas. Reflecting upon her experiences, she noted: "I was blown away by the need I saw but loved working with the people. When I returned to the U.S., I felt called to study and do more with my career."

Keith has been collecting data on the outcomes of the CenteringPregnancy program at Providence since early on. She tracks women's attendance rate, gestational age at delivery, infant birth weight, total maternal weight gain, whether women deliver vaginally or by C-section and whether they initiate breast-feeding. Her initial findings look promising, as do the outcomes reported by other clinics using a group model for enhanced prenatal care. She is encouraged that, when all the data comes in, there will be growing support from health care providers and payers for an enhanced prenatal care model.

"We're demonstrating positive outcomes by doing more," she said. "We're putting it all together by providing excellent care, education and support for these women in a cost-efficient model that improves the experience of both the women and their providers."

As these stories illustrate, nurses at Ascension Health are emerging as leaders who have the education, capability and vision to innovate and to spearhead improvements in care quality and safety. In this new era, when the model of what health care looks like is changing, when there are financial imperatives to provide better care at lower cost and ethical imperatives to create seamless care experiences centered on the needs of the person, it's vital to fully cultivate the potential of our nurses to serve as partners in bringing about this transformation.

ANN HENDRICH is senior vice president and chief quality/safety and nursing officer for Ascension Health, St. Louis.

NOTES

  1. Ascension Mission Statement http://ascension.org/living-the-mission/mission-vision-values.
  2. Institute of Medicine, The Future of Nursing: Leading Change, Advancing Health (Washington, DC: The National Academies Press, 2011). http://iom.nationalacademies.org/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx.
  3. David Pryor et al., "The Quality 'Journey' At Ascension Health: How We've Prevented at Least 1,500 Avoidable Deaths a Year — and Aim to Do Even Better," Health Affairs 30, no.4 (April 2011), 604-11.

 

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