Visibility, Accessibility, and Communication TL10

Visibility, Accessibility, and Communication TL10 How nurse leaders use input from direct-care nurses to improve the work environment and patient care. Staff nurses communicate work environment and patient care needs through formal and informal structures that facilitate open communication with nurse leaders at all levels. Nurse leaders use this input from staff nurses to implement changes to improve the work environment and patient care. Formal Methods Councils Anne Arundel Medical Center (AAMC) has a robust Nursing Shared Governance structure that includes eight councils. This structure has been in place since 2004, with ongoing modifications to ensure alignment with organizational goals and changes in healthcare. Every council has a varied composition based on its goals, and they include senior nursing directors, clinical nursing directors, nurse managers, clinical nurse educators, unit charge nurses, and staff nurses. Nurse leaders are present and accessible at every Nursing Shared Governance council as chair or clinical nursing director advisor. Councils provide a structure for staff nurses to recommend changes that impact the work environment and patient care. (Attachment TL10a, Nursing Shared Governance Council Charters 2013) AAMC Nursing Shared Governance Structure Council Professional Nurse Council (PNC) Clinical Education Council (CEC) Clinical Practice Council (CPC) Nursing Research/Evidence Based Practice Council (NR/EBPC) Nursing Quality Council Interdisciplinary Informatics Council (IIC) Goal Provide the voice of nursing for the advancement of nursing practice and service excellence at Anne Arundel Healthcare System Provide and promote opportunities for clinical staff competence and professional development Defines, implements and maintains standards of clinical nursing practice and patient care consistent with evidence-based standards of practice and requirements of regulatory agencies Promote the use of evidence-based practice and facilitate the conduct of nursing research Monitor the appropriateness and effectiveness of care provided by nursing staff while assessing and ensuring compliance with established standards of care and practice Enhance informatics usability, clinical practice quality, and patient safety by supporting changes that make the medical record fluid and seamless. IIC will support and facilitate changes that improve the accuracy of clinical documentation while optimizing the efficient use of Transformational Leadership 1

Nurse Executive Council (NEC) Nursing Operations Leadership (NOPS) medical informatics. IIC will operate as a sounding board for improvement suggestions, hold a framework for interdisciplinary discussion, and communicate a positive informatics message to staff members. Provide leadership and direction for all nursing councils Positively influence patient care delivery through leadership and collaboration regarding clinical practice, clinical operations, recruitment, education and retention of staff and maximizing resources Exhibit TL10-1, AAMC Nursing Shared Governance Structure Work Environment Example The Professional Nurse Council (PNC) consists of staff nurses representing each clinical nursing unit. The council chair is Brandy Brown, BSN, RN, RN-BC staff nurse, Heart and Vascular Unit, and the co-chair is Carrie Jackson, MSN, RN, RNC-OB, staff nurse, Labor and Delivery. Betsey Snow, MPH, BSN, RN, CNML Senior Nursing Director of Women s and Children s, serves as nurse leader advisor. (Attachment TL10b, Professional Nurse Council Membership Roster) PNC provides a forum for staff nurses to participate in planning and decision making for professional nursing at AAMC. (Attachment TL10c, Professional Nurse Council Charter) The work that PNC and its subgroups do in the areas of structural empowerment and exemplary professional practice give staff nurses a strong voice in advancing nursing practice and service excellence. At the January 25, 2012 PNC meeting, members identified barriers to staff nurses seeking clinical ladder designation. They recommended that changes be made to the clinical ladder structure and that the process be simplified for applicants. (Attachment TL10d, Professional Nurse Council Meeting Minutes, January 25, 2012) The goal of this recommendation was to increase participation in the clinical ladder, especially at the entry level. Sherry Perkins, PhD, RN, NEA-BC, Chief Operating Officer/Chief Nursing Officer, presented the PNC s recommendations to Irma Holland, MSN, RN, Clinical Nursing Director of Clinical Education and Professional Development, who is the Professional Development Initiative director lead. Senior nurse leaders discussed the recommended changes at a nursing leadership meeting on December 3, 2012. (Attachment TL10e, Nursing Directs Meeting Minutes, December 3, 2012) Based on the PNC recommendations and under Holland s direction and leadership, nurses participating in the Professional Development Initiative made modifications to the clinical ladder process and criteria. (Attachment TL10f, New Clinical Ladder Process) The training provided to staff nurses and nurse leaders included a Professional Development Day on April 19, 2013, which was attended by more than 50 staff nurses. (Attachment TL10g, Professional Development Day Flier) The revised clinical ladder was successfully implemented on May 1, 2013. Transformational Leadership 2

The changes made to the clinical ladder criteria and process based on staff nurse input have had a significant impact on the number of nurses seeking clinical ladder designation. The most dramatic increase in applicants has been at Level I, with the number of applicants more than doubling in the three months since the implementation of the new process. Level Increase in Clinical Ladder Participation Number of Nurses on Clinical Ladder Before May 2013 Changes Number After May 2013 Changes Additional Pending Approval (as of August 30, 2013) Level I 2 5 3 Level II 61 63 6 Level III 30 34 1 Exhibit TL10-2, Increase in Clinical Ladder Participation Nursing Strategic Planning Initiatives AAMC nursing uses Nursing Strategic Planning (NSP) Initiatives to achieve an excellent practice environment for nurses and excellent patient outcomes. Nurse leaders serve as advisors to staff nurses on each initiative. The first NSP Initiatives grew out of a gap analysis in 2007 and were launched at the NSP Retreat in June 2008. Ongoing yearly gap analyses have resulted in new initiatives, which are then launched at the yearly NSP Retreat. NSP Initiatives are chaired by a clinical nursing director and co-chaired by a staff nurse or clinical nurse educator. New initiatives are developed based on identified gaps, and existing initiatives are retired as gaps are closed and responsibility for monitoring and evaluation is transitioned to existing shared governance structures. The following are the current NSP Initiatives: Nursing Strategic Planning Initiatives NSP Initiative Term of Initiative Director Advisor Professional Development 2008 Present Irma Holland, MSN, RN, RN-BC Clinical Nursing Director of Clinical Education and Professional Development Staffing and Scheduling 2008 Present Ann Marie Pessagno, MSA, BSN, RN, NEA-BC, Senior Nursing Director of Acute and Critical Care Services Communications 2008 Present Julia Blackburn, BSN, RN, NE-BC, Clinical Nursing Director of Interventional Radiology, Cardiac Catheterization Lab and Procedural Care Unit Transformational Leadership 3

Commitment to the Community 2009 Present Eve Sage, MSN, RN, CMSRN, Clinical Nursing Director of Joint and Spine Unit and General Surgical Unit Cultural Diversity 2009 Present Nia Wright, MSN, RN, CNOR, Senior Nursing Director of Surgical Services Evidence Based Practice 2010 Present Cathaleen Ley, PhD, RN, PMHCNS-BC, Director of Nursing Quality and Research Senior Nurse Advisory Council 2011 Present Lil Banchero, BSN, RN, Clinical Nursing Director of Patient Access, Observation Unit, Acute Care of the Elderly, Flex Nursing Unit and Central Staffing Office Care of the Caregiver 2011 Present Christine Frost, MSN, MBA, RN, NEA- BC Clinical Nursing Director of Medical/Surgical Unit and Special Care Unit Exhibit TL10-3, Nursing Strategic Planning Initiatives NSP Initiatives include regularly scheduled forums for staff nurses to provide input to nurse leaders on many topics. Every initiative has a specific focus, providing an opportunity for substantive discussion and recommendations. Staff nurses representing nursing units across the organization bring diverse opinions and recommendations for change and improvements. Work Environment Example The Senior Nurse Advisory Council (SNAC) initiative was launched at the NSP Retreat in June 2011. The council, composed of older nurses, addresses senior nurses changing health and work life needs through more flexible scheduling, ergonomics and injury prevention, continuing education, health benefits, and retirement choices. Immediately following the retreat on June 21, 2011, Banchero, the SNAC nurse director advisor, emailed the nurses who attended the SNAC presentation at the NSP Retreat. (Attachment TL10h, Senior Nurse Advisory Council Email, June 24, 2011) Her email included an explicit request that this group of staff nurses decide what we want this initiative to accomplish. SNAC met and developed long-term goals on September 27, 2011, with suggestions submitted by all parties, including staff nurses. (Attachment TL10i, Senior Nurse Advisory Council Meeting Minutes, September 27, 2011) One of the three specific goals suggested and agreed upon by the SNAC members was: To value and facilitate the retention of the senior nursing population by addressing scheduling, flexibility, ergonomics and injury prevention, retirement choices including phased in retirement, benefits, mentoring and educational support. On November 29, 2011, the group of staff nurses and nurse leaders determined together that the presentation for retirement planning should be available to staff members of all ages; should Transformational Leadership 4

include information on retirement benefits available through AAMC, Great West, Social Security, and Medicare; and should include pearls for those planning or thinking about retirement. (Attachment TL10j, Senior Nurse Advisory Council Meeting Minutes, November 29, 2011) These suggestions and goals resulted in an education session, Plan to Retire in Style, hosted on May 17, 2013 by SNAC members. Nancy Luttrell, MBA, BA, Vice President of Human Resources, and Larry Ulvila, President of Insurance Solutions, were present to answer questions about retirement options. (Attachment TL10k, Plan to Retire in Style Invitation Announcement, May 17, 2013) Thirty-three senior nurses attended the session. (Attachment TL10l, Plan to Retire in Style Attendance Roster) Exhibit TL10-4, Senior Nurse Advisory Council Plan to Retire in Style Luncheon Organizational Committees Organizational committees in nursing and the organization work to achieve specific objectives related to the work environment and patient care. Organizational committees may be multidisciplinary, and meeting schedules vary. Every nursing committee is chaired by a clinical nursing director and co-chaired by a staff nurse or clinical nurse educator. Patient Care Example Transformational Leadership 5

The multidisciplinary, organizational Restraint Committee meets monthly for one hour. Restraint Committee Membership Name Position/Department Role Janice Drum, MSN, RN Senior Director of Nursing Chair Kelly Johnson, BSN, RN Staff nurse, General Surgical Unit Co-chair Jennifer Pullins, RN Unit Charge Nurse, Emergency Member Department (ED) Cindy Radovic, MS, RN, Unit Charge Nurse, ED Behavioral Member Health Christine Schaeffer, BSN, RN, ONC Clinical Nurse Educator, Joint and Member Spine Unit Mike Fuller, Sergeant Officer, Security Department Member Holly Sowko, BSN, RN, RN-BC Clinical Nursing Director, Heart and Member Vascular Unit Beth Gibbs, BSN, RN Staff nurse, Critical Care Unit Member Kathy Lester, MSN, RN Clinical Nursing Director, Nursing Member Informatics Debbie Smith, CNP CRNP, Doctor s Emergency physician Member assistant Jennifer Smell, MSN, RN, CCRN Nurse Manager, Pediatric Member ED/Inpatient Shirley Everette, RN Staff nurse, Critical Care Unit Past member Exhibit TL10-5, Restraint Committee Membership The Restraint Committee is responsible for monitoring regulatory compliance with medical/surgical and behavioral restraints, oversight of hospitalwide education on restraint use, making recommendations for practice change, and oversight of restraint-related policy and procedures. (Attachment TL10m, Restraint Committee Charter) At the July 10, 2012 monthly meeting, staff nurses discussed the ongoing issue of ED compliance with monitoring and documentation for behavioral restraints. (Attachment TL10n, Restraint Committee Meeting Minutes, July 10, 2012) The committee decided to implement a restraint alert that requires the ED unit charge nurse and attending physician to be called to the bedside for any patient with escalating behavior that is likely to require restraint. Everette recommended that the unit charge nurse be responsible for driving the process to ensure compliance. The role of the ED unit charge nurse was defined to include oversight of patient monitoring and documentation, which includes prompting the physician to enter the appropriate order and complete the face to face evaluation within one hour. Drum requested that Pullins, an ED unit charge nurse, develop a standard operating procedure (SOP) to guide the unit charge nurses and staff nurses in caring for patients requiring behavioral Transformational Leadership 6

restraints. Because behavioral restraints require very specific monitoring and care processes, Drum requested that a checklist be developed to guide the staff nurse responsible for the patient s care. Pullins presented the draft SOP and recommended process for restraint alert at the Restraint Committee meeting on October 9, 2012. (Attachment TL10o, Restraint Committee Meeting Minutes, October 9, 2012) Pullins outlined the process for calling a Restraint Alert and reviewed the SOP, including a revised checklist. (Attachment TL10p, Restraint Alert Standard Operating Procedure) Pullins also agreed to audit every record for patients placed in behavioral restraints and to meet with individual staff nurses when issues are identified through the audit. (Attachment TL10q, Restraint Audit Tool) Following the implementation of the Restraint Alert process, compliance with required monitoring improved significantly and has been sustained: Exhibit TL10-6, Restraint Monitoring Graph Unit-based Staff Meetings Nursing units hold monthly staff meetings to disseminate information and hear from staff nurses and other staff members about issues or concerns that may impact the work environment or their ability to deliver patient care. Staff meetings are led by clinical nursing directors, nurse managers and/or clinical nurse educators. These forums give staff nurses direct access to leaders and an opportunity to be heard. Work Environment Example Transformational Leadership 7

The ED holds two staff meetings every month, one early in the morning immediately after the night shift and one in the evening immediately after the day shift, to accommodate all staff members. At the November 27 and 29, 2012, ED staff meetings, Drum asked for staff nurses feedback about broken windows, which are things in the work environment that are inefficient or aggravating and hinder patient care and/or workflow. (Attachment TL10r, Emergency Department Meeting Minutes, November 27, 2012) Staff nurses noted that the five Dynamap machines (vital sign monitors) in the Rapid Clinical Evaluation (RCE) rooms were never used and that there was no easy access to Dynamap machines in the treatment area where they are frequently needed. Nancy Ciccarone, RN, and Tina Kilpatrick, RN, requested that the machines be moved from RCE and installed on the walls in the treatment area by every treatment chair to improve efficiency and workflow. Sally Grimm, MSN, RN, CEN, Nurse Manager, ordered the required brackets and requested that engineering move the machines to the location requested. The hardware was received and the machines were relocated, giving staff nurses and other clinical staff members easy access to vital sign monitors. Transformational Leadership 8

Exhibit TL10-7, Dynamap Machines in ED Treatment Area RN Satisfaction Survey AAMC nurse leaders ensure that nurses have the opportunity to provide anonymous feedback about the work environment and patient care by participating in surveys. AAMC conducts a Healthstream employee opinion survey every 24 month, the Agency for Healthcare Research and Quality (AHRQ) Culture of Safety survey every 18 months and the National Database of Nursing Quality Indicators (NDNQI) RN Satisfaction Survey every 24 months. The RN Satisfaction Survey is used to gather staff nurse-only feedback about the work environment and quality of patient care. Clinical nursing directors share the survey results, including unit scores and comparison to other hospitals for each category, with staff nurses on every nursing unit. Work Environment and Patient Care Example Transformational Leadership 9

Evelyn Rochlin, BA, RN, Clinical Nursing Director of Prep/PreAnesthesia Testing, Short Stay Unit and Hospital Pavilion Post Anesthesia Care Unit (HP PACU), presented the results of the 2012 NDNQI RN Satisfaction Survey at the HP PACU staff meeting on July 17, 2012. (Attachment TL10s, HP PACU Meeting Minutes, July 17, 2012) Rochlin expressed her appreciation for the 92 percent participation by the HP PACU staff and distributed copies of the summary to those in attendance, commenting on the positive scores. The entire report was also posted on the central bulletin board for all staff members to review. The HP PACU staff meeting on September 18, 2012, was dedicated to understanding the survey results and developing actions to address areas needing improvement. Rochlin led the meeting by engaging staff members in identifying processes that are working well and identifying opportunities for improvements in the work environment and patient care. Some specific actions were decided upon. (Attachment TL10t, HP PACU Meeting Minutes, September 18, 2012) Informal Methods Leadership Rounding The AAMC culture is such that brief meeting opportunities often result in a positive change or movement toward an improvement in the work environment or patient care. Leadership rounding provides an informal opportunity for communication that has become embedded in the routine of nurse leaders at all levels. Perkins has established clear expectations for nurse leaders to be visible and accessible to staff nurses across the care continuum. Nurse leaders, including senior nursing directors, clinical nursing directors and nurse managers, round at least weekly to give staff nurses an opportunity for direct access and communication. Rounding can include walking through the nursing units and talking with staff members or attending pre-shift huddles for broader access and visibility. Perkins regularly blocks time on her calendar to round on different nursing units and make herself accessible to staff nurses across the organization. (Attachment TL10u, Rounding Screenshot, Perkins Calendar) Unit charge nurses round daily to ensure staff nurses have the resources and support they need to provide patient care. Work Environment Example Rochlin routinely rounds with staff nurses in her areas of responsibility. In March 2012, she rounded in the Surgical Services Prep office, where staff nurses Barb Hagan, RN, and Donna Barlow, RN, told her that their hands-free telephone devices were old and difficult to use. They explained that using the outdated equipment was frustrating because they could not hear their patients well when performing telephone interviews, and they were often unable to use the headsets. Hagan and Barlow also expressed concern about ergonomics, as they spend most of their day collecting patient information over the phone using a handheld device propped against their shoulder. Rochlin called the hospital communications office and was able to quickly remedy the problem with the purchase of new and improved headsets. Within a week, staff nurses were able to work hands-free and comfortably to process patients in preparation for surgery. Transformational Leadership 10

Exhibit TL10-8, Prep Nurse with Headset Email Staff nurses have access to nurse leaders at all levels through email. Every staff nurse has access to Microsoft Outlook, AAMC s email system, and can send and receive emails at work and at home through Citrix. This quick and easy electronic communication gives staff nurses a direct connection to nurse leaders. Issues with the work environment and/or patient care can be communicated in real time, at any time, and are not dependent on nurse leaders being present. Work Environment Example On February 2, 2013, AAMC implemented an additional component of the electronic medical record system for patient revenue cycle. An unintended consequence of this implementation was that the Care Management staff could no longer easily access the daily work list containing the information needed to prioritize and manage their daily workload. Immediately before the conversion, the care managers were tasked with rebuilding their individual work lists by Transformational Leadership 11

selecting specific fields that would be displayed in an organized manner and drive workflow every day. On January 28, 2013, Pam Hinshaw, MSN, RN, CCM, Clinical Nursing Director of Care Management, received an email from Francis Gautreau, BSN, RN, Care Manager, with questions and concerns about creating the daily work list. Hinshaw responded immediately with the information that Gautreau needed. (Attachment TL10v, Care Management Email, January 28, 2013) Hinshaw collaborated with Uyen Joebchen, Information Systems Technologist, and within 24 hours they developed a work list template that all care managers could easily access. It was ready for use on February 2, 2013, with the go-live of the new system. Posted Office Hours Clinical nursing directors have posted office hours, giving staff nurses opportunities to access them and sending the message that they are interested and available. Having posted hours when nurse leaders are available to meet and talk with nurses in a private setting lends itself to spontaneity and real-time feedback. Work Environment Example Sage, the clinical nursing director of the General Surgical Unit (GSU), regularly posts office hours to meet with staff members. The December 2012 employee newsletter advertised her 6:30 to 8 a.m. open office hours for December 28, 2012, which ensured that day and night shift staff nurses would have access to their nurse leader. (Attachment TL10w, General Surgical Unit Newsletter) In March 2013, Beth Hoban, RN, GSU, took advantage of Sage s open office hours to speak to her about the frequent changes and shift variability of her work schedule. She explained that she was in school to earn her BSN and needed more consistency and predictability in her schedule. Sage pulled three months of old schedules to confirm the issue, and she made changes to the schedule to make it more amenable to Hoban s school schedule. Her scheduling issue was resolved, and she left the office having had a valuable and positive experience with her leader. Hoban sent an email expressing her gratitude for Sage s willingness to adjust the schedule to meet her needs. (Attachment TL10x, General Surgical Unit Thank You Email, August 14, 2013) Transformational Leadership 12