EP16 Nurse autonomy is supported and promoted through the organization’s governance structure for shared decision-making.
Provide one example, with supporting evidence, of clinical autonomy that demonstrates the authority and freedom for nurses to make nursing care decisions (within the full scope of their practice) in the clinical care of patients.
AND
Provide one example, with supporting evidence, of organizational autonomy that demonstrates the authority and freedom nurses to be involved in broader unit, service line, organization, or system decision-making process pertaining to patient care, policies and procedures, or work environment.
Example 1- Clinical Autonomy
NAME OFINITIATIVE
Decreasing Sitter Usage
BACKGROUND AND PURPOSE
The mission of Baptist Health South Florida is to improve the health and well-being of individuals, and to promote the sanctity and preservation of life in the communities it serves. Cost-effectiveness and quality service are essential in achieving this mission. Various studies have raised the issue of the cost effectiveness of direct observation in improving patient safety and the need to balance cost with quality health outcomes. This project at Homestead Hospital arose out of the need to achieve this balance. The finance department initiated conversations and inquiries about the increase in staff overtime (OT). During their analysis of OT causes, nursing leaders identified that clinical partners (CP) contributed to a large portion of the costs and hours leading to OT. They noted that many CPs were being used in the role of sitters. As a result, Chief Nursing Officer and Vice President Gail Gordon, RN requested to evaluate sitter usage and improve its efficiency.
Goal
In July 2012, Gordon gathered a group of nurse leaders to discuss the purpose and set the goals of the Sitter Task Force. The task force aimed to decrease sitter use and cost while maintaining patient safety. Sitter use was calculated by dividing total sitter hours per month by 1000 patient days.
METHODS AND APPROACH
The Sitter Task Force members elected Med/Surg 5 Patient Care Supervisor Maria Carrillo, RN to be the chairperson. They conducted several meetings to discuss current process, best practices, and solutions. During their discussions, they identified that sitters were frequently ordered by physicians without re-evaluation. As a result, the sitters would stay in use for a period longer than may be necessary. In order to harmonize Homestead Hospital with the other entities and best practices, the taskforce reviewed and revised the sitter policy and procedure (P&P). (EP16 01 Sitter Task Force Meeting Minutes 7/6/12, 7/10/12, 7/17/12) The revised P&P demonstrated the clinical autonomy of nurses in making clinical care decisions. This was done by applying a shared decision-making process among nursing staff to ensure sitters were assigned appropriately, thereby avoiding the expense of unnecessary sitter hours. The implementation of this shared decision-making model served as an example of increased focus on nurses at the facility being empowered to make clinical care decisions in patient treatment. The implementation of the revised policy and practice of managing sitters was in keeping with the mission of Homestead Hospital’s nursing staff to be the leaders in providing quality and evidence-based patient- and family-centered care by utilizing and ensuring patient’s comfort as described by the nurses’ selected theorist, Katharine Kolcaba, RN.
Organizational Governance Structure for Shared Decision-Making
The policy was finalized by the task force during the July 2012 meeting. (EP16 02 Sitter Policy) They established a “go-live” date of August 16, 2012. This allowed time for Gordon to present the recommendations to the Medical Executive Committee (MEC) for their approval. This was a critical element, since the new policy removed the physician from the process. Nurses were now going to be instrumental in monitoring sitter use while being held accountable for maintaining patient safety. The MEC fully supported the decision to allow the nurses and the nursing supervisors to evaluate the need for sitter use. As a result, the task force developed a communication plan to present the revised policy to other key stakeholders, which involved Patient Care House Supervisors (PCHS), Patient Care Supervisors (PCS), and the shared governance councils. The team also planned on having the policy discussed in staff meetings.
Clinical Autonomy
Historically, physicians made the decisions for the provision of sitters. This process did not allow for periodic reevaluation of the patient for continued need of sitter because of the nature of the physician’s work schedule and shifts. As a result, they often times automatically ordered sitters for patients who were reportedly periodically confused without trying other alternatives or assessing the patient for sitter use only for episodic events. This resulted in greater sitter use than necessary and resultant high costs. As nurses were responsible for the ongoing coordination of patient care, the need for sitters would be best determined by the nursing staff, under established guidelines. The procedure put forth supported this clinical autonomy by allowing nursing staff to determine what was in the best interest of the patient at the time it was needed. To demonstrate this, the task force developed the Sitter Flow Chart. (EP16 03 Sitter Algorithm) The process described in the algorithm promoted nurses’ clinical autonomy through a structured process of shared-decision making. (EP16 04 Sitter Request Form) In doing so, it improved care delivery and ensured a more efficient, timely and appropriate use of resources.
Education and Training
The task force identified PCS and the PCHS as “Train-the-Trainers”. Over a 3-week period, they educated more than 90% of the clinical nurses and 100% of the PCHS on the new policy. They continued education and training through October 2012 to ensure all staff involved were ready to adequately implement the procedure.
PARTICIPANTS
The Sitter Task Force members were:
Name/ |
Title |
Department |
Role in the Team |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer and Vice President |
Nursing Administration |
Team Leader/ Executive Sponsor |
Flor Amaya, RN, CMSRN |
Patient Care Supervisor |
MS4 |
Member |
Javier Bouza, RN |
Patient Care Supervisor |
ED |
Member; researched alternatives to sitters |
Raul Botana, MSN, RN |
Manager |
Staffing |
Member |
Anita Carillo, MSN, ARNP |
Patient Care Supervisor |
MS4 |
Member |
Maria Carillo, BSN, RN, CMSRN |
Patient Care Supervisor |
MS5 |
Chair |
Ingrid Hassani, DNP, RN, NEA-BC |
Director –Med/Surg |
Nursing Administration |
Member |
Ana Cabrera DNP, ACNP-BC, NEA-BC |
Director - ICU |
Nursing Administration |
Member, policy revision and review of best practices |
Greg Johnson, RN |
Patient Care Supervisor |
ED |
Member |
Aracely Olvera BSN, RN, CMSRN |
Clinical Nurse Educator |
MS5 |
Member |
OUTCOMES
Organizational Outcomes
Policy and Procedure
The revision of Homestead Hospital’s sitter policy resulted in supporting organizational efficiency, cost-savings, improved patient care while promoting clinical autonomy among nursing staff.
Efficiency and Cost Reduction
Increased efficiency and cost reduction were the main intended outcomes of the initiative. The transferring of clinical care decision-making authority to nurses with sitter use resulted in a reduction in sitter hours and associated costs. The reduction in monthly hours translated into reduced cost for the hospital. At a rate of $23 an hour, the cost of 1 sitter 24 hours a day, 365 days a year was $198,940. The average total cost for sitters prior to implementation was estimated between $1.6 to 2 million a year. Post implementation, the team realized a cost saving of $406,362 in the following fiscal year. The finance department conducted a sitter usage analysis. The actual reduction in cost and efficiency as a result of this initiative were as follows:
Fiscal Year |
Total Sitter Hours |
Total Cost ($) |
Change from Prior Year |
2012 |
70,808 |
1,099,924 |
Baseline year |
2013 |
44,079 |
693,562 |
-36.9% |
2014 |
51,049 |
809,473 |
16.2% |
Patient Safety
The Sitter taskforce accomplished its goal of decreasing sitter use and associated costs while maintaining patient safety.
Exhibit EP16a: Monthly Sitter Hours per 1000 Adult Patient Days
Analysis: The Sitter Task Force noted a trend towards a decline in monthly sitter hours after they implemented policy changes and a further decline after completion of “Train-the Trainer” education.
Summary of Attachments/Hyperlinks/Evidences
EP16 01 Sitter Task Force Meeting Minutes 7/6/12, 7/10/12, 7/17/12
EP16 02 Sitter Policy
EP16 03 Sitter Algorithm
EP16 04 Sitter Request Form
Exhibit EP16a: Monthly Sitter Hours per 1000 Patient Days
Example 2 – Organizational Autonomy
NAME OF INITIATIVE
Medical-Surgical Omnicell Reorganization
BACKGROUND AND PURPOSE
Clinical nurses at Homestead Hospital practice the art of nursing with both skill and compassion to a diverse population. To maintain the highest quality of service to our patients, the Resource Unit Practice Council (UPC) in an initial meeting in April 2012, brainstormed new ideas on improving nurses’ workflow. Resource UPC member and Clinical Nurse Earl Plowden, RN, who was part of the float pool RN team, expressed frustration when floated to different units. He articulated it took a long time to find patient supplies due to the inconsistencies of item locations from one Omnicell to another among the different units.
The Omnicell is an automated inventory control supply cabinet that dispenses supplies used in patient care management. It is stocked by non- medical personnel and managed by the Supply Chain department. It allows access by authorized personnel and keeps an inventory of available supplies. The Omnicell is useful in tracking patient charges which is essential for reimbursement. A nurse accessing the Omnicell to locate an item would swipe his/ her badge to gain access and select the patient from an Omnicell’s home unit list or a global list which allows the correct patient to be selected regardless of department location. Patients can also be added to the system manually by entering their name and account number. Once a patient is selected, the nurse would attempt to locate items needed for patient care by using a “find item” button, entering a key phrase or by visually searching for the item.
Governance Structure
The challenge arose when the nurse failed to enter the standardized pre-assigned phrase for the item to be located. The system would fail to guide the nurse to the item location in the cabinet. This left the nurse with no other option but to visually scan or “window shop” for the item in the Omnicell, which took up their valuable time. Nurses on their home units adapted to the location of items found in their home department’s Omnicell. However, when they were floated to another unit, they spent considerable time looking for items needed to care for their patients. This created inefficiency with completing tasks in a timely manner. This delay also resulted in frustration and wasted clinical time. This proposed project, if approved, would be a collaborative effort among all departments in the Medical-Surgical/Telemetry service line. (Exhibit EP16b)
Exhibit EP16b: Homestead Hospital Shared Governance Model with UPCs Involved in the Project Highlighted
The Resource UPC set a plan in motion by first reaching out to the leaders of the other Medical-Surgical/Telemetry UPCs to obtain feedback and gain consensus prior to voting on the project. Patient Care House Supervisor and then UPC Chair Yolande Loctar, RN sent an email invitation in May 2012 describing the UPC’s new project idea and pitched it to the UPC leaders of the Medical-Surgical/Telemetry units. She received positive feedback from the other UPC chairs. She also reached out to Supply Distribution Corporate Manager Calvin Brown to ascertain the complexity and limitations of the project. Armed with the approval of all Medical-Surgical/Telemetry UPCs, in June 2012 the Resource UPC unanimously approved the project of standardizing the Omnicells. (EP16 05 Resource UPC Meeting Minutes and Sign-In Sheet 6/18/12) Loctar sent an invitation letter to each Medical-Surgical/Telemetry UPC, inviting at least two unit members to represent their department as plans to standardize the Omnicell got on the way.
Goal
The goal of the team was to decrease the average time nurses spent locating items from the Omnicell by 50% thus improving staff efficiency.
METHODS AND APPROACH
Shared Decision-Making
The first collaborative meeting took place on July 25th, 2012 and included representatives from all 3 Med-Surgical/Telemetry units. The team formulated an action plan with deadlines to complete. The major initial responsibility was 2-fold. First, each unit’s UPC representative had the responsibility to distribute a predetermined check list of 10 items chosen by group to both staff Registered Nurses (RNs) and Clinical Partners (CPs) on their unit. Staff was asked to self-time or to have a buddy be their timekeeper as they located items from the Omnicell on their home unit and “away” units. Secondly, the team requested an itemized grid of the current Omnicell layout in each unit to use as a guide for implementing and streamlining changes. As a result of that exercise, the team discovered that the staff members who participated faced some challenges completing the activity. Those challenges included: the inability to locate items used infrequently; inconsistency with inventory supplied in each Omnicell; variation in the cluster of items in each Omnicell; labeling of items were not user-friendly; and staff time constraints that resulted in poor participation. (EP16 06 Medical-Surgical/Telemetry Collaborative Meeting Minutes and Sign-in Sheet 9/25/12)
As a result of feedback, the Omnicell collaborative group decided to develop and deploy an opinion survey to ascertain staff’s input on the current state of the Omnicell and changes they would like to see. The surveys results were shared during the October 2012 meeting as follow: (EP16 07 Medical-Surgical/Telemetry Collaborative Meeting Minutes and Sign-in Sheet 10/29/12)
- The overall feedback included the simplification of pre-assigned item names so that item search results would become more rewarding;
- Group supplies by tasks with commonly used items at eye level;
- Consider a physician-specific Omnicell with items only requested and used by physicians;
- Extend the time-out delay while searching visually for Omnicell items.
The team also noted from the survey results that clinical nurses had adapted to the Omnicell layout in their current condition and were willing to continue with the status quo. These results challenged the group’s intent to create needed changes. This led to a dwindling commitment of the team members to pursue the project. To bring focus back to the group, Loctar met with Nurse Scientist Maria Ojeda, ARNP in December 2012 to discuss the next steps for the project. Ojeda refocused the group and suggested the group go back to the original goal of measuring “time” and to simplify the list of items to be collected. Loctar and Chair-Elect Clinical Nurse Kelly Vazquez, RN became the official timekeepers. They watched and timed nurses while they were taking out a predetermined list of supplies from their home Omnicell and on other medical-surgical/telemetry units. It took an average of 1.42 (day shift) and 2.01 (night shift) minutes to collect items from their home Omnicells. On the other hand, nurses spent an average of 3.15 (day shift) and 2.25 (night shift) minutes to collect items from the other units’ Omnicell. Nurses took considerably longer to locate supplies when floated to another department. There were times when the nurse had difficulty finding 1 or 2 items on the list, even after asking another colleague to help out, resulting in frustration and wasted clinical time. Armed with these results, the Omnicell collaborative team proceeded with plans to implement a pilot in MS5 Omnicell.
Organizational Autonomy Pertaining to Work Environment
Patient Care Manager Hector Aleman, RN and Clinical Nurse/UPC Chair Steven Trush, RN agreed to pilot the project on MS5. The task of getting the project off the ground and implementing the first set of changes took some time. The team experienced challenges with this project in 2 key areas: (1) two of the key nurse members transferred to another entity resulting in the need to recruit new members to the collaborative subcommittee, and (2) the Supply Chain department was undergoing a major upgrade to their system which meant that the project implementation would be delayed. The project was on hold for approximately 12 months while waiting for the system upgrade to be completed. These challenges affected the project’s momentum and timeline but the Resource UPC stayed the course. They completed the changes to the MS5 Omnicell in April 2014 (Exhibit EP16c) and the staff on MS5 was given the opportunity to provide feedback in relation to the changes. The unit’s Clinical Nurse Educator Aracely Olvera, RN provided feedback from staff on the unit to the collaborative group. Most of the concerns pertained to availability of inventory. The team used the staffs’ feedback to reach out to the Chain Supply department to address inventory availability. The nurses were given a period of 2 months to get familiar with the changes made prior to collecting post data.
Exhibit EP16c: Revised Omnicell Lay-out
There was a separate Omnicell created to house items used by physicians. Loctar and Clinical Nurse/Present UPC Chair Kelly Vazquez, RN presented their findings in the NGC June 2014 meeting. (EP16 08 Omnicell Project Power Point Presentation)
PARTICIPANTS
Name/ |
Title |
Department |
Role in the Team |
Yolande Loctar, BSN, RN |
Patient Care House Supervisor |
Nursing Administration - Clerical |
Resource UPC Chair and project lead |
Kelly Vazquez, RN CMSRN
|
Clinical Nurse |
Imaging |
Resource UPC Chair Elect and Omnicell collaborative member
|
Deanna Royer, RN |
Clinical Nurse |
MS5 |
MS5 UPC representative and recorder |
Angela Solomon, BSN, RN |
Clinical Nurse |
3 South |
3South UPC Chair and representative; recorder |
Lydia Harris, RN |
Clinical Nurse |
MS4 |
MS4 UPC representative |
Janet Nicholson, RN |
Clinical Nurse |
MS4 |
MS4 UPC representative and timekeeper |
Sandy Jones, BSN, RN, CMSRN |
Clinical Nurse Educator |
3 South |
Provided support |
Candance McLaughlin, BSN RN |
Patient Care and House Supervisor |
Nursing Administration - Clerical |
Omnicell collaborative member |
Karen Anding, BSN, RN |
Patient Care Supervisor |
Nursing Administration - Clerical |
Omnicell collaborative member |
Steven Trush, RN |
Clinical Nurse |
MS5 |
MS5 UPC chair; provided support |
Hector Aleman, MSN, RN |
Patient Care Manager |
MS5 |
Supported MS5 pilot |
Angela Delgado |
Clinical Partner |
Float Pool |
Omnicell collaborative member |
Jeffrey Ferguson |
Clinical Partner |
MS4 |
MS4 UPC representative |
Calvin Brown |
Supply Distribution Corporate Manager |
Supply Chain |
Key advisor on project limitations and timeline |
Antonio Bryant |
Supervisor |
Supply Chain |
Collaborator for Omnicell changes |
OUTCOMES
Medical-Surgical/Telemetry Service Line Outcomes
The medical-surgical clinical nurses liked the layout when the method and grid used to make the changes was explained. The nurses expressed how much easier it was to locate the items in the Omnicell and hoped to see the changes made throughout the medical-surgical units. The team is in the process of implementing the changes in the other medical-surgical units.
Exhibit EP16d: Average Time RNs Spent Locating Items in the Omnicell in the Medical/Surgical Units
Analysis: Above graph shows that the average time nurses spent locating items in the Omnicell was markedly reduced after the reorganization. The team noted a significant reduction in time spent by the nurses looking for supplies in the “away” Omnicells when they were floated. They exceeded their goal by reducing the time by 77 %. This lent to better efficiency; reduced frustration among the nurses; and less clinical time wasted.
Summary of Attachments/Hyperlinks/Evidences
EP16 05 Resource UPC Meeting Minutes and Sign-In Sheet 6/18/12
EP16 06 Medical-Surgical/Telemetry Collaborative Meeting Minutes and Sign-in Sheet 9/25/12
EP16 07 Medical-Surgical/Telemetry Collaborative Meeting Minutes and Sign-in Sheet 10/29/12
EP16 08 Omnicell Project Power Point Presentation
Exhibit EP16b: Homestead Hospital Shared Governance Model with UPCs Involved in the Project Highlighted
Exhibit EP16c: Revised Omnicell Lay-out
Exhibit EP16d: Average Time RNs Spent Locating Items in the Omnicell in the Medical/Surgical Unit