TL3EO The CNO influences organization-wide change beyond the scope of nursing.
Provide one example, with supporting evidence, of a CNO-influenced positive change that had organization-wide impact beyond the scope of nursing services. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
NAME OF INITIATIVE
The Birth of the Laborist Program
BACKGROUND AND PURPOSE
Homestead Hospital’s Chief Nursing Officer, Gail Gordon, RN, identified an improvement opportunity in providing adequate intrapartum pain relief in the Labor and Delivery department related to the availability of epidural anesthesia. In October to December 2012, Homestead Hospital provided 29% of laboring women with epidural or spinal pain relief. This number was low compared to the 2011 National Vital Statistics report which documented that 61% of women, with singleton deliveries, received epidural or spinal anesthesia for pain relief during labor.
The physician component played a significant role in epidural availability when the American Academy of Anesthesiologists changed its recommendations. The practice change required a physician examination prior to epidural placement and for the doctor to be in-house while the epidural was being placed. This became a major workload challenge among the obstetric (OB) physicians who were all running independent practices.
The Joint Commission and Centers for Medicare and Medicaid Services (CMS) recognize pain as the 5th vital sign and concur that it is a patient’s right to be offered adequate pain relief. In 2011, the Press Ganey inpatient patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) “pain well controlled” response was at the 71st percentile. In the third quarter of 2013, the “pain well controlled” response was at the 89th percentile.
Gordon collaborated with Chief Executive Officer, William Duquette, and she made the initial push by beginning a review of the existing practices and policies on epidural administration. In the process, she recognized other areas of concern brought forward by the L&D Registered Nurses (RNs) related to the increased rate of unattended deliveries and the perceived high patient acuity due to high risk, unassigned obstetric patient volumes in the emergency department. In October – December of 2012, Homestead Hospital had 6.2% unattended deliveries, which was higher than the U.S. Department of Health and Human Services benchmark of 2.5%. Gordon then negotiated with senior leadership for the inclusion of this priority area into the organizational strategic goal for FY 2013. (TL3EO 01 Homestead Hospital FY 13 Strategic Goals, highlighted).
GOAL STATEMENT(S)
The goal was to provide in-house 24/7 obstetric/gynecology (OB/GYN) physician coverage in order to:
- Increase epidural/spinal percentage by 10%, from 29% to 39%.
- Decrease unattended delivery percentage by 2%, from 6.2% to 4.2%.
The measures used to demonstrate improvement were as follows:
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
Early in FY 12, Gordon recruited and on-boarded Jan Weatherspoon, RN, Perinatal Services nursing director, to help her develop a Laborist program. Weatherspoon has a strong operational background; previous experience with laborist models; and a proven track record as a change agent. In response to the ideas collected from Perinatal RNs during round tables; research into national/community standards and best practices ; and extensive literature review, Gordon formed an interprofessional taskforce to further explore the possibility of implementing an OB hospitalist/Laborist group at Homestead Hospital. The team which initially met in November 2012 consisted of senior leadership, an administrative project analyst, OB, anesthesia and neonatal physicians, an OB nurse leader and an OB educator.
Throughout 2012, the committee began by reviewing existing obstetric hospitalist models and brainstorming on different ideas for program implementation. The team enlisted the expertise of an external consultant who provided the group with examples of successful models and indications for the different models. They also conducted a cost/benefit analysis to assess the viability of the program. They examined data such as delivery volumes, triage numbers, emergency room assessments, epidural utilization and nurse delivery rates.
The data collection and cost/benefit analysis processes were lengthy and took a period of 12 months. Several corporate and hospital departments were involved in the vetting process as follows:
- Strategic planning - Validated the volume assumptions & revenue projections (based upon historical data).
- Internal Controls Management, Acquisitions - Facilitated the due diligence and validated the facility pro forma.
- Admitting - Worked through the registration process flow including service codes for patient status transfers.
- ED Charge Specialist - worked with Homestead Hospital’s Perinatal Services to develop the OB triage leveling process and charge entry.
- Patient Access / Corporate Registration - approved adding a new hospital service (OBE = OB Emergency Department) that interfaced with Essentris (OB electronic medical record) for fetal monitoring and T-Systems (ED electronic medical record).
- Clinical Business Systems: IT - Tested interface of new service to all ancillary services (other than Essentris and T-Systems) and interface functionality from Invision to Essentris and T-Systems.
- Revenue Pricing & Analysis - Added the appropriate charge code to the existing OB triage beds in L&D.
- Homestead Hospital Finance - Opened a new cost center as an extension of the ED (i.e. 400-3035).
- Clinical Business Consultant: IT (T-Systems) - created the Homestead Labor & Delivery Triage area in T-Systems for physician documentation.
- IT Financial System/Physician Services - provided the Laborist group with remote access to NetAccess (inpatient electronic medical record).
- Health Information System- facilitated physician documentation in T-System.
Thereafter, the committee identified an existing physician vendor and formulated a new model that fitted the unique culture and needs of Homestead Hospital by combining ideas from various existing models. In collaboration with the physicians, Weatherspoon developed the Laborist Scope of Services (TL3EO 02 HH-400-2000-1000 OB/GYN Hospitalist/OB/GYN Emergency Department [Laborist Program]: Scope of Services) which delineated the physician responsibilities to include quality and data collection.
Initially, two physicians were recruited. On May 1st, 2013, the first two Laborist physicians began to see patients. Locum physicians were used to cover a 24/7 in-house schedule until permanent physicians were recruited. Once the recruitment was completed, the laborists consisted of two male and two female OB/GYN physicians, who shared 24/7 in-house responsibilities for OB/GYN coverage. (TL3EO 03 Laborist coverage schedule) This fulfilled the need for a physician to be in-house for epidural placement, to care for OB/GYN ED patients without primary physician coverage and to respond to any emergencies. The physician’s lounge was renovated to provide more comfortable accommodations to the new and existing doctors. Additionally, Clinical Nurse Educator Kathy Adamson, RN, rolled-out the education to inform the Perinatal staff of the new process flow. (TL3EO 04 Laborist Program Process Flow).
PARTICIPANTS
The OB/Laborist task force members were:
Name/Credentials |
Years work experience/ Years Specialty Experience |
Title |
Department |
Role in the Team |
Gail Gordon, MSN, RN, NEA-BC |
45 years / |
Chief Nursing Officer (CNO) and Vice President |
Nursing Administration |
Chair |
Jan Weatherspoon, MSN, RN, NEA-BC |
30 years / |
Director |
Perinatal Services |
Member |
Kathy Adamson, MSN, RN |
35 years / |
Clinical Nurse Educator |
Perinatal Services |
Member |
Bill Duquette, MPH, MT(ASCP) |
30 years/ |
Chief Executive Officer |
Administration |
Executive Sponsor |
Kenneth Spell, MPH |
19 years/ |
Professional Services Vice President |
Administration |
Member; Physician Liaison |
Jackie LeBoeuf, MBA |
18 years / |
Administrative Project Analyst |
Administration |
Member |
Jorge Perez, MD |
29 years |
Medical Director, KidzMedical Neonatology Group |
Medical Staff, Neonatology |
Physician Champion |
Samir Kulkarni, MD |
24 years |
Medical Director, Anesthesiology |
Medical Staff, Anesthesia |
Member |
Charles Augustus, MD |
33 years |
Medical Director, Perinatal Services |
Medical Staff, |
Member |
OUTCOME(S)
Positive Changes
With the approval of the Medical Executive Committee, the laborists started consulting patients throughout the hospital. Due to the unanticipated gynecological volume, the group originally intended to add a 5th physician which would allow for one physician 24/7 and one physician Monday through Friday 9 a.m.-5 p.m. to accommodate the gynecology patient volumes and faster response time to patient consults in the ED. More recently, they started to explore bringing in nurse midwives as part of the laborist group. In the FY 2013 budget, an initial $1.3 million was allocated to ensure the program was financially supported through the first year. The FY 2014 budget reflected a reduction in the assessed monetary shortfall to $844,951 suggesting that the revenues collected by the laborist group has helped to off set the initial start-up cost of the program. In summary, Gordon’s influence and advocacy brought about many positive changes such as the creation of new laborist roles, increased spinal anesthesia events and more attended deliveries.
Exhibit TL3EOa: Labor Epidural/Spinal Anesthesia Utilization
Analysis: Exhibit TL3EOa shows a steady increase in the utilization of epidural/spinal anesthesia for labor pain relief since the inception of the Laborist program at Homestead Hospital exceeding the internal goal of 39% for 4 quarters and moving closer towards the CDC national average of 61%.
Exhibit TL3EOb: Percent of Unattended Delivery
Analysis: The data in Exhibit TL3EOb demonstrates a significant decrease in the number of unattended deliveries since the inception of the Laborist program on May 1st, 2013 exceeding both internal and national benchmarks for 4 consecutive quarters.
Summary Attachments/Hyperlinks/Evidences:
TL3EO 01 Homestead Hospital FY 13 Strategic Goals, highlighted
TL3EO 02 HH-400-2000-1000 OB/GYN Hospitalist/OB/GYN Emergency Department [Laborist Program]: Scope of Services
TL3EO 03 Laborist coverage schedule
TL3EO 04 Laborist Program Process Flow
Exhibit TL3EOa: Labor Epidural/Spinal Anesthesia Utilization
Exhibit TL3EOb: Percent of Unattended Delivery