TL7 Nurse leaders, with clinical nurse input, use trended data to acquire necessary resources to support the care delivery system(s).
Provide one example, with supporting evidence, where a nurse leader, with clinical nurse input, used trended data to acquire necessary resources to support the care delivery system(s).
NAME OF INITIATIVE
Increasing Palliative Care Coverage
BACKGROUND AND PURPOSE
Care Delivery System: Patient-and family-centered care
Patient- and family centered care is a relatively new approach for healthcare professionals. Historically, healthcare providers “steered the ship” in the direction they felt was indicated. Patient and families took a less active role in the decision making process. In the 1980’s to 1990’s, legislation and policies supporting family involvement in the care of handicapped or special needs children were adopted. By 1992, what is now known as the Institute for Patient- and Family-Centered Care was founded to foster partnerships and provide leadership for implementing this model in all practice settings. Over the years, several prestigious organizations such as the Institute for Healthcare Improvement (IHI), Institute of Medicine (IOM), the National Patient Safety Foundation and the Joint Commission supported and promoted this philosophy. BHSF and Homestead Hospital have embraced the concept of patient- and family- centered care and have incorporated it into its mission, vision and core values. Likewise, Nursing Services department with input from clinical nurses integrated patient- and family- centered care into its professional practice model. Supporting this philosophy, a Palliative Care Steering Education department and Steering Council was formed at the corporate level with individual (non-hospice) Palliative Care Services departments at each facility.
Palliative Care is an approach that improves the quality of life for patients and families who experience chronic, potentially life-threatening illnesses. Through early identification and treatment of pain, physical, spiritual and psychosocial problems, quality of life is enhanced, and may potentially influence the course of illness. Unlike hospice, palliative care is applicable early in the course of illness and is not dependent on prognosis. Other therapies may be initiated that are intended to prolong life, such as chemotherapy or radiation therapy, and manage distressing clinical complications (WHO, 2014; Center to Advance Palliative Care, 2012). Palliative care was not always embraced by healthcare practitioners. It was not until several randomized controlled trials in which traditional care of lung cancer patients was compared to traditional care plus palliative care supported its use. Patients in the latter group reported better quality of life, reduced symptoms, less depression, were less likely to be admitted to the hospital and lived three months longer than the usual care group (Temel, et. al, 2010).
The Palliative Care department at Homestead Hospital serves to provide relief from pain and other distressing symptoms, affirm life and regards dying as a normal process. The Palliative Care department also integrates the clinical aspects with the spiritual and psychosocial aspects of patient care by offering support to patient, families and the staff using a team approach.
Both clinical nurses and practitioners have seen the benefit of having a Palliative Care department as evidenced by the exponential growth since its inception. (Exhibit TL7a) In 2010, staffing enabled nurse practitioner (ARNP) coverage 7 days a week. By 2011 the department had grown into an interprofessional service with 2 ARNPs, 1 licensed social worker and 1 chaplain (which totaled 3.9 FTE) in response to growing demand and need.
Exhibit TL7a: Trended Data: Homestead Hospital’s Palliative Care Growth
Analysis: Above graph shows rapid growth of the Palliative Care Program over the years.
Exhibit TL7b: Trended Data: Homestead Hospital’s Palliative Care Consults/Referrals: Seen and Not Seen
Analysis: Above graph depicts the steady increase in the number of missed consults/referrals as the Palliative Care Program grew.
METHODS AND APPROACH
Nurse Leader Advocacy
In September 2013, the system Palliative Care Steering Council conducted its annual planning retreat during which strengths and opportunities were identified. Long highlighted Homestead Hospital’s well functioning program and its strengths that included: establishing goals of care; conferences held in language of choice including patient and families for any decision making; interprofessional approach; families invited to participate in ICU rounds; a community member as patient/family advisor on the Patient-and Family-Centered Care Committee; and community members on the Ethics Committee. During this retreat, Long advocated to the Palliative Care Steering Council the need to acquire additional human resources, specifically an ARNP full time equivalent (FTE), to expand coverage to 7 days a week. (TL7 01 Palliative Care Steering Council Strategic Planning Meeting Minutes and Sign-in Sheet 9/13/13) Long presented the above trended data that she has compiled. Referrals have continued to increase year after year without the addition of staff since 2011. Consequently, missed physician consults and nursing referrals have been increasing since 2011 from 23.3% to a projected 52.1% by year end in 2014. Long made her case for additional staffing and the system Palliative Care Steering Council endorsed her recommendations.
Clinical Nurses’ Input
Staff became accustomed to having the resources available to help support patients/ families regardless of the day of the week. By January of 2014, the weekday demands for consults and referrals were increasing at such an incredible pace that 1 ARNP could no longer handle the volume. The weekend ARNP was moved to help cover the weekdays in order to reduce the number of missed consults and referrals. (Exhibit TL7b) Long communicated this change to the clinical staff. The clinical nurses, particularly in the Critical Care departments, voiced their concern about the lack of support and guidance on the weekends with the Palliative Care specialist not being available. (TL7 02 Critical Care Staff Meeting Minutes and Sign in Sheet 1/27/14). When clinical nurses, along with the providers, have difficulty in establishing goals of care or having end-of-life conversations with the patient and family, they consult Palliative Care services to intervene. Clinical nurses felt supported when a palliative care nurse is involved in those often difficult decisions. Not only do the specialty palliative care nurses have the additional education and expertise in handling these situations, they also provide a sounding board and supportive environment for the clinical nurses to practice. Patient Care Manager Leslie Everett, RN passed along to Long the clinical nurses’ feedback.
In preparation for the upcoming FY 2015 budget, Long used the trended data together with the clinical nurses’ input to justify additional staff. She also garnered the support of nursing leaders and Chief Nursing Officer and Vice President Gail Gordon, RN. She initially requested during the budget process in May 2014 1.0 FTE for ARNP weekend coverage. Later on, she negotiated with Support Services Vice President Corey Gold and was approved to request 0.5 FTE. Long then met with Assistant Controller Liliana Fong from the finance department and presented her trended data and justification. Once all departments had submitted their FTE requests, the senior leadership team met and reviewed the requests. After a lot of deliberations and negotiations, senior leadership and the board of directors approved the FY 15 FTE budget in September 2014.
PARTICIPANTS
| Name/Credentials | Title |
Department |
Role in the Team |
Linda Long MSN, MBA, ARNP-C |
Manager |
Palliative Care |
Requested for additional FTE |
Blanca Chavez, MSN, ARNP, FNP-BC |
AARNP |
Palliative Care |
Care Provider, |
Gail Gordon, MSN, RN, NEA-BC |
Chief Nursing Officer (CNO)/ Vice President |
Administration |
Advocated for additional FTE |
Critical Care Clinical Nurses |
Clinical Nurse |
CU/PCU |
Provided feedback during staff meeting |
Leslie Everett, BSN, RN, CCRN |
Patient Care Manager |
Critical Care/ Progressive Care |
Provided support and communicated clinical nurses’ feedback to Palliative Care Manager |
Dell Slavin, MSW, LCSW, ACHP-SW |
Social Worker |
Palliative Care |
Care Provider, |
Corey Gold, MS, CRT |
Support Services Vice President |
Administration |
Approved additional ARNP FTE |
Juan Lopetegui, MD |
Critical Care Director |
Critical Care/ Medical Staff |
Provided support |
OUTCOME
Resources Acquired
For fiscal year 2015 Long obtained an additional 0.5 FTE for an ARNP that will be used to provide 7-day Palliative Care ARNP coverage for patient/family consults and referrals. (TL7 03 Homestead Hospital FY 15 Final FTE Budget). Long has posted the position and is in the process of filling it.
Summary Attachments/Hyperlinks/Evidences
Exhibit TL7a: Trended Data: Homestead Hospital’s Palliative Care Growth
Exhibit TL7b: Trended Data: Homestead Hospital’s Palliative Care Consults/Referrals: Seen and Not Seen
TL7 01 Palliative Care Steering Council Strategic Planning Meeting Minutes and Sign-in Sheet 9/13/13
TL7 02 Critical Care Staff Meeting Minutes and Sign in Sheet 1/27/14
TL7 03 Homestead Hospital FY 15 Final FTE Budget
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