Utilizing a DNP-prepared Clinical Quality Specialist to develop both an all-inclusive and innovative approach to achieving the nursing strategic plan metrics

Linda Benson DNP ACNP-BC CPHQ CCRN-K

Objectives Demonstrate how hospitals and inpatient facilities could incorporate the role of the clinical quality specialist to take advantage of the DNP skillset of • Data mining •  Performance improvement knowledge • Ability to serve as a change agent and • Ability to implement scientific evidence into

practice In other words… how to operationalize the DNP skill set in the hospital setting

Objectives Continued

Describe how the establishment of the DNP –prepared CQS role has led to •  a comprehensive nursing strategic quality plan

which is both inclusive and innovative, and •  involvement and engagement by all levels of

nursing staff towards attainment of the quality metrics

Sometimes the sun, moon and stars do align

Tampa General Hospital

•  1011 bed academic teaching hospital

•  Number one hospital in Tampa Bay per US News and World Report

•  Joint Commission accredited •  Three time Magnet designated

hospital •  US News and World report

recognized in multiple specialties

Chief Nursing Officer with DNP •  Janet H. Davis DNP, RN, NE-BC, CPHQ, Senior Vice President and Chief Nursing Officer

•  Understood the need for a DNP with CPHQ certification to serve as the Nursing Clinical Quality Specialist

DNP Essentials •  Scientific underpinnings for practice •  Systems thinking, healthcare organizations and

the APN leader • Clinical scholarship and evidence-based practice • Collaboration IT and patient care technology •  Interprofessional collaboration for improving

patient health • Clinical prevention for improving patient health • Healthcare policies for advocacy in healthcare • Developing ethical competency

Nursing Clinical Quality Specialist

• Attributes involve the components of a typical CNS role

• Coordinates the Department of Nursing Quality Improvement initiatives

•  Includes the development, coordination and maintenance of the Nursing Performance Improvement Plan

• Required CPHQ certification

Being data-driven…Collaboration with IT

• CQS joined forces with the Business Intelligence Analysts (BIAs) and System Analysts in the Information Technology (IT) Department to develop a series of compliance and safety reports to optimize the nursing scorecard measures.

• Data was disseminated electronically, discussed at meetings and on walking quality Gemba rounds.

Compliance reports covered a series of nursing-sensitive indicators •  pain re-assessment •  utilization of the Pasero Opioid-Induced Sedation

Scale •  SCD documentation • CHG bath completion •  device infection bundle implementation •  vaccine administration •  blood transfusion

CLABSI Bundle Compliance Report

Pre-op CHG Compliance Report

Specialty Units Compliance Reports

• Compliance with the American Association of Critical-Care Nurses ABCDEF Bundle was also tracked with separate reports for ventilator days, delirium screening and mobilization.

• Compliance with normothermia in the OR was also tracked

• At present there are nearly 20 total compliance reports

Statistical significance of the compliance improvements.

Data Dissemination • Disseminated to the nursing leadership on a

predominantly monthly basis •  Infection prevention and SCD data is

disseminated weekly • CQS recruited quality champions from each of

the nursing units to foster staff engagement in quality.

• Unit-based quality boards were designed • Walking Gemba rounds using SWOT analysis

are conducted at the boards by the CQS and the nursing leadership team

Specific meetings where the CQS disseminates data

• Nursing Leadership meeting • Nursing Quality Council • Nursing Quality Champions meeting •  Specialty Service Line meetings

Nursing Quality Champions Unit-based clinical nurses or nurse clinicians who served as quality experts by: •  Attending monthly meetings where

new data and interventions to improve the data are discussed

•  Disseminating data through a variety of methods including posting the data for display on the unit quality boards

•  Presenting unit based data in staff meetings or education blocks

•  Discussing urgent topics in huddles •  Providing surveillance and

monitoring of quality processes •  Identify ing opportunities for

performance improvement of the nursing metrics on a unit level

•  Disseminating quality improvement successes during Nurses’ Week, National Healthcare Quality Week and at regional and national conferences

Unit-based Quality Boards

Gemba Walks

In business, gemba refers to the place where value is created In manufacturing the gemba is the factory floor. It can be any "site" such as a construction site, sales floor or where the service provider interacts directly with the customer. Gemba walks are an activity that takes management to the front lines. Gemba walks denote the action of going to see the actual process, understand the work, ask questions, and learn. It is also known as one fundamental part of Lean management philosophy. Began with the Toyota company and management interacting with, engaging and empowering the workers on the assembly line.

SWOT analysis involved in the Gemba walk • Empower staff to discuss quality metrics. • Allow staff to celebrate success and discuss what

they do well. • Have staff identify opportunities for those

metrics that are not meeting goal; Identify interventions needed to meet goal.

• Ask staff what barriers they are experiencing. • Ask staff what you can further do to support

them.

Failure of data to optimize

• Gap analysis •  Implement evidence-based practice • Root Cause Analysis meetings

Examples of evidence implemented by CQS with interprofessional colloraboration

• Use of prophylactic skin dressings • Micro-positioning to prevent HAPIs •  Implementation of new pediatric falls risk

assessment (GRAF/PIF) • Development of evidence-based criteria for CVL

removal •  Instituted CAUTI prevention strategies such as

use of the bladder scanner when catheters are non-functional rather than irrigation

• Evaluation of products: fluidized systems to prevent occipital HAPIs and products to improve Pericare

Creative strategies where there was no evidence… • Dual personnel urinary catheter insertion which

eradicated CAUTIs in the ER (APIC conference) • Utilization of a multidisciplinary approach

(Nursing, Pharmacy, Psych Nurse Team) for delirium which reduced delirium resolution times below published reports (NICHE conference)

Root Cause Analysis Meetings

• HAPIs •  Falls with Injury • CAUTI • CLABSI • VTE/Patient Safety Indicator 12

PSI 12

Numerator: Discharges among cases meeting the inclusion and exclusion rules for the denominator with ICD-9-CM codes for deep vein thrombosis or pulmonary embolism in any secondary diagnosis field. Denominator: All surgical discharges aged 18 years and older defined by specific DRGs or MS-DRGs and an ICD-9-CM code for an operating room procedure. Heavily-weighted Patient Safety Indicator in regards to re-imbursement

Defining the evidence to practice gap

• Caprini Risk Factor Score • Appropriateness of anticoagulation based on

score • Missed doses of anticoagulation •  SCD application/documentation • Mobility • CVL removal based on criteria

Refused doses of anticoagulation

Results of VTE RCA

•  24% reduction in refused doses of anticoagulation through enhanced patient education

•  67% reduction in overall VTE PSI 12 rate to below national median

Development of the Nursing Scorecard

•  Patient Care Experience metrics • Quality and Safety metrics with AHRQ, NHSN,

and internal benchmarks utilized as goals • Value based purchasing goals for PSI 3, 12 and

13 •  Technology implementation goals • Magnet preparation

Components of the Nursing Strategic Plan Focus Areas

NURSING STRATEGIC PLAN FY 2018

Priority Focus Areas

Indicator Measure Benchmark/Goal

FY 2017 Interventions/Projects

Trend

Metrics and Measures •  Patient Care Experience •  HAPIs •  Falls with Injury •  CAUTI •  CLABSI •  MDRO •  Handwashing •  Decolonization •  CHG compliance •  SCDs •  Missed Doses of

Anticoagulation •  MEWS

•  Press-Ganey •  Patients/1000 discharges; PSI 3 •  Falls with injury/1000 discharges •  Internal benchmark + SIR •  Bundle compliance, Internal +SIR •  LAB ID SIR •  Observer data •  Internal benchmark •  Internal benchmark •  Internal benchmark •  Internal benchmark

•  Internal benchmark

Quality Metrics and Measures at Goal At goal Still with opportunity

•  HAPIs •  Falls with Injury •  CAUTI SIR •  CLABSI SIR •  MDRO SIR •  Handwashing •  CHG pre-op compliance •  SCD application •  MEWS

•  Post-op CHG Compliance •  Missed/refused doses of

anticoagulation

Clinical Value Compass: Outcomes

Business Plan for the CQS: ROI

lbenson@tgh.org

References

•  Butts, J. B.; Rich, K. L. (2011). Philosophies and Theories for Advanced Nursing Practice. Jones and Bartlett Learning.

•  Chism, L. A. (2010). The Doctor of Nursing Practice: a Guidebook for Role Development and Professional Issues. Jones and Bartlett Publishers.

•  Dreher, H. M.; Glasgow, M. E. S. (2011) . Role Development for Doctoral Advanced Nursing Practice. Springer Publishing Company.

•  Zaccagnini, M. E.; White, K. W. (2011). The Doctor of Nursing Practice Essentials. Jones and Bartlett Publishers.

Questions ???