SE - Structural Empowerment

SE1EO: Describe and Demonstrate Two Improvements in Different Practice Settings because of Nurse Involvement in Organizational Decision-Making Groups such as Committees, Councils, and Task Forces.

Rita Smith DNP, RN, NEA-BC, CNO and the institution as a whole has empowered nurses to become involved in decision-making groups, such as committees, councils, and task forces because they believe in the nurses’ ability to bring forth positive change. Jersey City Medical Center has allotted time flexibility to attend forums that encourage nurses to express solutions on how to maintain or improve the organization’s initiatives. These opportunities have allowed our nurses to develop into change agents who have contributed to change in practice. This change in practice has positively impacted improvement efforts within our institution. This can be seen through two improvements in different practice settings. One example is the remodeling of the Critical Care Charge RN as the Rapid Responding Nurse for the Rapid Response Team. The second example is the prevention of adverse obstetrical events using the Six Sigma methodology: define, measure, analyze, implement, and control (DMAIC).

Example Improving Rapid Response Team (RRT)

Jersey City Medical Center Rapid Response Team has been in existence for several years in support of the 5 million lives campaign, The goal of the Rapid Response Team is to prevent patients, outside of the Critical Care and Emergency Department, from decompensating. Jersey City Medical Center’s Rapid Response Team members have always comprised of an assigned critical care nurse, a medical resident on days or nights, a respiratory therapist, transport personnel, the patient’s primary nurse and physician. The responding RRT nurse was a critical care RN who was assigned this task in addition to his or her critical care patient assignment. The critical care nurses became concerned that this additional responsibility, on top of a patient assignment, would pose a possible safety risk for the critical care patients. The critical care nurse patient ratio for stable patients is one nurse for two critical care patients. When an RRT was called, the responding RRT nurse would handoff her assignment to the other nurses. This handoff would create a three to one ratio patient assignment for critical care nurses. In some cases, a third patient would have to be assigned to a nurse with an unstable patient. The responding RRT nurse was sometimes in a RRT that would take up to two hours. The critical care nurses felt this posed a great safety risk for the remaining critical care patients and proposed a new charge role that would maintain a safe care environment for both critical care patients and patients who need the assistance of the RRT responding nurse. Some of the nurses involved in this proposal were Amber Cioffo BSN, RN, Reshma Maniar BSN, RN, BSN, Doreen Jones, BSN, RN.

In a Rapid Response Committee meeting, Cristina Simeone BSN, RN, Critical Care Nurse Manager presented the critical care nurses’, who commonly responded to RRTs calls, idea of developing the charge nurse role as one that did not have a patient assignment. This new charge nurse role would include becoming the RRT responding nurse. This would also allow the charge nurse to manage the patient flow, the maintenance of a safe nurse-patient ratio in critical care during RRT calls, and the availability of the charge nurse to teach staff when to call an RRT. This idea was combined with the Quality & Safety Nursing Council members’ recommendations that the charge nurse should educate on RRT calls, be a resource to other charge RNs, respond to code sepsis, and perform follow up rounds on patients. Claudia Garzon-Rivera MSN, RN, CNL, CCRN, Clinical Nurse Leader, and chairperson of Quality & Safety Nursing Council brought forth these recommendations during the development of the Critical Care Charge Nurse role. The Critical Care nurses and the Quality & Safety Nursing Council members were influential in the development of the Critical Charge Nurse.

After the critical care nurses’ idea of the new Critical Care Charge Nurse role was presented, the role and team was developed. The Critical Care Leadership Nursing Team, including Ms. Simeone, Nicole Sardinas MSN, RN, CCRN, Critical Care Nurse Educator, Ms.Garzon-Rivera and Mabel LaForgia MSN, RN, CNL, CCRN, Critical Care Clinical Nurse Leader, developed the new role’s responsibilities. Ms. Simeone presented a budget proposal on the new responsibilities of the Critical Care Charge RN to administration. Once administration approved the budget for the new role, the applicants were interviewed. The team was comprised of nurses who were interested in achieving our goals in preventing deaths through early intervention in patients. Midyear 2011, the new role was introduced. The team included Amber Cioffo, ADN, RN, Prema Cotha BSN, RN, Anika Davis BSN, RN, Susan de la Pena BSN, RN, Danielle Diaz BSN, RN, Reshma Maniar BSN, RN, CCRN, Melissa Massa BSN, RN, and Erin Salmond BSN, RN, and Josephine Smith MSN, RN, APN.

SE1EO-Table 1

Multidisciplinary RRT Training for the Development of the RRT Team

The RRT training was conducted over a couple of days using the Agency for Healthcare Research and Quality’s “TeamSTEPPS Rapid Response Systems Module,” by Nicole Sardinas MSN, RN, CCRN, Critical Care Nurse Educator and Claudia Garzon-Rivera MSN, RN, CNL, CCRN, Critical Care Clinical Nurse Leader and Mabel LaForgia MSN, RN, CNL, CCRN, Critical Care Clinical Nurse Leader. In 2011, the emphasis on Rapid Response was the use of the Early Warning Scoring System (EWSS). RRT Team building sessions also included nurses from different specialties, medical residents, respiratory therapists, patient care technition, and unit clerks.

RRT Using Evidence-Based Practice for Early Detection of Patient Deterioration

The EWSS was modified to our organizational needs by the Rapid Response Committee which is a multidisciplinary team that includes nurses from other units. The EWSS is an evidence-based practice color scoring tool that encompasses a range of normal vital signs to abnormal findings that alert the end user to reassess the patient or call for a RRT intervention. The premise of the EWSS is to detect early deterioration before the patient decompensates. Before introducing the EWSS to all units, the EWSS tool was piloted on a medical/surgical unit. The staff’s feedback has been very instrumental in making the EWSS meaningful. The use of this tool has increased our RRT calls.

Due to the consistent team of rapid response nurses along with their continual education efforts on teambuilding, EWSS and RRT has facilitated the development of the RRT. This has influenced a change in culture that empowers anyone to activate the RRT when the need arises. By using evidence-based practice, providing on-going education, and continuous collaboration to improve the rapid response process, we have successfully decreased and maintained our code blue rates below target.

SE1EO-Table 2

The chair of the Rapid Response Committee collects monthly data on the number of RRT calls and code blues outside of the Critical Care & Emergency Departments. The Rapid Response Teams’ goal is to have 25 RRT calls per 1,000 patient discharges per month, and less than 3 Code Blues outside the Critical Care and Emergency Departments. The Rapid Response Team’s improvement has enabled the Rapid Response Team and the RRT Task force to accomplish its goal of decreasing code blues. Improvements such as:

  • The Critical Care Charge RN’s new role, as the RRT Responding RN
  • RRT Multidisciplinary training with TeamSTEPPS Rapid Response Systems Module
  • The EWSS

have assisted in commitment to reaching our goal. Presented below is a graph of a 2010 and 2011 comparison of code blues outside the critical care and emergency departments.

Code Blues Outside of the Critical Care Division and Emergency
Department 2010 Baseline data and 2011 Improved

Code Blues Outside of the Critical Care Division and Emergency Department 2010 Baseline data and 2011 Improved

Example Six Sigma Prevention of Adverse Obstetrical Event Team

Providing safe effective care is the Obstetrical Leadership Nursing team’s priority. They have developed, initiated, and advocated for improvement strategies, which promote optimal patient care. In 2010, the Obstetrics Charge Nurse, Rachele Dalalian MS, RNC, CLNC took interest in championing improvement strategies along with Dr. Michael Bimonte, Chairperson of the Obstetrics Department. Rachel’s interest stemmed from her knowledge that cesarean deliveries of live-born infants had been on the rise for over a decade in New Jersey. Also, that this increase was partially attributed to the increased incidence of elective inductions less than 39 weeks. During Rachel’s short time period as the charge RN, she assisted in assuring that the elective induction bundles were in place. As the charge RN for the obstetrics unit she was in an excellent position to assist in enforcing the compliance of the bundles.

In 2011, Rachele Dalalian MS, RNC, CLNC transitioned into a new position, in the Quality Improvement Department, but continued to assist with the obstetrics improvement process. Ms. Dalalian became part of the Quality Improvement team. In this new role, one of her responsibilities is a liaison between the Quality Improvement team and the obstetrics department in improving patient quality. Ms. Dalalian’s extensive years as an obstetrics RN and as a charge RN facilitated this process.

A six sigma task force assembled, which included Lillian Reyes BSN, RN Perinatal Nurse Manager, Dr. Michael Bimonte M.D., and Ms. Dalalian. This task force’s mission was to continue to improve elective induction bundle compliance, decrease the primary cesarean section rate, and eliminate inductions >39 weeks. The Six Sigma methodology guided them to define, measure, analyze, improve, and control the problem (DMAIC). Review the table for clarification of the problem in the DMAIC model.

DMAIC model

Barriers identified included the need for nurse/physician buy-in, development of a culture of safety among nurses, lack of communication and the need for education, an increase in “medically” indicated inductions and scheduling issues, for example, physicians will not schedule the induction appropriately. Other barriers identified included: A commitment by administration to prioritize patient safety for obstetrics, approval to acquire an external Perinatal Patient Safety Assessment, commitment to participate in NJHA Perinatal Collaborative and financial approval for significant upgrades to the current Centricity Fetal Surveillance and obstetric EMR charting.

Part of the implementation process included insuring the accuracy of the “due date” when scheduling inductions. The task force required that the Last Menstrual Period (LMP) be documented, the earliest ultrasound report must be available, the medical indication if the patient is being scheduled is below 39 weeks and a review of the perinatal chart is required. In the event of a controversy, the Chairperson of the Maternal Fetal Medicine Department makes the decision for appeals of any bundle denials.

Department Peer Review requires the participation of the obstetrical Resident and all outliers are reviewed during this process for educational opportunities. All physicians are required to receive ongoing Fetal Heart Rate education and all category 3 tracings are reviewed. The Labor and Delivery area also obtained a dedicated FAX line to insure that scheduled procedures would be reviewed in a timely manner. They also insured a greater efficiency with scheduling by utilizing the PHS system which is a scheduling system that was already being used in the operating room. By using this system they were assured that overbooking would not occur. See improvement process below:

Improvement Process

While improving obstetrical patient care processes in 2011, the team welcomed Randa Francis MSN, RN, CNM,WHCNP-BC, Perinatal Nurse Educator. She joined forces with Ms. Dalalian and Ms. Reyes to continue the improvement initiatives. Together they identified additional improvement initiatives that will assist in the delivery of quality patient care.

Additional Improvement Initiatives in 2012:

The task force was determined to improve patient quality care. After reviewing outlier cases and barriers, they developed protocols, policies, and goals to improve the delivery of care to the obstetrical patient population:

  • OB Hemorrhage Protocol
    • Development of a system to quantify blood loss as oppose to the traditional “estimating” of blood loss
    • Creation of an obstetrical hemorrhage emergency kit to prevent delay in obtaining needed instruments and supplies during an emergency
    • Initial and ongoing risk assessment on all laboring and postpartum patients to identify risk and prevent obstetrical hemorrhage. “Code OB”
    • Development of a code policy that will aid communication between EMS and the Maternal Child Health Department (MCHD) when there is a pending delivery in the ER or in route
  • Code OB Trauma
    • Development of a code policy that will aid communication between EMS, ER, MCHD, and the Trauma team when there is a pregnant patient involved in a trauma
  • NOELLE Simulation Doll
    • Plans of developing a MCHD simulation lab with an ongoing program of nursing and medical staff development through simulation learning
    • Aspire to become the first hospital in the county with a full OB simulation lab
  • Adapting to the National Institute of Child Health and Human Development’s (NICHD) electronic fetal heart rate monitoring (EFM) terminology

Outcomes: The task force which includes Lillian Reyes RN, Manager of the Perinatal Unit, Randa Francis MSN, RN, CNM,WHCNP-BC, Nurse Educator, and Rachele Dalalian MS, RNC, CLNC continued to reinforce all the implementation strategies throughout 2011 and 2012. Also, they continued to participate in control processes that were set in place to sustain and maintain the task force’s goals. Their effort to improve quality care is reflected in the improvement seen throughout 2011. In 2012, there is significant improvement in primary cesarean sections, as well as sustained improvement in elective bundle compliance and elective inductions. They attribute their success to their passion for providing optimal quality care which is shared with their Perinatal staff.

Outcomes 2011:

SE1EO-Table 3

Outcomes 2012:

SE1EO-Table 3