Closing the Quality and Safety Gap

    • July 30, 2009

Two new publications from the Robert Wood Johnson Foundation’s (RWJF) Charting Nursing’s Future series focus on critical issues in the effort to reform health care for the 21st century. Published as a “miniseries” under the banner of “Addressing the Quality and Safety Gap,” the publications are aimed at identifying ways to significantly reduce the number of avoidable medical errors, including those that claim an estimated 44,000 to 98,000 lives each year in U.S. hospitals.

The first of the two publications, “Case Studies in Transforming Hospital Nursing and Building Cultures of Safety,” points the way toward a variety of reforms that have been tested successfully in hospitals across the nation.

In Los Angeles, California, for example, Cedars-Sinai Medical Center has implemented two patient-safety reforms that rely on advanced on-the-job training for nurses. One reform is the implementation of a “universal floor” approach that allows patients to remain in one adaptable room and bed throughout their entire hospital stay, eliminating the costs, labor and patient risks associated with transfers from one unit to another. On average, 40 to 70 percent of patients on the typical inpatient nursing unit are transferred every day, and many move as many as six times during their stays, inviting a variety of problems including lost information, treatment delays, incompatibilities in record-keeping, and wasted supplies and staff time.

Cedars-Sinai established a 30-bed unit for the program and created interdisciplinary teams of eight nurses. Nurses’ on-the-job training is supplemented by compensation incentives for certifications in additional specialties. As part of the effort, the hospital places work stations next to rooms and supply carts in the rooms, reducing wasteful travel time for nurses. The result, according to Linda Burnes Bolton, Dr.Ph., R.N., F.A.A.N., vice president and chief nursing officer at Cedars-Sinai: “We have increased nurses’ time in direct patient care by decreasing documentation, placing patient supplies inside the room, and improving teamwork.” The universal floor concept has worked so well that Cedars-Sinai has expanded it to two additional units.

A second Cedars-Sinai reform decreases the reliance on registry or agency nurses hired on a per-day basis as “floating” part-timers. Cedars-Sinai has built an in-house professional pool of more than 100 full-time, permanent nurses who develop clinical competencies in more than one of eight areas.

Other reform approaches highlighted in the publication:

  • Staying Agile. South Dakota’s Prairie Lakes Healthcare System, with support from the Institute for Healthcare Improvement’s Breakthrough Series Collaborative and Transforming Care at the Bedside, have developed “agile teams” consisting of an R.N., L.P.N., and a cross-trained secretary or nursing assistant, as well as a “resource nurse” who backs up the team by taking on admissions tasks, answering questions, giving advice and more. Team members determine their respective roles on shifts on the basis of patient needs and census, covering 10 to 12 patients. The teams have dramatically increased staff efficiency and increased nurse time at the bedside by about 27 percent.
  • Getting Lean. In Seattle, Wash., the Virginia Mason Medical Center’s Intermediate Care and Telemetry Units have adapted “Lean Principles” from automotive giant Toyota, with the goal of eliminating waste and delivering the care patients need on time, every time, without errors. Where nurses once bounced from one end of long hallways to another, responding to patient call lights, they now care for patients in rooms organized in a U-shaped cell, minimizing walking. Morning rounds are sequenced to meet all the immediate needs of one patient before moving to the next. Also, nurse-to-nurse patient handoffs during shift changes are now scripted to avoid errors, and are done at the bedside so that patients are involved. The changes have dramatically reduced both waste and health complications for patients.
  • Mediating Staffing Standards. After a series of annual legislative battles in Washington State over staffing standards, nurses’ unions, the state nurse executives organization, the state hospital association and other key players agreed to a mediation process focused on finding areas of agreement. Gov. Christine Gregoire embraced the process, noting, “We are trying to drive up safety while driving down cost. Proper staffing is an absolute key.” In early 2008, the mediation yielded an agreement on staffing goals for ensuring quality and safety, and implementation is under way.

Putting Technology to Work

The second publication in the miniseries, “How Nurses Are Shaping, and Being Shaped by, Health Information Technologies,” explores opportunities for improved quality and safety offered by new technologies. The “transformation goes beyond hardware and software,” the publication says, “to incorporate modifications in workflow, organizational culture, and even architecture. Together, these components of work process redesign have the potential to remove barriers to patient safety and increase access to care. Nurses play a major role in determining whether this potential is, in fact, realized.”

The publication covers a range of topics, including:

  • Electronic Health Records. Thick manila folders stuffed with test results and medical histories are on their way out, gradually being replaced by electronic health records. But the records must also be compatible with multiple systems, and the software that uses them must be user-friendly. The University of Pittsburgh Medical Center has put electronic records to use in 22 specially equipped hospital rooms. Sensors in the rooms detect when nurses enter and display on a bedside monitor selected information from the patient’s electronic health record, such as known allergies and a listing of prescribed medicines, doses, and methods of administration—the information nurses need to provide good, safe care.
  • Bar Coding. The universal product codes common on retail products can carry much more information than prices, and the technology is now being deployed in support of the “five rights” of medication administration—making sure that the right patients get the right medication at the right time in the right dose by the right route. Notably, the Veterans Health Administration’s bar code medication system, now in use system-wide, was the brainchild of a nurse. In addition to getting medications “right,” the bar code devices also collect data about workflow that has helped fine tune hospital systems—the pharmacy cart schedule, for example.
  • Telenursing. Bedside nurses can attend to only one patient at a time, and travel between rooms, units, and even facilities, schools, clinics, and homes—or make patients travel to them. But for many patients, it can be more efficient to deliver care over telephone lines and Internet connections, using electronic monitoring equipment. In New York State, the Visiting Nurse Association of Hudson Valley has developed a telehealth program that provides an extra layer of monitoring for home care patients at high risk of rehospitalization. The agency’s telenurse makes “virtual visits” to patients via webcam, reviewing vital signs and more. Sentara Healthcare has developed an “eICU” program—the first in the nation, under which 100 of its intensive care patients at five acute care hospitals in Virginia are monitored from an off-site central command station. The eICU team supplements care delivered by bedside nurses, and has shortened lengths of stay for critical care patients and reduced the rate of ventilator-associated pneumonia.

“To face the health care challenges of the 21st century, we’ll need to harness available technologies in ways that work for patients and the professionals who deliver care,” says Maryjoan D. Ladden, senior program officer at RWJF. “It’s not enough simply to develop software and hardware that can keep track of vast quantities of data. We also need workplace systems that put the technology to its best use, and that allow nurses and other medical professionals to do what they do best: care for patients. We think these new publications share innovative ideas, pointing the way toward better and safer care.”

The briefs will be delivered to policy-makers on Capitol Hill this month, just as major health care reform legislation is taking shape, and to those working at the state and local levels. They are available online here.