Taking inspiration from a popular crime-fighting television show, nurses at seven hospitals in Kansas City are sniffing out unit-level opportunities to improve patient outcomes, devising reforms and putting them into effect. The Clinical Scene Investigation Academy of the Bi-State Nursing Workforce Innovation Center draws on the name of the popular “CSI” franchise, but unlike its fictional television namesake, the Kansas City program is having real-world results.
Launched in August 2008 with support from Partners Investing in Nursing’s Future (PIN), a collaboration between the Northwest Health Foundation and the Robert Wood Johnson Foundation (RWJF), the CSI Academy brought together nurses from local hospitals in the city to create sustainable changes at the unit level. Local partners in the project include the hospitals, the Health Care Foundation of Greater Kansas City, the REACH Healthcare Foundation, Children’s Mercy Hospitals and Clinics, and the University of Missouri, Kansas City.
Drawing on the methods and experience of the Integrated Nurse Leadership Program developed by Julie Kliger, M.P.A., B.S.N., R.N., and RWJF’s Transforming Care at the Bedside initiative, Susan Lacey, Ph.D., R.N., F.A.A.N., and her colleagues recruited local hospitals to participate. They also developed a locally tailored curriculum to help nurses at each institution identify problems ripe for nurse-led solutions.
Contributing to the development of the project was Lacey’s supervisor, Karen Cox, Ph.D., R.N., F.A.A.N. Both are alumni of the RWJF Executive Nurse Fellows program—Cox from the 1999-2002 cohort and Lacey from the 2006-2009 cohort. Over the course of 16 months, working in teams from each of the hospitals, the nurses came together for a series of classes designed to teach them how to identify a fixable problem, how to take on leadership roles within their hospitals, how to manage projects, how to develop and operationalize solutions and more.
Each participating hospital enrolled two to four nurses to lead the program in its units. All of the nurses were recommended for the program by their supervisors, thus ensuring a level of buy-in from the institution. Soon after the academy began, the nurses set about the task of identifying specific patient outcomes in need of improvement on their units, working within CSI’s requirement that the outcomes be drawn from the Centers for Medicaid and Medicare Services (CMS) list of “never” events or from the National Database of Nursing Quality Indicators.
“The truth,” says Lacey, director of the Bi-State Nursing Workforce Innovation Center, “is that it’s an empowerment strategy for the nurses. We tried to get them to identify something they had wanted to improve, and then, working with their colleagues, improve it.” At the beginning of the monthly sessions, Lacey says, many of the nurses had not met the other nurse participants from their own hospitals. “Some of the team members didn’t know one another,” she says. “We asked the hospitals for people with potential. And it was great to see them come together and cross-pollinate. They took the leap of faith showing up that first day of class, and over the course of the nine sessions, they came together amazingly.”
The initiative also identified for each of the nursing teams a leader from within the hospital who would help them avoid bureaucratic or policy snags, as well as an external mentor who was a successful nurse leader at the manager/director level elsewhere who was available to coach the nurses through a variety of sensitive issues.
Reforms Produce Results
The nurses’ projects yielded impressive results, for nurses, patients and for the hospitals, with estimated cost savings from the reforms exceeding $1 million.
Nurses from the Kansas City Veterans Administration Hospital developed a project to reduce the number of heel pressure ulcers, a CMS “never” event. Patients admitted to the VA hospital are often at elevated risk for heel ulcers, because of reduced mobility resulting from combat wounds, as well as other conditions. The nurses launched a house-wide campaign to educate their nurse colleagues about the issue, conducting mandatory educational sessions on the subject and arranging for a certified wound care nurse to make rounds checking to be sure all at-risk patients had and wore boots designed to prevent ulcers. To build awareness, the nurses designated one day a week as “Heels’ Angels” day, during which nurses were encouraged to wear a special heel-oriented t-shirt, and the hospital’s boot vendor provided informational posters detailing the proper placement of the boots and stressing the need to keep patients’ heels clean and dry.
The project worked, producing an 80 percent reduction in heel ulcers since its November 2009 kickoff. That success is meaningful not just to patients, but to the hospital’s bottom line. Precisely because hospital-acquired heel pressure ulcers are never reimbursed by Medicaid and Medicare, every penny of the up-to-$43,000 saved by each avoided pressure ulcer is money that can be spent on other important tasks. The project is ongoing, with new staff still receiving orientation, more t-shirts on order, and data collection continuing.
Nurses at Kansas City’s Providence Medical Center developed a model aimed at reducing medical errors during shift hand-offs. Replacing a model in which nurses would report on patient status amid the hubbub of call lights and other distractions, the nurses developed a more formal checklist and expanded the roles of certified nursing assistants, resulting in a system that has nurses from the outgoing shift reporting more systematically and without distraction to the incoming shift.
The result was a significant reduction in the number of daily change-of-shift communication errors, as well as reductions in the number of injury-causing falls, medical errors and restraint usage. The projected annual cost savings for the hospital was more than a quarter of a million dollars.
At Children’s Mercy Hospital, a third project focused on pain education and management for pediatric patients and their parents. The nurses created a parent-oriented guide to pain reduction so that parents could become more active participants, serving as a proxy for children, many of whom do not yet speak. The result has been parents who ask questions, report to nurses on what they’re seeing, follow up with nurses on pain medication and more. A survey of parents confirmed that the project had significantly increased their understanding of what to expect and how to take a role in pain management.
With the results from the CSI projects now in, Lacey and her colleagues at the Bi-State Nursing Workforce Center are now focusing on extending its success by partnering with “safety net” clinics in the area. Because such facilities rarely have staffing sufficient to allow nurses to take part in the kind of extended curriculum used in the CSI academy, Lacey says it will be important to focus the effort even more tightly. “We’re looking at blood test for diabetes, and doing a mini-academy for safety net clinics just on that,” she says. “And we’re looking at pediatric clinics, and developing projects around asthma control. But the reforms will still come from within. That’s really the key.”