Abstracts

 

1)    Virtual Mentoring to Promote Systems Thinking and Civility Awareness within an International Professional Organization

Josette Brodhead, RN, PhD, RNC, CNE

Ann Stalter, RN, PhD, M. Ed

Abstract Title: Virtual Mentoring to Promote Systems Thinking and Civility Awareness within an International Professional Organization
Abstract Background: The purpose of this study was to pilot a virtual mentoring program to promote  systems thinking (ST) and civility awareness within an international professional organization.
Abstract Methods: A mixed-method, nonrandomized pretest-posttest study examines an innovative virtual mentoring program on the awareness of systems thinking (ST) and incivility among members of the International QSEN Institute, RN-BSN Task Force.  Participants volunteer as either mentors or protégés. Authentic leaders serve as mentors, allowing for the exchange of information and wisdom to occur between mentors and protégés (Benner, Sutphen, Leonard, & Day 2011; National League for Nursing, 2006). The mentoring relationship is supported by Senge et al.’s (2015) three core capabilities of “seeing the larger system,” making room for reflective, procreative conversations, and moving from reactive problem solving to proactive approaches.  Protégés create change for a self-sustaining model of professional growth. The relationship is facilitated by matching and pairing the dyads according to protégé-identified goals. Phases of Kirkpatrick and Kirkpatrick’s (2010-2015) model will be used to guide interviews for qualitative data. Dolansky and Moore’s (2013) Systems Thinking Scale along with Clark’s (2013) Faculty-to-Faculty Incivility Scale will be used to quantify if program outcomes (improved ST and incivility awareness) are achieved among task force members.
Abstract Conclusion: Results pending.

References: Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Clark, C. M. (2013). National study on faculty-to-faculty incivility: Strategies to promote collegiality and civility. Nurse Educator, 38(3), 98-102. Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses (QSEN): The key is systems thinking. OJIN: The Online Journal of Issues in Nursing, 18(3). National League for Nursing (2006). Position statement: Mentoring of nurse faculty. Retrieved from http://www.nln.org/aboutnln/PositionStatements/mentoring_3_21_06.pdf Kirkpatrick, J., & Kirkpatrick, W. (2010-2015). An Introduction to the New World Kirkpatrick Model. Retrieved from http://www.kirkpatrickpartners.com/Portals/0/Resources/White%20Papers/Introduction%20to%20the%20Kirkpatrick%20New%20World%20Model.pdf?ver=2015-06-02-091614-907 Senge, P., Hamilton, H., & Kania, J. (2015). The dawn of system leadership. Stanford Social Innovation Review, Winter 2015. Retrieved from https://ssir.org/articles/entry/the_dawn_of_system_leadership

2)    Self-Leadership: A Scaffolding Approach

Linda Gibson-Young, RN, PhD, ARNP, CNE, AE-C, FAANP

Loretta Forlaw, RN, PhD, FACHE

Abstract Title: Self-Leadership: A Scaffolding Approach
Abstract Background: The purpose of this presentation aims to disseminate feedback gathered from graduate students on self-leadership and action items implemented to educate self-leadership strategies for students. So often it seems leadership discussions are theoretical or abstract. This work encourages the use of action in language and approaches to leadership for graduate students.
Abstract Methods: The educational innovation builds on the need for leadership development and growth in graduate students. Over the past five years, the authors have developed a web platform to access graduate students across the country. A needs assessment was developed to identify what graduate students require in action-oriented leadership development. This scaffolding process will be described in detail and all participants will be oriented to the platform, and student feedback.
Abstract Conclusion: Graduate students are challenged with learning content specific to specialty while acclimating to the new role and incorporating lofty leadership expectations. This web platform allows continual focus on self-leadership and adds a new and innovative method for building nurse leaders.
3)    Clinical Nurse Leadership Competency in Operating Room Nurses

Michelle Slater, RN, DNP, CNOR

Gayle Petty, RN, DNP

Abstract Title: Clinical Nurse Leadership Competency in Operating Room Nurses
Abstract Background: Patient safety errors continue to occur in the operating room. Three of the top ten sentinel events reported to the Joint Commission from 2012-2014 are directly related to surgical care. Root cause analysis of these events consistently identified leadership, human factors, and communication as the top three reasons for these errors with leadership identified as the number one reason over a ten year period of 2004-2014. The purpose of this project is to examine which clinical nurse leadership competencies are present in operating room nurses and to determine any relationships amongst clinical nurse leadership attributes. The variable of interest include clinical nurse leadership competency, certification in operating room specialty, organizational culture, and years of operating room experience.
Abstract Methods: A descriptive correlational study design was implemented for this national survey of operating room nurses via the AORN database. Participants completed a demographic survey and the Leadership Practices Inventory® by Kouzes and Posner. Composite sample subscale scores of operating room nurses where compared to variables of interest.
Abstract Conclusion: Analytic findings include statistical significance for the following: one subscale score with Magnet® recognized institutions, one subscale score with highest degree of nursing, and four of five subscale scores with type of leadership training. The evidence suggests a positive return on investment for leadership training at point of care. Future research correlating type of nursing degree to competencies may provide insight for implementation strategies. Leadership skill development is required to empower frontline nurses to intervene when patient safety is threatened.
4)    Workplace Violence in the Adult Emergency Department 

Gloria Letostak, ADN, RN, BA, CPHQ, CPPS

Abstract Title: Workplace Violence in the Adult Emergency Department
Abstract Background: In July 2016, when an ED mentally ill patient had been told she would be hospitalized, she ran from ED. One of our ED RNs ran after the patient; the patient jumped in her car, backed up and proceeded to run over the RN. Our RN sustained multiple fractures and has since recuperated. The incident prompted a study to learn more about ED caregiver roles and perceptions of Workplace Violence (WPV) in the ED.
Abstract Methods: A literature review was conducted as well as internal hospital data abstracted to determine scope and severity of WPV nationally as well as locally. The data included diagnoses such as schizophrenia, mood disorders, anxiety disorders, alcohol and substance abuse. A WPV Perception Survey was designed and distributed to all ED caregivers in September 2016 which resulted in a 76% response rate. The survey included ten questions with room for comments and was distributed directly by the nurse manager. A multidisciplinary Failure Modes Effects Analysis (FMEA) team commenced to address the issues identified in the WPV survey and develop an action plan in December 2016.
Abstract Conclusion: The WPV survey indicated 98.1% of respondents had been subjected to physical violence &/or verbal abuse by a patient/visitor whether sober, intoxicated by drugs or alcohol or mentally ill in the past year (includes getting hit, punched, kicked, slapped, hair pulled as well as cursed at, verbally intimidated & threatened with physical harm). The FMEA indicated a number of failure modes were occurring with high frequency, were high severity and were not easy to detect. The top two failure modes were identified. The first indicated the disposition process was done solely by the licensed independent practitioner without prior knowledge communicated to the caregiver team. The second was role confusion between caregivers and security when a mentally ill patient eloped. Based on the results of the WPV survey it was evident that caregivers in the ED were concerned about their safety with only 61% feeling safe and only 51% felt they were prepared to handle the violence. A number of processes have been improved as a result. Informatics is working on a way to alert all caregivers electronically when a patient has the potential to become or has already become violent. Increased Non-Abusive Psychological and Physical Intervention (NAPPI) training is now offered. A mandatory WPV Module is available on the hospital educational site. A Code Brown High Risk Patient Policy was implemented as well as a Code Violet debrief process now is in effect. A wanding process has been imbedded into the admission process when a patient comes through the ambulance entrance. Lastly, a repeat WPV Survey will be distributed in September 2017 to identify if improvements were sustained and to identify continued opportunities.
5)    Delirium Screening; When it works, it works

Gabrielle Flynn, RN, BSN, ANM, CMSRN

Linda Pasek, RN, MSN, CNS

Lynn Szoka MSN CNS NM, Sue Sturges MSN

Abstract Title: Delirium Screening; When it works, it works
Abstract Background: Nationally, delirium affects 10-30% of all hospitalized medical patients. In the first quarter of 2016, the prevalence rate was 1.6%. Despite education and re-education of the nursing staff by clinical educators in the second and third quarters of 2016, it was determined delirium resources and scoring were underutilized. A review of nursing units revealed that 3 main, a seventeen bed medical surgical unit with the average patient age of 77, had only a prevalence of 2.5%. Staff meeting minutes from July and August of 2016 reflected discussion of education on delirium based off of staff requests. The universal term for confusion continued to be used for patients who were acutely confused or delirious. Based on verbalized needs of staff and no correlation between escalation of untoward behaviors with inappropriate medications and interventions , a delirium pilot team was formed. It consisted of the NM, ANM, CNS, Director of Medical-Surgical Nursing, and psych physicians.
Abstract Methods: On January 6th 2017 delirium rounds were initiated. The floor’s census was looked at daily for patient’s who were scored positive for delirium (bCAM +). The enterprise EBI delirium dashboard was used as a reference. Promotion of communication with floor nurses about patient’s behaviors were addressed to see if any patients were being missed for delirium. Continuation of discussion at mid-day and shift huddles for patients with delirium vs. dementia. The ANM and CNS reviewed with staff on a 1:1 basis when increased educational needs were needed and for missed opportunities. The CNS audited charts to assess if there were early warning signs, missed opportunities, or trends. The ANM developed a resource pocket card with key points for nursing as a quick reference in identification and treatment of delirium in the older adult. Continuation of positive reinforcement for assessing and treating delirium followed.
Abstract Conclusion: Delirium is a symptom of an underlying problem and it should be considered a serious medical condition. When delirium is superimposed on dementia, detection is even less. It was found that nurses were used the screening tool on EPIC bCAM 95% of the time but were inaccurately assessing patients due to lack of knowledge regarding delirium. Because of this, effort to increase awareness of delirium by promoting discussion and starting delirium rounds. Educational pocket cards were created and handed out to RNs. Delirium accordion promotion was pushed on RNs. In summary, nurses have verbalized feeling more comfortable assessing their patients for delirium using the bCAM screening tool; this is reflected by the prevalence of delirium increasing to an average of 11%. This open discussion, awareness, fresh education will lead to more positive patient outcomes, less associated illnesses, less restraints, and more patients being discharged home vs. a skilled facility.
6)    Quality improvement as it relates to the Implementation of the Refugee Health Screener-15 (RHS-15) in Refugee Resettlement Sites in Massachusetts(RHS-15)

Holly Randall, RN, DNP, PMHCNS-BC,

Brant J.  Oliver PhD, MS, MPH, APRN-BC, RN

Chris Rovinski, MSN, ARNP

Abstract Title: Quality improvement as it relates to the Implementation of the Refugee Health Screener-15 (RHS-15) in Refugee Resettlement Sites in Massachusetts(RHS-15)
Abstract Background: In December 2013, the (RHS-15), a screening tool for PTSD, depression and BC, became a requirement of the Massachusetts Refugee Health Assessment Program (RHAP), the statewide health screening organization for newly-arrived refugees. Implementation raised concerns at the sites as to how to implement and successfully refer newly arriving immigrants to behavioral health treatment.
Abstract Methods: A clinical microsystems approach was used to assess the behavioral health referral process characteristics and patterns at six refugee health centers. Interviews were conducted and processes observed at each of the sites. From these, process flowcharts were created and then vetted with each organization. The combined evaluative tools of cultural elements and workflow provided a visual assessment of system characteristics and process complexity and allowed for comparison across the six centers.
Abstract Conclusion: Process mapping comparisons identified substantial variation between centers in process characteristics and complexity. The assessment also identified procedural gaps in clinical practice patterns and workflow processes that could be streamlined and improved to enhance the effectiveness of referrals. Clinical barriers and facilitators to behavioral health referrals included: (1) patient literacy; (2) patient in immediate distress; (3) patient interested in referral; (4) patient knowledge of referral location; (5) interpreter availability; and (6) referral; appointment accessibility. Workflow factors included: (1) process point when screening occurred; (2) screening administrator; (3) staff person making the referral appointment; and (4) feedback to the referring provider concerning attendance of the referred patient to the initial behavioral health appointment. The flow process assessment identified clinical and workflow factors critical to optimizing the behavioral health referral process, and discovered substantial process variation across the six centers.
7)    Fostering a Culture of Safety Through Innovative Competency Assessment for Leaders

Laurel More, MS, RN-BC, CPN

Ciara Culhane, RN, MS, RN-BC, CPN

Abstract Title: Fostering a Culture of Safety Through Innovative Competency Assessment for Leaders
Abstract Background: Since the publishing of the IOM’s two landmark reports, many healthcare organizations have implemented processes and programs to decrease preventable harm and improve patient safety. While much of the work has centered on direct care providers, the Joint Commission has noted the important role leadership plays in creating and sustaining a culture of safety. In a large tertiary organization, development of an innovative competency assessment tool for clinical and non-clinical leaders, provides a framework in which to build the knowledge, skills and attitudes needed to promote a just culture and eliminate preventable harm. Threading safety through the key competencies of business management, people management, and individual leader growth will help to connect how leaders’ decisions support the organizations culture of safety.
Abstract Methods: The American Organization of Nurse Executives (AONE) Nurse Manger Competencies, American Nurses Association Leadership Institute Competency Model, and Quality and Safety Education for Nurses (QSEN) were blended to create a standardized competency and orientation tool that aligns with the organizational leadership objectives. A literature search initially identified two frameworks/models highlighting nurse manager competencies promoting career growth, and the positive impact leaders can have on patient care. QSEN, was a natural fit for rounding out this tool as it is currently used for our clinical competency assessment format. This unique combination supports existing programs, and provides common leadership language which fosters collaboration between executive nurse leaders, Talent Development and Professional Development.
Abstract Conclusion: The collaborative environment opened the door for this work, which was initially developed to orient nurse leaders in a specialty practice, to be expanded to include virtually all leaders. The use of evidence -based frameworks, shared governance, and agreed upon basic leadership language set the stage for this standardized approach in evaluating competencies of both clinical and non-clinical leaders in the organization. Next steps in guiding this work will involve working with subject matter experts to identify additional competencies, resources, and outcome measurements required to support the growth and development of leaders.
8)    The impact of authentic leadership on team psychological safety as mediated by relationship quality

Mechelle Plasse, RN, PhD

Abstract Title: The impact of authentic leadership on team psychological safety as mediated by relationship quality
Abstract Background: The acute care setting is a high stakes environment and a thorough understanding of the factors involved in safe patient care is needed. Treatment requires the tangible measure of technical expertise and the less tangible measure of relational abilities, an inadequately studied area in healthcare. Relationship quality among healthcare providers (HCP) has been empirically linked to patient outcomes (Dupree, Anderson, McEvoy & Brodman, 2011). Unit leadership behavior sets the relational tone of the setting with the more relationally-based approaches shaping the foundation for relationship potential. Authentic leadership is empirically linked to concepts which require healthy interpersonal relating, such as team psychological safety (Edmondson, Bohmer & Pisano, 2001). The aim of this study was to explore to the impact of authentic leadership on team psychological safety, mediated by relationship quality among nurses.
Abstract Methods: A cross-sectional electronic survey design was used, with the target population of staff nurses and nurse managers on the medical-surgical units, critical care units and the emergency room. The survey included instrumentation on the variables of Authentic Leadership, relationship quality, incivility and psychological safety. All surveys remained confidential and IRB approval was obtained though no risks were anticipated with participation. Data analysis included: descriptive statistics, inter-correlations and the magnitude of the nesting effects within and across units. To determine the degree of dependence, intra-class correlation coefficients (ICC) were computed however these results were negligible so a path analysis was used to determine the direct and indirect effect of the endogenous variables of leadership and relationship quality on the outcome of psychological safety.
Abstract Conclusion: The analysis did not fully support the model as neither leadership nor relationship quality influenced psychological safety when controlling for covariates. There was a significant relationship found between authentic leadership and high quality relationships and an inverse relationship with incivility. The sample size and inability to complete a unit-based measure may have contributed to the lack of model support however consistent with the literature is the positive impact of authentic leadership on relationship quality among HCP. Safe patient care is a multifactorial phenomenon with many of those factors embedded in relational constructs which require further investigation.
9)    Management of Clinical Alarms: An Evidence-based Practice Project

Jennifer Douglas Pearce, RN, MSN, CNE

Abstract Title: Management of Clinical Alarms: An Evidence-based Practice Project
Abstract Background: Managing clinical alarms is an added task to nurses’ list of things to do, rather than a patient assessment tool (Srinivasa et al., 2017). The Joint Commission (TJC) addressed clinical alarm safety for patients as well as nurses and identified alarm fatigue as one of the factors that affect nurses and patients and has led to adverse events (TJC, 2013). The purpose of the doctorate of nursing practice project is to decrease the number of false and nuisance alarms nurses respond to through the use of evidence-based practice (EBP) strategies and examine the effects of clinical alarms on nurses’ perceptions and attitudes pre- and post-implementation of strategies. The overall goal of this project is to enhance patient safety by decreasing alarm fatigue.
Abstract Methods: The quality improvement project will be conducted with nurses on a 32-bed progressive care unit in fall 2017. Alarm systems data will be retrieved for 50% patients, in two-four hour increments, over a three day period to determine the number of alarms per patient day, the number of false and non-actionable alarms per patient per day and the nurses’ response to the alarms using a pre-and post implementation survey. Nurses will be invited to participate in an online education highlighting EBP strategies to reduce alarm rates. Over a six week period, EBP strategies will include: 1) daily skin hygiene with cardiac telemetry electrode changes; 2) customize patient alarms at the beginning of the shift and to meet the needs of patient’s condition and activity level; 3) decrease over monitoring of patients based on the AACN practice guidelines; 4) implement patient hourly rounding. All staff will receive an EBP strategy reminder.
Abstract Conclusion: Upon completion, nurses will complete a post-intervention survey and electronic data will be collected to determine the effectiveness of EBP strategies. Outcomes, such as decrease in false alarm rates, increase nurse and patient satisfaction are expected. Benefits to the unit can include enhanced quality of patient care, professional development, and implementing EBP at the point-of-care.
10) Behind Every Missed Dose of Medication is a Patient 

Jeanne Kloock, RN, BSN, NONE

Jennifer Tramte, RN, BSN, none

Abstract Title: Behind Every Missed Dose of Medication is a Patient
Abstract Background: Our goal in the dialysis unit is to improve patient safety by assuring that our patients receive his/her ordered and as needed medications 100 % of the time. In the past our dialysis had difficulty in meeting the time scheduled for medications and had to problem – solve the timeliness of acquiring pain and hypertensive medication. Missed medication led to medication errors and too many safety event reports , but ultimately patient safety was being compromised.
Abstract Methods: The dialysis nursing team collaborated with pharmacy and Operations to trend medication event data and to develop a financial and practice plan for installation of a medication dispensing system , including a medication refrigerator in the dialysis unit. All nursing staff were in -serviced on how to operate the medication dispensing system and what medications were available. Specific dose adjustments were needed to accommodate renal patients and a “medication” dialysis documentation line was added to our hemodialysis flow chart with the aid of Nursing Informatics , and includes the “type of medications” and “why the medication” is given .
Abstract Conclusion: In 2016 , sixteen missed medication errors were submitted into the safety event reporting system . March 2017 , with the access to available medications in the dialysis unit , there are zero medication safety event reports to announce. This activity is still being monitored and data trended for continuous quality improvement . As of August 2017 , our goal is being sustained. It is important that we follow through with safety event reporting , advocating for our patient’s safety , and by collaborating with multi-disciplinary teams to implement change. We will continue to measure quality and evaluate needs of medication and dose changes for inventory to our medication dispensing system. Measuring compromising patient safety issues is easy , applying change to real life is the challenge (Dovey & Leitch , 2016). Dovey, S., & Leitch, S. (2016). Triggering safer general practice care. BMJ Quality Safety , 26, 259-260. doi:10.1136/bmjqs-2016-005660
11) A Comparison of Tricyclic Antidepressant Prescriptions between Patients with and Patients without Identified Suicidal Ideation

Anna Blazejowskyj, MS, BS

Virna Little, PsyD, LCSW-R, SAP

Andrea Cole, Ph.D., LCSW

Abstract Title: A Comparison of Tricyclic Antidepressant Prescriptions between Patients with and Patients without Identified Suicidal Ideation
Abstract Background: Research has demonstrated the toxicity of Tricyclic Antidepressants (TCAs) and has identified that TCAs are implicated in intentional self-poisoning deaths. However, limited data exists on current trends in TCA prescribing, specifically among primary care providers and for patients with identified suicidal ideation (SI). This study aimed to fill this gap.
Abstract Methods: A retrospective secondary data analysis of electronic health record data for 6535 TCA prescription orders at a large Federally Qualified Health Center (FQHC) network was performed. Data included orders for 1805 patients who received TCA prescriptions between July 2013 to July 2016. Differences in prescriptions were compared between patients with and without identified suicidal ideation for indication, drug type, dose, quantity, number of refills, and specialty of provider. Analyses were completed using SPSS statistical software, and the Pearson Chi-Square Statistic or Test for Linear Trend was utilized as appropriate.
Abstract Conclusion: In total, 127 patients with a history of SI received TCAs. Patients with identified SI were prescribed TCAs for mental health reasons 67% of the time, while non-suicidal patients were prescribed TCAs most often for pain (51%). Patients with identified suicidal ideation received prescriptions that had fewer refills and were less likely to receive prescriptions written for 90 days or more. Overall, psychiatrists prescribed fewer refills and smaller quantities of TCAs than other providers (all comparisons, P < 0.001). In summation, providers at a large FQHC network prescribe TCAs with fewer refills and reduced quantities when prescribing to patients with identified suicidal ideation. However, non-psychiatry providers seem to be less likely than psychiatrists to consider safety concerns when prescribing TCAs These results suggest additional education may be needed for primary care providers around the dangers of proscribing TCAs to individuals with SI. In addition, these findings provide the foundation to consider subsequent examination of prescribing practices around other potentially lethal medications (e.g. Benzodiazepines, Barbiturates, and Opioids) for patients with identified SI. Such evaluations will provide the basis to create guidelines that promote optimal treatment and patient safety for this population.
12) Implementing New Standards for CLABSI Prevention

Malinda Burt, RN, BSN

Abstract Title: Implementing New Standards for CLABSI Prevention
Abstract Background: CLABSI prevention has been a priority initiative for our patient population (adult bone marrow transplant), as well as hospital-wide, for the past several years. While we have made many attempts to introduce new interventions or practice changes to prevent CLABSIs, we had yet to focus on fully standardizing best practices using process improvement strategies that include confirmation of competency and a plan for measuring continued compliance and sustainability. More importantly, we had failed to implement daily systems that focused on high-risk patients (rather than just practice compliance) and included empowering those patients to assist in prevention strategies. This initiative has been an opportunity for us to utilize resources, workflows and already existent roles to improve practice and implement change in a way that is visual, measurable, meaningful and truly patient-centered. And we’ve been able to achieve this without any additional associated cost.
Abstract Methods: LEAN Methodology is the foundation for performance improvement at OHSU. Phase 1: Training of all RN Staff on the inpatient, adult BMT unit (64 RNs) -All nurses were scheduled for brief inservices during productive hours, in which they received content education, as well as training on the processes we would be using for competency confirmation and sustainment. Phase 2: Competency Confirmation -Peer collaboration and confirmation was utilized, with each nursing performing central line access and dressing changes at the bedside. The tool used for confirmation was a K-Card (“checklist”). -All abnormalities found during these confirmations were tracked and analyzed to help identify barriers to competency and opportunities for education/retraining. Phase 3: Compliance Confirmation and Sustainment -Peer collaboration and confirmation continues to be utilized in this final phase. However, the focus has shifted to identification of especially high-risk CLABSI patients each shift, the goal being to complete a K-Card (“checklist”) on those specific patients. -The K-Card has been modified in this phase to include confirmation that patient education has been provided. -All abnormalities found during this phase are tracked and analyzed to help identify barriers and opportunities for education/retraining, as well as additional information to help facilitate future changes when completing +CLABSI case reviews. -We are mirroring the work that’s been done in fall-risk assessment and intervention implementation, which is something we’ve not done before with CLABSI risk.
Abstract Conclusion: This initiative has resulted in tremendous growth in our ability, as a unit, to implement standardized practice changes. More importantly, it has created a shift in how we approach these changes, in that we are now focusing on what is value-added for the patient and how best we can include the patient in these improvements. We have run into many barriers along the way and will continue to do so, but we feel as though we now have a method for addressing barriers, learning from them, and moving forward with full momentum. As a Nurse Manager, I am excited about the engagement with quality improvement that this initiative has created for my nursing staff. This is a huge area of opportunity in daily practice, and although we have lots more work to do, this initiative has truly inspired the culture in our setting.
13) Reducing Turnover Times in Ophthalmology: A Quality Improvement Initiative

Meredith Allison Arensman, RN, BSN, MD, MBA

Anne Tomolo, MD, MPH

David Paine, MD

Purnima Patel, MD

Steven Urken, MD

Abstract Title: Reducing Turnover Times in Ophthalmology: A Quality Improvement Initiative
Abstract Background: Turnover time is a primary determinant of operating room (OR) efficiency and access. Prior to this project, our institution had a three-month waitlist for cataract surgery and mean turnover of 26 minutes (95% CI 24.8 – 27.2) for ophthalmology cases. Reducing turnover time by 3 minutes would allow an additional patient to be scheduled each operative day. The aim for this quality improvement initiative was to reduce the mean ophthalmology turnover time by 3 minutes by July 2017.
Abstract Methods: A multidisciplinary team developed a swim lane process map and cause effect diagram to identify bottlenecks and used an impact/effort matrix to prioritize interventions. Data was collected from one OR on eight consecutive Wednesdays. During weeks 1-4 three interventions were trialed as PDSA cycles and turnover was directly monitored using data collection templates. During weeks 5-7 the staff was encouraged to implement team huddles and set turnover goals as data was collected remotely using the electronic medical record. Turnover time variation was analyzed using an XMR SPC chart.
Abstract Conclusion: Turnover data yielded 36 observations. In weeks 1-4 (direct observation) the mean turnover time decreased to 17.19 minutes. The mean turnover time for the seven weeks of the study was 19.97 minutes. Special cause variation was observed during PDSA cycle 1 and 2 as a shift showing a reduction in turnover time. The aim of the study was achieved. However, the current incentive structure may not support or sustain institutional aims to improve utilization and access. Currently, we are developing shared goals and interventions including surgeon and nursing-led huddles, audits, and enhanced communication.
14) Multidisciplinary Collaborative to Reduce Fecal Immunochemical Test (FIT) Specimen Rejections among Veterans

Caleb Cheng, MD

Shelly De Peralta, RN, DNP, VAQS

Marianne Chumpia, MD

Linda Kim RN, PhD

David Ganz, MD PhD

Evelyn Chang, MD

Abstract Title: Multidisciplinary Collaborative to Reduce Fecal Immunochemical Test (FIT) Specimen Rejections among Veterans
Abstract Background: A fecal immunochemical test(FIT) is an effective early screening method used to detect colorectal cancer; however, as many as 33% of specimens submitted by patients are rejected in a four-week period at VA Greater Los Angeles. Retesting is inefficient and cumbersome for both patients and providers; therefore, reducing the number of rejected specimens is critical. This project’s goal is to improve colorectal cancer screening rates amongst Veterans at the VA Greater Los Angeles Healthcare system by reducing the number of rejected FITs.
Abstract Methods: A multidisciplinary team consisting of physician, nurses, administrators, and lab technicians, applied continuous quality improvement tools to understand causes of FIT rejection, including gemba walks and the development of process maps, statistical process control charts, and Pareto charts. Overall, we found that a robust and standardized data collection system for rejected specimens was lacking. However, analysis of 265 rejected specimens revealed that they could be aggregated into six categories: expired specimen >14 days after collection (47.9% of specimen rejections), no collection date/time on specimen(22.3%), no orders submitted to process the specimen(18.1%), missing patient information (5.3%), illegible handwriting (5.3%), and miscellaneous causes(1.1%). Thus, we created a new rejection log and trained staff in a new data collection process. To address expired specimens received by the laboratory, our facility implemented an automatic calling system reminding patients to mail in their FIT kits. In addition, working with pathology and outpatient clinics, nurses began placing bright orange stickers on envelopes reminding patients to return FIT kits within 48 hours of collection. Lastly, collaborating with the clinic nurses, we initiated attempts to script nurses’ instructions to patients, emphasizing the need to return FIT kits within the appropriate time frame. To address other rejection causes, we created a new laboratory Standard Operating Procedure (SOP); new label printers will be made available at the three clinic sites that have been handwriting patient labels.
Abstract Conclusion: Development of a robust data collection system, performing gemba walks, holding extensive discussions with front-line staff, and interprofessional collaboration were all necessary precursors to implementing an improvement strategy to reduce rejected FIT specimens and thereby enhance colorectal cancer screening rates.
15) Optimizing Patient Safety and Staff Incident Reporting in Radiation Oncology

Susan Swanson, RN, DNP

Sean Cavanaugh, MD

Felipe Patino, MBA

John Swanson, PhD

Corrine Abraham, DNP

Carolyn Clevenger, DNP RN, GNP-BC, AGCPNP-BC, FAANP

Elain Fisher, PhD RN, CNE

Abstract Title: Optimizing Patient Safety and Staff Incident Reporting in Radiation Oncology
Abstract Background: Technological advancements in radiation oncology increase the potential for cure and fatal patient treatment errors. Crew resource management (CRM), used successfully in commercial aviation, has reduced errors that lead to accidents by using structured training and mandatory incident reporting to optimize team safety performance (Konschak and Sirois, nd). We customized and implemented a dual CRM intervention in an advanced radiation oncology setting and evaluated its impact on the rate of staff incident reporting over a six-month period.
Abstract Methods: 16-months of retrospective radiation oncology incident data from a generic reporting system were analyzed preintervention. Six-months of weekly CRM team training customized for radiation oncology and staff, was subsequently performed by senior department leadership in a culture of non-retribution. During the six-month study period, staff continued reporting on the generic system. After the first three-months of training, staff voluntarily used a cloud-based, anonymized electronic incident reporting adapted from a commercially available application (ASTRO, 2016), which included 27 discipline-specific categorical questions such as, incident type, workflow location, and potential severity. Reporting rates were normalized to monthly incidents per 1000 fractions). SPC charts were used for weekly data analyses and follow-up by a multi-disciplinary project advisory committee.
Abstract Conclusion: An upward trend in the number of incident reports (average, 9.3 reports per month) as compared to baseline (average, 1.8 per month) was observed throughout the six-month intervention period. A significant increase (> 3 sigma) in reporting rates (1.39 per 100 fractions) compared to preintervention rates (0.25 per 100 fractions) was noted, with a sustained upward trend exceeding the upper control limit during the remaining three-months of intervention when the custom reporting system was added. Utilization of a discipline-specific incident learning system combined with routine CRM training and key leadership support, are effective methodologies for increasing staff incident reporting and engagement, leading to a more systematic, team-based mitigation process. These combined strategies allowed for real-time incident reporting, analysis and learning, that can be used to enhance patient safety, improve teamwork, streamline communication, and advance a culture of safety. References Konschak, C. and Sirois, M. (n.d.). Flying lessons: Crew resource management in healthcare. Divergent. Retrieved from http://www.betahg.com/services/ed/ed/Option_5_-_ Communication/crew_resource_management_whitepaper.pdf ASTRO. (2016). ROILS. Radiation oncology incident learning system. Retrieved from https://www.astro.org/RO-ILS.aspx
16) The UAB Nursing Partnership:  Collaborative Leadership to Strategically Improve Quality and Safety for Alabamians

Rebecca Miltner, RN, PhD

Shea Polancich, RN, PhD

Cynthia Selleck, PhD, RN, FAAN

Terri Poe, DNP, RN

Doreen Harper, PhD, RN, FAAN

 

Abstract Title: The UAB Nursing Partnership: Collaborative Leadership to Strategically Improve Quality and Safety for Alabamians
Abstract Background: The American Association of Colleges of Nursing (AACN) recommends stronger academic/practice partnerships to transform the healthcare system. Academic-practice partnerships are intentional and formal mechanisms for advancing nursing practice to improve quality of care and population health. They are based on mutual goals, respect, and shared strategic planning and action. The UAB Nursing Partnership was created to leverage the education, clinical practice and research resources of the health system (UAB Medicine) and the UAB School of Nursing (SON) to support the highest quality of patient-centered care and to improve the health of the populations served.
Abstract Methods: Although UAB Medicine and the UAB SON have a decades’ long relationship, senior organizational leadership in the academic and practice environments strategically aligned a stronger and more formal partnership to advance the mutual goals of providing the safest, highest quality provision of care delivery in Alabama and beyond. Leaders from the health system and faculty from the SON created a three year strategic plan for the partnership activities based on four priorities: 1) creating a sustainable, mutually beneficial partnership, 2) partnering in research and scholarship, 3) leveraging resources in the provision of outstanding patient care, and 4) developing and aligning the nursing workforce of the future. Each priority has multiple objectives. For example, we are creating an infrastructure to support priority areas through the assignment of faculty to roles at the hospital as well as building faculty practice opportunities within the system as part of priority 1. For priority 2, the team is aligning all levels of academic student projects with improvement opportunities identified by the health system to create meaningful learning activities as well as improved patient care. The partnership implemented and tested new models of care delivery that have improved care for vulnerable populations and aligned the curricula of educational programs to support the development of the next-generation nursing workforce.
Abstract Conclusion: The UAB Nursing Partnership is driven by our shared vision to champion excellence in academic nursing and clinical practice for the future. Our strategic plan is driving our partnership activities including resource allocation so that we can support high quality patient centered care.
17) The UAB Nursing Partnership:  The Discharge Process Improvement Project

Rebecca Miltner, RN, PhD

Shea Polancich, RN, PhD

Cynthia Selleck, PhD, RN, FAAN

Terri Poe, DNP, RN

Doreen Harper, PhD, RN, FAAN

Abstract Title: The UAB Nursing Partnership: The Discharge Process Improvement Project
Abstract Background: The mission of the UAB Nursing Academic-Practice Partnership is to leverage the education, clinical practice and research resources of the health system (UAB Medicine), and the UAB School of Nursing to support the highest quality of patient-centered care and improve the health of the populations we serve. The Partnership team, composed of nursing faculty and staff, has undertaken a large scale improvement project to improve the discharge process with the primary goal of reducing re-admissions and improving patient engagement outcomes.
Abstract Methods:  The partnership activities are built upon the fundamental concepts associated with improvement and safety science. To improve the discharge process within the health system, a three phase project was implemented in May 2017. Based upon the UAB Nursing Partnership model, 4 implementation groups have been assigned specific assessment and evaluation activities for the current state of the inpatient discharge process. These activities include observation of the discharge process and interviews of patients and staff on a select pilot group of inpatient units, an appraisal of the best evidence associated with a safe effective discharge process, and evaluation of current financial and clinical outcomes related to re-admissions and patient engagement. In phase 2, improvement experts will pool and analyze phase 1 findings and make recommendations for pilot interventions targeting improvement in areas with opportunity. Finally, in phase 3, implementation teams will pilot 2-4 discharge process interventions with the goals of improving patient experience with discharge and reducing readmissions. Simultaneously, we will evaluate methods to incorporate BSN, MSN, and doctoral nursing projects related to the discharge process into this 18 month project.
Abstract Conclusion: Early results verify variation is occurring in the discharge process. Strong academic-practice partnerships have the opportunity to transform patient care delivery. This is our initial attempt at a large scale project to improve the discharge experience for patients and reduce readmissions within our health system.
18) Applying a QSEN Framework to Nursing Competencies in an Urban Academic Teaching Hospital

Laura Startsman, RN, MSN

Amy Costanzo, RN, PhD

Abstract Title:  Applying a QSEN Framework to Nursing Competencies in an Urban Academic Teaching Hospital
Abstract Background: QSEN is the present and future of nursing education. Nursing academic programs blend the six QSEN competencies throughout their curriculum to train the next generation of caregivers. However, patient care settings have been slower to embrace the QSEN framework: there has been a disconnect between the language of education and that of nursing practice. Many organizations traditionally focus on skills alone without linking them to the knowledge and attitudes that make implementation meaningful. This project aims to narrow the gap between education and practice by adapting inpatient nursing competencies to a QSEN framework.
Abstract Methods:  Eighteen nursing skills competencies were rewritten with input from bedside nurses, unit educators, and two hospital-wide committees. The skills described vary from administering blood transfusions to accessing a central line to preventing pressure ulcers. Previously, each competency was a simple description of process steps. Now, each competency guides the evaluator to document across three different columns whether the nurse has met measurable objectives in terms of knowledge, skills, and attitudes. The competencies were then incorporated into our inpatient new hire orientation and ongoing education. With these tools, we intend to promote a more mindful, purposeful environment of care. These new competencies will also mirror the education provided by nursing schools, perhaps helping new graduate nurses to transition into practice more effectively.
Abstract Conclusion: Knowledge can be validated through methods such as verbalization or online assessments: skills are assessed through return demonstration in a clinical or simulated setting. To measure attitudes with objectivity, however, we have needed to rely somewhat on self-report. For example, we determine whether the nurse can provide meaningful feedback and whether they can verbalize the role of each competency in regard to patient safety standards. Staff nurses and educators report that assessing competencies in terms of KSAs can open doors for discussion and inform nursing practice.
19) Inclusion in the Nursing Curriculum of ADA Law Regarding Service Dogs Using QSEN Competencies

Suzanne Rosenberg, RN, MSN

Abstract Title: Inclusion in the Nursing Curriculum of ADA Law Regarding Service Dogs Using QSEN Competencies
Abstract Background: Service dogs are increasingly present in the health care setting in the United States, but few nurses are aware of the guidelines put forth by the Americans With Disability Act. Recognizing the law and integrating it into the nursing student’s practice will be more effective if introduced in the nursing curriculum prior to students entering the workforce . Using QSEN competencies, students can have the opportunity to integrate the law into the healthcare setting and explore the benefits as well as the resistance that might ensue. A discussion on the benefits of service animals to the disabled needs to be reviewed in the nursing program. Through QSEN competencies, students will be able to examine how service dogs can significantly improve the quality of life of the disabled. By using a concept care map as a way of understanding the content, and creating a case study or simulation experience, students can demonstrate the cognitive, affective and skills domain necessary to transform their healthcare setting into a service dog friendly environment. Reviewing the QSEN competencies via a case study/simulation experience, students can more effectively explore the implications of bringing a dog into the healthcare setting and all the barriers they may face. Learning it through the patient’s eyes, practicing how to work with a resistant team and creating a safe environment can be practiced. Quality improvement is a process and students can explain how this can benefit patients and better integrate the law and thus better promote full community participation for people with disabilities as Healthy People 2020 strives for. Leadership skills are developed through practice and preparation. Students can be given the exercise of practicing a review their health care facilities policies and working on updating policy to be compliant with ADA law. Resistance to dogs in the hospital setting has been identified at several facilities, so students need to learn how to negotiate, advocate and become resilient to the pressures of those who are resistant to change. Through education and the opportunity to learn and explore the content access of service dogs in the healthcare setting will improve.
Abstract Methods: Students in small groups can create a concept care map addressing prompt that faculty provide. Afterward them can practice within a Simulation experience, or be given a case study which will guide them to respond to the QSEN competencies. The simulation can be reviewed by other students and peer comments can be given during debriefing. Using Case Studies, small groups can share their findings with the larger groups and faculty and other students and comment and expand on their findings. The students knowledge will thus be demonstrated, and their attitudes should surface during this experience. The leadership skill to create and implement a dog accepting environment will be evident.
Abstract Conclusion: Patients with disabilities have found that their dogs are often not well received in community settings and met with discrimination. This situation needs to be reviewed and the quality of life for handlers of service dogs needs to more compliant with the law. This quality improvement issue can be remediated if nursing students have a better understanding of the law, how it affects the disabled and how improvement in nursing practice can help. If nursing students have the opportunity understand the law and the reasons for its creation, and practice implementing it in the healthcare setting improvement is likely to occur. Practicing leadership can lead to change in workplace environment and more comfort in including service dogs in the healthcare setting.
20) Patient and Family Centered Care:  An Interprofessional Education Project to Lead the Improvement of Quality and Safety in Healthcare

Deana Hays, RN, DNP

Judy Didion, RN, PhD

Abstract Title: Patient and Family Centered Care: An Interprofessional Education Project to Lead the Improvement of Quality and Safety in Healthcare
Abstract Background: The purpose of this project is to develop and implement strategies that provide Interprofessional development for the purpose of incorporating a Patient and Family Centered Care model in professional education and practice. This innovative project is a collaborative leadership effort between a large health system, a School of Nursing and a School of Medicine in the Detroit metropolitan area. The goal of the project is to develop a program led by nursing and medicine that educates health care professionals and students on how to engage patients and families in the Interprofessional Team and ultimately their plan of care. Evidence suggests that patients who engage in their care have better health outcomes and incur less cost. Beaumont Health, in partnership with Oakland University William Beaumont School of Medicine and the Oakland University School of Nursing identified a need to design, develop, implement, and evaluate a system-wide faculty and staff development program to meet this goal. The program will include inter-professional content as well as implementation strategies. The target audiences include Physicians (in all disciplines), Nursing (in all disciplines), the School of Nursing and Medicine faculty, Pharmacists and Allied Health Professionals. Currently, several education models exist in various sites of the health system and with varied content. To achieve consistent, empathic, and effective communication methods between patients, families, students and health professionals; a robust course of offerings will be offered to students and healthcare professionals within the organization. Faculty development is essential in all content areas and will be the first group to receive the IPE curriculum. This group seeks to design Inter-Professional Education (IPE) utilizing team-based didactic, simulation methodology and competency based assessment.
Abstract Methods: Implementation methods will incorporate the Stanford Principles, Communication in Healthcare modeled from Cleveland Clinic’s R.E.D.E Model and TeamSTEPPS.
Abstract Conclusion: Program effectiveness strategies include Culture of Safety Measurements, Pre-Post Surveys, Retention/Burnout – Professional Quality of Life, Staff Satisfaction, Patient satisfaction surveys and measures of Physician and Nurse Communication.
21) Integration of Safe Quality Nursing Care Care Concepts in Interdisciplinary Human Patient Simulator Scenarios and Higher Order Learning Goals

Kim Amer, RN, PhD

Abstract Title:  Integration of Safe Quality Nursing Care Care Concepts in Interdisciplinary Human Patient Simulator Scenarios and Higher Order Learning Goals
Abstract Background:  Human Patient Simulation (HPS) is a pedagogy that has been used extensively in the past decade in both academic and hospital settings. The HPS scenario and manner of teaching varies greatly among teaching sites. Because of the variety of pedagogical approaches this project developed a template and designed scenarios that focus on safe quality nursing care with an interdisciplinary focus. The strength of HPS is the ability for teachers to observe many students at one time. Educators can build meaningful and compelling experineces that can guide learners into deeper and more nuanced understanding of complex situation.
Abstract Methods: Because of the variety of pedagogical approaches the simulation council developed a safety focused template scenarios that focus on safe quality nursing care with an interdisciplinary focus. Scenarios were developed focusing on more complex situations with advanced critical thinking and communication skills needed. Two advanced level HPS scenarios were designed with health conditions with cultural competencies required and health conditions with comorbidities and significant health promotion teaching needs. The scenarios were created with the California Simulation Alliance and the International Nursing Association for Clinical Simulation and Learning standards as a guide.
Abstract Conclusion: Two higher order learning complex HPS scenarios were created to help establish a standard of inclusion of safety in all HPS scenarios. Presently scenarios do not include templates that assess handwashing techniques, confirmation of patient identity, dosage checks and medication safety or environmental safety. Our goal is to establish a standard HPS safety template that should be used both in academic settings and hospitals.
22) A Thematic Analysis of Self-described Authentic Leadership Behaviors Among Experienced Nurse Executives.

Catherine Alexander, RN, DNP

Ruth Palan Lopez, RN, PhD, FAAN

Abstract Title: A Thematic Analysis of Self-described Authentic Leadership Behaviors Among Experienced Nurse Executives.
Abstract Background: The American Association of Critical Care Nurses (AACN) recommends authentic leadership as the preferred style of leadership for creating and sustaining healthy work environments. Behaviors associated with authentic leadership in nursing are not well understood.
Abstract Methods: A purposive sample of seventeen experienced nurse executives were recruited from across the United States for this qualitative study. Thematic analysis was used to analyze the in-depth, semi-structured interviews.
Abstract Conclusion: Four constructs of authentic leaders were supported and suggest unique applications of each including: self-awareness (a private and professional self); balanced processing (open hearted); transparency (limiting exposure); and moral leadership (nursing compass). Authentic leadership may provide a sound foundation to support nursing leadership practices, however, its application to the discipline requires additional investigation.
23) Incorporating Applied QI and leadership Skills in a Nurse Practitioner Residency Program: A Synergistic Approach

Catherine Alexander, RN, DNP

Connie Cowley, RN, DNP

Brant Oliver PhD, NP, MPH, APRN-BC  

Abstract Title:  Incorporating Applied QI and leadership Skills in a Nurse Practitioner Residency Program: A Synergistic Approach
Abstract Background: Leading quality improvement (QI) in a clinical microsystem requires a complex and specific set of knowledge, skills and attitudes. Current literature in QI educational design lacks specificity in theoretical design, implementation strategy, and evaluation methods. Further, the critical elements of leadership are often taught in isolation of QI content or not at all. The Veterans Administration Nursing Academic-Clinical Partnership for Graduate Education (VANAP-GE) at White River Junction, VT Medical Center created an opportunity to develop and evaluate an innovative education program for the Nurse Practitioner (NP) within a one-year post graduate residency. The VANAP-GE program was designed to develop competency as “clinicians, leaders, improvers” offering post graduate nurse practitioners the opportunity to learn leadership skills and QI concepts synergistically while building core competencies to lead a quality improvement project in their clinical practice.
Abstract Methods:  Two nursing faculty with expertise in leadership and QI co-taught the curriculum synergistically using applied learning methods. QI projects were selected by the residents early in the residency with the goal of improving the clinical microsystem they were working in. Specifically, leadership theories on change management, culture, organizational behavior and facilitation skills were taught throughout the year. Personal leadership skills focused on building trusting relationships with colleagues, enhancing ones self-awareness, leading from ones strengths, values and beliefs, and developing the skills necessary to manage crucial conversations with both patients and staff. The curriculum for the nurse residency program was theoretically linked to both QI and leadership content. Over the year long program, elements included bimonthly seminars, selected readings, videos, discussion, reflective practice, role play and guest speaker presentations. Students selected projects early in the year and worked with faculty to accomplish their project aims. Residents completed two PDSA cycles that resulted in practice changes in the clinics where they worked.
Abstract Conclusion: The evaluation plan is based on Kirkpatrick and developmental evaluation. The evaluation plan included measures of Resident learning, perceptions of seminars, evaluation of assignments and engagement in the seminars and discussion. Residents were asked to complete pre and post-tests after every session. Evaluation included both Resident and clinical faculty feedback after each session. Based on this feedback, sessions were reevaluated to ensure that synergy of the leadership and QI content was sustained throughout the year. Qualitative results to date suggest the program objectives were aligned with student learning needs. Quantitative results from these projects indicate a 60% increase in proper patient checkout and Improvement in POLST documentation by clinicians during clinic visits. In conclusion, this pilot program represents an innovative educational approach for NP Residents to lead improvement in the clinical microsystem that led to improved systems level performance at the WRJ VA.
24) A Change In Practice: Nurses Leading Clinical Transformation

Aliya Aaron, RN,BSN, MSHS

Abstract Title: A Change In Practice: Nurses Leading Clinical Transformation
Abstract Background:  The purpose of this project was to have nurses lead a quality improvement initiative to standardize electronic documentation and improve workflow at a small rural hospital in Indiana.
Abstract Methods:  To gather data, nursing focus groups were held every two weeks for 2-4 hours over a 2-month period to discuss current challenges with documentation and workflow, and to identify evidence-best practice solutions. The focus groups consisted of a mixture of resources: nurse managers, subject matter experts, and members of the clinical team from the other departments to explore interprofessional practices. Focus group sessions were led by an experienced moderator, and were scheduled at a time that maximized participation. The group discussed issues or concerns encountered during daily patient care process, as well as specific topics based on unit population. Discussions were documented and tape recorded to ensure accuracy for the reports. Staff were encouraged to speak honestly about their perceptions. The group’s recommendations for improvement were taken to nursing leadership to be reviewed for approval. Upon approval, a nursing training manual was developed by the group with over 60 quality improvement processes that would be implemented. Nursing training sessions were scheduled in 4-hour blocks over a two-week period. Training sessions were led by subject matter experts and mandatory for all nurses and managers to attend. A 60-day post implementation survey will be used to measure the the improvements in productivity, data quality, completeness, and availability and nursing satisfaction.
Abstract Conclusion:  The findings from the nurse lead quality improvement initiative are indicative of the major role that nurses play in clinical transformation. The results of such collaboration were new care processes and practices, as well as documentation standards that better support a patient‐centric approach to care. In conclusion, if nurses are to continuously improve their practice, they must continue to take a lead in driving change at the organizational level. Findings from the post implementation survey will be available soon.

Document: 2017 Abstract Presenters