Bringing Quality to the Bedside
The Evolution of the Nurse Quality Champion
Sue Nuss, PhD, RN
Nikki Clark, BSN, RN
Kelli Jacobs, BSN, RN
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Objectives
• Illustrate process to get approval for unit-based
nurse Quality Champions
• Describe role of Quality Champion
• Share experiences of 2 Quality Champions
Strategic Plan
Our Goal
Exemplify and enhance a patient-centered, innovative culture of quality and
safety throughout the health care journey that is based on evidence and research
Supporting Tactics
To have a standardized nurse driven Q/PI structure throughout the organization
• Have a Q/PI team on every nursing unit /department
• Have a “Quality Champion” in each nursing unit / department
• Quality Champion to work with Manager/ANM to assure quality care is foundation
of culture
• Quality and Patient Safety Curriculum
Monthly or Quarterly Nursing Grand Rounds to disseminate Quality initiatives/issues
throughout the organization (Align with Practice Pillar to accomplish objective)
“Vision” for Quality Champion
Expectations:
• 16 or 24 hours per month for these
duties
Tenure:
• 2 year term with option for 2 consecutive
terms
Duties:
•
Work with Manager/ANM to review
opportunities for improvement per unit
“quality” scorecard
•
“Go to” person for staff re: quality issues
•
Disseminate quality information (from unit to
NQC and NQC to unit)
•
Work with Q/PI team to:
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–
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Qualifications:
•
•
•
RN (BSN prepared)
3 years experience (at least 1 year at NMC)
Prefer some Q/PI experience
Facilitate no more than 3 team projects per year
Assist with development of action plans
Initiate, monitor, and recommend based on action
plan
•
Member of unit Q/PI team, but not in chair
position
•
Given resources to empower QC to make
changes related to quality issues
•
Complete Foundations in Continuous
Improvement training within 6 months of
acceptance
Cost of Quality Champion
16 hours / month
24 hours / month
• 0.9 FTE to 1.0 FTE
• Remain 0.9 FTE
• 8 hrs/pay period
• 12 hr shift/pay period
• Average RN salary = $25.97
• Average RN salary = $25.97
• 16 hrs/month = 192 hrs/yr
• 24 hrs/month = 288 hrs/yr
• Annual cost = $4,986.24
• Annual cost = $7,479.36
Cost-Effectiveness
Estimated Cost of One Hospital Acquired Complication
CVL-BSI
25,000
CA-UTI
Cost
20,000
Injury Fall
Pressure Ulcer
15,000
VAP
10,000
5,000
25,000
4,000
8,583
0
1
5,344
11,000
Annual QC 24 hr
cost
Annual QC 16 hr
cost
 Reducing one infection/complication on each unit per year
would pay for the cost of the Quality Champions
Estimated Cost by Unit (July-Dec 2010)
(UTI, BSI, VAP, Injury Falls)
350,000
Cost in dollars
300,000
250,000
200,000
150,000
100,000
50,000
0
800/8
OHS
8
AICU APCU
BURN 5W
6W CPCU
SOTU 9N
6N/S
6N
50
CU
TELE
Total Cost 140,58 142,16 24,583 349,16 42,166 88,332 37,749 114,83 41,749 251,24 58,166 108,58 126,83
Literature’s Approx. Cost of Adverse Events Included in Graph
(UTI = 4,000; BSI = 25,000; VAP = 11,000; Injury Fall = 8,583)
Steps Taken
• Presented proposed QC role to Nursing Directors
• Challenged with “how does QC differ from
ANM”?
• Further analysis
– Queried ANMs
– Analysis using 12 hours per month
ANM Responses
• Only 50% response rate (7 of 14)
• Only 2 stated they had enough time to work on “quality indicators”
• HOWEVER, most of these indicators are day to day indicators
o Quadramed reliability
o Incident reports
o Financial reports
o Unclassified patient data
o Staffing variances
o Patient rounds
o Personnel issues
o Mentoring
o Press Ganey
ANM Responses
•
“Time spent on this is hard to quantify”
•
“ No data collection is being done; only reviewing reports due to lack of time”
•
“Lack of managerial support to work on QI tasks”
•
“Some weeks are filled with meetings and makes it hard to focus on this kind of work”
•
“Other tasks associated with the ANM-personnel issues and mentoring, patient
rounds, meetings, budget, supplies, staff evaluations, availability to staff, etc.
•
“ I would say that overall there is enough time to work on those above tasks. There
may be days when you cannot spend the necessary time due to other situations of
the floor, but overall it is manageable”
ANM Responses
“I strongly feel that the QC person should be a staff
nurse that is well respected by the nurses at the
bedside. They need to be the voice that is heard, with
the management team in the supporting role. Change
is better received when it comes from those who are
impacted by the change . . . the bedside nurse”
Suggestions
1. Quality Champion needs to be a staff nurse not an ANM
a. More “approachable” for staff
b. “Voice” of staff – not management
c. More staff representation on Nursing Quality Council
2.
Compromise from original proposal regarding hours
a. 12 hours per month
i. Meetings – UBC, PI, NQC
ii. Quality work
b. Cost would be $3740 per year
c. Manager / ANM could assign “opportunity” type projects to QC
Suggestions
3.
Suggestions for PI teams:
a.
Ideally each unit would have some version of a team dedicated to
Quality initiatives
i.
ii.
iii.
Unit based PI team
PI work done within UBC
For areas with Service / Product Line PI teams, QC would
represent specific unit
Measures of Success
1.
Decrease in hospital acquired adverse events (HAI, NPSG, PSI)
A. Organization level
B. Unit level
2.
Improved and sustained Core Measure / SCIP compliance
3.
Improved Patient Satisfaction scores
4.
Improved staff knowledge of “quality”
5.
Professional growth of QC
A. Poster presentations
B. Publications
C. NDNQI Quality Award 
What was the end result?
Starting in July 2011 . . .
• 23 QCs identified
 All inpatient areas
 Several ambulatory / procedural based
areas
• Given 12 hours per month to work on
“quality” work
Expectations of Quality
Champions
What will QC time look like?
Time Allotment
5%
Project work (6 hrs)
25%
Investigation (2.4 hrs)
50%
20%
Meetings (3 hrs)
RRT / Codes outside ICU
(0.6 hrs)
Time Allotment
• Investigation (20%)
– Scoping of project
– Defining problem
• Meetings (25%)
– UBC / Unit PI
– NQC
– UBMD / Mgr / QC
• Project work (50%)
– Preparing
– Doing
– Leading “the work”
• RRT/Codes outside ICU (5%)
– Look at unit trends
– Discuss with staff
– Develop action plans
Unit Quality Triad
Goal of triad is to drive
unit specific quality
initiatives – from a
medical, administrative,
and direct care provider
perspective
Manager /
ANM
Medical
Director
Quality
Champion
Expectations
• Use time efficiently  do investigating or project work on a
day when already coming in for a meeting
• Work with unit-based Quality Triad to improve outcomes
• Reach out to other QC  work on similar projects collectively
• Come prepared to discuss QC work at NQC
• Track time dedicated to “quality” work
What the QCs is not expected to do?
• Routine documentation audits
• Program certification or regulatory work
• Work that does not align with HQC goals or
unit goals
What are QCs working on?
• Infection Related
– CA-UTI (early foley removal)
– CL-BSIs
• Care of the central line (creating a
standardized process)
– Decrease UTI rate in thoracic patients
• Patient Satisfaction
– Pain control and monitoring
– Patient Satisfaction
•
Nurse Communication
– HCAHPS
•
RN Communication Domain
– Press Ganey Patient Satisfaction
– Response time to call lights
• Patient Safety
– Falls
– Medication errors related to change in
concentration and mislabeled bags that
protect light sensitive medications
– Common E's and Trends on Incident
Reports
• Miscellaneous
– Saline flush confirmation and
documentation
– Unit Throughput
– Discharge planning
– Patient education and conversion to
outpatient learning
– Accurate documentation for immediate
use sterilization
Real life experiences
• Testimonials from 2 QCs
– Kelli Jacobs, BSN, RN
– Nikki Clark, BSN, RN
QC Perspective – Kelli Jacobs, BSN, RN
•
My background
– RN for 5 years
– Work on Solid Organ Transplant Unit
•
Why I wanted to be a QC
– Opportunity to learn more about QI process and work directly with QI projects
•
Current project is NS Flush Documentation
– SOTU nurses to barcode scan all NS flushes that they administer to their patients
•
•
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To provide accurate documentation of the quantity used
Barcode scanning also supports our institution's expectation of real-time charting
Why this project?
– The majority of saline flushes used by the nurses were not being documented or recorded in
the pt's I&O
– Opportunity existed to improve
•
•
Reimbursement for flushes
Quality of patient care by providing a reliable way for nurses to document all of the flush syringes that
are used
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QC Perspective – Kelli Jacobs, BSN, RN
•
Success of the QC role
–
–
•
Success of Quality Triad Model
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•
Helps build relationships between the staff nurses, manager, and the unit-based medical director
By working together, valuable input and ideas are acquired that would probably otherwise be overlooked
It improves communication and builds trust between team members and allows the team as a group to look
at a quality issue from different perspectives
This aids in being able to address quality improvement issues more thoroughly and completely
Opportunities
–
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•
Provides a great opportunity to work hands-on with unit-based and hospital-wide quality projects
Gives staff nurses the power and ability to directly affect quality of patient care and nursing processes
Still have an opportunity to strengthen our triad meetings by creating a standing agenda and trying to
schedule a set date and time for meetings
Medical director tries to attend not just the triad meeting, but all of our quality meetings if he is able
Overall, this has created opportunities, not just for the triad members (QC, manager, UMD), but also for
other staff nurses, as anyone is welcome to join the unit Quality team and partake in quality improvement
projects
Next Project
–
Hand Hygiene compliance
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QC Perspective – Nikki Clark, BSN, RN
•
My background
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–
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•
Why I wanted to be a QC
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•
Healthcare for 13 years
Cancer research for 3 1/2 years
RN for 3 years
Work on Oncology-Hematology Special Care Unit
My background in research
Wanted to make a difference by influencing and demonstrating best practice to our patients and staff
Wanted new staff to have the opportunity to ask questions and bring concerns to someone that worked on
the floor
Helps me brush up on skills, policies, and procedures
Helps to demonstrate to others so that they too are following policies and procedures
Current project is NS Flush Documentation
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Reducing central line blood stream infections through looking at all aspects that the RN takes part in:
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•
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5 second scrub the hub/line accessing
Dressing changes
Port needle changes
Bathing
Why this project?
–
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According to our HCAHP scores, this was an area that we needed to work on
It is important means to infection especially in immunocompromised patients.
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QC Perspective – Nikki Clark, BSN, RN
•
Success of the QC role
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Success of Quality Triad Model
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The triad model is great if you have parties on board
When the MD is involved, they tend to have more clout when pulling strings to get things accomplished in certain situations
Having active management involvement created rapport and demonstrates that they do care about what is happening on the
floor
QC serves as a liaison between management/MDs to staff on the floor
Opportunities
–
–
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•
Serves a liaison person for staff to express concerns about practices on the floor
QC can help drive the focus to look into the issue and take action if necessary
QC can take concerns to management for support and updates
It is also something that I enjoy doing 
There are always opportunities.
I wish I could have more involvement from my medical director
Opportunities to initiate change in a nonthreatening way so that staff is more receptive to changes in practice in order
to complete best practice according to evidence based practice
Have found that staff sometimes think they are doing something correctly, only to find out that according to policy
they are missing a few steps
Next Project
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TBD
Always looking at falls
Brushing up with RNs on required education that needs to be given to pt before/after chemo and/or transplant.
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