Improving Quality of Hospital Care using
Clinical Nurse Leaders
Grace Sotomayor, MBA, MSN, RN, FACHE, NEA-BC, CNL
Chief Nurse Executive, Carolinas Medical Center
Nov 02, 2012
Content
• Background
• Process
• Goals
• Current Deployment of CNLs
• Results to Goals
• Other Results
• Questions
CHS
• >10.5m patient encounters /year in >800 care sites across
the Carolinas
• 2,800 Physicians and ACPs
• Primary Care Network with 3m active patients
• 60,000 employees
Mission: To create and operate a comprehensive
system to provide healthcare and related services,
including education and research opportunities, for the
benefit of the people it serves.
Carolinas Medical Center
CMC
• 893 beds
• Level 1 Trauma Academic teaching facility
• Multiple Hallmarks designated units
• Multiple TJC DSC designations
• Council structure for Nursing Shared Governance since
2003
• Magnet submission entered Aug 01, 2012
CMC Nursing Practice Model
7
CNL
• Masters prepared generalist nurse
• Preparation Foci:
• Practice is at the microsystems level
• Client care outcomes are the measure of quality practice
• Practice guidelines are based on evidence
• Client centered practice is intra and interdisciplinary
• Information will maximize self care and client decision making
• Nursing assessment is the basis for theory and knowledge
development
• Good fiscal stewardship is a condition of quality care
• Social justice is an essential nursing value
• Communication technology will facilitate the continuity and
comprehensiveness of care
• The CNL must assume guardianship for the nursing profession
CNL
• Role areas
• Clinician
• Outcomes Manager
• Client Advocate
• Educator
• Information Manager
• Systems Analyst/Risk anticipator
• Team Manager
• Member of a profession
• Lifelong learner
• Programs in NC: UNC, Queens University
Why CNL?
• Linkage between education and outcomes
• Performance on Nurse Sensitive Indicators critical for
patient quality/safety and reimbursement
• Nursing Leadership philosophy
• Direct care nurses need to be well educated
• Direct care nurses know best how to improve nursing care
Implications for Nursing
• IOM Report on Future of Nursing
Implications for Nursing
• IOM Report on Future of Nursing
Implications for Nursing
• IOM Report on Future of Nursing
CNL Role
Planning
• 3 year Duke Endowment matching grant funds: 36 CNLs for
adult Medical Surgical units at CMC
• Partnered with Queens University, Charlotte for curriculum
development
• 38 credits
• Created PCL course to jump start process
• 2 days: Health Care Reform, Finance, Quality, Change Management,
Case Management, CNL Role
• PCLs take course at CMC in final year of school
• Candidates selected carefully, must want to work in direct
care
PI Goals
By Dec 2012:
• Quality
• Zero falls with injury
• Zero HAPU
• Cost
• Turnover- annual rate 12% or less in med-surg units
• Satisfaction
• Inpatient satisfaction: overall Quality of Care 90th%ile
• NDNQI RN Job satisfaction >60
Implementation
• Information sessions for staff and managers
•
AACN White Paper on CNL role
• Visited USF and Baycare: Morton Plant Mease
• Attended annual CNL meetings co-sponsored by VA and
AACN
• Changed care delivery model on targeted units to be budget
neutral
• Implemented 8 hr /5 days/week model on day shift as “
Attending Nurse “ in ~ “12 bed hospital”
• Partnered with Dartmouth for Micro system learning
Budget Neutrality
Key Points
• Did not want role to be additive exposing it to potential
deletion in the future
• Work of CNL to be part of the nursing workflow at the
bedside
• The CNL is a direct care nurse with advanced skills
• Assignments restructured by direct care staff on each
unit to accommodate the CNL
• Transitioned from Action OI as benchmarking vendor to
Premier in 2011
14.00
12.00
11.45
10.86
10.77
10.00
10.26
10.14
9.93 10.03
9.71
9.59
9.73
9.08
Budgeted WHPPD
10.47
9.66 9.55
9.39
9.79 9.77 9.69
9T
11T
8.00
6.00
4.00
2.00
0.00
3T
4T
5T
2009
2010
2011
11A
Current CNL Deployment
Total 22 YTD 2012
•
3T
1 year
•
4T
2 months 36 beds ; Full complement of 3 CNLs since August, 2012
•
5T
1 year
•
APC 2 years
13 beds ; Full complement of 2 CNLs since August, 2010. One
CNL working in Women’s meso- system and one in HROB
•
9T
1 year
36 beds ; Full complement of 3 CNLs since August, 2011
•
10A
0
36 beds. 3 PCLs
•
10T
10 months 36 beds; 1 CNL on evening shift since January 2012; 1
CNL since Aug 2012; remainder 2 PCLs
•
11A
1 year
24 beds; 2 CNLs since August, 2011; Full complement of 3 CNLs
since August, 2012
•
11T
1 year
36 beds; 1 CNL since August, 2010; Full complement of 3 CNLs
since December, 2011
36 beds; Full complement of 3 CNLs since August, 2011
36 beds ; 2 CNLs since December, 2011; Full complement of 3
CNLs since April 2012
CNL Process
• Ensure EBP at bedside
• Bedside report
• Hourly rounding
• Pain management
• Teaching on the spot
• Galvanize the inter professional team
• 5P Assessment
• Care planning
• Physician rounding
• Lean huddles
• Lead PI
• Teaching strategies, clinical care, Throughput
• PI team participation e.g IPE, Transitions, ADOD
Template for 5P Assessment
The 5Ps: Purpose, Patients, Patterns, Processes , Professionals
Results
Falls/1000 Patient Days
Falls/1000 Patient Days
All CNL units
CNL Only units
Goal
7.00
6.00
5.63
5.48
5.76
5.08
4.91
4.99
4.36
5.00
N
4.32
4.22
3.84
4.00
4.08
3.58
3.00
2.19
2.47
2.8
2.00
1.00
0.00
1Q09
2Q09
3Q09
4Q09
1Q10
2Q10
3Q10
1st cohort
graduated
4Q10
1Q11
2Q11
3Q11
2nd cohort
graduated
4Q11
1Q12
2Q12
3Q12
3rd cohort
graduated
F
a
v
o
r
a
b
l
e
Falls with Injury/1000 Patient Days
1st cohort
graduated
2nd cohort
graduated
3rd cohort
graduated
Hospital Acquired Pressure Ulcers
Hospital Acquired Pressure Ulcers
RN Turnover - 2009
All CNL Units
Goal ≤12% by 2Q12
2009
Goal
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
3T
4T
5T
APC
9T
11A
11T
2009
4.7%
27.1%
18.6%
9.1%
15.1%
5.2%
22.3%
Goal
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
3 Units at or better than goal
RN Turnover - 2010
All CNL Units
Goal ≤12% by 2Q12
2010
Goal
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
3T
4T
5T
APC
9T
11A
11T
2010
11.7%
14.1%
10.4%
17.3%
11.7%
0.0%
4.8%
Goal
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
5 Units at or better than goal
RN Turnover - 2011
All CNL Units
Goal ≤12% by 2Q12
2011
Goal
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
3T
4T
5T
APC
9T
11A
11T
2011
13.0%
11.2%
16.3%
11.0%
10.0%
7.4%
4.5%
Goal
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
5 Units at or better than goal
RN Turnover – 2QYTD Annualized
All CNL Units
Goal ≤12% by 2Q12
2QYTD12
Goal
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
3T
4T
5T
APC
9T
11A
11T
2QYTD12
12.8%
8.2%
3.8%
8.6%
0.0%
4.6%
4.2%
Goal
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
12.0%
6 Units at or better than goal
Patient Satisfaction
1st cohort
graduated
2nd cohort
graduated
3rd cohort graduated
RN Job Satisfaction ( Enjoyment)
Other Indicators
Baseline Collected Pre-Canopy Implementation
Data Source: Unit Admission/Discharge Log | Manually entered by Unit Secretary
N=237
N=210
N=217
N=115
N=106
N=55
N=233
N=204
N=151
N=166
N=160
N=148
N=195
N=185
N=85
N=183
N=221
N=56
N=186
N=197
N=56
D/C to Home < 120 min of MD Order
Baseline Collected Pre-Canopy Implementation
Data Source: Unit Admission/Discharge Log | Manually entered by Unit Secretary
N=237
N=210
N=217
N=115
N=106
N=55
N=233
N=204
N=151
N=166
N=160
N=148
N=195
N=185
N=85
N=183
N=221
N=56
N=186
N=197
N=56
D/C to Home before 12:00 Noon
Next steps
• Complete model on evenings and weekends
• Ongoing education for CNLs: value based purchasing;
performance improvement; micro system learning
• Develop novice to expert competencies
• Institute a CNL preceptor program
• Institute a CNL Practice Council
• Develop the CNL as coach
The CNLs – second cohort pinning
Questions?