Essentials of Advanced Nursing Practice Field ExperienceC 157Heather MooreDiazWestern Governors University Essentials

Essentials of Advanced Nursing Practice Field ExperienceC 157Heather Moore-DiazWestern Governors University Essentials of Advanced Nursing Practice Field Experience C157Purpose As healthcare providers we are held accountable in our provision of care by multiple groups of people with the most important being the community we serve. The purpose of this paper is to identify an opportunity within my organization to improve patient care outcomes. As a consultant I will be conducting a nurse leader interview, analyze current data (HCAHPS scores, community needs, evaluate the community standard) and devise a plan for implementation that will change current practice ultimately improving patient care. Overview The chairperson of the Unit Based Council for the B4 Telemetry Step Down unit was interviewed about her role within the organization, the shared governance process and its direct impact on quality improvement activities to improve quality outcomes. A face-to-face interview was conducted over two hours. Highlights of the interview included the hierarchy involved in driving change within our organization, the community we serve, and the challenges of meeting the community needs as well as the effect on patient care outcomes. The metrics evaluated during the interview included HCAHPS scores, benchmarking at the state and national level as well as comparing assessments of the facilities within the east bay area. Based on the interview there are areas in the HCAHPS survey that have not meet our organizational goal and have been declining in the past quarter. It is evident that a new strategy will need to be developed to improve nursing communication. The approach will be multifaceted with changes being made in the hospital policy to support performance expectations (mandatory nursing bedside report), education for the nurses to improve communication (bedside report) as well as developing a tracking tool to keep all stakeholders aware of real time data. The plan will include evaluating the current HCAHPS survey results to develop interventions that will support an environment where patients feel they are always listened to and participate in their plan of care. The goal will focus on improving the HCAHPS score in the category “How often did nurses communicate well with patients?” more specifically to question 3 in the survey, “How often did nurses explain things in a way you could understand?” I will evaluate the effectiveness of implementing bedside report by having frontline leaders conduct unannounced rounds to monitor compliance with the bedside report process, evaluate current HCAHPS results and display both results in the staff break room for all stakeholders to view. Description of Organization John Muir Health has been the premier provider of health care services in Contra Costa County (East Bay Area), California since 1920. John Muir Health is a non-profit organization that has combined four campuses into one health system through it transformation efforts. The health systems origin began in 1930 as Mount Diablo Hospital (now John Muir Health- Concord Campus). Mount Diablo Hospital was founded by a nurse who operated in a four-bedroom house across the street from the hospitals current location with a focus of community health for the city of Concord. In 1940, John Muir Health Walnut Creek was founded by a group of physicians whose focus was on the community in Walnut Creek. To put this into perspective, Concord and Walnut Creek are sister cities with both hospitals being 5 miles from one another. In the past 10 years the health system combined both campuses to remain financially viable and to increase the communities access to care close to home. Most recent were the additions of the Behavioral Health Center and San Ramon Regional Medical Center to the John Muir Health System. In its current state of healthcare delivery, John Muir Health serves the entire community of Contra Costa County extending into Alameda and Solano counties. John Muir Health’s motto “We listen, We explain, We work together as a team” extends to their 9000 employees across their 554 bed medical facility in Walnut Creek, 245 bed medical facility, 73 bed psychiatric facility and more than 30 outpatient offices. John Muir Health specializes in a myriad of categories including cardiac surgery, orthopedics, robotic surgery, weight-loss surgery, neurology, cancer care, and high-risk obstetrics. The Walnut Creek Campus is the sole trauma center for Contra Costa County and the Concord Campus is the destination for all cardiac care. Both campuses are accredited by the Joint Commission with a gold seal of approval, have received Magnet recognition for Nursing and were the only non-academic centers in Northern California to consistently be ranked as two of the nation’s top hospitals by U.S. News and World Report. Additionally, the health system has received gold performance by the American Heart Association / American Stroke Association, Chest Pain Center Accreditation, Commission on Accreditation of Rehabilitation Facilities, Leaders in LGBT Healthcare Equality and are centers of excellence for knee and hip replacement. I was unable to identify the number of patient encounters for the year however I was able to identify that our emergency room at the Concord Campus evaluates on average 250 patients a day with 75% of the patients being admitted to the Concord campus hospital. The Organizational chart is as follows: The Board of Directors is comprised of community members whose sole purpose is to ensure that the mission of the organization is being served to the community with oversight in quality metrics, approval of proposed initiatives and financial viability. The executive team includes the CEO, Executive President of the Health system, CAO of the John Muir Physician Network, Chief Transformation Officer, Chief Nursing Executive, Assistant Chief Nursing Officers, Nursing Directors, Nursing Managers, Charge Nurses and Nursing staff. Primary Needs of Population John Muir Health serves 1.2 million people across 715 square miles throughout Contra Costa County. The county has two other hospitals, Kaiser and Contra Costa Regional (county hospital) with John Muir Health being the largest Health System in the county. 58% of the population is 18 to 65 years old with the median age being 41 years. 15% is older than 65 and 27% being under the age of 18. Contra Costa county is primarily Caucasian (65%), with 26% Hispanic, 17% Asian and 9.5% black/African American. 34% of the population’s primary language is not English with homelessness affecting 25,000 people. (Contra Costa n.d) Being a non-profit organization John Muir Health conducts a community needs assessment every three years to be in compliance with the Patient Protection and Affordable Care Act. The goal of a community needs assessment is to identify the assets of a community and determine potential concerns it faces. (Sharma 2000). The last assessment by John Muir Health was completed in 2016. The assessment identified the needs of the community in the following order: 1.Obesity, Diabetes, Healthy Eating and Active Living 2. Economic Security 3. Healthcare Access & Delivery, including Primary & Specialty Care 4. Oral/ Dental Health 5. Mental Health 6. Substance Abuse, including Alcohol, Tobacco and Other drugs 7. Unintentional Injuries 8. Violence and Injury Prevention (2016 Community Assessment 2016). John Muir Health is addressing the health needs of the community through various approaches. The first approach is community outreach and support. John Muir Health is an active participant at the local farmers market where they educate the community about obesity prevention, maintaining a healthy diet and increasing their amount of daily physical activity. Additionally, John Muir Health sponsors multiple no cost classes that rotate through the health system (hospitals, urgent care centers, primary care centers) that support the communities needs in the prevention of obesity, nutrition, physical activity and diabetes management/support. By educating the community on obesity prevention we can hope to avoid unnecessary hospitalizations to manage their disease process. John Muir Health has been steadily working on improving the community’s access to health care by opening their own primary care centers within the county as well as partnering with specialists at Stanford and the University of San Francisco. The next approach John Muir Health has taken is through its transformation efforts to decrease the cost of their insurance product. This has supported the community with the lowering the cost of care and battling the current high cost of care (insurance, co-payments, deductibles). John Muir Health’s position is that health care should be affordable and close to home to increase compliance with healthcare and improve the quality of life of the community. That being said John Muir Health has a robust charity care program where they have partnered with community clinics to provide subsidized care to underserved community members. Lastly, John Muir Health is developing a public service campaign focusing on the use of their primary care, the emergency room and hospital services. It is important to educate the community about the use of each level of care to help the community understand where they should go to seek appropriate care. This will have a dramatic impact on the volume of patients our emergency room cares for, appropriate the care in the most cost effective manner and decrease the cost burden to our community. Case in point: sore throats can be evaluated in the primary care office and the emergency room can treat legitimate emergencies. By taking all of the aforementioned steps John Muir Health is addressing the community needs and supporting their health. Nurse Leader’s Role I interviewed Holly who is the Unit Based Council Chairperson for her unit. She described her role as a frontline leader who attends the UBC leadership meetings, supports the unit in performance improvement initiatives and improves morale on the unit. She identified the key concern for our unit and hospital has been improving communication amongst nurses and the patients we care for. She explained that through the shared governance process the UBC leadership group was able to highlight the nursing communication issue and make it a priority amongst the executive nursing leadership team. In addition to her role in performance improvement she clarified that the role is not solely rooted in performance improvement and that nursing morale in our department as well as hospital wide has been a challenge with the change in the structure of our executive leadership. She described her approach to support her team as intuitive caring. She has implemented a cheerful check-in process to support team members throughout their shift where no one sits down until they have checked in with their colleagues to evaluate if they need assistance in completing tasks. She has taken this approach to the next level, by independently and confidentially reaching out to colleagues who have personal crisis’ that could affect their performance in the workplace. In her opinion, the whole person needs to be addressed in order to support the current quality improvement initiatives, which align with the high quality care provided to our patients. As the Unit Based Council chairperson she has informal and formal influence amongst her unit based team as well as hospital wide team. The American Association of Colleges of Nursing has identified nine roles that are essential for the MSN prepared nurse. The nine roles are: I. Background for Practice from Sciences and Humanities, II. Organizational and Systems Leadership, III. Quality Improvement and Safety, IV. Translating and Integrating Scholarship into Practice, V. Informatics and Healthcare Technologies, VI. Health Policy and Advocacy, VII. Interprofessional Collaboration for Improving Patient and Population Health Outcomes, VIII. Clinical Prevention and Population Health for Improving Health and IX. Master’s-Level Nursing Practice (Denisco & Barker, 2016). It was apparent during our interview that Holly’s role as the Unit Based Council Chairperson strongly aligned with essentials II, III, and IV. Essential role II (Organizational and Systems Leadership) provides safe high quality patient care by effectively communicating with staff, patients and families The nurse leader demonstrates communication techniques that are respectful with teams and teamwork, including team leadership, building effective teams and nurturing teams (Denisco & Barker 2016). Holly shined in this role. Despite her personal objections in the prioritization of hospital wide performance initiatives, she was able to illustrate her position in focusing on nursing communication at the leadership level while supporting her unit-based team. Essential role III (Quality Improvement and Safety) is the cornerstone of Holly’s role as the Unit Based Council Leader. Being comfortable with analyzing quality measures and correlating them to patient safety is a top priority for a nursing leader. Without the ability to do so would disable the leader in improving patient care as they would be unable to identify the successes and/or opportunities for improvement for their health system. The unit based council chair persons position within the organization aligns with this essential role because they are able to readily correlate safety concerns with unit based activities as well as hospital wide activities. For example, Holly mentioned that the fall rate had increased within our unit however it had remained stagnant or decreased in the other units of the hospital. When she assessed the previous quarters data she was able to identify the trend that affected the patients who fell. Which was that the hospital supervisor had oversaturated our unit with a challenging patient population and we had a higher rate of external staff (registry nurses) working in our department. The combination proved to be catastrophic for our patients. Holly discussed with her colleagues what they thought could have been done differently to support our patients. She took those recommendations to the Unit Based Council leadership group who developed a plan with the support of nursing leadership to not oversaturate a nursing unit with one patient population and to disburse registry personnel amongst the units with assigned buddy’s to verify they are complaint with the hospitals policies. Holly was able to promote quality care by using high reliability techniques whilst analyzing errors to improve patient care ( Denisco & Barker 2016). Lastly, Essential IV (Translating and Integrating Scholarship into Practice) I believe is the most important for the nurse leader. As it is the ability to integrate theory, evidence and clinical judgment to collaborate with teams to improve care outcomes and support policy changes. The policy changes are generated by knowledge dissemination, planning and evaluating knowledge implementation ( Denisco & Barker 2016). As the unit based chairperson Holly was able to utilize evidence based practice and translate it into the implementation of purposeful hourly rounding to increase our patient satisfaction scores. Characteristics of Organization John Muir Health like all organizations has strengths and weaknesses. The strengths I identified were the support provided to the UBC chairperson to implement changes in practice to improve the delivery of patient care. The support was team focused with a common goal of caring for our patients. The unit-based team embraced their UBC leaders recommendations and was successful as a result of executive leadership support. This was in alignment with the hospitals motto “ We listen, We explain, We work together as a team”. A weakness I identified during the interview was the lack of communication amongst the care team when providing care to their patients. Patients raised concerns that they were not being listened to about their symptoms, physicians were not explaining the plan of care to the patients or nurses, and nurses were spending a large portion of time chasing down the physician to discuss the a patient’s status and were dissatisfied with the lack of collaboration with the plan of care. If the physicians had reached out to the nursing team prior to rounding on the patient the nurse would have an opportunity to discuss the patient’s symptoms, responses to treatments and suggest amendments in the plan of care. Once the physician and nurse completed their dialogue it would

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