pre-pandemic acute care nursing care models must change. The time is now. here’s how.
Acute care hospital Nursing and other Clinical leaders have a unique window to turn recovery into opportunity for making a fresh impact on patient experience and outcomes with change in nursing care models. Here’s a 5-step model to use in preparing for the flood of demand that’s coming.
Author
Heather Long, MSN, BA, RN
Founder and CEO of Reveal Solutions
COVID-19. It crippled the globe taking tens of thousands of lives. At the time of this writing, the impact is far from over. Thankfully, a glimmer of light appears to be breaking through as the curve for the leading indicator (new cases) has plateaued.
Still, widespread stay-at-home orders have nearly emptied acute care hospitals in the Southeastern and Southcentral regions of the US. And while these hospitals have largely avoided the bed capacity challenges experienced in New York, the impact has likely created an impending new challenge. Furloughs and layoffs will in the acute care space are likely ending soon. As the country and hospital leaders prepare to phase back into “opening up”, the demand for acute care in hospitals is expected to rise. And it’s likely going to be big, fueled by multiple sources:
Catastrophic Unemployment.
Unemployment numbers not seen in multiple generations are already amplifying domestic abuse, suicide, and other crime that results in acute care demand. But it’s not just the crime. The other part of the ripple is the possible increase in heart disease and other illnesses.
Pent Up Elective Demand.
Picture a river, full at its banks, flowing well. Then, one day, a giant concrete wall was dropped in front of it, damming it up. That’s how a lake is formed. Except in the case of elective demand, the lake was not intentional, and the dam is temporary. There will be upwards of 2 months of paused demand for most hospitals, PLUS the newly created demand that flowed into the temporary lake. This demand alone makes for a busy 2020 as hospitals work to spread out 9 months of work across 6 months.
New Demand from Delayed Care.
A spike in new demand may come from people delaying care that would have been better served sooner rather than later, but was not considered emergent at the time of the stay-at-home orders.
Regular Demand.
There will of course be “regular” demand for acute care based on life in general.
More COVID-19.
We all know it’s not going away. While most experts agree that another surge like the initial hit is unlikely, communities are “reopening”. It is possible hospitals will see periodic COVID spikes in new cases.
Whether hospitals have been nearly empty or overflowing (as has been the case in New York), hospital leaders have been tested. And this is only the beginning. Although different communities are experiencing different waves of demand, or lack thereof, one thing is consistent:
The need to effectively manage increased demand at the point of care is only going to intensify.
The next few months represent a critical window of opportunity for hospital clinical leaders to prepare to be better in the delivery process of care. So how do they do that in light of this impending shift in the landscape?
First, there must be a light shined on an underlying, chronic problem that existed before COVID-19; a problem only exacerbated by this new normal of demand. And it’s been festering since the market-sweeping advent of the EHR more than a decade ago. By itself it drags down nursing engagement and workflow efficiency, while spiking direct labor costs:
The Screen Trap.
The Screen Trap is a real thing for nurses. Before COVID-19, Nurses spent an average of 3 hours per shift in front of a screen…not caring for patients. It’s not that documentation is bad. But playing part-time data clerk disrupts critical thinking and dulls that nurturing nature so important to a patient’s health.
Nurses from New York, undisputed heroes currently serving on the COVID-19 frontline, recently describe a renewed intensity in the need to stay focused on caring for patients and minimizing their time in the EHR. And they are exactly right. While it’s tragic that we are in this crisis, it has shined a bright light on this problem and the need to claim a fresh approach in how we deliver care every day, not just during a crisis.
Take for example scribes, workflows, and checklists. While these things are not new (scribes for physicians have been successful for over a decade), scribes for nurses is a fairly new concept. More importantly, how these three things work together in context of a best practice framework focused on exceptional outcomes…that is fresh and innovative.
Now that we have the problems thoroughly identified and a peek at a better answer for them, what can hospital clinical leaders do about it? Acknowledging that a blog post is not going to magically solve the issue tomorrow, it can represent a new beginning. And we could all use a new beginning now and then. In this season of life, now is a really good time. So brave clinical leaders, here are 5 things you can do, or at least begin to evaluate doing, for your hospital.
1. Embrace the right mindset.
Uniting the hearts and minds of your nurses activates greater focus in purpose, effort, and effectiveness. It is more than empathizing with their pain about what’s not working in their day-to-day, or improving relations with physicians, or putting out today’s fires. Uniting the hearts and minds means that leaders commit to affecting outcomes with incremental, yet systemic change. It means believing that more focus on clinical activities with patients will be achieved with clinical care standards, practical efficiency in workflows, and applied support from resources like scribes.
Embracing this mindset and belief is the first step in understanding and communicating that hearts and minds are different but connected. In fact, they must both be properly “nourished” as they both originate in the mind. Good people on your team will step up (early adopters). Other solid people will follow (early majority), and the rest that “make it” (late majority) will improve. The laggards will leave, and you won’t have a recruiting or staffing problem. Your reputation will draw in more of the first 3 types of nurses to solve your gaps. It is possible and has happened. In the end, your mindset translates to your people. Choose the right mindset and then stick with it.
2. Identify the right pilot.
Work with your inner circle of “field” leaders to identify the right, single unit to pilot a change initiative. Remember, as the clinical leader, it is your responsibility to make sure you make the final call. Your team is there to help you make a more informed decision. While you seek agreement to help ensure adoption, it is your decision to make. This step requires as little as a few days but could take longer depending on the demands of your time and your commitment to prioritize this effort. The criteria for identifying the right pilot unit is as follows:
Select the right unit leader. This person must be someone who embraces change, even looks to do it…someone who is hungry to lead a pilot that hasn’t been done before. This person must have the energy to go beyond the day-to-day and do things outside routine. And this person must be someone you can trust to be transparent with you personally about things that go on in the unit. Keep in mind that the right unit leader may not currently be working in the right unit for the pilot. Oh, and have a backup person identified. Your first choice may have a life event no one saw coming. Or it may just not be a fit like you thought. Minimize single points of failure with redundancy.
Select the right unit. Qualify the right unit based on the perceived opportunity available. This will likely be more challenging because of the pandemic. Whether your units have been empty or busting at the seams, use the following baseline criteria by considering pre-pandemic data in your evaluation:
The propensity for super user adoption is high (you may have to manufacture this by putting a support champion or two in place in support of your ‘right’ nursing unit leader)
High overtime (particularly units where end-of-shift overtime is high due to late clock outs to complete documentation – this scenario could add a direct labor cost of up to $60k/mo/30-bed unit)
Quality performance metrics are erratic (doesn’t mean the unit is in the bottom, rather that consistency is difficult to achieve)
Patient experience is underperforming (a unit at the bottom of your units in this area would make for a good pilot candidate, in context of the first two qualifiers
High RN separation rate (if you have a virtual “turn-style” for nurses in one of your units)
Documentation has been a repeat challenge (your hospital has experienced readmission challenges or legal battles due to unclear documentation about something like undocumented present on admission conditions or the use of restraints, or other similar issues)
Number of falls is consistently higher than expected
Call light metrics are consistently at the bottom of unit performance
Make sure you have at least 2 target units with a max of 3. Rank them. Again, you are minimizing single points of failure.
3. Assess your first-choice unit.
This step requires approximately 10-20 days depending on your current job demands and those of your team. Now that you and the team have walked a focused path for identifying and qualifying the right unit, it’s time to assess it. Work with your unit leader and super user(s) to take the following steps:
Form the observation team and assign roles. This is a delicate thing depending on whether or not your current unit leader is going to be the future unit leader when the pilot goes live.
Determine your 3-5 signature care standards. This part can be tough, but it is worth the effort. Because of the pandemic, you will likely already be engaged in this type of effort seeking innovation to apply in use of PPE and other practices. Nonetheless, this is where the rubber meets the road with respect to the practical side of executing quality care. Signature care standards are principled statements of expected outcomes. They are informed by using top quality metrics as the baseline goals for outcomes such as the 10 domains of HCAHPS or overall patient experience, timeliness of care, and caregiver optimization to name a few. They include “best practice” of tactical activities that are necessary in supporting the outcomes. Determine your standards of care 3-5 principles (they support on patient experience, quality indicators, and timeliness of care, caregiver optimization).
Prepare the whole unit team for observation by communicating the what, why, and how of the assessment exercise. Demonstrating transparency and authenticity with the team is paramount. Don’t leave this task to the potential new unit leader or the current one. You be the person to deliver the message and the acting unit leader will support it with action by reaffirming the message and listening for feedback.
Initiate the observation exercise.
Make sure to encourage the team to set aside any potential bias and simply observe.
Encourage the observation team to take copious notes and avoid interfering or attempting to ‘fix’ things.
Map current workflows by shadowing the units.
Look for things that don’t work well.
Also, look for things that do work well.
Gather the observation team to download and prioritize findings.
Make the conversation a safe place to share.
Focus on issues rather than people.
Once you have it on the table, prioritize and rank areas of opportunity based on the following…
Identify and prioritize 2-3 easy wins to begin change with minimal disruption (will help build consensus for change among the unit nurses)
Identify and prioritize the top 3 biggest winning opportunities, staging them based on difficulty (starting with the least)
4. Create and communicate the plan for the pilot.
This part really centers on you and your ‘right’ unit leader. It’s up to you two to document the priorities, create the timeline of project milestones, recruit your stakeholders, and integrate the reporting cadence into your current meeting framework. Avoid isolating this project as a separate thing in your world. You don’t have time for that and doing so can single-handedly set you on a path to failure. Milestones need to include:
Set goals for the project (how do you specifically define success for the project, not just metric goals within signature care standards)
Determine the pilot timeline (90 days is a reasonable period of time to affect some measurable impact, to achieve wins, and to create learning that can be collected and prepared for duplicating in other units)
Define roles and responsibilities for stakeholders (jobs descriptions for the unit leader and the super users will change, but so will be the case for those nurses working in the unit)
Identify and source scribes for nurses (this is truly worthy of a blog series in of itself, but is a critical investment that can quickly deliver a return particularly for high-overtime units)
Prepare the plan for socializing with the entire team
Prepare the training content and the training team for delivery of training
Train the team on the plan, the signature care standards
Setup project progress reporting
Integrate the reporting cadence into current meeting agendas where possible
Hold final pilot evaluation
5. Go-live, monitor, and evaluate.
Go-live needs to have a clear start, but keep it tempered with perspective. That really comes down to communication from you and the unit leader. The unit leader’s focus centers on the super user(s) and keeping the troops engaged in achieving the low hanging fruit wins. Here are some key things to accomplish in this part of the pilot:
Getting some key wins in the first 30 days is a worthy goal. If not achievable, don’t fret. Simply evaluate what you learned and pivot to achieve them within 60 days.
Make sure you are communicating with your unit leader, directly, often, even outside the normal cadence. While you don’t want to overwhelm, do stay connected throughout the live period. Feedback is critical, not just from the leadership but from the super user(s) and the rest of the nurses on the unit. Your unit leader is your ticket to feedback. This will help you achieve your micro pivots which you will undoubtedly need to make throughout the 90 days.
Celebrate wins with the nurses and the entire team. Encourage your unit leader to drive this and you participate in some select times. Be just visible enough that everyone knows this is a priority and that it’s special, but not too much that you overshadow your unit leader.
Be sure to report on key milestones with your executive peers as you go along. Invite them into the process and even into the celebration, encouraging them to show appreciation and support to the troops.
Work with your unit leader and super user(s) to document your findings from the pilot within 20 days of day 90. Depending on your results, but ideally, you will have created a better nursing care model…a best practice nursing care model that can be scaled to drive meaningful change across as many units as you have under your care.
So why do all this?
Because you are a leader with an opportunity to make a new beginning for so many people. Not only will you see your quality metrics improve, in some cases dramatically, your patients and your team will have a more satisfying experience…which we all know is tough to achieve in acute care. Furthermore, you will empower your hospital(s) with more financial value, tangible financial value to reinvest back into more innovation within the organization.
You have the opportunity to do something truly great, and deeply impactful for so many. Isn’t that a big part of why you became a clinical leader?
One final note. Change management is hard. If you get stuck, don’t stay stuck. Get help. You operate in a uniquely complex environment. It is hard to step outside your work while in it, to work on it, strategically, and then step back in and execute change. Choosing to entrust the right guide with inside experience and an outside voice will help you stay focused on the day-to-day while effectively driving meaningful change. And while yes, this author loves that kind of work, it doesn’t have to be me. If you know someone who can do this, bring them in! The point is to commit and make it happen. At the end of the day, you are the one who holds the key.
About the Author
Heather Long, MSN, BA, RN
Founder and Chief Executive Officer of Reveal Solutions
Caregivers do their best work when their hearts and minds are connected and nurtured together. They are then empowered with an overwhelming sense of purpose and conviction in delivering holistic care. This passion is at the heart of making the impact of change possible in healthcare, and it’s what drives Heather. Her experience includes service as Senior Vice President of Clinical Services, Chief Nursing Officer, Chief Operating Officer, and years of service in direct care. Highlights include employee engagement scores that increased from the 58th to 92nd percentile, while at the same time exceptional patient outcomes were achieved and proved sustainable under her leadership.
Want to learn more about the principles and practices deployed to achieve the aforementioned results? Take a look at Synchrony.
Connect with Heather at heatherlong@revealsolutions.org.