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The Clinical Nurse Leader: Its Time Has Come


The Clinical Nurse Leader: Its Time Has Come Presentation to: 2010 CNL Summit The CNL: On the Leading Edge of Healthcare Reform San Diego, CA January 21, 2010 – PowerPoint PPT presentation

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Title: The Clinical Nurse Leader: Its Time Has Come

The Clinical Nurse Leader Its Time Has Come
  • Presentation to
  • 2010 CNL Summit
  • The CNL On the Leading Edge
  • of Healthcare Reform
  • San Diego, CA
  • January 21, 2010
  • Rosemary Gibson, M.Sc.
  • Author, The Treatment Trap
  • and Wall of Silence

Overview of Presentation
  • Discuss how the work of clinical nurse leaders is
    timely in the context of health reform
  • Explore ideas for how clinical nurse leaders can
    multiply their impact
  • Highlight what the work of clinical nurse leaders
    means for patients and reflect on the goodness of

The Timeliness of CNLs Health Reform
  • Health reform unlike 1994 health reform which
    was about insurance coverage, now, coverage and
    quality are on the table
  • Quality matters at high levels President Obama
    mentioned HAIs, medical mistakes, and overuse in
    speeches and interviews
  • This dialogue is responsive to a public that is
    expressing its concern about quality and safety.

The Timeliness of CNLs Public Reporting
  • Public reporting of health care indicators,
    including nursing sensitive measures, is here now
    and will continue
  • Its not a matter of if, but when
  • Still learning how to do public reporting in a
    way that meets the needs of providers and also
    the public

The Timeliness of CNLs Payment Reform
  • Health care reform is calling for payment reforms
    that move toward accountable care organizations
    and paying for bundles of care rather than
    individual care processes
  • We cannot continue with 1,000 measures in 1,000
    days approach

Policy Voice for Nursing on Quality
  • Nursing Quality and Safety Alliance being
    established at George Washington University
    Nursing as neutral convener and facilitator
  • Its purpose is to support a collective voice for
    nursing on national policy especially CMS
    actions on public reporting and payment reform,
    and the work of the National Quality Forum among

Policy Voice for Nursing on Quality
  • NQF is the go-to place for obtaining consensus
    around future measures that CMS will use for
    public reporting and payment reform
  • CMS will continue to ask for comments in the
    Federal Register on proposed measures for public
    reporting and nursing needs a clear and sustained
  • What if mini public policy internships for
    nurses with NQSA to bridge the worlds of policy
    and clinical care

What CNLs Do For Quality
  • What caught my attention about the role of the
  • Outcome-based decision making, implementation of
    evidence-based strategies within a microsystem
  • The CNL evaluates patient outcomes, assesses
    cohort risk, and has the decision making
    authority to change care plans when necessary.

  • An arranged marriage with TCAB?
  • Improve quality and safety of patient care (in
    and beyond med-surg)
  • Increase vitality and retention of nurses
  • Engage and improve patient and family experience
    of care
  • Improve the effectiveness of the entire team

Power of Discovery vs. Someone Told Me To Do It
  • A narrative from Dr. Paul Miles, VP American
    Board of Pediatrics
  • A case of overuse of a surgery for sinusitis and
    what his practice did to discover the reasons for

The Power of Discovery vs. Someone Told Me To Do
  • He began to rigorously examine the care he was
    providing to his patients. One of his first
    efforts was to reduce the number of children who
    were having a new surgical procedure that he and
    the physicians in his practice believed was being
    performed unnecessarily by surgeons in their
  • A group of ear, nose and throat (ENT) physicians
    had discovered a new procedure, endoscopic sinus
    surgery, to treat chronic sinusitis. The ENT
    doctors convinced the health insurance company to
    pay them 12,000 for performing it

The Power of Discovery vs. Someone Told Me To Do
  • After that, the rural Idaho community had one of
    the highest rates of this procedure in the
    nation. Dr. Miles and his colleagues believed
    that the surgery was expensive, potentially
    dangerous, and of questionable efficacy. More
    than 100 children a year in their small community
    had had this operation.
  • Dr. Miles says, The CT scans for some of the
    kids looked pretty normal and our pediatric group
    was upset that they were having surgery.

The Power of Discovery vs. Someone Told Me To Do
  • The five of us pediatricians in our practice
    looked at our referral pattern to the ENTs for
    this surgery and how we defined, diagnosed and
    treated chronic sinusitis. What we found
    surprised us. In a three-month period we
    diagnosed chronic sinusitis in 150 children. One
    physician in our practice diagnosed it 96 times
    and referred the patients for surgery, while
    another doctor diagnosed it only twice and
    recommended surgery

The Power of Discovery vs. Someone Told Me To Do
  • With this huge difference, we asked ourselves
    how each of us defined chronic sinusitis and
    learned that we had six different definitions. We
    also asked how each of us examined the children,
    and it turns out that we examined them
    differently. To our surprise, we learned that we
    were part of the problem of the increase number
    of surgeries because we were inappropriately
    diagnosing children with chronic sinusitis, which
    led parents to seek relief with the new surgical

  • While we were indignant with the ENT physicians
    performing these operations for what we
    considered an acute remunerative procedure, the
    finger of blame came back at us. We developed a
    practice guideline and were successful in
    reducing the number of children in our community
    who had the surgery

  • Now, we ask ourselves 3 questions
  • - Why do you do what you do
  • - How do you know what works?
  • - How can you improve what you do?

(No Transcript)
Article From Fast Company
Toyotas Approach to Quality
  • Typically, the Big Three auto makers take an
    all too American approach to the idea of
    improvement. Its episodic, its goal-oriented,
    its something special. Its a pale imitation of
    the approach at the Georgetown (Kentucky) Toyota

  • If you go to the Big Three, youd find
  • improvement projects just like youd find at
  • Georgetown. But they would be led by some
  • kind of engineering group, or a Six Sigma
  • black belt, or a lean-manufacturing guru of
  • some kind. They might even do as good a job
  • as they did at Georgetown. They might say,
  • Look what we did

  • In a year, that happens a couple of times in a
  • whole plant for the Big Three. And it would
  • get all kinds of publicity in the company.
  • Toyota is doing it in every single department,
  • every single day. Theyre doing it on their
  • own, no black belts, and theyre doing it
  • regularly, not just once.

Swim Upstream?
  • Can CNLs multiply their impact by swimming

A Case of an 8-Year Old Boy on Oxygen at a
Midwest Hospital
  • Patient has asthma, pneumonia
  • On oxygen, bronchodilators, antibiotics
  • Transported for a chest x-ray and on oxygen at 15
    l / minute
  • Upon return to the floor, oxygen tank was empty
  • Patient was cyanotic, admitted to intensive care

Investigation/Process Improvement Oxygen
Cylinder Hand-off
Patient is being transported, intubated,
ventilated with ambu bag at 8 liters per minute
of oxygen supplied by this tank. Please fill out
Question How Long Before the Tank is Empty?
  • 1650 psi
  • 8 Liters/minute
  • If the trip to radiology and back may take an
    hour, do you have enough oxygen for the trip?

Investigation findings source of process
  • Profound lack of knowledge re oxygen cylinders
    except for respiratory therapists and
  • Inadequate hand-offs between med-surg units and
    diagnostic areas
  • Need for standardized reliable methodology
    regardless of training, experience

Oxygen Tank Assessment Tool
  • Is it possible for CNLs to identify a known
    hazard and work together with manufacturers and
    purchasing organizations to engineer the hazard
    out of the health care system?
  • It would be broadly analogous to the actions
    anesthesiologists took in the early 1980s to
    improve anesthesia patient safety

(No Transcript)
What Your Work Means to Patients
  • Have you ever thought about what your work means
    to patients?
  • Lets step back for a minute.
  • Think about the totality of your work on
    improving outcomes

What Your Work Means to Patients
  • Has your work reduced harm from falls? Pressure
    ulcers? Failure to rescue? Infections?
  • Every data point is a person

(No Transcript)
  • Your work prevents these events
  • Reflect for a moment on the good of it all
  • Back home, take time to honor the goodness of it

  • Elderly confused woman recently admitted to the
    hospital family present in the unit
  • Patient was missing during the night
  • Nurse supervisor informed the CNO

  • It was a Sunday morning and I was having
    breakfast with the night staff. It was Nurse
    Recognition Week. A new nurse supervisor came up
    to me and said that a patient had been missing
    during the night

  • The family was angry, blaming the hospital.
    I said, Lets go talk with the family. We
    walked to the patients room. The supervisor was
    a big guy and he was very shaken. I was

Benevolent Gestures
  • I went into the room, sat down and introduced
    myself and said, I am so, so sorry. I came to
    apologize on behalf of the hospital.
  • The daughter started crying and I held her
    hand. I realized the family was blaming
    themselves in part because they were there the
    whole time.

More Benevolent Gestures
  • I said, There is not going to be any
    blaming in this room.
  • After searching the hospital, we did find the

More Benevolent Gestures
  • We had the patient thoroughly checked in
    the Emergency Department they went over every
    inch of her whole body, and the family saw that
    we took great care in making sure their mother
    was alright. I stopped in to see the woman and
    her family every day
  • l.

Restoring Trust
  • The family thanked me for coming to see them
    -- they were stunned. We restored the familys
    trust in us.
  • I said to them, If you have lost faith in
    the unit where your mother went missing, we can
    move her to another unit. The family did not
    want that because their trust had been restored

Role Modeling for Nursing Staff
  • The nursing staff were in the room and
    standing in the hallway as I was talking to the
    family and holding the daughters hands.
  • They had never seen someone take ownership. I
    was stunned to hear the next day how many people
    knew about this. People came up to me in the
    halls and said, I heard about what happened and
    what you did
  • l.

Breaking the Cycle
  • I remember as a 25-year old nurse being
    publicly ridiculed for a mistake. There was a
    surgeon I trusted. The patients hand was
    swelling after surgery. He said to cut the back
    of the dressing. I should have asked more
    questions. He screamed at me in the middle of
    the nursing station.

Breaking the Cycle
  • Now, years later in my role at the hospital,
    nothing punitive is going to happen if someone
    makes an unintentional mistake.

  • Drive out fear so that everyone may work
  • Deming

  • A patient is the most important visitor on
    our premises. He is not dependent on us. We are
    dependent on him. He is not an interruption in
    our work. He is the purpose of it. He is not an
    outsider in our business. He is part of it. We
    are not doing him a favor by serving him. He is
    doing us a favor by giving us an opportunity to
    serve him. Gandhi

  • Be the change you want to see.

  • You are the change you want to see.