Building a Self-driven Quality Process
Through Transparency, Education and Support
Empowering nurses at the bedside to implement quality initiatives has led to dramatic improvements in quality metrics across the Memorial Hermann Mischer Neuroscience Institute at the Texas Medical Center, particularly in the Neuroscience Intensive Care Unit where patients are most at risk.
“We set a goal of reducing our catheter-associated urinary tract infection (CAUTI) rate by 25 percent during fiscal year 2014,” says Allison Murphy, RN, B.S.N., CNRN, quality improvement coordinator in the Neuroscience ICU (NSICU). “A literature review showed that the two populations at highest risk for CAUTIs are neuroscience and burn patients, but there’s not much data specific to the prevention of CAUTIs in neuro patients. Basically, there’s one way to lower the CAUTI rate – if the patient doesn’t need the Foley catheter, it should come out.”
As part of a multidisciplinary quality initiative, rounds were instituted twice a day – including an attending physician, quality improvement nurse, infection prevention, nurse manager and the bedside nurse. The goal was to remove invasive lines from patients as soon as they became unnecessary. To raise awareness, nurses involved in the care of a patient who developed a CAUTI were asked to submit a short overview of their thoughts on the care of the patient and what the nursing staff could have done to prevent the infection.
At the same time, nurses began meticulous screening of patients for urinary tract infections during the first two calendar days after admission, as recommended by the Centers for Disease Control and Prevention, which resulted in the discovery over a three-month period of more than 40 patients out of 470 who were admitted with a UTI.
“By making this a joint effort between nursing and physicians, we exceeded our 25 percent goal during fiscal year 2014,” Murphy says. “By looking at catheter necessity twice a day, we discovered that many of them weren’t needed. In the NSICU, nurses now have the permission of the medical director to make the decision to remove a Foley catheter if the patient does not meet the guidelines describing the need for the catheter. Over the past fiscal year, we’ve reduced our CAUTI rates in the NSICU by 35 percent.”
One factor leading to the success of this initiative and others was a move to improve nurse performance through metrics transparency. Murphy developed a dashboard, which is posted monthly, showing the individual nurses’ names and their performance metrics.
“The culture here is to own the work you do and be proud of it,” she says. “I love working in a unit like that. We allow nurses to do exceptional work without interference and applaud the ones who do. For nurses who need to improve their metrics in specific areas, we’re here to provide education, coaching and support. Nurses know exactly where they stand from month to month so there are no surprises. It’s a very self-driven quality process.”
Transparency, awareness and education have led to a 58 percent reduction in mislabeled specimens, a 42 percent reduction in blood culture contamination, a 75 percent reduction in falls and a 35 percent reduction in CAUTIs during the past fiscal year.
“The improvements we’ve made in quality in the Neuroscience ICU are not just because of one or two people, but because of the work everyone on the unit has done,” Murphy says. “The dashboards are great in showing where each individual nurse stands. We give them the tools, and they run with it. That sense of engagement and empowerment has made a huge difference.”
Leadership at the Mischer Neuroscience Institute helps nurses improve quality in other ways. “We encourage and support nurses in getting certifications,” says Nicole Harrison, RN, B.S.N., M.B.A., administrative director of the Institute. “When they pass their test, they’re reimbursed for costs incurred for certification. Ultimately, certifications help them move up the career ladder and translate to salary increases when they reach that next level in their nursing career.”
Memorial Hermann-Texas Medical Center also pays for airfare and conference fees to expand opportunities for education and support nurses in learning more about their discipline. Colleen Zuckero, RN, B.S.N., CNRN, clinical education specialist and manager of the Neuroscience ICU, attended the American Association for Neuroscience Nursing Annual Education Meeting, held in Anaheim, California, in March 2014. “There were at least 200 different sessions to choose from, so we had the opportunity to tailor the curriculum to our particular interests and educational needs,” Zuckero says.
“The benefit is huge. You improve your evidence-based practice and come back to the hospital and present new knowledge in ways that motivate nurses to improve their own practice. It sparks initiative and inspires them to begin research projects to be presented at future conferences. I think of everyone on this unit as a potential educator. We’re all learning, teaching and working to improve quality. When I hear nurses say that what they do at the bedside isn’t really leadership, I tell them, ‘No! You’re leading the country by setting national benchmarks.’”
Paul Gordon, RN, B.S.N., SCRN, CNRN, attended the 2014 International Stroke Conference held in San Diego in February 2014 and describes the experience as very enlightening. “It gave me a new view of my practice and also made me aware that we could improve the quality of research if more nurses were involved,” he says. “My goal is to attend every national stroke conference and encourage my colleagues to do so as well.”
Gordon, a staff nurse on the Stroke Unit and chair of the Unit Practice Council, shared what he learned at the council’s monthly meeting. “Everything we learn and share helps our practice,” he says. “New nurses here will find people who open their arms and help. They’ll find proper compensation in a welcoming environment, as well as support for achieving certifications and an emphasis on conducting and publishing research to be presented nationally.”
Nurses interested in leadership roles can apply for the Nursing Leadership Development Academy, which was established by Memorial Hermann-Texas Medical Center chief nursing officer Victoria King, M.H.A., M.S.N., RN, CNOR, NEA-BC. “We’ve graduated one class and are finishing up our second,” she says. “The academy is closely linked to quality improvement because of our focus on evidence-based best practices. Nurses begin to understand how we’re driving quality at the uppermost part of the organization. The grand thing is that eight of them from the first class of 30 have been promoted to leadership roles.
“Nursing has a voice at our hospital, and nurses play an important role in creating our processes,” King adds. “We support them through incentive programs for critical staffing, preceptor bonuses, certification reimbursement, service awards, nomination of nurses for local and national awards, handwritten letters from senior leaders for outstanding performance, continuing education opportunities and paid travel and attendance at conferences, to name just a few things we do to encourage quality. Our nurse retention rates are proof of our success. In the future nurses will have even more responsibility and autonomy. As the focus of healthcare reform moves toward keeping people healthy, nursing will become even more important. As nurses, we teach health. Opportunities will abound for us to lead the way.”