What Works

1 What Works

Running head: WHAT WORKS

What Works Colleen Paquette NUR626: Leadership for Advanced Practice Nurses SUNY Upstate, College of Nursing 11/11/09

I work on the cardiovascular telemetry unit at University Hospital. I believe that what works in our environment, is in fact our working environment and the overall idea of “decentralized nursing”. This has occurred with the move to the new east tower. The

2 What Works decentralized area that I would like to focus on is that of decentralized charting stations and supply areas. A decentralized charting station is found between every patient room, and has a laptop and telephone. The decentralized supply area found in the patient room includes a locker accessed with our ID badge that has all of the common everyday nursing supplies we may need. It is the large med room condensed into a small locker with five drawers. There is also a cupboard that stores a few days worth of linen and a dirty linen cart hidden inside another cupboard. This allows the nurses to spend more time treating the patients and less time searching for and gathering supplies. It also cuts down on time spent looking for a computer that is not in use. Additionally, all of the charting stations have windows that give us a direct view as we do our documentation. According to HealthGrades (2007), which is the healthcare quality company, “an average of 195,000 people in the United States died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002.” Medical errors cost the health care system over six billion dollars a year (healthgrades.com). In response to that expense the Centers for Medicare and Medicaid Services no longer pays for eight specific medical errors that they deem to be preventable. One of these eight medical errors is that of hospital related injuries like falls (Wachter, Foster & Adams-Dudley, 2008). This idea of decentralized charting stations and supply areas focus mostly on this area of falls. It also helps prevent and reduce the incidence of hospital related injuries that incur heavy costs on the health care system. The decentralized work environment overall has decreased nurse turnover rate on our unit, showing increased job satisfaction. This positive change in environment was reflected in our Press Ganey scores, where we scored 89%, the highest in the hospital for last quarter. This achievement shows high levels of patient satisfaction. There are several cultural qualities of nursing that support the decentralized charting stations and supply areas. Many of these areas are internal components of culture (Schein, 1999), affecting work environment, nurse patient relationships and allocation of rewards and

3 What Works status. According to the Center of Health Design (2004) approximately 29% of nursing staff time was spent walking, only secondary to providing patient care activities, which was about 57% of the time. There was a study done at Christus St. Catherine Hospital on a 38-bed unit. The results showed that staff traveled almost 8,000 miles annually. This travel represented 2,800 hours per unit of non-productive nursing care (ASHE, 2006). Travel to and from linen rooms, supply rooms, medication rooms, dirty rooms and patient rooms, not only wastes time but also creates exhaustion. A demanding environment leading to nurse fatigue is a major cause of medical errors. Also, the more time a nurse has to spend with her patients, the less likely they are to fall. Patients report higher satisfaction levels when their nurse has an adequate amount of time to spend with them, as seen through the rise of our Press Ganey scores. The rise in Press Ganey scores and having the highest score in the hospital for the past quarter is a reward for our work and a status symbol for our decentralized patient care unit. Having such a rise in Press Ganey scores was a major goal for our unit, an espoused value that we met (Schein, 1999). The idea of decentralized charting stations and supply areas is highly supported by the Upstate organization and those in positions of leadership. Right when you get onto the University Hospital website, you see an external component of culture (Schein, 1999), a mission statement, “The best care. When you need it most”. The best care does not include medical errors or “never events”. The hospital also has to abide by JCHAO National Patient Safety Goals, another external component of culture. These goals work to prevent those “never events” from occurring. Whatever the hospital can do to prevent “never events”, like falls from occurring they will do. This was seen through providing decentralized charting stations and supply stations so the nurse can spend more time with the patients, and less time searching for computers and supplies. Decentralized nursing care is also of interest to the organization as the cost of patient falls is estimated to be 32 billion dollars by 2020. In addition to that, CMS is no longer paying

4 What Works for falls acquired in the hospital. It is in the organization’s best interest to pay the up front costs associated with putting supply stations in patient rooms and having more charting stations. This up front cost will pay for itself in a short amount of time. There will be reduced patient falls, reduced staff injuries and reduced staff turnover, all which cost the hospital money. According to a Clinical Educator at University Hospital, the cost to orient a new nurse is approximately $63,000 (personal communication, April 9, 2009). A nurse who spends the least amount of time walking around looking for supplies and available computers will be less exhausted. This in turn will allow the nurse to spend more one on one time with the patients. As Schein (1999) would put it, as a result of the organization espousing its mission and goals there is increased patient and nurse satisfaction and a decreased nurse turnover rate, all saving the organization money. When looking at leadership and culture, Herzberg’s motivation-hygiene theory fits well with the idea of decentralized charting stations and supply stations. An underlying assumption of culture is the nature of human nature. According to Herzberg, “the motivation of employees is important to organizations since it is one of several factors that significantly affects productivity of employees”. Humans will ultimately work harder and be more productive if they are satisfied with their job and work environment. According to Herzberg, two motivational factors are recognition, and work itself. These are both enhanced through the decentralized work environment via the rise in Press Ganey scores (recognition) and the ability to spend more time with our patients (the work itself). Dissatisfaction factors include working conditions. A negative working condition demanding nurses to spend much of their time hunting for supplies and computers creates exhaustion and less time to spend with patients. This leads to errors and job dissatisfaction and ultimately costs the hospital more money. Nurses are most productive when they are able to do their jobs adequately, and avoid the exhaustion associated with searching for supplies and computers. If nurses are able to adequately provide for the patients, there will be more nurse satisfaction and fewer nurse

5 What Works turnovers. There will also be more patient satisfaction, less falls and other “never events”. All of this is profitable to the organization, boosts Press Ganey scores and saves the hospital money. The idea of decentralized charting stations and supply stations may seem out of reach for units that were not able to move to the new east tower. Many people may think that they are not possible without a billion dollar renovation, however I believe that they can occur anywhere. In the hospital there are still a few units, such as 5B a surgical unit that did not move to the east tower. This unit still has double rooms and one main charting station, supply and med room. My proposal to introduce decentralized charting stations and supply stations would be quite simple and I believe very feasible. The change plan would include mounting computers on the walls between the patient rooms. Yes this would not be a station per se, but it would be extra computers added to the unit for use by the nursing staff. Also, in every patient room there is a closet, much of the time the entire closet is not taken up by the patient’s belongings. I would take the upper half of the closet and make that a spot for clean linen storage. This may not allow a week’s worth of linen to be stored, but at least a few days worth. As far as a supply cart goes, I would recommend something small that can fit the everyday, very common supplies, such as flushes, blood drawing supplies, gauze, etc. It would be ideal if this could somehow be mounted on the wall, like a medicine cabinet. It could take the place of the mirror above the sink, and if possible, it could still have a mirror on it for the patient’s use. Maybe there could be another one mounted somewhere on the window patient’s side of the room as well. This would mean that there would be two storage cabinets per room, one for each patient. This means that the nurse would have access to supplies no matter what side of the room they are on. Of course, only the staff would be able to access it either with a code or a swipe of their badge. A dirty linen cart could be made a piece of equipment that goes in every room. The cart would go in the front of the room between the two garbage cans. This would decrease the

6 What Works amount of time spent searching for a dirty linen bin and walking to it. If needed, smaller dirty linen carts could be purchased to fit better in the space. Obviously, in implementing this change plan there are some barriers that need to be addressed. The major barrier that I can think of is the staff having to work in a construction zone, while the computers are being mounted and cabinets being installed. This may create a need to close a patient room per day for the small construction to occur and not interrupt patient care. First of all I would have to get the staff on the unit on board to change. Using Lewin and Schein’s change theory I would first try to motivate or “unfreeze” the staff. I would have the staff tour the new east wing of the hospital and talk to staff members who work with the decentralized charting stations and supply stations. The staff will have to see how the change will lead to more satisfaction and then confirm that that current working conditions they have are leading to dissatisfaction. Of course this change may create some anxiety, using new computers and new unfamiliar supply carts. As they will have to unlearn what they have been doing, that is running around searching for available supplies and wasting a lot of time. Next, the change will occur, this is the unfreezing process. This will happen when staff realizes just how nice the conditions are for the nurses and patients with the decentralized charting and supply stations. Finally, the staff will make the behavior of using the decentralized charting stations and supply stations habitual. This is known as the refreezing stage and may take time. Personally, I have been using the decentralized charting station and supply station since July and still find myself walking around looking for linen and supplies at times. The nurse needs to develop the concept of decentralized nursing care and adapt to it. This is done as one establishes a new nursing identity through the extra time they have to spend one on one with their patients. In all environments, something works! Personally, I am lucky to be working in an environment where many things work well, as the whole environment is fresh and new. Some changes that work well in one environment may seem impossible to implement to other units.

7 What Works Using change theory and getting staff on track to change can make all the difference in introducing a change that may have once seemed impossible.

References: Inside American Society for Health Care Engineering (ASHE). 2006. Taking the Guesswork out of Nursing Unit Planning. Cms.hh.gov. (2006). Eliminating Serious, Preventable, and Costly Medical Errors-Never Events. Retrieved March 5, 2008 from http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863. Healthgrades.com. (2007). In-Hospital Deaths from Medical Errors at 195,000 per Year, HealthGrades’ Study Finds. Retrieved on March 10, 2008 from http://www.healthgrades.com/media/DMS/pdf/InhosptialDeathsPatientSafetyPressRelea s e072704.pdf Schein, E. (1999) The Corporate Culture Survival guide. San Francisco: Jossey-Bass. Wachter, R.M., Foster, N.E., & Adams-Dudley, R. (2008). Medicare’s decision to withhold payment for hospital errors: The devil is in the details. The Joint Commission Journal on Quality and Patient Safety, 34(2), 116-123).