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10
creative
nursing ideas
that helped transform an entire health system
nursing ideas
both physically and emotionally. And with this
new perspective, my role as a leader became that of
facilitator and barrier remover.
flourish.
Every patient should
feel like theyre our
favorite patient.
As we shifted our focus, things began to change How do you measure quality? Here at University of
Utah Health Care, its not just reflected in our data
#1 in Quality in the Nation
slowly at first, then more dramatically. This year, Quality and accountability study among academic medical centers
we were honored to be named #1 in Quality by the and metrics. Its the smile on a patients face. Its a hug ranked by the University HealthSystem Consortium
University HealthSystem Consortium for our clinical given freely to a family member in crisis. Its nurses
Five years ago, the nursing department at University
outcomes, as well as Top Improver by Press Ganey for and physicians and researchers and administrators UniversityofUtah
of Utah Health Care began a journey to be nationally 2010/1stoutof98
all working together to deliver an exceptional patient HealthCare 1
known for the professional practice of nursing. We our dramatic rise in patient satisfaction. Now, wed 200931stoutof93
like to share some of the ideas that got us to this point experience along with superior clinical outcomes. And 200850thoutof88
looked at our current practice and began imagining
in our journey, and wed love to hear your great ideas its what we do, each and every day.
where we wanted it to be. We knew that excellence
was not a plaque on the wall, but a feeling that as well. Please take a look at the top 10 creative ideas
everyone would noticea palpable culture that that helped transform our organization. Then, take Transforming
combined unsurpassed clinical outcomes with a new amoment to share your ideas with us at
NursingInnovation.UofUHealth.org.
patient care.
level of care that made every single patient feel that
they were, in fact, our favorite patient. Five years ago when we began this journey, University
I look forward to hearing from you. of Utah Health Care was an excellent medical center. 20 20 28 20 10
We also looked at our financial situation and But something was missing. Although wed always
Centers
Centers
Centers
Centers
Centers
determined where we needed to be in the future to provided outstanding care, our quality and patient
contribute to the healthy, vibrant organization we satisfaction scores ranked us in the middle of the pack
all envisioned. We started with a strategic plan for for academic medical centers. We knew we could do
nursing, we identified gaps and we put a laser focus on bettermuchbetter.
three areas: patient experience, quality outcomes and Margaret Pearce, RN, Ph.D. Developing creative
Chief Nursing Officer To drive transformation, our nursing department
fiscal responsibility.
looked at everything we did through a single lens: the nursing ideas.
To build on this strategy, we worked hard to create patient experience. From our professional practices to Some of the changes we made seemed too small to
a culture where anyone in our organization could educational opportunities to physical spaces, everything make an impactlike giving needy families a free meal.
contribute creative ideas that would be valued and was subject to change. And every change we made had Others seemed too monumental to get approvedlike
to answer the ultimate question: Will it improve our building a multi-million dollar ICU. But when the
patient care? idea was the right thing to do for the patient, we got
it done. And with every change we made, something
Five years later, the answer is yes. In addition to ranking
remarkable happened: our satisfaction numbers shot up,
#1 for most improved patient satisfaction, University
our operational costs went down, and our professional
of Utah Health Care is currently ranked #1 in quality
practice flourished.
among academic medical centers. We did it by thinking
creatively, working together, and empowering every staff How, exactly, did we do it? Read on to discover the
member from every level of the organization. creative ideas behind our remarkable transformation.
01. Run
your nursing
department like
a business.
Everything we do is for our patients. But
in order to do it, our hospital must stay
financially viable.
Eric Allen, Senior Business Financial Analyst
>
on our Performance Excellence Team to identify 1. Analyze the data
ways to work smarter, leaner, and fasterall while
Listen to staff concerns, examine financial nue
providing better patient care than ever before. We reve
performance data, and pinpoint any gaps in quality Net
assigned a quality specialist to each unit to ensure or patient safety.
consistent collaboration, ongoing analysis, and continual
improvement. No one is sitting in an office, evaluating 2. Develop a pilot 107,000(11%)
ays
>
Try out the new idea on one unit and measure $220M td
data and telling nurses what to do, says Mike
Pa tien
Swanicke, a management engineer on the Performance results.
Excellence Team. Were working together to 3. Expand the program
solve problems. 96,700
Bring the idea to other units after a pattern of
success has been established with the pilot.
When it comes to staffing, Nursi
labor g
n
costs
look at the big picture. $73M
For a hospital to stay financially viable, every $1.2 Million Saved $70M(4%)
>
departmentand every person within that department By predicting vacancies
must work efficiently. But we couldnt get there when we
staffed nurses unit by unit. Wed bring in agency nurses and staffing globally,
only to find that we didnt need them. Wed staff up to
weve increased our labor
2008
2009
2010
2011
meet a perceived need only to find that we had too many
nurses for the tasks at hand. Wed send nurses home on management efficiencies,
one unit, while hiring someone new on another. It didnt
make sense.
resulting in annual savings
of $1,248,000. With centralized, global staffing and smaller, flexible nursing pods on each unit, University of Utah Health Care has a healthier financial
Global staffing changed all that. We put our entire outlook than ever before, taking care of 11% more patients with 4% less labora reduction in nursing labor costs of $100 per patient
nursing department on a centralized staffing grid and day.
should walk in
it is to be a patient.
Teri Olsen, Director of Project Development
shoes.
professional practices. a hug. With empathy training, our nurses have a chance
to reach inside of themselves and really identify with
Empathy training shifts nurses personal thinking and their patients, says Teri. And that has made all the
professional actions. At the end of each session, nurses difference.
are asked to commit to this new perspective by stating
what theyll stop doing as well as what theyll start
Nurses cant go through the difficult work of treating
patients if they dont care about them. And while our Imagine that
nurses have always cared about our patients, it simply
+ You come to the hospital for the birth of
wasnt showing five years ago like it should have.
Our patient satisfaction numbers were uncomfortably
your second child, and your wife dies
lowand to turn them around, we knew we needed to during labor.
better connect with the emotional needs of our patients + You need emergency surgery, but you
and their families. So we created a whole new type of
dont have enough insurance or money
professional development for our nurses, and we called it
to cover the medical bills.
empathy training.
+ You get in a serious car accident, wake
Compassion as up in the ER, and learn that youre
curriculum. paralyzed.
These are just a few of the real-world patient scenarios
Nurses are constantly building their clinical skills, but
that we work through during empathy training.
thats only part of what they need to be successful. With
empathy training, we help them understand what it feels
like to be in a hospital and to feel angry or scared or
confused or helpless or alone. In other words, we help
them understand what it feels like to be a patient.
Food, shelter,
clothing
and a better comb.
By surveying patients and staff throughout the hospital,
our Patient Experience Team pinpointed a number of
small kindnesses and conveniences that brought big
smilesor simply a sigh of relief. We started giving free
cafeteria meal coupons, pre-paid phone cards, and even
free hotel stays to families who seemed to need them.
We gave cards to patients who were spending their
birthdays in the hospital. We provided new clothes for
Championing compassion: Christine Pettit, unit champion trauma patients to go home in. We upgraded the flimsy
and clinical nurse coordinator for Womens & Childrens Services, combs in patient rooms.
knows that small gestures of empathy can have a big impact on
patientsatisfaction. When a new mom cant leave the hospital as soon as
expected, we do everything we can to make her stay a
Patient satisfaction isnt just measured by numbers on a chart. little easier, says Christine Pettit, unit champion and
Its also measured by the hugs, smiles, and thank yous we clinical nurse coordinator for Womens & Childrens
receive each and every day.
Building patient satisfaction White nursing uniforms color. Ultimately, they chose three color options for
pants, along with all-white tops; not because they
University of Utah Health Care National Percentile Rank create positive patient loved the color white, but because they felt it was the
Press Ganey perceptions. right thing to do for our patients.
05. Transform
We knew that the difficulty for nursing hopefuls was
getting an RN, and once that was accomplished, the
Student success story:
RN-to-BSN program was more readily available. So From cafeteria to clinicals.
we developed an RN associates degree program in
into a highly
University of Utah Health Care employees, so staff with
a hard time moving forward. I was working in the
the right grades and prerequisites have an easier way to
cafeteria at the UI just wanted to get into the hospital
get into school, get trained and get to work. We pay for
any way I could, and I knew I had to start somewhere.
each students tuition and books with a single caveat:
They must agree to work with us as an RN for three
trained SWAT
When she got accepted to our Salt Lake Community
years after they graduate. College nursing program, she knew she was finally on
her way to fulfilling her dream. It was shocking and
Students are elated thrilling to get in, she says. The opportunity to receive
team.
when they find
free tuition and books is pretty unbelievable. Today,
Carmen is finishing her program, confidently making it
out they have the through her clinicals, and preparing for her next move:
a doctorate in psychiatric nursing. The SLCC program
SWAT team: highly Were changing the way people think about resource
nursing, says Karen. And were changing the way
trained, autonomous, resource nurses work in our health system. Gone are the
days when unit nurses would have to take time out of
and ready for their shifts to show the float staff what to do. Instead,
anything.
our resource nurses can teach them a new skill or take
on a challenging patient. They add real value to our
professional nursing staff, says Karen. Theyre an
Karen Nye, Manager, Resource Nursing
integral part of our critical care service line.
The front lines of critical care: With our new AirMed track for
Overtime hours decrease for five ICU units resource nurses, every nurse at our hospital gets the training they need
to build a dream career. Pictured here: Amanda Lawrence, Flight Nurse.
Averageovertime
62% reduction in
hoursaweek
45
overtime hours
Rolloutofpreschedulingbegins.
40 Before implementing pre-scheduling, our ICU units
averaged 42 hours/week of overtime. Now, they
35
average 16 hours/week of overtime.
30
25
20
15
$102,000 saved annually
10 Proactive scheduling has enabled our hospital to
save $102,000 annually in overtime pay costsjust
5
in our ICU units alone.
0
7/10 8/10 9/10 10/10 11/10 12/10 1/11 2/11 3/11 4/11 5/11
Overtime hours for our five ICU units have decreased significantly since the implementation of proactive scheduling for resource nursing staff. Overtime hours
increased temporarily in February and March during the transition of an additional unit to the resource pool.
efficiency.
We couldnt keep thinking the same way and expecting
different results, says Tracey Nolen, Nurse Manager
of the Flex Unit. The critical red census alerts were
unacceptable. Going on divert was unacceptable.
mean a lot.
hospital is the last place in the world that they want
grumpy, if not downright angry, the Flex Unit has made
to be; especially if they feel like theyve been put in the
each patient feel like they are welcome, cared for, and
wrong place due to overcrowding. Its our job to turn
exactly where they should bewhich is why patient
that around. Citing excellent clinical care as a basic
satisfaction consistently soars
patient expectation and right, Tracey talks about how
her Flex Unit nurses consistently exceed that expectation.
video cameras
and fewer patient
sitters.
When we started extolling the virtues of video We answered these concerns in the same manner that
monitoring, skepticism was understandably high. How wed answered concerns about other innovative-but-
could we possibly replace human sitters with impersonal controversial ideas: We created a pilot program.
video cameras? If we didnt have someone in the room,
could we really keep patients safe? Would we be able to
respond quickly enough? And how would our patients
feel about being on camera 24/7?
08. Prevent
The Neuro Acute Care unit volunteered to be our first video monitoring on close supervision patients, we had
video monitoring pioneers. We were hesitant at first, just two falls.
says Elizabeth Armour-Roth, the units nurse manager.
But we also recognized that it could be a great thing Building better
falls with
for our unit. Working with the management engineers
on our Performance Excellence Team, we developed a perceptions.
structured methodology for training staff on the new Video monitoring made our patients and their families
technology and proceduresso everyone felt confident feel safe, says Elizabeth. It promoted a sense of caring.
signed patient
that patients would stay safe. Patients knew we were watching over them, honoring
their concerns, and anticipating their needs. Perceptions
Increasing close among hospital staff have changed, too, as physicians
agreements.
about the pilots success.
As it turns out, video monitoring allowed us to keep
patients safer than ever before. With a health care
assistant dedicated to watching up to six patients at
$282,000 in savings
a time on the monitor, we were able to provide close From September 2010 to June 2011 we gradually
supervision to patients who wouldnt have received implemented video monitoring in four units, and
it otherwise. And with fewer staff members sitting
in patient rooms, we were able to better allocate our
were able to increase close supervision cases while
dramatically decreasing sitter costs. Savings will
Janiel Wright, nurse manager at our Orthopaedic
Hospital, can remember the moment when the light bulb We can get so caught
nursing resources. continue to grow as a result of our acute care areas
using this technology.
for her creative nursing idea came on. Wed already
had a bad month with a few heartbreaking falls, she
up in our fear of
Boosting patient safety. says. Then one of my nurses came to me and she was offending the patient,
Expanding the pilot. extremely upset. Theyd had another fall, even though
We located our video monitoring station close to our
With the success of the pilot on the Neuro Acute Care
the nurse had spent extra time with the patient, talking that we miss
opportunities to keep
patients rooms, so that we could react to any sudden about the risks. So what, exactly, had the nurse said to
movements or behavior changes in an instant. And even unit, video monitoring has been adopted by all acute her patient at the end of their falls prevention chat? Call
them safe.
though wed removed sitters from many of our rooms, care units throughout the hospital, including our Rehab me if you need anything.
something remarkable happened: in our first year of Unit, which has seen a significant drop in falls since
implementing video monitoring. Thats when Janiel knew it was time to get creative. Janiel Wright, Nurse Manager, Orthopaedic Hospital
And specific. Instead of simply telling patients to call for
Rehab Unit Results help, her team created a Patient Assistance Agreement
documentand they asked each and every patient on
their unit to sign it prior to receiving any medication
#offalls Implementingvideomonitoring
or going into surgery. With this simple action, patients
14 Allfalls formally acknowledged that theyd call for help anytime
Withvideomonitoring they needed to get out of bed or even when they just
12 13 13
needed to reach for an object.
10 11
8 9 Talking just doesnt have the same impact as actually
signing something, says Janiel. Our patients took
6
6 the agreement seriously, because we were taking their
4 5
4 safetyseriously.
2 3 3
2
0
9/10 10/10 11/10 12/10 1/11 2/11 3/11 4/11 5/11
With an uncomfortably high number of falls, our Rehab Unit was a perfect candidate for video monitoring. Two falls occurred initially while staff oriented to
the video program. After quickly changing their processes, falls in the unit decreased dramatically, and falls on video-monitored patients dropped to zero.
Getting it in writing: Every patient in the Orthopaedic Hospital
formally agrees to call for help anytime they need to get out of bed, or
even when they just need to reach for an object.
24 / 2011 nursing report 2011 nursing report / 25
08. Prevent falls with signed patient agreements. (cont.)
physician, and
Orthopaedic Hospital Inpatient Unit / Falls by month
FallsPilotProject
Falls
researcher
3
heads together
assistedfall
1
0
2009 2010 2011
Since implementing Patient Assistance Agreements in August 2009, there have been only two falls at the Orthopaedic Hospital.
for better patient
Involving patients,
families and staff.
Committing to safety.
The prevention process doesnt end after the agreement
is signed. Patients and families are verbally reminded of
outcomes.
Before implementing the Patient Assistance Agreement,
their commitment throughout their hospital stayand
fall prevention ideas had been limited to putting high-
the agreements are posted conspicuously in patients Traditionally, nurses in leadership roles manage other Center. Its the perfect match for this highly collaborative
risk patients in grippy socks or taping falling leaves to
rooms. Info posters with the message Please call, dont nurses, not global research centers. But we dont follow environment, where nurses, research fellows, and
their doors. Asking all Orthopaedic patients to sign an
fall are also hung in each room. And when a patient tradition for traditions sake. And Jeremy Fotheringham, physicians work together to translate cutting-
agreement was a bold shift in falls preventionand
does call, nurses drop everything to go to their bedside. a former bedside nurse and the current director of our edge academic research into real-time patient care
some worried that patients would be offended. But
Everyone takes ownership and commits to holding up Comprehensive Arrhythmia Research and Management procedures. And its this team approach that has led to
it was an idea whose time had come. Its okay to be
their end of the bargain, says Janiel. Patients, families, Center (CARMA), embodies this philosophy groundbreaking new tools and resources for diagnosing
firm with patients when its for their own protection,
staff we all hold each other accountable. and treating atrial fibrillation, the most common cardiac
saysJaniel.
Jeremy is the bridge between nursing and medicine arrhythmia. In fact, the CARMA Center is one of the
2 years, 2 falls. at CARMA, says Margaret Pearce, our CNO. Hes
helping us to build nursing as a professional practice.
few places in the world that can stage AFib using
three-dimensional, high-resolution MRI technology
After implementing Patient Assistance Agreements, Jeremy not only serves as director of CARMA, but also and this enhanced diagnostic tool brings patients from
the Orthopaedic Hospital went seven months as the nursing director of the Cardiovascular service around the globe to our Utah center.
without a single fall. And in the two years that the line, managing inpatient cardiovascular units as well as
program has been in existence, there have been EP and Cath Labs.
only two falls, one of which was an assisted fall. The
agreements have been so popular and successful, Boasting a law degree as well as a business
that they are now being used by other units within administration background, Jeremy Fotheringham
our hospital, including the surgical post-op unit. brings business acumen, team building skills, and
nursing expertise to his leadership post at the CARMA
From bedside nurse to been turned down. I decided to find out exactly why it
had been declined in the past, and I built a new proposal
jobsite manager. that removed those barriers, says Colleen. The biggest
barrier turned out to be the request to spend $20 million
Like her colleague Jeremy Fotheringham (see Idea #9),
in a single fiscal year. So Colleen proposed spreading
problems quickly. Equipment rooms are centralized for On time, on budget.
Colleen has been given a unique leadership opportunity easy accessibility.
it out over four yearsand the ICU build-out was By seeking out the best possible pricing for
thats highly uncommon for nursesand yet perfectly
finallyapproved. On the heels of this project, Colleen will lead the build- construction materials and leveraging legacy
suited to her expertise. I started at University of Utah
out of our new Burn Unit, which will be renovated to equipment from the existing unit where possible,
Health Care as a staff nurse, she says. And as nurses,
we know whats going to work or not work for a units
Building the dream. meet similar patient- and staff-friendly standards. Weve Colleen is expected to finish the ICU build-out on
taken the best pieces from all around the hospital and time, with a 33% contingency.
physical space. We understand the flow. After all, weve The old medical ICU had only a single bathroom for
lived it. Combine this practical nursing experience incorporated them into these designs, says Colleen. Whats more, by working closely and consistently
12 beds. Its rooms were too small for family visits, and
with a collaborative, can-do attitude, and youve got the Shes also brought together the ICU nursing staff in every with ICU staff and involving them in every decision,
there was barely enough space for nurses to manage the
perfect person to lead two major construction projects step of the decision-making process. And this culture of the real savings are most likely to come at the very
equipment and patients. Our new ICU, under Colleens
for the hospital. collaboration is key to the ICU build-outs success. Weve end of the project, because costly, last-minute
leadership, changes all that. Patient rooms boast
been trusted to work together, make decisions and figure changesthe kind that arise all too often due to lack
picturesque windows, more square footage, and pull-
I feel like Im the luckiest person in the world, says it out, she says. The result? A place thats altogether of communicationwill have been avoided.
out beds for family members. Nursing areas are wide
Colleen. Our organization has given me, and so many better for the hospital, the staff, and most importantly, the
open, so that staff can see each other and communicate
patients we serve.
Writer
Kimberly Grob, Write On Network
Designer
Sean Bates, Gridshift
Photographer
Kevin Lee, Kevin Lee Photo