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NOMINATED BY MAUREEN HOGAN, MSN, RN
The North Florida/South Georgia Veterans Health System is a comprehensive and integrated healthcare delivery system that provides quality clinical programs and services to veterans. The system includes two hospitals, two large satellite outpatient clinics (SOPCs) and several community-based outpatient clinics (CBOCs). The hospitals are located in Gainesville and Lake City; the SOPCs in Jacksonville and Tallahassee; and CBOCs in The Villages, Ocala, Lecanto, St. Augustine and Marianna, FL, and St. Mary's and Valdosta, GA.
 Geographically, we span across two states and time zones. In an area roughly the size of West Virginia, it takes 49 hours of drive time to make clinic rounds along 2,449 miles.
The clinics are responsible for 72 percent of the primary-care workload (>110,500 enrollment). The population, in numbers and complexity, has increased by 66 percent since 1999. One chief nurse and nine managers/supervisors are responsible for 140 clinical staff.
In August 2008, an informal assessment revealed there were nine independent, talented and professional clinics with extremely hardworking staff. Our goals were to unify the OPC nurses into a collaborative team and enhance nursing communication, collaboration and best practices within the clinics. We facilitated a "clinic nurse strategic planning process" as a methodology to achieve the clinics' commitment to quality care and enhance team excellence.
Laying the Groundwork
The strategic planning process included three phases: an environmental analysis, a strategic plan and a timeline. Extensive environmental analyses were conducted to assess nursing clinical practices in the SOPCs and promote the delivery of quality coordinated patient care.
The goals that emerged included the following:
• establishing right-size staffing;
• standardizing processes and templates;
• developing and implementing a continuum-of-care process;
• developing an orientation process that is clinic-specific and addresses unit-based clinical competencies; and
• developing a process to share strong practices.
After 1 year, the results demonstrated an enhancement of quality patient care, decreased costs, increased staff satisfaction and morale as evidenced by some of the best practices achieved within the past year.
Local Outcomes
Results from the fiscal year 2009-10 outpatient clinic initiatives yielded several impressive achievements.
Jacksonville SOPC: The team developed an interdisciplinary council to assess patient care. The process significantly increased patient-focused access to care for the 23,000 patients enrolled. Staff also developed a CPRS record for GI procedures that electronically documents a continuum of care for patients from entry into the GI suite to recovery.
Lecanto CBOC: Telephone triage lines have significantly increased access to RNs for patients calling into the clinic who do not have appointments.
Ocala CBOC: A new video has helped streamline a process where all new patients (40-50 per week) received standard, quality information; developed a video production that is a model for all SOPCs. Additionally, an interdisciplinary Coumadin clinic was set up to ensure appropriate and timely oversight of patients who take the medication.
Marianna CBOC: Staff uses the SBAR patient handoff template and process, ensuring efficient transition of care from one shift to the next.
Marianna, The Villages and St. Mary's CBOCs: These locations have strategically shared an agency RN between three OPCs to support a nurse-run Coumadin clinic. The process has demonstrated excellent use of resources despite distance and time zone challenges the patients face.
St. Augustine CBOC: An emergency medication transport box was implemented so staff can readily respond to patients in emergent or urgent situations in any location throughout the clinic.
Tallahassee SOPC: A telecare pilot project helped decrease phone calls to the clinic by half, enhancing the nursing triage process for unscheduled appointments.
Valdosta CBOC: A numeric check-in system was initiated to ensure veterans were signed in by order of arrival times. The process has minimized excessive wait times by streamlining the check-in process.
Systemwide Outcomes
In all clinics, the RN recruiting process has shifted from HR to nursing recruitment. It has significantly streamlined the recruiting process and increased quality of applications for interviews. Additionally, staff standardized the triage process in all SOPCs for the estimated 15,000 unscheduled patients per month.
In collaboration with dietary and transportation, a process was developed to ensure diabetic food boxes were available in each clinic as required per that specific disease protocol.
Collaboration among chief medical officers and nurse managers/supervisors helps identify which medications and procedures are available in all the outpatient clinics. Ensured clinical competencies were developed for each procedure, establishing a continuum of care for patients discharged from Gainesville and Lake City VA medical centers' specialty clinics, and ensuring appropriate and timely follow-up in the SOPCs in a timely manner.
Dynamic Team
This group of nurses continues to evolve into a dynamic, synergistic team. System cohesiveness, decreased fragmentation, enhanced delivery quality care and a sense of team integration have emerged.
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