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Street Smarts for Nurses

Program helps Kansas City nurses investigate their own units.

If you're a fan of crime dramas, then you probably have a favorite show among those in the CSI franchise, aired regularly on CBS television. But a different type of drama is unfolding in Kansas City, albeit under the same nomenclature.

Nurses at seven regional hospitals have both realized their own potential and improved patient care thanks to the Clinical Scene Investigation (CSI) Academy, a program of the Bi-State Nursing Workforce Innovation Center.

The idea, according to Susan Lacey, PhD, RN, FAAN, director of the center, is to help staff-level nurses affect change, whether or not they have leadership experience.

"We really wanted these nurses to understand that they are the clinical experts," she explained. "And we wanted them to realize they could impact policy and be heard by the entire nursing staff and beyond."

R&R Still Central

The CSI Academy is rooted in efforts to address an all-too familiar issue within healthcare: the recruitment, retention and development of qualified nursing talent.

"My role is program officer for the Health Care Foundation (HCF) of Greater Kansas City, and we are a conversion foundation that provides grants to healthcare organizations, particularly to the uninsured and the underserved," explained Mary Kettlewell, LMSW, LCSW.

The foundation was formed following the 2003 sale of a nonprofit, multihospital health system, Health Midwest, to HCA Inc. "By law, part of that profit had to go toward charity care," Kettlewell said. "So, they formed two foundations - HCF and the REACH Healthcare Foundation."

Originally, Kettlewell's foundation was to service three counties on the Missouri side, while REACH was to service three counties on the Kansas side. But in reality both foundations work together to serve all six counties, striving to assist traditionally underserved populations in the Greater Kansas City region.

In 2005, Kettlewell said, the HCF board came to realize their efforts to assist their target populations could meet with only limited success unless issues affecting the local nursing workforce were addressed.

"They decided our target population would suffer if we did not do something to make sure they had qualified healthcare professionals available to them, whether that's in acute, long-term or other healthcare environments," she explained.

The HCF board decided to develop a nursing workforce shortage initiative, bringing together local nurse leaders in healthcare and education to create a nursing advisory board. The advisory board counseled the foundation and its partners on where funds would best be spent to address a variety of workforce issues, including increasing local nursing faculty, increasing faculty and student diversity, and increasing the matriculation of nursing students - particularly minority students.

Empowering Staff Nurses

After several years of supporting local colleges and universities in addressing such issues, the foundation turned its attention to the retention of local hospital nurses.

To do so, it sought the expertise of Karen Cox, PhD, RN, FAAN, executive vice president and co-chair operating officer of Children's Mercy Hospitals and Clinics; and Susan Lacey, PhD, RN, FAAN, director of patient care services research at Children's Mercy.

Both Cox and Lacey are alumni of the Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellows program and have collaborated on various projects aimed at improving work environments for staff nurses, as well as empowering them to affect change within their organizations.

"The foundation approached us and asked, 'What's the next thing we can do to help nurses?'" Lacey said. "As part of my Robert Wood Johnson Executive Nurses Fellows program, I had created a business plan centering on the concept of a nursing workforce center, so the synergy started there."

That synergy led to the creation of the Bi-State Nursing Workforce Innovation Center, thanks to additional support from Partners Investing in Nursing's Future (PIN), a collaboration between the Northwest Health Foundation and the RWJF.

"We co-received, through the foundation and a PIN grant, $500,000 for a 2-year project, the Clinical Scene Investigation Academy," Lacey said. Its goal: to affect sustainable changes at the unit level in seven Kansas City hospitals - changes identified as necessary by staff nurses on those units and driven by those same nurses.

Supporting Innovation

Essentially, the CSI Academy aimed to empower staff nurses by teaching them how to identify fixable problems on their units and how to go about addressing them in an effective manner.

To do so, Lacey and her colleagues first identified hospitals willing to participate in the project - hospitals that would ensure their support to the staff nurses involved and whose leaders understood the goals of the CSI Academy. Supervisors from each of the seven participating hospitals identified 2-4 nurses from their staff to participate.

"We were very strategic from the beginning," Lacey explained. "When all seven hospitals agreed to participate, we brought in all the CNOs and we explained what the expectations were going to be and asked them to be supportive. We also asked each to identify internal coaches for the staff nurses participating in the academy - coaches who were at the director level or above, who made sure the participants were not getting snagged up in any kind of bureaucratic stuff that could impede their process," she said.

"So we had an intermediary, so to speak, embedded in each organization to keep negative things from happening."

In addition, nurses participating in the program were connected with nurse leaders from outside their organizations who could act as mentors as they progressed through the program, creating yet another level of support.

The nurses from each of the seven hospitals received internal coaching, and all teams gathered together for nine monthly training sessions as well, Lacey said. The classes focused on making process improvements, quality improvement methodology and how to operationalize solutions to specific patient outcomes the nurses believed needed improving. The academy required these outcomes relate to the Centers for Medicaid and Medicare Services list of "never" events or from the National Database of Nursing Quality Indicators.

Change From the Bedside

The results of each team's efforts were nothing short of inspiring, Lacey said. Nurses participating in the program actualized solutions that improved patient outcomes, saved their organizations money and, in many cases, emboldened them to become leading voices for change in their hospitals.

At the Kansas City VA Medical Center, nurses took on heel pressure ulcers, an issue that's more important than ever within the VA system, Lacey said, as an increasing number of soldiers return home from combat operations abroad with injuries that reduce their mobility.

The CSI team educated nurses throughout the hospital about heel ulcers through mandatory classes. They also arranged for regular rounds to be made by a certified wound care nurse, who ensured all at-risk patients both had and wore the boots designed to prevent heel ulcers. In addition, the nurses created a weekly "Heels Angels" day to maintain awareness among staff and patients alike.

Thanks to their efforts, the VA hospital saw an 80 percent reduction in heel ulcers since the program started in 2009. It's saved the hospital's patients further injury while also saving the hospital upward of $1 million. "In fact, we are meeting with the local VA to discuss a proposal to scale the tools and techniques they used so we can push it out to VA hospitals at large," Lacey said.

Another success story unfolded at Providence Medical Center, where nurses saw an opportunity to reduce medical errors related to shift hand-offs. The CSI team developed a formal checklist and expanded the role of certified nursing assistants to help them accurately report each patient's status to oncoming nurses.

As a result, Providence Medical Center saw significant reductions in communication errors, injury-causing falls, medical errors and restraint usage. What's more, the hospital estimates it's saving more than $250,000 as a result of the CSI's efforts.

At each of the seven hospitals participating in the CSI Academy, projects nurses have established deep roots, Lacey said. "Even though the funding for CSI stopped in August, they continue to do all this work," she explained. "So, the sustainability has been very impressive."

Institutional processes and cultures weren't the only things that changed thanks to the CSI Academy. Many of the nurses participating in the program have seen their career paths permanently altered.

"One by-product of the CSI Academy is that these nurses are looking at their roles in healthcare with new eyes and new ideas," lacey said. "Many have been promoted; many have moved into more supervisory roles and many have decided to go back to school."

More of a Good Thing

Thanks to the CSI Academy's success, Lacey and her colleagues are planning to expand the concept to local clinics and other healthcare providers whose nurses, given the proper support, could actualize similar improvements.

"We know hospitals have a lot of ways to flex personnel and resources . but nurses at clinics do not have the same opportunities to be innovative. So we are partnering with various clinics and modifying the program for them, saying, 'OK staff nurses, you are the ones who look the patients in the eye every day; help us figure out how to change the processes and how to improve outcomes for your patients,'" Lacey said.

'We want to teach staff nurses at clinics how to be efficient, how to be efficacious and how to teach people like diabetics how to keep out of the hospital, because once you start down that road you are talking about a massive consumption of healthcare goods and services."

And while the backdrop might change, Lacey said the focus of this next phase will remain the same: the empowerment and education of nurses who otherwise may not have considered themselves movers and shakers.

"What's really powerful is that these are not nurse managers, CNOs or directors; these are staff nurses who come in every day, work hard and do not have any formal leadership training, but they were the ones who drove the changes happening at these hospitals," she said.

"We know that nurses can do this work. They just need the empowerment from leadership, the change in culture and the ability to implement ideas. Because I tell you what: You give a nurse a pen, a pencil and an IV pole, and we're like MacGyver. We just figure it out."

Timothy A. Mercer is a contributor to ADVANCE.

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