The current health care environment has heightened the importance of achieving positive patient outcomes and excellent customer satisfaction. To remain competitive, health care organizations must adapt quickly to changing regulatory requirements, quality improvement initiatives, and customer expectations. To ensure nursing practice at the Saint Clare's Health System in Northwest New Jersey is at the forefront of leading change, the nursing staff has embraced the Institute of Medicine report The Future of Nursing: Leading Change. The empowered nursing team has applied Benner's Novice to Expert model and McCauley's CarefulNursing Theory as the foundation for nursing practice. The ability to apply evidence-based nursing research and cultivate professional development at the bedside has resulted in retention of expert nurses at the bedside. Engaging the nursing team has resulted in increased patient satisfaction and improved clinical outcomes. Advanced practice nurses play an important role to mentor the nursing staff and promote an interdisciplinary, collaborative relationship between all health care disciplines and community support programs. Nurses are recognized for their accomplishments and encouraged to obtain specialty certification, advanced degrees, and earn state and national recognition through professional organizations. The professional nurses at the Saint Clare's Health System are prepared to work in whatever environment the new normal creates.
THE SAINT CLARE'S HEALTH SYSTEM (SCHS) located in Northwestern New Jersey is part of the Catholic Health Initiatives (CHI) of Denver, Colorado. Founded in 1895 by the Sisters of the Sorrowful Mother, the SCHS is composed of 4 hospitals and multiple outpatient health care facilities throughout Morris and Sussex Counties. The SCHS offers a full range of comprehensive health care services including robotic, orthopedic, and general surgery, a full line of women's health services, and maternal child health, behavioral health, cardiovascular care, and emergency services. SCHS is a Joint Commission-accredited Primary Stroke Center and a recipient of the Get With The Guidelines Gold Plus Award, a Bariatric Center of Excellence accredited by the American Society for Metabolic and Bariatric Surgery, and a Centers for Medicare & Medicaid Services-accredited diabetes center. Other services include visiting nurse home care and a world-class cancer center.
Today's competitive health care environment has heightened the importance of achieving positive patient outcomes and excellent customer satisfaction. In addition, today's consumer is more informed, and with the cost of health care rising, they have greater expectations of the health care delivery system's ability to provide high quality, compassionate, and professional health care. To remain competitive and fiscally responsible, health care organizations must adapt quickly to ever-changing regulatory requirements, quality improvement initiatives, and customer expectations. Saint Clare's has embraced the recommendations of the Institute of Medicine Report: The Future of Nursing1 to position nurses at the forefront to respond to the needs of the consumer, lead change in health care, and promote wellness.
Through a shared leadership model that represents unit-based councils, the role of the professional nurse has been clarified and developed. Members of the nursing staff developed a differentiated practice model using Benner's Novice to Expert theory2 to match the nurse's skills and expertise to the needs of the patients. The Benner model recognizes the development of nursing expertise from the new graduate novice nurses to competent and high-level proficient nurses as the foundation of bedside care in our system. The nursing department at the SCHS defines the scope of practice for bedside nurses using the American Nurses Association standards of nursing practice3 and New Jersey Board of Nursing Laws.4 The Nurse Practice Council selected as their conceptual framework Mother Catherine McCauley's Careful Nursing Theory.5 This framework guides their decision making regarding professional practice at the SCHS.
Foremost, in the IOM report is the recommendation to allow nurses to practice to the full extent of their education and licensure.1 The nurse leadership team at the SCHS has implemented numerous programs that enhance the role of the professional nurse.
Through implementing changes and improvements in our nursing organization, the SCHS has improved patient outcomes and satisfaction (Figures 1 to 3).
|Figure 1. Three hope quietness of area. Abbreviations: FY, fiscal year; Q, quarter.|
|Figure 3. Four West staff doing everything they could to help with pain. Abbreviations: FY, fiscal year; Q, quarter.|
These changes will position the SCHS for the Pay-for-Performance program from the Centers for Medicare & Medicaid Services and for the transition from hospital-oriented health care to post-acute care and home care. The SCHS has the lowest length of stay in New Jersey with the lowest cost per case. The organization continues efforts to reduce the readmission rates.
Maximizing the use of technology to improve processes and enhance the delivery of safe quality care is fundamental to the transformation of the future of nursing. ClairVia (ClairVia Incorporated, Durham, North Carolina) is the integrated care value management system used by the SCHS and the CHI. The software applications are powerful tools to capture real-time information from the electronic medical record to provide a patient-centered, outcomes-driven approach to allow for measurable improvements to the delivery of care. The ClairVia system provides timely acuity data to enable nurses to adjust staffing and patient assignments to match the needs of the patient to the competencies of the nurse to promote positive patient outcomes.6
Operations managers who are master's prepared administrative nurses are promoting care redesign using lean reengineering principles. The nursing staff members participate in the Transforming Care at the Bedside program.7 These efforts have significantly reduced the cost of bedside care. Although the focus of care in the future will not be in the hospital, patients will still require hospital care. Hospital leaders must make sure that affordable, quality care is accessible to our patients. CHI has embarked on a program throughout to reduce the cost of care while improving patient outcomes. These efforts will result in new models of care delivery that will continue to address issues of patient care, quality, and safety (Figure 4).
|Figure 4. Hospital: total hours per case mix index-adjusted discharge.|
Staff nurses with guidance from nursing and quality leadership have implemented 9 evidence-based practices, which include 21 quality measures designed to improve outcomes and eliminate hospital-acquired conditions. These evidence-based practices were developed collaboratively in nationwide workgroups at the CHI organizations. These practice enhancements have resulted in some of the lowest levels of hospital-acquired conditions in the nation (Figures 5-8).
|Figure 5. Saint Clare's Health System: Total catheter associated urinary tract infection rate (2009-2011).|
|Figure 8. Saint Clare's Health System: Total |
Advanced practice nurses play an important role in the care of patient's at the SCHS and in ensuring outcomes are achieved and readmissions are avoided. We recently were awarded a Grotta grant to develop a transitions-in-care program for congestive heart failure patients. Two family practice nurse practitioners work collaboratively with an interdisciplinary team to ensure that the patient has a seamless transition from hospital to home. The goals of the Care Transition Program are to reduce preventable readmissions and emergency department visits, improve health outcomes, enhance the transition system in our community, and reduce health care costs. The specific transition being addressed is patients in the target population moving from inpatient hospital care to a skilled nursing facility or to home care with or without the services of a visiting nurse. The project focuses on implementing procedures designed to increase patient autonomy and self-confidence, improving systems internal to the SCHS and among the partnering organizations, developing and executing an extensive training and orientation component, and enhancing the communication processes within the SCHS and with partners along the continuum of care. The diabetes advanced practice nurse has developed a collaborative program with the endocrinologists who assist both newly diagnosed diabetic and patients with chronic diseases to improve their blood glucose control and avoid costly complications and hospitalizations.8
Education is another vital element in the Caring Transitions Program. Resources are mobilized to provide educational materials for the patients and their family caregivers in addition to training on the program for physicians, staff members, and staff members at the partnering organizations. Reverse site visits between the partnering organizations will help build appreciation, understanding, and cooperation. The program also includes a rigorous data collection and analysis plan to measure the impact the interventions and education will have on health outcomes, hospital readmissions, emergency department visits, and ambulatory patient quality.9
Recognition of nurse's accomplishments is an integral part of promoting professionalism in nursing. At the SCHS, nurses are recognized throughout the year at management council, in the bimonthly nursing newsletter, and during Nurses Week. Recognition includes board certification in all specialties, completion of advanced degrees, Safety Awards, Daisy Awards, Nurse Excellence Awards, and nominations for state and national awards. Nurse's nametags announce board certification. Safety awards are given to staff members who identify safety issues or intervene to protect patients. Celebrations of life-long learning foster an environment to empower nurses.
The IOM report calls for an increase from 50% to 80% of nurses to be baccalaureate prepared by 2020.1 The complexity of acute care patients at the SCHS requires a baccalaureate-prepared nurse to ensure appropriate critical thinking and positive patient outcomes. Since 2009, the SCHS only hires baccalaureate-prepared nurses and encourages associate degree-prepared staff to continue their education. To achieve the goal set by IOM and to assist with a seamless progression through all levels of nursing education, the SCHS is collaborating with surrounding universities to offer classes on-site at reduced tuition rates. The hospital provides generous tuition reimbursement and works with employees to accommodate school schedules as we strive to achieve our goal of 80% bachelor of science in nursing-prepared nurses by 2015.
Because New Jersey has a surplus of new graduate baccalaureate nurses, the SCHS implemented an unpaid 16-week residency program. This innovative program prepares the new graduate to compete for jobs formerly only available to experienced nurses. The residents are not guaranteed a position at the end of the residency; most of the new graduates have been successful candidates for positions at the hospital. These well-educated and well-oriented new nurses continue to raise the level of practice for all nurses through confidently entering the role of professional nurse. The retention rate for new graduate nurses at the SCHS has increased to 96% since the program began 18 months ago.
Since SCHS includes a number of subacute care businesses and programs, a new graduate associate degree nurse orientation program has been designed and implemented in long-term care, respiratory rehabilitation, and skilled nursing areas. We are currently reviewing the role of the new graduate associate degree nurse in home care. As needs of these patients become more and more complex, we believe a partnership of associate degree, bachelor's degree, and advanced practice nurses will be necessary to provide quality care in this arena.
The IOM report emphasizes the need for nursing involvement in health policy development.1 To encourage nurses to become active in their nursing organizations and to have a voice in the health care reform debate, assistance is provide for annual dues and paid time off is provided to attend annual conferences. Several of the nursing leaders hold adjunct faculty appointments and are members of advisory boards at local university schools of nursing. This allows nurse leaders the opportunity to provide input into the curricula and training of future nurses. This partnership enhances both education and practice in our community. A number of nurses serve as officers for national nursing organizations further enhancing their ability to influence change for the profession.
The last element of the IOM report was to create a robust database for workforce development.1 The SCHS contributes to the National Database of Nursing Quality Indicators database and works with the CHI to improve our abilities to maintain workforce information in accurate online records.
A masters-prepared nurse recruiter leads our internal workforce development efforts. She has developed a strategic workforce plan that addresses the SCHS future needs for nurse recruitment and retention. She works collaboratively with the education department to provide support and mentoring for emerging nurse leaders and is always on the lookout for emerging talent. She also coordinates outreach to middle and high schools to encourage careers in nursing.
The SCHS mission of service to community requires us to consider myriad changes that face us. We believe that whatever shape the new normal takes, professional nurses must lead the way to ensure that patients and their families are always the focus of our efforts. We must build the framework for the future of nursing practice to deal with the mounting complexities of providing effective, accessible care with excellent outcomes while using fewer resources. The work we do will continue to drive nurse innovation leading to improved patient outcomes and satisfaction while reducing readmissions for our patients.
1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. [Context Link]
2. Benner P. From Novice to Expert: Excellent and Power in Clinical Nursing Practice. Upper Saddle River, NJ: Prentice Hall; 2001. [Context Link]
3. American Nurses Association. Nursing: Scope and Standards of Practice. 2nd ed. Silver Spring, MD: Nursesbooks.org; 2010. [Context Link]
4. New Jersey Division of Consumer Affairs. New Jersey board of nursing laws. Title 45, Chapter 11, 1999. http://www.njconsumeraffairs.gov/laws/nursinglaws.pdf. Accessed December 30, 2011. [Context Link]
5. Connell-Meehan T. Careful nursing: a model for contemporary nursing practice. J Adv Nurs. 2003;44(1):99-107. [Context Link]
6. HFMA Learning Solutions, Incorporated. Getting the logistics right. Leadership. 2011; (Spring/Summer):18-28. [Context Link]
7. Rutherford P, Lee B, Greiner A. Transforming Care at the Bedside. IHI Innovation Series White Paper. Boston, MA: Institute of Healthcare Improvement; 2004. http://www.IHI.org. Accessed December 28, 2011. [Context Link]
8. Vineym M, Batcheller J, Houston S, Belcik K. Transforming care at the bedside: designing new care systems in an age of complexity. J Nurs Care Qual. 2006;21(2):143-150. [Context Link]
9. Coleman E, Smith J, Frank J, Min S, Parry C, Kramer A. Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. J Am Geriatr Soc. 2004;52(11):1817-1825. [Context Link]
empowered professional nurse; health care reform; improved clinical outcomes and patient satisfaction; IOM report on the future of nursing