INTRODUCTION
In December 2007, I served as WOC nurse manager in a large health care system in upstate South Carolina. Part of my role was to evaluate WOC nursing care delivery, identify unmet needs, and develop programs to meet those needs. At the time this project began, our health care system employed 3 full-time equivalent (FTE) WOC nurses. Although we provided both inpatient and outpatient services, WOC nursing services were primarily delivered in our acute care hospital, along with occasional services to ostomy patients in an outpatient clinic. WOC nursing services were available Monday through Friday from 0800 to 1700. Consults were received through computer-generated orders; WOC nurses also carried pagers, but they could be contacted only during business hours. The limitation in days of service sometimes adversely affected our ability to respond to consults in a timely manner, which resulted in delayed initiation of optimal treatment. In addition, the lack of coverage in settings other than acute care frequently caused communication problems and gaps in care when the patient moved from one setting to another. Recognition of these problems prompted me to critically evaluate the services being provided and to consider new strategies and approaches to meeting patient needs. This View From Here column describes the needs and issues we identified, our approach to analysis and correction of the identified issues, and a review of our outcomes.
PRODUCTIVITY MEASURES
At the time this project began, the total census for the WOC nurse department averaged 17 to 21 patients per day, along with 4 to 5 new consultations per day. The average time required to respond to a new consultation was 1 hour, and follow-up visits averaged 45 minutes. The frequency of WOC nurse follow-up varied according to the specific needs of the patient; the median frequency was twice weekly until discharge. Hospital length of stay averaged 4 days; for patients with complex health care needs such as those with pressure ulcers, length of stay was extended from 10 to 12 days. A roster of patients being followed by the WOC nurse team was printed daily; it included only the patient's name and location. The team manually added current treatment plans to enable communication among the WOC nurses.
The WOC team comprised 2 full-time WOC nurse clinicians as well as me (acting as WOC nurse manager). I had both clinical and administrative responsibilities. One problem identified at baseline was a very heavy workload on Monday mornings; we often faced a load of 17 to 21 existing patients, along with as many as 15 new consultations. We spent first hour of each Monday conducting telephone triage of new consultations to determine which patients needed to be seen that day and which could wait another 24 hours. In many cases, consultations generated Friday evening were not seen until Monday (or even Tuesday), which led to patient and family complaints regarding delayed service. Although our policy did not dictate a time frame for WOC team response to new consults, the delay in initial evaluation was not consistent with the goals and philosophy of our WOC nurse team.
In order to justify new WOC nurse team members or a new approach to care delivery, we needed objective data regarding our productivity. We chose to modify a tool from the Emory WOC Nursing Education Program to reflect both direct patient care services and administrative functions (Figure 1). We then worked with our quality specialist and a software program being used in our system to create and trial an electronic version of the productivity tool. Each day the WOC nurse clinicians entered productivity data on a census sheet using the productivity codes, for example: "W-1 1.0" (Wound initial consult taking 1 hour to complete), "W-3 1.50" (Wound complicated follow-up taking 1.5 hours to complete), and then added the information to the electronic record. Electronic record keeping allowed me to generate daily, weekly, or monthly reports summarizing productivity and accountability. I used these data to support plans for streamlining and expanding WOC nurse services.
Evaluation of the productivity reports identified opportunities for streamlining efforts and increasing efficiency. For example, I found that productivity was impaired by the time required for WOC nurses to handwrite a plan of care beside each patient's name on the printed daily patient roster. Instead, we identified the need for an electronic version of the WOC team patient list (census) that included a plan of care in an electronic internal document (spreadsheet). Physician portal user-editing features provided an excel template for each patient including name, room number, date of birth, admission date, and other pertinent data; this information was copied and pasted to the WOC patient list (Excel spreadsheet). The document was then modified to include treatment plan, date seen by WOC team, and the date for WOC team follow-up visit (Figure 2). The WOC nurse team printed this document each morning, which provided an overview of the visits scheduled for the day and a synopsis of planned care for each patient. In addition, the WOC team member on call (carrying the team's pager) was able to respond more easily using information from this electronic document.
WEEKEND COVERAGE
After addressing these initial issues, I turned my attention toward issues associated with the large number of existing patient services requiring attention each Monday morning and the need to triage responses to consultations generated between Friday and Sunday evening. In response to this problem, I proposed a 10-week trial of weekend coverage. This did not prove to be a popular idea with team members. In an effort to generate the needed data and to encourage team member acceptance, I agreed to cover every weekend during the trial period. I limited weekend coverage to new consultations and patients with pressing needs such as persons with ileostomies or enteroatmospheric fistulas and pouching issues. A negative consequence of weekend coverage was the need to provide compensatory time for the WOC nurse covering weekends and the reduction in staff coverage during weekdays. In contrast, weekend coverage markedly reduced patient complaints, increased staff (both nurse and physician) satisfaction with WOC nurse services, and resolved Monday morning overload issue. The WOC team electronic patient summary proved valuable during this time; it supported rapid communication among team members, even on days when one member was absent due to compensatory "off" time.
Results from the trial period led to a team decision to continue the 7-day workweek, with limited coverage on the weekends. While this strategy eliminated delayed weekend coverage of new consultations, it increased the number of delayed consultations received on Tuesday to Thursday owing to reduction in available staff. The WOC nurse team critically reviewed productivity data following implementation of weekend coverage, considering both services provided and the number of consults or follow-up visits delayed due to inadequate personnel; we used a custom-made data collection tool to quantify the number of initial or follow-up visits delayed to the next day. Results indicated that, on average, there were 20 consultations per week that were not completed in a timely manner. I further noted that initial visits required approximately 1 hour; therefore, 20 missed consultation visits per week would justify 20 additional hours, which translates into a 0.5 FTE. In addition, the electronic reports identified growth in the demand for WOC services over the previous 6 months. Productivity measures, missed/delayed treatments, and expanded weekend coverage provided the basis for a comprehensive business plan that was presented to the Vice President Operations Council. The combination of 20 hours per week in missed visits and 16 hours of weekend coverage justified an additional FTE WOC nurse position.
SYSTEM OVERSIGHT
Electronic data collection assisted me in identifying a number of value-based services that helped justify the WOC nurse role in our system, including product formulary management, initiatives to reduce hospital-acquired pressure ulcers (HAPUs), and management of patient support surfaces and rental beds. For example, in-depth knowledge of wound, skin, ostomy, and incontinence products makes the WOC nurse a valuable member of any system's value analysis committee that enables the system to make informed decisions regarding products to be added to or deleted from their formulary.
Clinical experience overwhelmingly indicates that WOC nurse services are also valuable for reduction of HAPUs. In our setting, we developed a Wound Care Council led by the WOC nurse team; this Council was charged with developing a program to optimize preventive care, to significantly reduce HAPUs and other types of skin breakdown, and ensure accurate classification of wounds protecting the validity of our prevalence and incidence data. A subcommittee of this Council is responsible for reviewing prevalence and incidence data and benchmarking our outcomes against national averages in comparable facilities. In addition, the Council is responsible for conducting a critical review of care (root-cause analysis) for all patients with facility-acquired pressure ulcers in the acute or long-term acute care (LTAC) settings.
Our system also formed a standard of practice subcommittee, whose work drives education and modifications in policies and procedures. I believe that the expertise of the WOC nurse team is critical to all of these initiatives. Specific contributions of the WOC nurse team include major responsibility for root-cause analysis, ongoing feedback to unit-based leadership regarding opportunities for improvements in care, and monthly quality reports with team review of any HAPUs and implications for changes in care. I have also found that WOC nurses play a key role in selection and management of bed and chair surfaces; appropriate selection of these surfaces requires in-depth knowledge regarding the impact of care surfaces on prevention and treatment of skin breakdown, an area of WOC nursing expertise. This expertise extends to selection of beds, wheelchairs, stretchers, and recliners. In addition to the WOC nurse, this multidisciplinary team includes physical therapy, environmental services, risk management, central patient transport, facilities management, and purchasing personnel. Purchases made in 2008, 2012, and 2013 resulted in group 2 surfaces for all agency inpatient beds; 50% of our surfaces incorporate low air loss features. Use of a decision tree supported by WOC nursing oversight ensures appropriate use of rental beds and mattresses throughout the system. Our team uses productivity measures and a zero-cost charge master to justify and quantify the WOC nurse time required to manage our fleet of specialty and rental beds and to quantify the value of time spent in patient consult and follow-up visits. A charge-master code for specialty beds is entered daily that allows us to track service costs by diagnosis related group. For example, charges for WOC nurse services for specialty bed management (and for consultation and follow-up) can be tracked for patients with a diagnosis of pressure ulcer; these codes add no direct cost to our patients, but they provide us with valuable information supporting service allocation and WOC FTE justification. The WOC nurse team also provides clinical oversight and assurance of timely pick up of rentals through a daily monitoring process; this oversight ensures cost-effective use of rental surfaces and is another way that the WOC nurse team proves value to the agency (Figure 3).
EXPANDED SERVICE LINE COVERAGE
A critical review of the gaps in WOC care indicated a need for enhanced care for our ostomy patients. According to "The WOCN Public Library" Web site,1 the standard of care for new ostomy patients includes preoperative stoma site marking, rehabilitative teaching postoperatively, and outpatient follow-up for problem solving and support for adaptation. In 2008, we expanded our ostomy services to include ongoing outpatient follow-up of patients with an ostomy. Billing for outpatient visits in our health care system is managed by the outpatient wound center. Referrals for outpatient ostomy care may be generated by the surgeon, primary care physician, or long-term care facility. Physicians may order follow-up for evaluation and treatment of peristomal complications, teaching and counseling, or assistance with pouching (eg, patient who consistently reports poor pouch wear time). Preoperative referrals for stoma site marking and patient education are managed in this same manner. The patient's appointment is scheduled in the outpatient arena with a nurse-only visit. The wound center physician provides medical supervision and signs all notes for nurse-only visits. Currently, we use appropriate Evaluation and Management (E&M) codes to bill for these visits, but efforts are ongoing to explore a different billing matrix that allows for expanded billing based on the acuity of visit.
Our health care system also includes a home health care agency. Initially, the home health care agency employed a full-time WOC nurse who provided follow-up visits and education for patients with wounds and ostomies. However, the agency's WOC nurse was isolated from the acute care team and had only limited contact with the physician group; this led to challenges in collaborative practice and in smooth transitions from the acute care setting to home health. In order to correct these problems, in 2008-2009, our home health care agency WOC nurse position was incorporated into the systemwide WOC nurse team; this was a joint venture between home health and WOC team leadership. Goals included collaboration between the acute and home health care setting that included staff orientation and education, improved communication between the 2 settings, and continuity of care for the patient. I found this collaboration effective in eliminating isolation of WOC nurse services in our system. Based on this experience, our team identified a need to provide WOC nurse coverage for hospice-related services in both home care and hospice house (an in inpatient care setting). This service line has also been incorporated into the services offered by our WOC nurse team.
Actively seeking out opportunities for enhancing systemwide coverage for patients with WOC issues had other benefits. For example, the WOC nurse team identified a need to provide offloading for inpatients with neuropathic ulcers; in response, physical therapy and WOC leadership collaborated to move an FTE orthopedic technician to the WOC nursing team. This service expansion improved patient outcomes and also supported continuity of care. In addition, the technician served as a WOC nurse extender by providing both administrative and clinical support for the WOC nurse team. Administrative duties included running reports, preparing the daily census, returning phone messages, assisting with electronic photo storage, and providing systemwide project assistance. This use of nonlicensed personnel to support team functions increased the team's productivity significantly.
In 2012, our health care system's LTAC facility contracted with the WOC nurse team to provide services for their patients. The WOC nurse team was able to implement clinical pathways for patients with complicated wounds and fistulas and ensure continuity for patients transferred from the acute care facility to the LTAC, and ultimately to the outpatient or home health care setting. This strategy standardized education and staff training, improved clinical outcomes, and patient/family satisfaction.
At this point, the WOC team included 7 nurses and 1 wound technician. The team had merged all service lines except for our outpatient wound center. It became evident by mid-2012 that we needed to "close the loop" and include the physician-run wound center within a systemwide, patient-centered program. The medical director of inpatient, outpatient, and LTAC and I collaborated to form a wound-healing service line. Three pillars of leadership were created to integrate the wound-healing service line throughout the health care system. The first pillar involved nursing leadership. The clinical team was realigned under the nursing division, and a new Director of Nursing position was established to provide leadership for this clinical team. The nurse manager for the inpatient and outpatient wound care teams reports to this new director, who, in turn, reports directly to the chief nursing officer. The second pillar addressed medical leadership; the medical director assumed leadership/management responsibilities for the physicians in the outpatient clinic area as well as inpatient wound services. The inpatient WOC nurses work with the individual patient's medical team in establishing a plan of care. However, the Wound Medical Director provides an integral link between physicians when their services are required. The third pillar involves effective management of the business components of the WOC service line (coding, compliance, and billing). This responsibility was assumed by a newly approved full-time Business Clinic Manager, who reports to the medical group leadership. Thus, the 3 pillars speak to nursing, medical, and business management and leadership for WOC services throughout the system.
The goal of seamless care and positive clinical outcomes throughout the health care system continues to guide decisions. The physician-run wound center has continued to grow and provides outstanding clinical outcomes. However, we have recognized the need for increased numbers of certified WOC nurses who are prepared to serve as case managers. As a result, 3 nurses were enrolled in a Wound, Ostomy and Continence Nurses Society-accredited education program and they will sit for WOCNCB certification. Over the next year, we plan to offer the Wound Treatment Associate program for the remaining licensed staff within the outpatient wound center, with the goal of providing high-level clinician support to the physician and certified wound care nurses.
CONCLUSIONS
We found that ongoing and electronic documentation of services provided useful productivity data and aided in the identification of unmet needs. I used these data as a basis for expansion in our WOC nurse team. Based on my experiences, I found that documenting delay times between receiving and responding to a consultation was especially useful because it provided a basis for expanding staffing levels and the scope of our services. I also found that creation of a systemwide team improved patient outcomes and patient satisfaction. In order to build a successful program, I recommend ongoing evaluation of your health care system's needs and outcomes and collaboration with specialists in your agency to build effective systems for tracking productivity and outcomes. I also recommend active participation in systemwide initiatives and committees that directly affect product selection and quality services. Finally, I found it essential to ensure responsible financial stewardship of rental products by creating a process for tracking and accountability.
REFERENCE