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NK7EO- INNOVATION

NK7EOa-Provide one example, with supporting evidence, of an improved outcome associated with clinical nurse involvement with the design or redesign of work environment.

Introduction

Innovation is a way of life for nurses at Stamford Health.  They are supported through access to new knowledge, transparency of the clinical, quality and financial data and access to internal as well as external experts to engage them in the dialogue about improvement.  They are encouraged to use technology and work flow process change to improve care and care experience for patients, families and the community.

The Redesign of the Pediatric Unit 

Problem

The nursing strategic plan indicated that goals for improved patient satisfaction should be reviewed and acted upon in each unit board.  The Press Ganey mean score on the question: “Accommodation and comfort for visitors” was 72.7 in Quarter 2 of 2017 on the Pediatric Unit at Stamford Health.  Staff commented that a new unit would improve patient satisfaction. The existing Pediatric Unit was comprised of multiple semi-private rooms, shared bathrooms and limited monitoring capabilities. There was no space for nourishment rooms and little to no space for families and visitors. 

Goal Statement

Improve the Press Ganey mean score for the question: “Accommodation and comfort for visitors” on the Pediatric Unit at Stamford Health.

Participants

Pediatric Unit Nursing Team

Name

Discipline

Title

Department

William Lore, RN 

Nursing

Clinical Nurse

Pediatrics

Stephane Pady, RN

Nursing

Clinical Nurse

Pediatrics

Sharon Fearon, RN

Nursing

Clinical Nurse

Pediatrics

Miriam Solis, RN 

Nursing

Clinical Nurse

Pediatrics

Koleta Forcelli, RN

Nursing

Clinical Nurse

Pediatrics

Delrita Davis, RN 

Nursing

Clinical Nurse

Pediatrics

Michelle Cruz, RN

Nursing

Clinical Nurse

Pediatrics

Gina Saldua, RN

Nursing

Clinical Nurse

Pediatrics

Kathleen LiVolsi, RN

Nursing

Director, Clinical Operations 

Maternal Child Health

Description of Intervention

During the 3rd quarter of 2017, weekly meetings were held with the pediatric nurse design team to plan for the new Steven and Alexandra Cohen Children unit.  The Cohens had donated money to renovate the unit.  Feedback from these meetings was also brought by the nurse manager to the entire staff during monthly staff meetings for their input.

Nursing staff comments impacted the design decisions: 

  • Use of all private rooms with bathrooms that include a bathtub
  • The placement of cardiac and respiratory  monitoring capability in each room
  • A nursing workroom located directly behind the nurse’s station. This would be visible to patients and families in case they came to desk for a request during report or meeting times.
  • Additional space requests included: a nourishment room, a patient family consult room, a playroom for all and a family lounge to accommodate visitors.  

The new space would meet patient, family and visitor needs by offering privacy.  The staff all felt that private rooms would also improve efficiency by eliminating the need for room transfers because of roommate concerns, isolation requirements and the limited availability of monitoring capability in each room.  All these concepts were built into the design of the new unit and the renovation was accomplished during the 3rd quarter of 2017.  The staff added ideas to the new family lounge space so that it would be comfortable and accommodate more people.  They added space for siblings and friends who could potentially also visit. The new unit was opened for patient occupancy at the end of the 3rd quarter of 2017.

Outcome(s)

Press Ganey mean score for question “Accommodation and comfort for visitors” on the Pediatric Unit at Stamford Health

Pre-data

Quarter 2 of 2017

72.7

Intervention

Quarter 3 of 2017

 

Post-data 1

Quarter 4 of 2017

87.5

Post-data 2

Quarter 1 of 2018

97.2

Post-data 3

Quarter 2 of 2018

92.3

 

NK7EOb-Provide one example, with supporting evidence, of an improved outcome associated with, clinical nurse involvement with the design or redesign of work flow in an ambulatory setting.  

Bennet Cancer Center improves work flow to decrease medication errors.

Problem

Patient weight is a key measure for safe medication management and monitoring of patients.  Despite the clinical importance of body weight measurement for accuracy of ordering and administration; it is not consistently and systematically recorded in patients, due to interruptions to the workflow and/or heavy staff workloads.  Recording of patient's body weight on admission at the infusion suite and the accuracy of prescription of oncologic drugs have a direct impact on patient outcomes.  In oncology care, a correct, recent patient weight is required for accurate prescription and efficacy of treatment while reducing toxicity.  Because of an inaccurate patient weight process, a medication error occurred resulting in a rate of 4.7/1000 patient visits during the week of July 21 – 27, 2019.  A team was developed to review the workflow and redesign it to prevent further errors immediately.

Goal Statement

Reduce the rate of weight-related medication infusion errors per 1000 patient visits in the Bennett Cancer Center at Stamford Health

Participants

Project Workgroup Members

Name

Discipline

Title

Department

Claudia Millan, RN

Nursing 

Nurse Manager

Bennett Cancer Center

Maria Bourque, RN

Nursing 

Clinical Nurse

Bennett Cancer Center

Laurie Backus, RN 

Nursing

Clinical Nurse

Bennett Cancer Center

Audrey Brown, RN

Nursing 

Clinical Nurse

Bennett Cancer Center

Andrea Coscarelli, RN

Nursing

Clinical Nurse

Bennett Cancer Center

Susan Glass, RN

Nursing

Clinical Nurse

Bennett Cancer Center

Holly Kostuk, RN

Nursing

Clinical Nurse

Bennett Cancer Center

Sharon McGhee, RN

Nursing

Clinical Nurse

Bennett Cancer Center

Wayne Vorpahl, RN

Nursing

Clinical Nurse

Bennett Cancer Center

Hopeton Kongal

Nursing

Clinical Assistant

Bennett Cancer Center

Description of the Initiative

Patient weight is an essential parameter for medication safety and oncology treatment.  Drugs where body weight is important in the dose assessment are often prescribed without a same day recorded weight due to provider writing orders during the office visit   weeks before the infusion treatment.  

Workflow redesign process 

On July 22, 2019, a sentinel event occurred in medication administration of chemotherapy in the Infusion center.  A route cause analysis (RCA) was completed immediately following the medication error.  Review of the RCA brought to the attention of nursing and medical leadership that the workflow processes that were currently used to record weight measurement before oncology treatment needed review. 

Clinical nurse observations and chart reviews brought to our attention large numbers of patients are were not weighed during day of infusion treatment.  The weight was measured during the physician appointment, which occurred seven to ten days prior to the infusion date in BCC. 

Chemotherapy and biotherapy drug prescribing is performed during the medical oncologist visit (7-10 days prior of infusion).  The weight recorded during this visit is the one used for treatment prescription.  Weight variations do occur for patients between the time of the oncology visit and the actual infusion time.  Not having a process to ensure accurate weight at the time of the infusion poses a potential risk for the patient population by either under-dosing or over-dosing medication.

Implementation of workflow changes 

The clinical nurses redesigned the workflow in the ambulatory setting which included changing the process of obtaining an accurate weight at the time of the infusion visit. The infusion visit weight was the most accurate for the MD to order the appropriate weight-based dose.  It was also a good time for the nurses to assess any weight loss or gain and discuss patients’ nutritional habits.  Nurses were able to make a referral to the nutritionist on staff and discuss their assessment with the MD at the time of the visit. 

During huddles, the nurses communicated the workflow change asking all staff to obtain a weight on all patients during the infusion visit and record that weight into the medical record.  The MDs were notified of the change and where to look for the most accurate weight before writing the dosing orders.  This was implemented within the following week of July 28 to August 3, 2019 and there have been no medication errors related to an inaccurate patient weight since the workflow changes.  The immediate results were positive, and the staff continues to have zero medication errors related to inaccurate weights.

Outcome 

Weight-Related Medication Infusion Error Rate per 1000 patient visits in the Bennett Cancer Center 

Pre-Data

Week of July 21-27, 2019

4.7

Intervention

Week of July 28-August 3, 2019    

 

Post-Data 1

Week of August 4-10, 2019

0

Post-Data 2

Week of August 11-17, 2019

0

Post-Data 3

Week of August 18-24, 2019

0

 

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