Carilion Roanoke Empowers Nurses to Design & Deploy Improvement Initiatives

Added on Oct 24, 2019

nurse_PatientInWheelchair_chartCarilion Roanoke Hospital Empowers Nurses to Design and Deploy Quality Improvement Initiatives
By Whitney M. Fishburn

Putting performance data in the hands of staff-level nurses has led to significant improvements across key nursing-sensitive indicators at Carilion Roanoke Memorial Hospital and helped the Virginia-based facility achieve Magnet designation in less than seven months.

“Giving staff nurses access to data means they can immediately see the relationship between improvement efforts and performance trends,” said Pamela Lindsey, RN, Magnet program director at Carilion Roanoke, which is the main teaching campus for the Carilion Clinic system in Virginia. “Their engagement is baked in when they can see things clearly and connect their actions directly with results.”

Before Lindsey arrived in early 2017, morale across the nursing units was low, quality improvement projects were lagging, and the culture was reactive, she said. Many units were underperforming against national benchmarks, particularly for avoiding catheter-associated urinary tract infections (CAUTIs).

In addition, there had been three different quality directors in two years, putting Carilion’s fourth Magnet designation in question. “We had only seven months left on the Magnet journey, so it was apparent that moving quality initiatives forward was essential,” Lindsey said.

To accelerate the improvement journey and streamline the necessary documentation for Magnet designation, the quality team and senior leadership decided to utilize Press Ganey’s Nursing Excellence Solution (NES) because it aligns measurement of nursing-sensitive quality indicators, nurse engagement, and patient experience.

Although staff were already able to access the NES data by linking it to the organization’s electronic health records (EHR), the flux in leadership had made leveraging the data a nonpriority, according to Lindsey.

Once the data were prioritized as an improvement lever, it was determined that NES would be the optimal tool for getting staff buy-in and leadership’s input on the direction quality improvement should take, because NES gives unlimited and easy-to-read access to the staff nurses and allows all stakeholders to view the range of performance outcomes at a granular level, according to Rama Doucoure, the hospital’s quality improvement facilitator. “NES lets each unit view their current and historical performance trends, benchmarking them against other teaching hospitals nationally. This allows the units to customize their performance improvement action plans and make immediate adjustments when trends go in the wrong direction,” Doucoure said.

Through a series of boot camps across the organization’s 51 units, staff nurses were shown how to use the EHR to access NES data on their performance trends and were given the rationale for how the data were collected and tracked. The staff nurses were then asked to coordinate with unit nurse leadership to create individualized action plans to move their respective unit benchmarks into the “outperformance” range for overall quality improvement and for Magnet designation. The units could focus on whatever initiative they wanted, but Carilion also used NES performance data to track the data necessary for the Magnet journey.

From Q2 2016 to Q1 2017, the number of units at the hospital that were outperforming national benchmarks for preventing CAUTIs doubled. Meanwhile, units outperforming benchmarks for preventing inpatient falls with injury went from 20 to 31. Slight improvements were also seen across the units for outperforming national benchmarks in preventing central line blood stream infections and Stage 2 and higher hospital-acquired pressure injuries. Together, this helped Carilion Roanoke meet strategic organizational goals and helped the hospital meet its Magnet journey requirements, becoming the only hospital in the state to have four such designations.

“We gave an hour-long presentation [to the Magnet appraisers] focused solely on how we had turned our CAUTI performance around. We used graphs and charts from NES data to show them how we had identified the issues, created paths to improvement, monitored our progress, and what the results were,” Lindsey said.

They also noted that creating their presentation materials took a fraction of the time it used to take. Previously, the time spent gathering, analyzing, and synthesizing the necessary data for Magnet designation was a burden on staff and leadership, according to Doucoure. “Trying to make sense of and coordinate all the different data across the units would take us more than 300 hours,” she said. “This time, it took just 72 hours.”

In less than one year, Carilion Roanoke’s ranking for nearly all nursing-sensitive indicators went from averaging in the low 40th percentile to above the 60th percentile. Lindsey attributes this high return on investment to staff nurses being able to track their current unit performance and compare it from quarter to quarter.

“For the first time, the majority of our units are outperforming national benchmarks, and three of our six critical care units are outperforming both internal and national benchmarks,” Lindsey said.

Culture Change through Accountability and Empowerment

Empowering the nurses to meet their individual and unit goals while also encouraging them to consider how their performance ranked nationally led to a change in culture, according to Lindsey. “We found that if you give staff the tools to see, understand, and apply the data in the necessary framework, they will start to talk the language of leadership. They will want to do something with that information. That meant it was beneficial not only for our Magnet journey, but strategically for the organization as a whole,” she said.

And because NES also gives internal data on which units are outperforming others, “this creates a healthy incentive in the units to compete with their sister units without pushing anyone down,” Lindsey said.

Since NES also tracks patient experience, staff can connect how their quality initiatives directly influence patient outcomes. From Q4 2017 to Q3 2019, there was improvement in outperforming the national benchmarks in all patient experience domains, but especially in the pain and service recovery domains, where the number of units outperforming nationally doubled and increased by 42%, respectively.

“The nurses all want to see that their patients’ needs are being met, so now [the ability to link patient experience and outcomes] drives them even more toward quality,” said Lindsey, noting that patient experience at Carilion has also been trending upward since leveraging the NES data.

Further, Lindsey noted, “staff satisfaction and engagement have increased because the nurses like having immediate feedback that shows how their individual efforts can lead to positive outcomes.”

Currently, discussions are underway to expand the use of staff-level data throughout the system. “We want to continue promoting our quality initiatives from the staff level up,” said Lindsey. “Connecting NES to our EHR provides the access our staff needs to drive continuous improvement.”