Registed Nurses' Association of Ontario

Chatham-Kent Health Alliance ROUND AND ROUND WE GO: To improve patient quality and safety

Katie Goldsmith
Chatham-Kent Health Alliance

The experience of completing an RNAO fellowship at CKHA has been a highlight of my nursing career thus far. From this experience, I have a better understanding of the effort that goes into project implementation and the difficulties of sustaining the change that was introduced. It has also provided me with the ability to further develop and strengthen my skills as a novice leader, increase my knowledge of implementing a change management project and it has improved my self confidence when presenting in front of large crowds. One opportunity that was a great benefit to my fellowship was attending the RNAO Best Practice Guideline Summer Institute; I feel I was better prepared and I am more knowledgeable about guideline implementation. The projects chosen to promote a healthy work environment and to improve the quality of the care provided to the patients on the inpatient surgical unit was the implementation of purposeful patient rounding, per Studer (2003), and the introduction of quality and safety board huddles.
The quality and safety boards that were on the inpatient surgical unit were poorly utilized, and staff engagement was low. The frontline staffs were unaware of the unit performance, which did not promote accountability. The intention with the new quality and safety boards was to have the unit metrics updated on a regular basis, to increase awareness of organizational goals and events, and to have it visible for all health disciplines, patients and family members to see. The staff voiced that they would like to be aware of the educational opportunities offered within the organization, and this was incorporated in the boards as well. By allowing the staff to be more aware of the unit performance, I hope to promote a culture of safety, and a competiveness to strive for excellence. The quality and safety boards will provide staff, patients and family members the chance to post ideas for improvement, which are then placed on the PICK chart (possible, implement, challenge and kibosh), and then discussed with the group present. The safety huddles are to be held on a tri-weekly basis (Monday, Wednesday, Friday), where everyone is welcome to attend.

On the inpatient surgical unit, there was no method that provided consistency between each healthcare provider and how they completed their patient rounds. With the introduction of purposeful patient rounding, also known as the 6 P’s, the staff will have specific questions and assessments to be completed. The 6 P’s to be addressed are Pain (assess current pain level and provide the appropriate interventions), Personal care (help to the washroom), Position (offer assistance to reposition/provide queue to reposition), Pumps (ensuring all cords are off the floor and that there are no trip hazards), Possessions (all necessary belongings are within reach, such as the call bell) and Promise (providing the patient with a timeframe as to when they can expect the nurse to return). By addressing this practice, the intent is to improve the unit metrics; such as patient satisfaction, patient falls and hospital acquired pressure ulcers. The unit metrics will be reviewed with all health disciplines during the safety huddles, and the impact will be visible for all health disciplines to see. From staff suggestions, it was decided that the purposeful patient rounding would occur at a minimum of every two hours from 0700-2200, and then hourly from 2300-0600. CKHA data revealed that the highest numbers of falls per time of day was from 2400-0400. The incorporation of these statistics into the staff education presentations was crucial, because it allowed the nursing staff to recognize the importance of completing hourly rounding during the night shift. Lastly, in order to show accountability, each staff member is required to sign for the rounds completed on the purposeful rounding flow sheet found in the patient’s room.

From the learning plan created, a carefully thought-out and organized timeline was devised, maximizing my fellowship experience. Two activities which have been of great value to my education was participating in the weekly coffee breaks with my mentorship team and attending the Leaning Forward Wave 2 initiative at CKHA. During the coffee breaks, I was able to observe and participate in rich discussions regarding nursing leadership articles, from various leadership lenses, and debate the questions generated. This time also provided the chance to discuss with my mentorship team about any challenges I was having with my project. From the feedback received, I was able to expand my personal knowledge of project planning, implementation and sustainability strategies for a change management project. By attending the Lean classes, with the guidance of my sensei (Lean expert), I have gained a new perspective of how to analyze a process, and to use specific tools to interpret, guide and introduce efficient project implementation. The classroom environment created a network of individuals in the organization who were utilizing the same tools, and doing similar initiatives. Also, it provided a safe environment to discuss any challenges or obstacles I was facing. The time spent in the classroom was beneficial because it allowed the opportunity to practice my presentation skills in front of my cohorts, as I will have to formally present my project in front of senior management and all hospital personnel. This dedicated time for learning, afforded by the fellowship, allowed me to concentrate on the project rather than taking on this project as an extra.

Project planning and implementation was a much more difficult task to accomplish than I had originally anticipated. The team I collaborated with consisted of my mentors, professional practice team colleagues, Lean sensei and cohorts. Through each phase of my fellowship, I felt my supportive network offered valuable feedback from their previous experiences, as many of them had encountered similar barriers. It was not until I attended the summer institute and the Leaning Forward classes that I realized the importance of getting the staff “buy-in” and showing them “what’s in it for them”. When providing staff education for the role out of purposeful rounding, two staff meetings were scheduled on site. The biggest wins for the staff were the decrease in the number of call bells, and the ease of knowing that each nurse will complete their patient rounds in the same manner, which promotes consistency. The meetings had poor attendance, and so I resorted to completing brief presentations on numerous dates to the staff on the unit while they were scheduled to work. By making this change, I was better able to disseminate the information, and gather more staff feedback for the first PDSA cycle. One barrier which I faced prior to project implementation was resistance from staff members that had been part of a similar initiative on another unit which was not sustained. These staff members brought a negative aspect towards purposeful rounding, and my fear was they could impose their thoughts on others. It was decided with my primary mentor that we should speak directly to these individuals; to discuss and generate ideas from their previous experiences, and come up with solutions to make this project a successful endeavor. This method proved beneficial, and ideas were created that had not previously been thought of. I also sought the help from the surgical unit based council members (UBC) and the Best Practice Champions to support and help their peers during the project implementation, and to encourage staff compliance afterwards. Each day I was able to complete staff audits, and monitor compliance. I was pleased to see the number of nurses that were proactive and completed the rounds as scripted. Unfortunately, there were individuals that did not share the same enthusiasm and required further follow up from the clinical manager. Through each PDSA cycle, staff comments were reviewed, and the changes made were incorporated into the following cycle. I enjoyed going on a site visit to another organization that has implemented the same initiatives, to learn from their experiences and to receive direct feedback from the frontline staff.

The Quality and Safety boards posed a challenge in itself, as to what information should be shared and to develop a process on how to lead the safety huddles. In order to receive staff feedback, three boards were put up on display on the unit. Staff members were able to provide direct feedback as to what they liked about the display, and what information shared in safety huddles would be of benefit to them. The surgical unit has really responded well to this, and the safety huddles have been well attended since implementation. The quality and safety board is now kept in one central location, visible for all to see; whereas previously, staff gathered unit information from three different locations. During my fellowship, the unit clinical leader (UCL) involved with me in the Lean events has changed roles, but I was very fortunate to have gained a new UCL that demonstrates excellent leadership skills, and whom the frontline staff respect and value.

From the beginning of the implementation, I facilitated the safety huddles. Since then, the UCL has become familiar with the quality and safety boards, and has done an excellent job to engage staff and lead the huddles. It is the intention further down the road to have the safety huddles led by the frontline surgical staff. I believe the staff will rise to this challenge, and it will become embedded in our culture as a unit.

The fellowship experience has allowed me to do many great things, pushing myself beyond my comfort zone, to accomplish tasks and take a leading role that previously I would have been hesitant to do. Speaking in front of large crowds is not an easy task for me. In many occasions, I was responsible for leading staff education sessions, safety huddles, leading discussions with directors and formal leadership, and to provide presentations regarding my fellowship and Lean projects.

From the meetings attended with formal leadership within the organization, I was able to witness various leadership styles and characteristics. Each leader displayed various traits, but what I have learned is that an individual can possess more than one leadership style, and that certain leadership styles are necessary dependent on the situation. Prior to my fellowship, I had not considered what type of leader I was, and from this experience, I believe that I am a transformational leader. As I return to my previous role in the clinical environment, my hope is to continue to strengthen my leadership abilities and to build upon the new skills I have acquired.

I found the frontline staff very reluctant to change in the clinical environment. It was challenging to introduce a quality improvement initiative that would alter the method in which a nurse practices’; as they are very set in their way and believe their own method is best. After completing staff surveys and through discussions, dependent on the patient condition, it was found that the majority of the staff completed patient rounds with the same concepts of purposeful rounding. From this realization, the nurses became more optimistic about standardizing the care between each healthcare provider. The culture of the unit is individually led nursing, as opposed to team nursing, which would be of great benefit when completing patient rounds. Team nursing was suggested to staff as an alternative to trial during the PDSA cycles, but many continued to practice independently.

My greatest concern after completing the fellowship is sustaining purposeful rounding. Much of the responsibility will fall upon the clinical manager and the surgical UCL to monitor and promote staff compliance. The clinical manager will be reviewing the purposeful rounding flow sheets, and complete random weekly audits. From my experience of completing flow sheet audits, I required assistance from the clinical manager to speak to certain individuals, because my approaches had not been effective when addressing concerns. The UBC members and the UCL will act as super users for the unit, and will also train new staff members. A questionnaire has also been created for the patient advisor’s to ask the patients. It will be suggested in my final evaluation to have the questionnaire completed at 1, 3, 6 and 12 months post implementation. The questionnaire provides specific questions as to how the nursing staff complete their rounds, how it has impacted their hospital stay and any additional comments. Once this initiative goes organization wide, the intent will be to educate new hires and students of all health disciplines about purposeful rounding. CKHA NRC Picker data should be gathered pre-implementation, and monitored at each quarter post implementation. This information should be shared with the front line staff, to show the impact of their efforts.

Each month at the UBC council, as chair member, I intend to discuss the progress of purposeful rounding on the unit, any comments generated from the staff, and try to generate ideas to overcome any barriers.

As I complete this fellowship, I will take what I have learned during this time period and carry it on to the next steps of my nursing career. I feel that I have gained valuable experiences as a novice leader, and I look forward to applying these skills when I return to my clinical environment. This opportunity has opened my eyes to various aspects of the nursing field, and possibly areas of which I would like to pursue my career, as I truly did enjoy completing research and leading staff education. I am grateful for this experience I was given, and I hope that I have made a positive impact on safe and quality care at the Chatham-Kent Health Alliance.

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