The Clinical Nurse Leader: a Catalyst for Improving Quality and Patient Safety

Journal of Nursing Management, 2008, 16, 614–622 The clinical nurse leader: a catalyst for improving quality and patient safety 1 2 3 JOAN M. STANLEY PhD, CRNP, FAAN , JANE GANNON DNP, RN, CNM , JESSE GABUAT MSN, RN ,SUSAN 4 5 6 HARTRANFT MS, ARNP, CNL , NANCY ADAMS MS, RN, CNL , CHRISTY MAYES MS, RN, CNL ,GINAM. 7 8 9 SHOUSE MSN, CMSRN, CNL , BARBARA A. EDWARDS BSN, CMSRN and DANITA BURCH MSN, RN, CNL 1Senior Director of Education Policy, American Association of Colleges of Nursing, Washington, DC, 2Assistant Clinical Professor, College of Nursing, University of Florida (UF), Jacksonville, FL, 3Director, General Medical/ Surgical and Orthopedic/Neurology Departments, St Lucie Medical Center, Port St Lucie, FL, 4Coordinator of Nursing Research, Morton-Plant Mease, Clearwater, FL, 5Clinical Nurse Leader, Morton-Plant Mease, Clearwater, FL, 6Clinical Nurse Leader, Morton-Plant Mease, Clearwater, FL, 7Clinical Nurse Leader, St Lucie Medical Center, Port St Lucie, FL, 8Clinical Nurse Leader Student, St Lucie Medical Center, Port St Lucie, FL and 9Clinical Nurse Leader, Shands Jacksonville, Jacksonville, FL, USA Correspondence STANLEY J.M., GANNON J., GABUAT J., HARTRANFT S., ADAMS N., MAYES C., SHOUSE G.M., Joan M. Stanley EDWARDS B.A. & BURCH D. (2008) Journal of Nursing Management 16, 614–622 AACN The clinical nurse leader: a catalyst for improving quality and patient safety One Dupont Circle NW Suite 530 Aim The clinical nurse leader (CNLÒ) is a new nursing role introduced by the Washington American Association of Colleges of Nursing (AACN). This paper describes its DC 20036 potential impact in practice. USA Background Significant pressures are being placed on health care delivery systems to E-mail: [email protected] improve patient care outcomes and lower costs in an environment of diminishing resources. Method A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region. Results Cost savings, including improvement on Centers for Medicare and Medic- aid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model. Conclusions With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs. Implications for nursing management Nursing is in a unique position to address problems that plague the nationÕs health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings. Keywords: clinical nurse leader, microsystems of care, patient safety, pay-for-performance, quality improvement Accepted for publication: 25 March 2008 DOI: 10.1111/j.1365-2834.2008.00899.x 614 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd The clinical nurse leader comes, and innovation. Within each domain, a set of Introduction possible metrics are identified, which could be mea- In 2004, 78 schools of nursing with multiple and diverse sured by data already being collected by most health practice partners responded to an invitation sent by the care settings. In 2006, the CNL Scorecard was piloted American Association of Colleges of Nursing (AACN) at TennValley Inc. over a 3-month period on several to join a national initiative to develop a masterÕs cur- units where a CNL had practised for at least riculum to prepare graduates with the set of compe- 6 months. The purpose of the pilot was to test the tencies, skills and knowledge delineated in the AACN definitions, data collection processes and analyses. In white paper titled The Education and Role of the this brief 3-month period, positive patient care out- Clinical Nurse Leader (2007). These education-practice comes were observed, including a decrease in read- partnerships were also challenged to transform one or mission rates and decreased length of stay for heart more units within the health care setting to integrate the failure patients, decreased patient falls, and decreased CNL role into the care delivery model. Since that time, post-surgical infection rates (Harris et al. 2006). Fol- the number of partnerships engaged in the initiative has lowing the pilot, education-practice partners were grown to include 92 schools with 192 health care asked to replicate the evaluation in health care settings institutions. The practice sites are primarily acute care where CNL graduates and students were beginning facilities but also include school health departments, to practise. The goal of these evaluation efforts was to visiting nurses associations, public health agencies, and expand data collection and comparison of findings to long-term care and rehabilitation facilities. additional and diverse sites and over extended periods In autumn 2006, the first CNLs graduated from 12 of time. This paper describes some evaluation efforts masterÕs nursing programmes. These graduates repre- to date in three different practice sites. sented both post-baccalaureate nursing masterÕs programmes and second degree or generic masterÕs degree Background of the need for a new health care programmes1. The CNLÒ Certification examination, professional developed by AACN and first administered in autumn 2006, created a unique credential for graduates of the Over the past decade, reports from the Institute of CNL programmes. The CNLÒ credential, a registered Medicine (2000), the Joint Commission on Accredita- trademark, indicates the individual has met a national tion of Healthcare Organizations. (2002) and the standard of requisite knowledge and experiences, American Hospital Association Commission on Work- including graduation from a masterÕs programme that force for Hospitals and Health Systems (2002) have prepares him/her with the CNL competencies, has had described the USÕs health care system as broken and in specific required clinical experiences, and has practised serious need of repair. Other reports (Institute of in the CNL role in a formal clinical immersion experi- Medicine 2001, 2004) have stressed that the health care ence (AACN 2007). As of February 2008, 329 indi- system does not make the best use of its resources, and viduals have successfully achieved the CNL credential others (Kimball & OÕNeill 2002, Institute of Medicine and over 1250 students were enrolled in CNL pro- 2003) have urged the health professions to educate grammes across the country (AACN 2008). future practitioners differently. With a heightened From the beginning, evaluation has been an impor- awareness of the need to enhance health care quality tant component of the CNL initiative. The CNL and patient safety, national nurse sensitive indicators Implementation Task Force, the first task force have been identified that are being used to determine the charged in 2004 with overseeing the CNL initiative, quality of care being provided. These include the 2008 worked with education and practice representatives to National Patient Safety Goals (NPSG) established by develop an evaluation plan. At the centre of this plan the Joint Commission (2008a,b) and the 15 National was the CNL Evaluation Scorecard, patterned after the Voluntary Consensus Standards for Nursing Sensitive Kaplan and Norton (1992) Balanced Scorecard. The Care developed by the National Quality Forum. The CNL Evaluation Scorecard includes four domains: Centers for Medicare and Medicaid Services (CMS) quality internal processes, satisfaction, financial out- have implemented pay-for-performance on core measures, which encourages improved quality of care in all 1Second degree or generic masterÕs degree programs are health care settings. CMS is collecting data on 34 those that admit students with baccalaureate and higher quality measures related to five clinical conditions, and degrees in other disciplines and no previous nursing hospital-specific data are being publicly reported on the education. CMS web site. Hospitals scoring in the top 10% for a ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of Nursing Management, 16, 614–622 615 J. M. Stanley et al. designated set of quality indicators are paid a bonus (US and understandings (Wolf & Tymiz 1977). The case Department of Health & Human Services, Centers for study is the most appropriate form for reporting the Medicare & Medicaid Services 2005). In addition, CMS results of a naturalistic, summative evaluation such as is moving rapidly to limit payment for services that this (Guba & Lincoln 1981). result from improper care or events that could reason- To highlight the early impact the CNL is having on ably be expected to be averted during hospitalization the health care system, three different partnerships or (Rosenthal 2007). Of the eight conditions for which health care agencies were asked to describe the imple- Medicare will no longer reimburse hospitals, at least mentation of the CNL within that setting, changes that six of the eight are directly impacted by nursing care have occurred, and the impact on patient care. These services. three settings, selected from one geographic region, In response to changes in patient demographics and represent different agencies and patient populations, the health care delivery environment, the American and

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