Implementing the Clinical Nurse Leader Role: a Care Model Centered on Innovation, Efficiency, and Excellence

Implementing the Clinical Nurse Leader Role: A Care Model Centered on Innovation, Efficiency, and Excellence

Denise M. Wienand, MEd, MSN, RN, CNL, Prachi R. Shah, MSN, RN, CNL, Brandy Hatcher, MSN, RN, CNL, Alison Jordan, MSN, RN, CNL, Jennifer M. Grenier, MSN, RN-BC, Angela M. Cooper, RN, MSN, CNL, Rachel Start, MSN, RN, and Karen Mayer, MSN, MHA, RN, NEA-BC, FACHE

urses must become Nfull partners with other healthcare disciplines to become involved and take responsibility for identifying system problems. Nurses devise and implement improvement plans, track improvements over time, and make necessary adjustments as lead- ers who implement change and help improve the healthcare system.1 We are facing the dilemma of fragmented healthcare that can only be improved through “new innovative care delivery models…that address patient needs and wants, span sites of care, result in more efficient use of resources, and demonstrate measurable improvement in patient satisfaction and quality outcomes over time.”2 With the implementation of the clinical nurse leader (CNL) role, the innovation unit as developed at Rush Oak Park Hospital (ROPH) addresses current healthcare system concerns, such as the creation of more effective interdisciplinary care, point-of-care coordination, and the implementation of evidence-based practice findings.3

OPH in Oak Park, Illinois, is a 176-bed, not-for-profit, The CNL role has been defined as a nurse who is a confi- Rgeneral medical and surgical community hospital that is a dent clinician, a leader within a microsystem, and a quality clinical partner of Rush University Medical Center in Chicago. manager. The CNL seeks evidence-based practices and has The initial innovation unit was implemented on ROPH’s 24- the ability to analyze system outcomes.4 Research shows that bed telemetry unit in September 2012. The general population the use of the CNL as a clinical decision-maker and active is a diverse, mainly elderly population with patient conditions member of the interdisciplinary team helps to drive the including congestive heart failure, chronic renal failure, compli- design and direction of cost-effective, evidence-based care cations of diabetes, sepsis, and pneumonia. within a microsystem.5 The CNL role is being explored

78 Nurse Leader August 2015 today by many practice institutions and employers. O’Grady Figure 1. CNL Patient Pamphlet and VanGraafeiland6 demonstrated that various uses of the CNL role since its development have helped to reduce the fragmented care in many institutions today. The reduction in fragmentation seen in ROPH since the implementation of the CNL role has led to improvements in care coordination, quality outcomes, patient satisfaction, and interdisciplinary relationships. The role of CNL is unique as compared with that of the registered nurse (RN) in that CNLs have the knowledge of a bedside nurse combined with the leadership skills to focus on patient- and family-centered care.6 BACKGROUND The innovation unit was developed with the ROPH vision and mission in mind to promote patient- and family-focused health, support, and education throughout a patient’s lifes- pan.7 The Rush Oak Park nursing care delivery model is a team-based, primary care nursing model for providing humanistic and focused patient-centered care based on Jean Watson’s Theory on Human Caring.7 The intended mission of the innovation unit is to develop processes for improving efficiency through the introduction of the CNL role. Processes for improvement were coordinated with all members of the interdisciplinary team utilizing the latest evidence-based practices. These processes promote the enhancement of patient safety, quality care, and patient and team satisfaction. After designating certified CNLs from within the hospital to lead the innovation unit, hospital outcomes were reviewed. Information analyzed before setting goals included patient and RN satisfaction scores, nurse-sensitive indicators, and the latest evidence-based information. The innovation unit goals set were to increase collaboration and satisfaction among members of the interdisciplinary team, enhance patient education, decrease average length of stay (ALOS), decrease patient 30-day readmission rates, improve quality indicators (such as falls, pressure ulcers, and central line infections), and successfully implement the CNL role. With these goals in mind, specific interventions were created for the implementation of the innovation unit. The interventions chosen were daily, CNL-led interdisciplinary rounds, a unit status board, Interdisciplinary Rounds teach-back for heart failure patients, and post-discharge fol- The interdisciplinary rounds intervention is a collaborative, low-up phone calls. interdisciplinary, team-based patient rounding process. Rounds are completed at the patient’s bedside and used to INTERVENTIONS share information and discuss the plan of care with input The admission process initiates the introduction of the encouraged from the patient or family. Patients help identi- CNL to patients and their families to help facilitate the fy their preferences related to their goals, care needs, dis- patient’s progress through the healthcare environment. The charge planning, and any transition barriers.8 The CNL CNL is a critical member of the interdisciplinary team who leads interdisciplinary rounds for all admitted patients on a helps guide patients through today’s complex healthcare daily basis (Monday through Friday) and is responsible for system and acts as a resource for solving complex nursing- reviewing the patient plan of care established by the team related problems.4 As new admissions occur, the CNL makes through any previous interdisciplinary rounds meetings. contact with the patient and family to explain his or her The CNL documents the outcome of rounds using the role. Contact information is supplied to patients through interdisciplinary rounds note (Figure 2). If the newly admit- business cards and a pamphlet (Figure 1). The CNLs monitor ted patient has a diagnosis of heart failure, the CNL also and help facilitate all patients’ progress toward discharge completes the heart failure assessment note to document while they are on the unit. whether heart failure core measures have been met (Figure www.nurseleader.com Nurse Leader 79 Figure 2. Interdisciplinary Rounds Note

Interdisciplinary Rounds Note (CNLROUNDS) Comments:

CNL confirmed all team members have introduced themselves by name and role? CNL/RN: Is patient 30 day readmit? Patient's reason for admit, plan of care, progress towards discharge. Isolation? Fall risk? DM/Stroke/HF education points added? CNL/RN: Lines that could be removed (Foley, PICC, Central Line).

CNL: Any nutritional issues? A1c>=7.0? Dietician consult ordered?

CNL/RN: reviewed/verified patient's immunizations/injections.

CNL: PT/OT needed? Order placed? PM&R consult necessary?

Pharmacist reviewed the patient's scheduled medications for today. Any medication issues? CM reviewed where the patient will likely go after discharge/who will be helping with care, needs, and possible discharge barriers. RN communicated the patient's daily goal(s) and updated the patient's white board. RN communicated the patient's greatest safety risk.

CNL asked patient/family: any concerns, questions? Has the staff cared for your mental, emotional, and spiritual health? CNL: Any ethical issues/concerns?

3). A CNL-developed tool called the Heart Failure Journey almost there, just give me another hour,” and green ϭ “I’m (Figure 4) is placed in the patient’s room as a visual good”), the RN or PCT may update the unit status board reminder for all nurses caring for the patient to ensure that with any changes. The charge RN or unit clerk is responsi- all heart failure core measures are met before discharge. ble for frequently updating the unit status board with the Journey “reminder” signs were also developed for stroke, number of anticipated discharges, admissions, transfers, and surgical care improvement process, acute myocardial infarc- any changes in patient information. The charge RN is also tion, venous thromboembolism, and falls. responsible for coordinating the breaks and buddies (ie, the During rounds, the RN is responsible for updating the RNs and PCTs who cover for each other when off the team about the patient’s diagnosis, morning assessment, and unit) for the shift along with their estimated break times. progress; reviews with the team the patient’s plan of care for The unit status board provides staff with a global picture of the day; and updates the patient’s information board in their what is occurring on the unit. The unit status board, when room. The pharmacist reviews scheduled medications (indi- updated at the beginning of each shift, is a shared process cations and side effects) with the patient during rounds and and visual indicator for managing breaks, staff workloads, the case manager reviews discharge plans and any potential patient flow, and patient status.9 discharge barriers. The CNL is responsible for facilitating the resolution of any issues discovered in rounds regarding HEART FAILURE TEACH-BACK the patient’s plan of care and then obtains an estimated At the time of admission, the CNL will have identified discharge date. patients who have been admitted with a diagnosis of heart failure.10 The CNL educates those patients about the heart UNIT STATUS BOARD failure teach-back intervention and reviews information During the unit’s change of shift, the charge RN uses the contained in patient education folders developed specifically unit status board (Figure 5) to facilitate a brief discussion for heart failure patients. regarding patient code status, behavioral or safety risks, pro- During focused heart failure education, the patient may cedures, falls, and other indicators being followed. RNs and be asked questions to ensure the teaching has been under- patient care technicians (PCTs) use the board to give others stood. The CNL asks the patient 4 specific heart failure on the unit a subjective look at any status changes in their teach-back questions daily to reinforce learning and assess workload throughout their shift. With the use of a colored patient understanding of what has been taught regarding magnet system (red ϭ “I’m swamped,” yellow ϭ “I’m heart failure.11 In teach-back, patients are asked to teach

80 Nurse Leader August 2015 Figure 3. Heart Failure Assessment Note

Heart Failure Assessment Note (CNLHFASSESS) Comments: Patient specific discharge instructions for diet and activity ordered?

LVS function assessment completed?

If LVS function assessment is not required, has the reason been documented? For patients with LVEF < 40%, ACE-Inhibitor/ARB prescribed at discharge? If ACE/ARB is not prescribed on discharge, is contraindication documented?

Figure 4. Heart Failure Journey

back the information that has been taught to them, in their ments the ability of the patient to answer teach-back ques- own words, in response to the questions asked. This allows tions through the completion of the heart failure teach- the person teaching to understand whether the patient has back note (Figure 6). comprehended the information and also gives the teacher insight into whether there is a need for the use of addition- TRANSITIONS ADVOCATE al teaching methods to help aid in comprehension. Heart As a patient advocate, the CNL helps patients make a failure teach-back is a process designed to focus on smooth transition from hospital to home. In addition, the improving patient care and safety by increasing communi- CNL keeps the patient processes moving along post-dis- cation. This process allows for assessment of the patients’ charge. The CNL role allows better facilitation of progress understanding of information provided by using specific through the continuum of care with the coordination of open-ended disease-related questions.11 The CNL rein- key activities.12 The CNL acts as a partner with the forces heart failure education at admission, at discharge, and patient’s attending physician to determine the necessity of again during a post-discharge follow-up telephone call follow-up appointments and then schedules a follow-up using the heart failure teach-back process. The CNL docu- appointment with the patient’s primary care physician or www.nurseleader.com Nurse Leader 81 Figure 5. Unit Status Board

Figure 6. Heart Failure Teach-Back Note

Heart Failure Teach Back Note (CNLHFTB) Comments: What is the name of your water pill?

How much weight gain would you want to report to your healthcare provider?

What high-salt foods do you need to avoid/be aware of?

Can you name 3 to 4 symptoms in the yellow zone (warning signs of when you want to call your healthcare provider)? Time Spent Teaching

Patient Orientation

Score

physician’s office if necessary. The CNL is responsible for ed and documented through the CNL discharge phone contacting all heart failure patients post-discharge to assess call note (Figure 7). Calls are made weekly until 30 days patient satisfaction and understanding of their diagnosis, post-discharge. Furthermore, the CNL has the ability to education, and self-care. With the use of an outpatient follow up with the attending physician through e-mail to electronic medical record charting system made available communicate any questions or concerns that the patient to the CNL, telephone follow-up phone calls are complet- may have post-discharge.

82 Nurse Leader August 2015 Figure 7. Transitions Advocate Discharge Phone Call Note

Discharge Phone Call Note (CNLDCCALL) Comments: Have you experienced any new symptoms or have previous symptoms worsened? Did you receive a discharge summary and have you reviewed it? Do you have an appointment with your primary care physician for follow-up? Have you had your follow-up appointments? Are you waiting for any follow-up tests? Are you receiving any type of home care? Has your home health provider contacted or visited you yet? Has your transition back to home been difficult? Do you have questions about your medications? Were you able to fill all of your prescriptions? Are you having any problems with your medications (headaches, dizziness, nausea)? Are you weighing yourself daily? What is the name of your water pill? How much weight gain would you want to report to your healthcare provider? What high-salt foods do you need to avoid/be aware of? Can you name 3 to 4 symptoms in the yellow zone (warning signs when you want to call your healthcare provider)? Is the patient advised to call PCP or specialist physician? Is the patient advised to go to the ED? Need to call MD and call patient back? Need to call outpatient pharmacy and call patient back?

PROJECT MEASURES decrease the ALOS, improve specific quality indicators, and To determine the success of the innovation unit, specific meas- improve overall satisfaction. ures were defined to determine whether the interventions have led to positive outcomes. Project-wide measures include deter- OUTCOMES mining whether there is an increase in collaboration and satis- The care model change was implemented October 1, 2012, faction among all members of the multidisciplinary team. on our telemetry unit. Through the implementation of the Collaboration and satisfaction was measured with the use of CNL role, data collected have shown improvements in all the Healthcare Team Vitality Instrument tool,13 which was outcomes: decreased ALOS and improved CMS core meas- administered before the implementation of the innovation unit ures, reduced quality indicators (falls, pressure ulcers, cen- and 1 year post-implementation.14 Other project-wide meas- tral line infections, and urinary tract infections), and ures to be used in determining positive outcomes that indicate increased HCAHPS scores (Figure 8). Subjective data have successful implementation of the CNL role were measures shown an increase in overall staff satisfaction and an such as HCAHPS scores, core measures, ALOS, and 30-day increase in the knowledge base of staff. On the initial unit heart failure readmission rates provided by the Rush Oak Park (telemetry), the readmission rate for heart failure patients Quality department. Measures are used to determine whether (Figure 9) dropped from 23.5% (October 2012) to 7.1% the innovation unit helped to enhance patient education, (February 2014). On our medical-surgical unit, where the www.nurseleader.com Nurse Leader 83 Figure 8. HCAHPS Telemetry-Communication With RNs

HCAHPS Telemetry-Communication with RN's

100

95 Communication 90 w/t RNs

85 Linear (Communication 80 w/t RNs)

Figure 9. Telemetry Heart Failure Readmission Rate

Telemetry Heart Failure Readmission Rate 50 45.4 45

25 22.2 21.4 Rate (%) 19.0 19.0 20 Linear (Rate (%)) 23.5 23.5 15 13.3 10.0 8.0 7.1 10 7.1 9.1 9.0 5 9.0 8.3 0 Jul-13 Jan-13 Jan-14 Jun-13 Oct-13 Oct-12 Apr-13 Sep-13 Feb-13 Feb-14 Dec-12 Dec-13 Aug-13 Nov-13 Nov-12 Mar-13 May-13

CNL role was initiated in October 2013, data have shown a was designed without adding any additional full-time decrease in ALOS (Figure 10) from 5.73 days (October equivalent personnel. 2013) to 4.85 days (May 2014). Data collection has been ongoing for both the telemetry and medical-surgical units DISCUSSION with consistent improvements on both units being realized. With the implementation of the CNL role, the innovation unit This was a cost-effective strategy because the care model developed at ROPH helps to address current healthcare system

84 Nurse Leader August 2015 Figure 10. Medical-Surgical Unit: Average Length of Stay in Days

Medical-Surgical Unit: Average Length of Stay (Days)

6 CNL Role Implemented 5.8 5.73 5.65.6 5.6 5.535.53 5.38 5.4 5.4

5.2

5 4.9 4.91 4.88 4.85 4.85 4.78 4.8

4.6

4.4

4.2 Jul - 13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 concerns through the interventions implemented. Throughout 11. White M, Garbez R, Carroll M, Brinker E, Howie Esquivel J. Is "teach-back" associated with knowledge retention and hospital readmission in hospitalized the implementation process, a learning process has occurred and heart failure patients? J Cardiovasc Nurs. 2013;28:137-146. challenges have been encountered and addressed. Overall, the 12. Agency for Healthcare Research and Quality, Boston University. An overview implementation of the CNL role has led to improved outcomes. of the reengineered discharge (RED) toolkit. 2011. Available at: https://www.bu.edu/fammed/projectred/newtoolkit/1.%20An%20Overview% Precise data collection and review continue to help in under- 20of%20the%20RED%20toolkit%203.2.11.pdf. Accessed July 2, 2012. standing how to further develop and fully integrate the CNL 13. Lee B, Upenieks V. Healthcare Team Vitality Instrument. 2011. role hospital-wide so that nursing can continue to use the latest http://www.ihi.org/knowledge/Pages/Tools/HealthcareTeamVitalityInstrument. aspx. Accessed August 8, 2012. evidence-based care while coordinating with all members of the 14. Upenieks VV, Lee EA, Flanagan ME, Doebbeling BN. Healthcare team vitality interdisciplinary team, promoting the enhancement of safety and instrument (HTVI): developing a tool assessing healthcare team functioning. quality patient care, and improving patient and team satisfaction. J Adv Nurs. 2010;66:168-176 Using the CNL role to meet today’s healthcare challenges should be synonymous with becoming a pivotal leader in Denise M. Wienand, MEd, MSN, RN, CNL, is Clinical Nurse Leader Liason at Rush Oak Park Hospital in Oak Park, Illinois. change in an ever-changing, complex healthcare system. NL She can be reached at [email protected]. Prachi R. Shah, MSN, RN, CNL, is Performance Improvement Specialist at References Rush Health in Chicago, Illinois. Brandy Hatcher, MSN, RN, 1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing CNL, is Clinical Nurse Leader at Rush Oak Park Hospital in Health. Washington, DC: National Academies Press; 2011. Oak Park, Illinois. Alison Jordan, MSN, RN, CNL, is Clinical 2. Kimball B, Joynt J, Cherner D, O’Neil E. The quest for new innovative care Nurse Leader at Rush Oak Park Hospital in Oak Park, Illinois. delivery models. J Nurs Adm. 2007;37:392-398. 3. Buerhaus P, Ulrich B, Donelan K, DesRoches C. Registered nurses’ perspec- Jennifer M. Grenier, MSN, RN-BC, is Unit Director, Telemetry at tives on health care and the 2008 presidential election. Nurs Econ. Rush Oak Park Hospital in Oak Park, Illinois. Angela M. Cooper, 2008;26:227-235. RN, MSN, CNL, is Unit Director, Intensive Care Unit at Rush 4. Smith SL. Application of the clinical nurse leader role in an acute care Oak Park Hospital in Oak Park, Illinois. Rachel Start, MSN, RN, delivery model. J Nurs Adm. 2006;36(1):29-33. is Magnet Program Coordinator at Rush Oak Park Hospital in 5. Lammon CA, Stanton MP, Blakney JL. Innovative partnerships: the clinical nurse leader role in diverse clinical settings. J Prof Nurs. 2010;26:258-263. Oak Park, Illinois. Karen Mayer, MSN, MHA, RN, NEA-BC, 6. O’Grady EL, VanGraafeiland B. Bridging the gap in care for children through FACHE, is Vice President, Patient Care Services at Rush Oak the clinical nurse leader. Pediatr Nurs. 2012;38:155-158, 167. Park Hospital in Oak Park, Illinois. 7. Rush Oak Park Hospital. Mission, Vision and Values. 2012. http://roph.org/about/mission.html. Accessed August 1, 2012. 1541-4612/2014/ $ See front matter 8. Institute for Healthcare Improvement. How-to guide: multidisciplinary rounds. Available at: http://www.ihi.org/resources/Pages/Tools/ Copyright 2015 by Elsevier Inc. HowtoGuideMultidisciplinaryRounds.aspx. Accessed July 8, 2012. All rights reserved. 9. Lee B, Shannon D, Rutherford P, Peck C. Transforming care at the bedside http://dx.doi.org/10.1016/j.mnl.2014.11.011 how-to guide: optimizing communication and teamwork. Available at: http://www.ihi.org/resources/Pages/Tools/ TCABHowToGuideOptimizingCommunicationTeamwork.aspx. Accessed July 8, 2012. 10. Institute for Healthcare Improvement. How-to guide: improved care for patients with congestive heart failure. Available at: http://www.ihi.org/resources/Pages/ Tools/HowtoGuideImprovedCareforPatientswithCongestiveHeartFailure.aspx. Accessed July 8, 2012. www.nurseleader.com Nurse Leader 85