Nurse Navigator Fellows in Pittsburgh Developed Projects to Improve Patient Care and Patient Safety
The Jewish Healthcare Foundation (JHF) of Pittsburgh designed the Nurse Navigator Fellowship as a one-year pilot project to train nurses in southwestern Pennsylvania to collect and analyze data and improve patient outcomes at the point of care. Nine fellows completed the training and developed projects in their home institutions.
- JHF designed the fellowship based on a model used by Toyota to involve frontline workers in making improvements. The Discovering Data Curriculum, designed specifically for this initiative by the Pittsburgh Regional Health Initiative, taught nurses to apply rigorous scientific methods to quality-improvement projects.
- All of the fellows developed special projects in their home institutions. One project eliminated nursing turnover in one patient unit during the fellowship year, four projects sought to improve quality of patient care and four projects sought to improve patient safety.
The Robert Wood Johnson Foundation (RWJF) supported this project with a grant of $93,810 to JHF from September 2005 through March 2007. JHF provided matching funds.
The Jewish Healthcare Foundation, a Pittsburgh-based not-for-profit organization committed to improving health care services to vulnerable populations in western Pennsylvania, has been involved in a number of efforts to strengthen leadership within the nursing profession.
In 2005, the Jewish Healthcare Foundation and the Oncology Nursing Society, a professional organization also based in Pittsburgh, convened a summit to develop strategies by which hospitals can gain "magnet" status. The American Nurses Credentialing Center awards magnet status to hospitals in which nurses deliver excellent patient care, have high job satisfaction and are involved in research and decision-making at the point of care.
After the summit, the Jewish Healthcare Foundation surveyed many hospitals in the region and found that they were pursuing magnet status but viewed the requirement that nurses pursue research as a major obstacle. Nurses who realized that research had direct application to patient care were more likely than those who did not to collect and use data, but most did not have the time, training or institutional support required to learn how to do this properly.
With the goal of transforming the field of nursing and improving health care at the bedside, the Foundation's focus on nursing shifted in 2002 from one on access to one on quality. Nursing initiatives since that time have focused on improving the quality of patient care.
RWJF's signature nursing initiative, Transforming Care at the Bedside (TCAB), exhibits this changed paradigm; the program's explicit aims are to improve the quality and safety of patient care and to increase retention of experienced nurses.
In addition, the Interdisciplinary Nursing Quality Research Initiative (INQRI), which provides funding for interdisciplinary studies that address critical gaps in what is known about nursing quality and for the synthesis, translation and dissemination of results to key stakeholders, was designed to assess the impact of nursing workforce and work environment characteristics on nurse and patient outcomes.
RWJF began working with the Pittsburgh Regional Healthcare Initiative in 2000. This work was part of RWJF's effort to reduce the gap between what is known about the best ways to care for people with chronic diseases and what is actually practiced. Under the aegis of the Clinical Care Management Team, RWJF was then focused on specific chronic conditions, such as depression and pediatric asthma.
According to RWJF's 2000 Annual Report, support for the Pittsburgh Regional Healthcare Initiative was "of a more exploratory nature an effort spearheaded by area business, health care, and philanthropic leaders to dramatically improve the quality of care in the region. Initially, the Initiative is attempting to eliminate in-hospital infections and medication errors."
The Pittsburgh initiative is part of a national network, the Network for Regional Healthcare Improvement. The network originated in 2004 when the leaders of two regional health care improvement coalitions, one in Minnesota and one in Pittsburgh, began to explore topics of common interest. As of 2008, there are six member coalitions (two in Minnesota, one each in Massachusetts, California, Wisconsin and Pennsylvania [Pittsburgh]) participating in monthly teleconferences. RWJF provides grant support for the national network.
In the years since this initial grant, RWJF's objectives have evolved. As of 2008, RWJF is seeking to help communities set and achieve ambitious goals to improve the quality of health care in ways that matter to all patients and their families, and in particular to patients from specific racial and ethnic backgrounds who often experience lower-quality care. See Grant Results ID# 041743.
In 2008, RWJF issued a Call for Proposals for its Advancing the Science of Continuous Quality Improvement national program. Like the Nurse Navigator Fellowship, this program is grounded in Toyota's efforts to improve quality on an ongoing basis.
The Jewish Healthcare Foundation designed the Nurse Navigator Fellowship as a one-year pilot project. Its short-term goal was to provide nursing fellows in southwestern Pennsylvania with the resources to make changes in their institutions by:
- Increasing their ability to identify problems in patient care processes.
- Using data at the point of care to improve patient outcomes.
- Creating supportive networks among colleagues.
The long-term goals of the fellowship were to improve both nurse retention and the quality and safety of nursing care.
Under contract with the Jewish Healthcare Foundation, the University of Pittsburgh School of Nursing evaluated the Nurse Navigator Fellowship by interviewing participants and collecting quantitative and qualitative data about the projects that each fellow created.
The Pittsburgh Regional Health Initiative designed the Discovering Data Curriculum specifically for this fellowship to teach nurses to apply rigorous scientific methods to quality-improvement projects. The Pittsburgh Regional Health Initiative is an operating arm of the Jewish Healthcare Foundation that develops tools and strategies to help health care leaders improve their organizations. The Jewish Healthcare Foundation evaluated the Discovering Data Curriculum through interviews and informal discussions, supplementing the University of Pittsburgh's more formal evaluation of the entire program.
According to reports to RWJF:
- The Jewish Healthcare Foundation designed the Nurse Navigator Fellowship to give fellows the necessary information, support and tools to drive and measure nurse-led improvements in clinical care outcomes. The fellows:
- Attended an intensive five-day course, called the Perfecting Patient CareSM. The course was adapted from Toyota's model of work redesign, which involves frontline workers in making improvements.
- Spent eight hours a month in class time, over 12 months, using an interactive and discussion-based approach. Guided by the Discovering Data Curriculum, fellows learned to conduct literature reviews, analyze data, identify problems, communicate a vision and share strategies for change.
- Worked with coaches, who attended meetings in order to promote dialogue, share information and provide insight as fellows developed their individual projects.
- Eleven professional registered nurses from health care facilities in southwestern Pennsylvania were accepted as fellows into the Nurse Navigator Program, and nine completed the program. They represented 10 institutions, including rural and suburban community hospitals, teaching hospitals and a community-based mental health clinic. The host institutions donated time for nurses to participate, and the Jewish Healthcare Foundation provided $10,000 stipends to each fellow.
- All of the fellows developed a special project in their home institutions to improve nurse retention, quality of care or patient safety and presented a business case for pursuing these initiatives. The projects are summarized in Appendix 1 and in "Nurse Navigators: Guides to Quality" (see the Bibliography).
Evaluators at the University of Pittsburgh School of Nursing concluded that the Nurse Navigator Fellowship could "provide the necessary information, support and tools to drive and measure improvements in health care outcomes thus supporting nurse-led, evidence-based modification in a health care system."
They also reported the following findings:
- One project eliminated nursing turnover in one patient unit during the fellowship year, four projects sought to improve quality of patient care and four projects sought to improve patient safety. The project director added that two of the projects resulted in cost savings: $18,500 from redesigning nursing steps in a hospital emergency department and $880,000 in recruitment and training costs by eliminating nursing turnover in a transplant unit. See Appendix 1 for project descriptions.
- The Nurse Navigator Fellowship created a network of colleagues, as measured by program attendance and continuing relationships. Over the course of the year, 67 percent of the fellows attended all educational sessions. All nine fellows continued to network with at least one other fellow after the program ended.
- All fellows reported administrative or upper-level management support for their projects. When fellows did report a lack of institutional support, it came most frequently from other staff nurses. Lack of support from middle managers also may have been a problem, but the evaluation was not structured to measure this fully.
- Eighty percent of the fellows reported time constraints as a major concern. They indicated that completing their projects took longer and had a greater impact on their other workplace responsibilities than they had anticipated.
The curriculum evaluators reported to RWJF that the Discovering Data Curriculum:
- Touched on the major themes of evidence-based nursing research and practice and successfully introduced new research and data concepts. However, the curriculum did not appear to break new ground with its treatment of evidence-based research.
- Presented the curriculum material in a somewhat problematic order. In particular, training on data collection and measurement was interspersed with other, "softer" topics, which may have detracted from the focus on rigorous research.
- Provided the fellows with inadequate training in certain technical skills, such as use of Excel and PowerPoint®.
The University of Pittsburgh School of Nursing evaluators cited the following limitations:
- The sample size of nine fellows may not have provided sufficient quantitative data for a meaningful analysis.
- All of the fellows should have been tested both prior to and after the fellowship in order to assess any impact of their educational levels or experience.
The University of Pittsburgh School of Nursing evaluators recommended that:
- In choosing fellows, nurses with management experience should be given priority over frontline nurses. The evaluation suggested that nurse managers were more likely than other nurses to remain in the program.
- Nurses should not pursue projects that require system-wide assessment data about patient and staff satisfaction. These data are not readily available.
The curriculum evaluators recommended that the Discovering Data curriculum be revised to:
- Focus more precisely on quality-improvement interventions.
- Provide sufficient time for theoretical, methodological, technical and experiential learning.
- Cultivate the leadership potential of nursing staff. "Leadership and improvement potential is often buried within our organizations. We have really committed wonderful, strong individuals who, for the lack of some training, some skills and some time, are not able to reach their full potential. With the appropriate support and tools, it can be brought out to benefit patient care and organizational success." (Project Director/Nancy Zionts)
- Provide institutional support for individuals trying to promote change. "The current structure of our institutions does not support the ability of people at the front lines to get support on a regular basis. Wouldn't it be nice if the systems embraced calling in experts and working in teams to promote systemic change?" (Project Director/Nancy Zionts)
AFTER THE GRANT
Since the first Nurse Navigator Fellowship was completed, the Jewish Healthcare Foundation has used the model to train pharmacists, who need skills in conducting research and building a business case for change; and librarians, who need skills in using the Internet to help underserved people find health information. They plan to conduct further Nurse Navigator Fellowships.
GRANT DETAILS & CONTACT INFORMATION
Co-funding the Nurse Navigator Fellowship Program to Improve Skills in and Increase Accountability for Hospital Quality Improvement
Jewish Healthcare Foundation of Pittsburgh (Pittsburgh, PA)
Dates: September 2005 to March 2007
The Nine Projects of the Nurse Navigator Fellowship
The projects undertaken by the nurse fellows are described by evaluators at the University of Pittsburgh School of Nursing here and in "Nurse Navigators: Guides to Quality":
- One project eliminated nursing turnover in one patient unit during the fellowship year. Improving communication, identifying bottlenecks and creating systems by which overwhelmed nurses could call for help halted staff departures at the University of Pittsburgh Medical Center at Shadyside's abdominal transplantation unit. By contrast, 22 nurses had departed in the 20 months prior to the project. Project staff estimates having saved $880,000 in recruitment and training costs by eliminating turnover.
- Four projects sought to improve quality of patient care:
- University of Pittsburgh Medical Center at Shadyside allowed nurses to initiate therapy in intensive care units, using flowcharts and standardized protocols. As a result, patient length of stay was reduced by an average of 2.2 days per patient among the first 100 patients treated following project implementation.
- Nurses at Family Services of Western Pennsylvania introduced a standardized tool to expedite the initial patient evaluation process at a mental health center. The result was a 17 percent decrease in waiting times for appointments, a 7 percent increase in the time doctors spent with patients and a 10 percent increase in the time nurses spent with patients.
- After observing the time-consuming steps that nurses were taking to start IV lines, draw blood and give medication, nurses at the Alle-Kiski Medical Center Emergency Department in Natrona Heights, Pa., introduced a number of strategies to improve the environment, including relocating supplies. The resulting efficiencies saved $18,500 in a year, according to project staff.
- Children's Hospital of Pittsburgh standardized the "hand-off" of patient care when shifts change or patients are transferred by creating a uniform system of reporting information. The new approach will be tested and refined.
- Four projects sought to improve patient safety:
- Monongahela Valley Hospital declared "zero falls" to be a hospital-wide goal, and the nursing team evaluated various high-tech and low-tech options to prevent patients from falling. The hospital has increased its use of bed alarms and low beds, implemented an evidence-based falls prevention protocol and experienced an overall decrease in falls.
- To eliminate problems of mistaken identity, and the inappropriate treatment that can result, Grove City Medical Center, jn Grove City, Pa., sponsored 29 mandatory educational sessions for approximately 300 staff members and made patients and community members aware of the measures being introduced to ensure patient safety.
- To lower rates of hospital-acquired infections at the University of Pittsburgh Medical Center at Shadyside, a nursing team ordered more comfortable protective equipment, including gowns and gloves, and added a patient care technician or nurse's assistant to emergency response teams in order to assist clinicians in donning their gear. As a result, isolation equipment is more readily available and more comfortable, and staff members have expressed greater "buy-in" related to their ability to generate change.
- After transferring from an intensive care unit to an obstetrics unit, a nurse at Allegheny General (Pittsburgh) recognized that the obstetrics unit was not as well prepared to respond to emergencies. Her project helped educate staff about rapid responses and helped relocate emergency medicine to the bedside.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Grunden N. The Pittsburgh Way to Efficient Healthcare: Improving Patient Care Using Toyota Based Methods. New York: Productivity Press, 2007.
"Nurse Navigators: Guides to Quality." Branches. Pittsburgh: The Jewish Healthcare Foundation, Winter 2007.
"Nurse-led improvementtimes 9." PRHI Executive Summary. Pittsburgh: Pittsburgh Regional Health Initiative, January/February 2007.
"Nurse-Led Discovery: Saving Steps, Saving Patients." Branches. Pittsburgh: The Jewish Healthcare Foundation, Winter 2007.
Report prepared by: Nina Berlin
Reviewed by: Karyn Feiden
Reviewed by: Marian Bass
Program Officer: Susan B. Hassmiller