INSIDE Motivate staff to achieve peak performance without ... · Motivate staff to achieve peak performance without increasing pay ... and performance more effectively than policies

INSIDE

Rule #1: Tie rewards to perform-ance: What you reward is whatyou get. For example, if you wanthigh performance, your high per-formers should be rewarded dif-ferently from your low performers.And if you want teamwork thenyou must reward team players.

Rule #2: Tie rewards to individ-ual preferences: Because everyemployee has different needs and wants, it’s important to knowyour employees and what moti-vates them. Ask them what theirinterests are and what gets

Managers believe that money is atop motivator, but it really doesn’tencourage employees to put forththeir best efforts. Research showsthat pay will achieve two objec-tives: it will ensure that employeescome to work and that they staywith your facility.

That’s certainly nothing to com-plain about, however, increasedpay is clearly not inspiring peakperformance.

Follow these rules to achieve peakperformance from your staff:

Leadership

Vol. 4 No. 8August 2004

> p. 2

Patient safetyRead these ideas for getting your staff excited about patientsafety initiatives on p. 3.

Interdisciplinary care cornerRead how one hospital created a new documentation process to improve interdisciplinary communication on p. 4.

Management skillsRead tips and suggestions onhow to navigate through the various groups within a healthcare facility on p. 6.

Nursing shortageRead how one veteran OR nurseis working to stem the nursingshortage on p. 7.

TrainingLooking for ways to engageresistant learners? Learn how toget through to unmotivated staffon p. 8.

Time managementAre you working hard but notgetting much accomplished? Read how efficient nurse managers “work smart” on p. 12.

Motivate staff to achieve peak performance without increasing pay

medications” order because he orshe intends for the patient to be-gin retaking the antiarrythmic. Butbecause the physician discontin-ued the order rather than holdingit, the patient may not be told totake the antiarrythmic. This couldhave harmful effects if the patientneeds the drug.

“The physician is the only onewho knows what he or she means,”say Sarah Moake, RN, nursemanager of the medical-surgicalunit at Henderson (TX) MemorialHospital.

Blanket orders, such as “resume all medications,” are dangerous be-cause physicians could forget toinclude previous vital medications,or nurses and pharmacists maymisinterpret the order.

For example, a physician could discontinue an antiarrythmic drugbefore a procedure, says MichaelHoying, RPh, MS, pharmacy direc-tor at Fairview and Lutheran hospi-tals in Cleveland.

After the procedure, the physicianmay issue a blanket “resume all

Communication

> p. 2

How to combat dangerous blanketmedication orders in your facility

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Motivate staff < p. 1

Medication orders < p. 1

Leadership

them excited.

Rule #3: Reward employees in public: Wheneverpossible recognize team members in front of theircolleagues. You should always punish in private andreward in public.

Rule #4: Reward staff in a timely manner: Re-ceiving a reward or recognition six months after anurse has gone the extra mile loses its impact. So do it now. And don’t worry if not all employees arepresent. It’s far better to get the recognition one-on-one, instead of not at all.

Rule #5: Be specific: When recognizing teammembers in public, be very clear about what isbeing rewarded or recognized. That level of speci-ficity allows other team members to emulate theright behavior and increases the probability that similar actions will be repeated.

Rule #6: Reward at random times: You are violat-ing this rule if employees get upset every time youare not rewarding them. Recognizing team membersrandomly causes the desired behaviors to be morelikely repeated and reduces the “WIIFM”—what’s init for me effect.

Rule #7: Tell stories: Get extra mileage out of your rewards and recognitions by becoming a storyteller. Telling stories about how a nursewent the extra mile to ensure that the patient re-ceived the best possible care helps staff internalizewhat’s important, and begins to shape behaviorand performance more effectively than policies or statistics.

Source: Don’t Oil the Squeaky Wheel and 19 OtherContrarian Ways to Improve Your Leadership Effec-tiveness. Rinke, W. J. McGraw-Hill, New York,2004.

It’s important to train nursing staff to automaticallycall the physician if they receive a vague order. Suchphone calls lead to better communication amongcaregivers and can prevent potential errors fromblanket orders.

If a physician gives an order to “continue home meds,”have staff find a list of the patient’s home medica-tions and have that present when they call to con-firm the order, says Sandra Fly, RN, HendersonMemorial’s director of performance improvement,quality, and JCAHO accreditation.

“It just comes down to being as professional as pos-sible and having as much information as possible,”Fly says.

Tips for staff to communicate efficientlywith a physician about a blanket order:

�Make sure you have enough informationabout the patient’s medications when youcall a physician to clarify an order.

�Write a clarification in the patient’s chartwhen you receive an order interpretationfrom the physician so another nurse doesn’thave to call the physician again.

Source: Hospital Pharmacy Regulation Report,June 2004, HCPro, Inc.

Communication

Page 3Strategies for Nurse Managers—August 2004 © 2004 HCPro, Inc.

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Patient safety

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Are you stumped for ways to get staff excited aboutyour facility’s patient safety initiatives? The followingare three inspiring suggestions that have worked infacilities across the country.

1. Design a patient safety–relat-ed crossword puzzle and giveprizes out to the first five or 10staffers who complete it correct-ly. (See sample puzzle on p. 5.)Consider distributing the puzzleat staff meetings or in nurses’mailboxes.

2. Sponsor a slogan contest. Award prizes for theperson who comes up with the catchiest phrase topromote your latest patient-safety project, suggestsDebra Molnar, a patient ombudsman at Wadsworth-Rittman (OH) Hospital. Print the winning slogan onpens, t-shirts, or balloons. Winning slogans atWadsworth-Rittman have included, “Patient Safety:Caring Without Compromise,” and the acronym“THINK,” which stands for:

Take your timeHandle with careInform others of concerns

Notice your surroundingsKnow your limits

3. Ask staff to sign a “Com-mitment to Patients” inwhich they pledge to not usecertain abbreviations or topause for a time out beforesurgery. Post the contractprominently throughout theunit. Nurse leaders should besome of the first in the hospi-tal to sign the contract and

should consider posting their signed copy prominentlythroughout each unit, says Barbara Organ, RN, direc-tor of licensure, certification, and accreditation forMemorial Regional Hospital in Hollywood, FL.

“It provides a level of accountability,” says Organ,whose hospital asks medical and nursing staff tosign such contracts. “If I sign on that I’m going todo this, then I’m going to work really hard to makeit happen.”

Source: Briefings on Patient Safety, July 2004,HCPro, Inc.

Three creative ideas to get your staff excitedand committed to patient safety initiatives

“[The contract] provides a level of accountability. If I sign on that I’m going to do this, then I’m going to work really hard

to make it happen.”

—Barbara Organ, RN


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Interdisciplinary care corner

During the JCAHO survey at Halifax Regional Med-ical Center in Roanoke Rapids, NC, the surveyortook a close look at patient records and noticed thatclinicians didn’t document how specialists from vari-ous disciplines communicated with one anotherabout their patients’ care plans.

However, nurses, physicians, and therapists did com-municate with one other daily—they simply didn’tdocument it.

“The surveyor wanted us to have one place in the patient record where everyone could see whateach discipline’s goals were for the patient,” saysMargaret Rose, the performance improvementdirector and hospital risk manager. Each disciplineneeded to be able to look at the big picture of thepatient’s care.

Problem #1: Some disciplines, such as nursing,entered their notes for patients into electronic med-ical records. Others, such as respiratory therapy,wrote their notes longhand and placed them into thepatient’s hard-copy file. Surveyors wanted more con-sistency so that all disciplines could open a patient’schart and with one glance, know what each clini-cian’s goals were for the patient.

Problem #2: The electronic documentation systemwas cumbersome. It required nurses to pass throughseveral screens before they reached the appropriatescreen allowing them to enter plan-of-care informa-tion. In addition, other caregivers, including physi-cians, were unable to access the information ifsomeone else was working on one of the unit’savailable computers.

Problem #3: Surveyors wanted to see that special-ists communicated with physicians, nurses, dischargeplanners, and case managers consistently to learnabout each patient’s care plan and any changes to it.

Improving interdisciplinary communication:How one hospital revamped its documentation

Those meetings occurred for patients with complicat-ed needs or who had extended hospital stays, butnot for all patients, says Rose.

Brainstorming solutionsThe hospital formed a task force that included 17people from various disciplines. The team split intotwo groups that brainstormed ways to improve thehospital’s documentation process for communicationamong disciplines. The teams gathered together atthe end of the five weeks to compare ideas andselect the best solutions.

Solution #1: The teams decided to create a simpletwo-page form that nurses must insert at the front ofeach hardcopy patient file. The form contains a des-ignated section for each discipline to enter basicinformation, such as the patient’s diagnosis, goals,expected length of stay, medications, special needs,and goals.

Providers from each discipline must fill out their cor-responding section of the form. If a provider from aparticular discipline doesn’t provide care for the pa-tient, a nurse must check off N/A, for nonapplicable,in the space reserved for that discipline’s notes.

“We didn’t want to leave anything blank,” says Rose.“We wanted to have some way to document that thepatient wasn't receiving certain care so that it wouldn’tlook as if it had been left blank due to an oversight.”

Solution #2: The task force also developed a 10-page handbook with care-planning language to tutorproviders who don’t document patient goals regular-ly. The handbook explains what care planning isand how to create and use an interdisciplinary planof care.

“Care planning has been an integral part of the nurs-ing process for a long time, but not with other


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disciplines, such as respiratory therapy,” says Rose.

Solution #3: In 2004, the hospital plans to move toa fully electronic documentation system that willmake it easier to enter and share patient informationwithin the organization. It will integrate the interdis-ciplinary information contained on the two-pageform.

ReactionSome nurses didn’t like the new form and regard-ed it as duplicate documentation because theyalready entered each patient’s goals into an elec-tronic record. The task force emphasized that nurs-

es merely needed to write their major goal for thepatient on the form and then check a box marked,“see documentation.”

“They didn't know that they didn’t have to put all oftheir detailed documentation on there,” says Rose.“It's just an overview.”

If you would like a copy of the two-page form thatHalifax Regional Medical Center developed contactRebecca Delaney at 781/639-1872, Ext. 3157 or [email protected].

Source: Briefings on JCAHO, April 2004, HCPro, Inc.

Patient safety puzzleNote: Find the answers on p. 11.

Across:1. Team participation in the development

of a patient’s plan of care should be_______.

3. You must use two of these when takingblood samples or administering medica-tions or blood products.

9. An infant abduction or patient suicidewould be a ______ event.

12. _______ on medical machinery shouldbe audible, never silenced, and attendedto promptly.

16.This is an absolute must while mixing orpreparing medications.

17.Morphine 2–5 mg IV every hour is anexample of a _____ order.

18.This should be part of your preop verification process.

20.These are high-alert medications. 21.Do this to help identify failure points

in high-risk processes.

Down: 2. Acute Myocardial Infarction, Pneumonia, and Congestive

Heart Failure are three such measures.3. This should have free-flow protection. 4. Number of nurses or licensed staff required to verify a

patient’s identification during blood administration. 5. Post-operative complications, wrong-site surgery, and

medication errors are a few examples of this. 6. U, IU, Q.D., Q.O.D. 7. This requires a definitive marking.

8. The JCAHO’s preferred mode of survey readiness. 10.Errors rarely occur in this manner. 11.This happens after a verbal or telephone order has been

written down. 13.The culprit behind medical errors.14.MS, MSO4, and MgSO4 are often _______ with one another. 15.Passé expression for hospital-acquired infections.19.Staff should always wash their hands before entering a

patient’s _____.

Source: Baylor Medical Center.Reprinted with permission.


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In any organization there are different “tribes” or groups of people who have their own culture and their way of thinking and communicating. Nowhere is this more evident than in a healthcarefacility, said Peg Neuhauser, MA, in her presenta-tion, “Orchestrating Healthcare Teams” during theCase Management Society of America’s annualmeeting in Nashville, TN, in June. Neuhauser gavefour tips on managing various groups within afacility to better lead staff and serve patients.

1. Watch out for tribal warfare. The first step to successful communication with various groupsis recognizing the groups that exist in your facil-ity and what has historically has been a stickingpoint between you and the people in this group.If there’s a group with which you have a historyof bad feelings or confrontation, prepare beforeyou meet with them.

Try brainstorming all of things they could say to you that could frustrate you, so that you’re not caught off guard during the meeting, saysNeuhauser. “If you’re prepared you can stay onfocus and on message,” she said. Also, if you usea word or phrase that usually irritates this grouptry to avoid repeating it when speaking withthem. “You have a huge vocabulary, use it,”advises Neuhauser. “Don’t let language interferewith your message.”

2. Informal connections are as important as for-mal connections. Take a look at the different“connectors” between groups. Neuhauser saidthere is always a “go-to person” who connectsvarious groups through informal relationships.You can get more accomplished by going to thisperson than through formal channels. “Seek thesepeople out; they’re incredibly valuable people totap into,” she said.

3. Develop the habit of connecting. When speak-

ing with staff or other nurse leaders make a habitof asking questions that link groups. Some ques-tions that are good to work into conversationinclude the following:

• What do you think?

• Who else might be affected by this?

• Who else needs to know about this?

Also, Neuhauser advises nurse leaders to bypasse-mail and call people or, even better, meet withcolleagues face-to-face. “The more electronic thecommunication, the less personal and the harderit gets to make connections,” she said.

4. Create the sweep effect. According to Neuhauser,a leader only needs 25% of staff to buy into ideasfor change—after you influence this segment mostlikely the rest will follow. “Identify the movers andshakers in your organization, these are the peoplewho will help get the momentum going and helpyou get things done,” she says.

Source: Orchestrating Healthcare Teams: The CaseManager as Leader, Peg C. Neuhauser, MA, CaseManagement Society of America annual meeting,Nashville, TN.

Management skills

Managing the masses: How to navigate through the various groups in a healthcare organization

Questions? Comments? Ideas?

Contact Associate Editor Rebecca Delaney

Telephone: 781/639-1872,

Ext. 3157

E-mail:[email protected]


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Nursing shortage

Veteran OR nurse works to stem nursing shortage

Louise DeChesser, RN, CNOR, MS, is worried. As a54-year-old babyboomer she knows as she growsolder and her health fails the dearth of qualifiedperioperative nurses will mean less quality care inthe OR.

DeChesser, who is the president of Surgical Solutions,a healthcare consulting company, knows firsthandhow serious the current shortage of OR nurses is, andshe says it will only get worse. “There are so few ORnurses that many facilities are using technicians to cir-culate through the OR and administer medications,”she says. “The OR nurse is on the decline and we’reusing more ancillary staff as a Band AidTM, but it’s nota permanent solution.”

Before going into ambulatory care administrationand nurse education, DeChesser worked as an ORnurse for 35 years. Today she teaches a unique,hands-on course to educate experienced RNs how towork in the operating room. Most nurses today don’tget that hands-on experience during their nursing

education, according to DeChesser.

“In the 60s and 70s students had a rotation in theOR for three months, and you could spend moretime there for an elective,” explains DeChesser.“Now nursing students get one day of observationand that’s their whole experience in the OR.”

Because of that lack of education nurses are notattracted to OR nursing, says DeChesser, and thosewho are interested in working in the OR are facedwith a dilemma. “It’s a double-edged sword,” shesays. “You can’t begin working in the OR withoutexperience, yet how can you gain experience with-out working in an OR?”

The course, developed by the American Organiza-tion of Perioperative Nurses, is geared toward vet-eran nurses and provides hands-on, practical training.It also provides college credit and continuing edu-cation credits if the nurse completes the semester.For more information, visit www.aorn.org.

Stress management

Quick tips to reduce stress in your day

Unfortunately, stress is a fact of life for both nursesand nurse leaders. Christine Dumas, DDS, andKevin Soden, MD, MPH, two national medical re-porters, provide tips on dealing with stress to helpyou handle the demands of your day:

• Put your coffee cup down. After drinking fouror five cups of coffee during the day, your bodyhas an elevated level of stress hormones all theway into the evening, making you feel morestressed out than you actually are.

• Reduce your stress on the spot. “Find a buddyto confide in,” advises Dumas. Whether it’s aglance at a meeting to convey your frustration ora quick phone call to let off steam, sharing the

cause of your stress with a friend as soon as pos-sible will lessen the effect it has on your work.

• Take a mini-vacation every day. “Go outside fora few minutes and walk around. You need to getaway from work to refresh yourself,” says Soden.

• Stop working when you leave work. “Theaverage person thinks about work for two hoursafter they leave,” says Dumas. It may be difficult,but try to leave the problems your dealing withon your unit when you walk out the door.

Source: Improving American Health Through CaseManagement, Christine Dumas, DDS, and Kevin Soden,MD, MPH, Case Management Society of America an-nual meeting, Nashville, TN. Reprinted with permission.

How to get through to change-resistant learners


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Training

transition from the familiar to the unknown.

• What trends and forces of change currently affectnursing?

• What are your strengths?• Which of these strengths will continue to make

you successful in the future? • What new skills do you need to learn to stay

valuable in the healthcare industry? • What have you learned in the past six months? • What do you expect to learn in the next six

months? • What do you need to unlearn? Which skills are

becoming obsolete? What practices (e.g., attitudes,behaviors, work routines, etc.) that worked foryou in the past are no longer valid?

This technique could help resistant staff adjust tonew concepts by offering a broader perspective on change. It encourages employees to reevaluatetheir individual contributions to the organization’sculture, and to consider how their attitudes andskills affect hospitalwide patient satisfaction andquality improvement.

Source: Healthcare Training Weekly, HCPro, Inc.

The one constant in the healthcare industry ischange. Whether you have to train staff on theJCAHO’s Patient Safety Goals, a new piece of equip-ment, or a new unit policy, introducing change canbe challenging—especially when staff members arenot receptive to learning about the change.

One principle of adult learning is that adults are self-directed learners. But what happens when adultsdirect themselves not to learn?

Resistant learners are restless, sometimes rebellious,and often sullen. Their negative body language andverbal remarks clearly communicate that they do notwant to participate, regardless of the topic or thelearning environment. Their attitudes influence otherstaff, making it difficult to establish and maintain apositive atmosphere. How can you deal with thisproblem and maintain your own positive attitude?

If your staff don’t always see change as an opportu-nity for professional or personal growth, use thisquick exercise to show them that mastering newconcepts and skills benefits their organization andaffects their performance reviews. Discuss thesequestions at an upcoming staff meeting to ease the

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JCAHO

plugs, a warm blanket, or a brief massage. If thepatient was still awake and requesting assistance 30minutes later, caregivers offered an over-the-countermedication to relieve minor pain that might interferewith sleep. If another 30 minutes pass, they provideda low dose of sleep medication that is not generally

associated with falls.

The collaborative found that 44%of patients fell asleep after re-ceiving warm tea or other inter-vention. Another 44% fell asleepafter receiving a nonprescrip-tion pain killer.

Another factor in patientfalls was the confused or

disoriented patient who doesn’t understand thathe or she should not walk without assistance. “Pa-tients need to be reminded that they’re on a numberof medications, in an unfamiliar environment, andbeing put through a routine of tests, procedures, andbed rest, all of which can make them weaker andmore susceptible to falling,” says Melissa Krauss,a researcher coordinator at Washington Medical Uni-versity Center.

According to Borgshdorf, the Madison collaborativealso implemented a “safe-room” setup, which in-cludes placing bedside tables on the nonexit side ofthe bed, locking bed wheels, tucking away electriccords, and installing bed-exit alarms. The collabora-tive provided continual fall-prevention educationwith a half-day inservice training program involvinga nurse known as a “unit champion” from eachunit.

Source: “Hospital Falls Study Suggests Ways to ReduceRisk,” Washington University in St. Louis, School ofMedicine and Briefings on Patient Safety, May2004, HCPro, Inc.

Reduce risk: Steps your facility can take to avoid patient falls during hospitalization

Nothing is more counterproductiveand frustrating for patients, their fami-lies, and caregivers than an injury sus-

tained in a fall during hospitalization. A new studyconducted by the Washington University School ofMedicine in St. Louis found that most patient fallsresulting in an injury occurred when thepatient was either in the bathroom, onthe way to the bathroom, or whileusing a bedside commode.

The JCAHO targeted patientfalls in its proposed NationalPatient Safety Goals for 2005.Patient falls are the second most-frequent cause of harm for patients,topped only by medication errors, saysAmanda Borgshdorf, MHSA, coordinator ofthe Madison (WI) Patient Safety Collaborative.

The following are suggestions to help reduce patientfalls in your unit:• Expand the use of regularly scheduled, assisted

trips to the bathroom for patients at risk for falling.

• Ask patients whether they use a walker or caneoutside of the hospital. Ensure that canes, walk-ers, and other assistive devices are available forpatients who need them. Many falls documentedin the study occurred when patients who normal-ly used a walker or a cane outside of the hospitalwere not using one when they fell.

• Avoid sleeping pills. Certain medications, such asthose that aid sleep, increase the risk of falls.

A group called the Madison Collaborative, composedof three medical groups and four hospitals started afall prevention program in 2001. The collaborativefocused on reducing the use of sleeping aids, offeringnatural sleep inducers, such as warm herbal tea, ear

Patient falls are the second most-frequent

cause of arm for patients,topped only by

medication errors.

—Amanda Borgshdorf, MHSA


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• Inadequate staffing, which can be perceived asnegligent judgment by the nurse manager

Ask yourself the following questions after an adverseevent to manage your risk:

• Did my staff follow organization policies, proce-dures, and practices? If not, did I adopt changesas soon as possible after the event occurred toprevent another adverse event?

• Was the nursing documentation reviewed foraccuracy and completeness?

• Were the necessary departments notified aboutthe event?

• Was an intensive investigation or root-cause analy-sis with staff completed as close to the event aspossible?

• Were the necessary changes adapted as soon aspossible?

• Were staff informed of the possible root causes of the event?

• Was education provided based on any changes to policies, procedures and practices?

Legal matters

Nurse supervision: Understand your responsibilities

Editor’s note: The following is an excerpt from Man-aging Documentation Risk: A Guide for Nurse Man-agers, written by Patricia A. Duclos-Miller, MS, RN,CNA, and published by HCPro, Inc.

As a director, nurse manager, or supervisor, you must ensure that patients have appropriate care and that staff members providing care have sufficient supervision. If a patient is injured and suspects that your staff were not adequately super-vised, he or she could allege that your supervisionwas negligent.

Your liability will be based upon the following:

• Your delegation of patient care to a nurse whowas unable to perform the care

• Your failure to personally supervise the nursewhen you knew or should have known thatsupervision was necessary

• Your failure to take the necessary steps to avoidpatient injury when you were present and able to intervene

The study’s authors tie their statistics to thenurse recruitment and retention problem afflictingcountless hospitals, stating their findings, “makeit clear that the processes used to identify er-rors, assign responsibility for them, and resolvepatient safety issues may have unintended, unfa-vorable effects on nurse recruitment and retention.”

Source: “An Error by Any Other Name,” Ann Freeman Cook, PhD, Helena Hoas, PhD, Katari-na Guttmannova, MA, and Jane Clare Joyner,JD, RN, American Journal of Nursing, June 2004.

Nursing in the news

Pointing the finger: Nurses blamed for most errors

Although only about 8% of physicians considernurses part of the decision-making team when itcomes to patient care, nurses are held account-able for the majority of medical errors, accordingto a study from the University of Montana, pub-lished in the June issue of American Journal ofNursing.

Researchers surveyed nurses, physicians, pharma-cists, and hospital administrators at 29 rural hospi-tals for three years. Ninety percent of hospitaladministrators surveyed said patient safety is pri-marily the responsibility of nurses.


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The first radio program solely devoted to nursesrecently aired its inaugural broadcast in May—featur-ing interviews with nurses from across the country.Nurseradio.org, operated by the New EnglandSchool of Whole Health Education and the AmericanHolistic Nurses Association, profiles nurses withinspirational stories, such as a nurse who workedwith victims of the Chernobyl nuclear disaster and anurse who served a tour of duty in Vietnam in the1960s in the business of nursing and public jealthnursing.

“I think nurses are feeling somewhat unsupportedin their efforts to provide the best patient care pos-sible,” says Mary-Anne Benedict, MSN, RN, chairof the Nurse Radio advisory board. “This radioprogram provides them an opportunity to hear from

nurse leaders and to grow professionally.”

With the seemingly permanent nursing shortage andincreased complexities and needs of patients, nursesare at high risk for burnout. Georgianna Donadio,PhD, producer and host of the program, says shehopes her show provides inspiration and motivationfor nurses to continue working in their field.

“Nursing is experiencing a tremendous crisis rightnow,” says Donadio. “Nurses are dissatisfied withthe work environment and they’re dropping out of the profession. We want them to know they’reappreciated.”

To listen to the radio program, visit www.nurseradio.org.

Celebrating Nurses

Tune in, breaking news: The first nurse-focused radio show launches on Web

Audioconferences:

8/3/2004: Effective Competency Assessment:How To Build Performance-Based JobDescriptions That Comply With JCAHO HRStandards

8/17/2004: Redesigning The Patient Care WorkEnvironment: How To Improve Patient Flow,Staff Satisfaction And Patient Safety

8/25/2004: How To Identify And Respond To Resident Falls

9/16/2004: Preparing Nursing/Clinical Teams To Adopt New Technologies

For more information call our Customer ServicesDepartment at 800/650-6787 to register.

AUG/SEPT Upcoming events

Puzzle answers

Across:

1. Multidisciplinary

3. Patient

identification

9. Sentinel

12. Alarms

16. Focus

17. Range

18. Time out

20. Electrolytes

21. FMEA

Down:

2. Core

3. Pump

4. Two

5. Sentinel event

6. Do not use

7. Site

8. Continuous

10. Isolation

11. Read back

13. Root cause

14. Confused

15. Nosocomial

19. Room

(from p. 5)


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Strategies for Nurse Managers

Editorial Advisory BoardShelley Cohen, RN, BS, CENPresident Health Resources UnlimitedHohenwald, TN

Sue FitzsimonsSenior Vice PresidentPatient ServicesYale-New Haven HospitalNew Haven, CT

David MoonExecutive Vice PresidentModern Management, Inc.Lake Bluff, IL

Bob Nelson, PhDPresidentNelson Motivation, Inc.San Diego, CA

Tim Porter-O’Grady, EdD, RN, CS, CNAA, FAANSenior PartnerTim Porter-O’Grady Associates, Inc.Otto, North Carolina

Dennis Sherrod, EdD, RN Forsyth Medical Center Distinguished Chair of Recruitment and Retention Winston-Salem State University Winston-Salem, North Carolina

Strategies for Nurse Managers (ISSN 1535-847X) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $179 per year. • Postmaster: Sendaddress changes to Strategies for Nurse Managers, P.O. Box 1168, Marblehead, MA 01945. • Copyright 2004 HCPro, Inc. All rights reserved. Printed in the USA. Except where specificallyencouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at 978/750-8400. Please notifyus immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For renewal or subscription information, call cus-tomer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available toselected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. • Opinions expressed are not necessarily thoseof Strategies for Nurse Managers. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specificlegal, ethical, or clinical questions.

Working smart: How to accomplish more in your day without working more hours

What is the difference betweenworking hard and working smart? Many people worklots of hours and feel they have really worked hard,yet they may not have been working smart. With allthe demands on a nurse manager’s time, it is oftendifficult to prioritize and work efficiently and effec-tively. When you are exhausted at the end of theday and feel like you’ve been spinning your wheelsand didn’t accomplished much, it’s time to ask, “wasI working hard or smart?” The following are tipsfrom managers who work smart:

• Determine before the day begins the most impor-tant task that needs to get accomplished that dayand don’t let yourself get distracted from complet-ing that goal.

• Don’t let staff decide priorities for you. A staff

Time management

We want to hear from you For news and story ideas:Contact Associate Editor Rebecca Delaney • Phone: 781/639-1872, Ext. 3157• Mail: 200 Hoods Lane, Marblehead, MA 01945• E-mail: [email protected]• Fax: 781/639-2982Publisher/Vice President: Suzanne PerneyGroup publisher: Kathryn LevesqueExecutive Editor: Emily Sheahan

Online resources:• Web site: www.hcpro.com• Visit HCPro’s Nursing site at www.hcpro.com/nursing

Subscriber services and back issues:New subscriptions, renewals, changes of address, backissues, billing questions, or permission to reproduce anypart of Strategies for Nurse Managers, please call ourCustomer Service Department at 800/650-6787.

member’s emergency doesn’t always have toreplace the first item on your “to do” list. Maybethe nurse’s emergency can go to your #3 or #4item.

• Ask yourself, what can I do today that will havethe most effect?

• Realize that sometimes smart work is work-ing with staff, helping them with tasks andprocedures. You may not be getting to the pile of paper on your desk, but you are get-ting more done by gaining trust and inputfrom staff.

Source: Adapted from the “Manager Tip of theMonth” by Shelley Cohen, RN, BS, CEN, HEalthResources Unlimited.

➤

A supplement to HCPro publications

Verifying NurseCredentials:Methods to reduce risk

and ensure patient safety

2 Verifying Nurse Credentials

Verifying Nurse Credentials:Methods to reduce risk and ensurepatient safety

BackgroundThroughout his 15-year nursing career, Charles Cullen, RN, workedat nine hospitals and one nursing home—and murdered 13 patients.As he moved from hospital to hospital, Cullen’s employers say theynever knew of his checkered past, which included an investigationinto his nursing care, an accusation that he had stolen drugs, and aconviction of criminal trespassing and harassment after he broke into anurse’s home in 1993. In 2004, Cullen pleaded guilty to 13 murdersand two attempted murders of patients in his care.

Investigators in the case learned that when Cullen applied to vari-ous hospitals, human resources representatives called his formeremployers who only disclosed the dates of his employment. Thiswas the case at Somerset Medical Center in Somerville, NJ, whereCullen worked for 13 months, killed 13 patients, and tried to killtwo more. When he came under criminal investigation for patientoverdoses, Somerset Medical fired Cullen, and he applied for a newnursing position at another New Jersey hospital. He lied on his ap-plication, stating he was fired from his previous nursing job for ob-taining a nursing license under false pretenses, when in fact he wasunder criminal investigation.

Cullen also lied on his New Jersey nursing license renewal formin 1999. When asked whether any licensed healthcare facility hadtaken action against him that affected his employment between 1997and 1999, Cullen answered no. In reality, he had been fired by theLiberty Nursing and Rehabilitation Center in Allentown, PA, for im-properly administering medications in 1998.

Although less extreme, the story of Susan Ann Robertson in Louisianais still alarming because of the serious threat posed to patient safety.

3Verifying Nurse Credentials

Robertson applied for a nursing job at Gambro Healthcare in Gonzales,LA, filled out an application, and told a hospital supervisor she wasa RN licensed in New York state. She said she applied for a Louisianalicense, but didn’t have it with her during the interview. Gambrohired Robertson, and she worked at the facility for three monthsuntil the administrators caught on, called the state boards in Louisianaand New York, and found out she was not and had never been alicensed nurse in either state.

“Why would you let a nurse, who underwent less scrutiny than aphysician, work in your critical care unit?” asks Hugh Greeley,founder of The Greeley Company in Marblehead, MA, and medicalcredentialing expert. Accounts of nurses and impostors such as Cullenand Robertson send a chill through the healthcare community, notonly because of the horrific breach of trust between caregiver andpatient, but also because healthcare administrators know that theytoo could have nurses who are hiding a shady past working on unitsand caring for patients.

Stories of nurses faking credentials, hopping from job to job in various states, and harming patients are a reminder that you mustbe diligent in verifying nursing applicants’ licensure, criminal back-ground, and education before hiring them to work on your units.

When hiring Cullen, Somerset Medical Center followed its own veri-fication procedure and called his previous employers. Unfortunatelythese former employers did not provide critical information that ulti-mately could have prevented the deaths of 13 patients. Although eventhe most rigorous verification process may not expose every incon-sistency in a nurse’s past, the more stringent the process, the morecapable your facility will be to find discrepancies in applicants’ back-grounds.

Unfortunately, the nurse-credentialing process in many facilities isinadequate—allowing nurses who may have had action taken againstthem by another state nursing board, a criminal history, or incom-plete education onto the unit—making patients vulnerable and the


facility liable. Most facilities verify nursing credentials in a processdifferent from physician credentialing. However, considering howclosely nurses work with patients, subjecting nursing applicants to aless stringent credentialing process may not be in your facility’s orpatients’ best interest.

Applicants hiding their pastsIt is a sad reality that it is no longer reasonable to assume yournursing applicants are telling the truth on their applications and intheir interviews. Raymond Jacobs, a vice president at Kroll Back-ground America in Nashville, TN, a background-screening company,estimates that 13% of applicants for hospital positions have a crimi-nal past. Also, one out of every three job applications has an inten-tional error, according to CBSMarketwatch.com.

Human resources complianceThe “Management of Human Resources” chapter of the JCAHO’sComprehensive Accreditation Manual for Hospitals states that hospitalsmust have a process to ensure an applicant’s qualifications are con-sistent with the position’s responsibilities. Under standard HR.1.20, thehospital must verify the applicants licensure, education, experience,competency, and criminal background according to the law, the facili-ty’s policy, and regulations.

Verifying licensure and credentialing nurses can be a confusing pro-cess. Today, more nurses move from state-to-state throughout theircareers, and different states have different requirements for licensure.Twenty-three state boards do not conduct criminal background checkson applicants for nurse licensure—they rely on the applicant to dis-close such information on the license application.

Unfortunately, applicants can’t always be trusted when answeringthese questions, and their past could come back to haunt the insti-tution when the truth eventually comes out. “If the nurse isn’t com-petent, that will be realized quickly because each nurse is undersupervision of a dedicated, highly skilled nurse manager,” says Greeley.However, a nursing applicant’s criminal past isn’t as obvious, he says.


Although your facility may be compliant under JCAHO because it follows policies and regulations when hiring nurses, current poli-cies may not adequately spell out how to scrutinize a nurse’s back-ground. Examine your facility’s bylaws or human resources (HR)policy and procedures to see whether they protect your patients andsufficiently screen applicants for dangerous nurses or impostors.

Proposed legislationAfter the Cullen murders came to light, there was a groundswell ofcalls for reform. New Jersey Senators Jon Corzine (D) and FrankLautenberg (D) proposed legislation earlier this year to expand theNational Practitioner Data Bank (NPDB) to include nurses and otherhealthcare professionals.

The NPDB is a federally funded clearinghouse for information onphysicians, dentists, and other healthcare practitioners. Facilities canfind information about medical malpractice payments, adverse licen-sure actions, adverse clinical-privilege actions, and adverse profes-sional society-membership actions.

If passed, Corzine’s and Lautenberg’s legislation would require hos-pitals to report to state nursing boards and to the NPDB when theytake any adverse action against a nurse. They would also have toreport a nurse if he or she violates a federal or state law, includingstate health professional standards, such as drug diversion, falsifica-tion of documents, or repeated medication errors. When hiring nurses,facilities would be required to first check the NPDB for informationon the applicant’s background. If a facility did not report informationto the database or did not check the NPDB before hiring a nurse,they could be fined up to $50,000 per violation.

The senators’ legislation also provides protection to healthcare“whistleblowers,” or employees who report activities that violatestandards of care to the NPDB.

Currently, there is no similar central repository for disciplinary infor-mation on nurses. The National Council of State Boards of Nursing


maintains NURSYS, a database of nurse license and license disciplineinformation provided by participating state boards of nursing. Currently27 states provide license information to the NURSYS database.

The New Jersey state assembly also reacted to the Cullen case bydrafting a bill that would allow hospitals to share more detailedinformation about a former employee when contacted by anothermedical facility looking to hire that individual. An amendment wasadded to the bill to allow the state board of nursing to double-checkinformation provided by license applicants and nurses applying forrenewal.

A centralized credentialing process Credentialing nurses usually falls to the HR department in most in-stitutions, while the medical staff office handles physician and advance-practice RN credentialing. Because of this split, the credentialingprocess is often different for nurses than it is for the medical staff.

This should not be the case, says Laura Harrington, RN, MHA,CPHQ, practice director of external peer review, credentialing, andnational seminars at The Greeley Company. “It doesn’t matter whetherthey’re an employee or part of the medical staff, facilities should usethe same procedure to verify licenses during the initial application,”she says.

Harrington says creating a consistent credentialing process will ensurethat everyone who has contact with patients has been properly vetted.This is common sense considering how much time nurses spend one-on-one with patients.

Current practicesIn a recent HCPro survey on nurse credentialing, 98% of respondentssaid their facility did have a process in place to verify nurse creden-tials. However, credentialing processes are laden with weaknessesof which a fraudulent applicant could easily take advantage. Forexample, when asked how they verify a nurse’s credentials, 78% ofrespondents said they photocopy the nurse’s license. “It’s not good


enough to photocopy a license and stick it in the file,” says Harrington.“With today’s technology, visual verification of a license is not suffi-cient. Someone can easily forge a license and use it to obtain a nurs-ing position if the facility does not verify the license with the stateboard.”

Several respondents said they verify credentials merely by lookingat the nurse’s license, and only 38% of respondents said they con-tact nursing applicants’ previous employers during the hiring process.

Best practicesTake the following critical steps to verify nurses’ credentials and toensure your patients’ safety and your facility’s integrity:

Step 1: Gather applicant’s informationThe application for employment should be thorough and shouldobtain the information needed to ensure patient safety in your facili-ty. “If this first step isn’t well done, then the entire decision processis compromised,” says Greeley.

Ask for the following information on your application:

• The applicant’s name as well as other names they have used(e.g., a maiden name)

• Education, degree obtained, and name and location of educa-tional institution

• Professional licensure, state where the license was issued, dateissued, license number, and expiration date

• Specialty certifications

• Employment history

• Disciplinary actions on their license


Also be sure to ask whether the applicant has ever been convictedor pleaded guilty or no contest to any criminal charges (other thanspeeding violations). If the answer is yes, ask the applicant to speci-fy the charges and the dates they occurred. Also inquire whether theapplicant has ever been convicted or pleaded guilty or no contestto a drug or alcohol-related offense and ask whether he or she hasever been suspended, sanctioned, or otherwise restricted from par-ticipating in any private, federal, or state health insurance program(e.g., Medicare or Medicaid), or similar federal, state, or health agency.

Step 2: Verify applicant’s information After asking the applicant the questions above, it’s imperative toverify this information to the best of your ability. Document eachverification step, even if you don’t find anything, to further reduceyour institution’s liability. Some facilities hire a third party to verifyapplicants’ information, but most often the HR department completesthis task. Either way, make sure there’s a specific, established processfor verification.

Primary verification is the best method to check an applicant’s qual-ifications, including education, licensure, and past employment.Most state nursing boards post licensure information on their Websites. However, one state nursing board head recommends thatfacilities call their state board for the most up-to-date information.“Our Web site is up-to-date, but if something happened in the pastfew days, although it may not be up on the site, we would stillknow about it,” says Dorothy Fulton, RN, MA, executive adminis-trator for the Alaska State Board of Nursing. Also check the stateboard in every state where the nurse has worked.

Also, consider running criminal background checks on all applicants,even if your state nursing board runs a check of its own. The nursemay have committed a crime after receiving his or her license. Inmost states, the responsibility is on nurses to notify the state boardif they are convicted of a crime—which they may or may not do,putting your facility at risk.


When checking past employment, facilities will most likely onlyprovide the dates the employee worked and if he or she is eligiblefor reemployment. “We try to get more information than dates theemployee worked, but these days facilities are hesitant to give youa whole lot more,” says Debra Rapert, HR director for Marion (OH)General Hospital. Rapert says it’s a red flag if a facility tells her anapplicant is not eligible for rehire. “That should tell you what youneed to know,” she says.

Another important step in credential verification is checking federalsanctions lists. If a nurse who has been sanctioned by the Office ofInspector General or General Services Administration works in yourfacility, you could be fined thousands of dollars. Reasons for sanc-tioning run from defaulting on a student loan to Medicare fraud. Re-member, these sanctions do not always show up on a state boardlicensing Web site.

Warning signsKeep an eye out for the following “red flags” when gathering andverifying an applicant’s information:

• Gaps in job history: Ask the applicant about any gaps inhis or her job history, but realize there will be interruptionsfor life events such as the birth of a child or a family emergency.

• Moving from state to state: “This could potentially be a redflag, because so much information could be buried,” says CeceliaRagland, RN, MSN, from SCM Associates, a credentialing firmin Bellflower, CA. If a nurse has worked in several states, besure to carefully check the status of his or her license in eachstate.

• Job hopping: Any HR professional would take a second lookat any applicant who has jumped from job to job. When hir-ing nurses, patient safety is at stake, so carefully check the


applicant’s work history by calling each employer to verify thatthere were no disciplinary actions taken against the nurse.

Step 3: Continually verify employee’s license after hire dateMost facilities check their nurses’ licenses when they come up forrenewal to make sure they’re current and active. However, it is cru-cial that facilities institute a process to check licenses more often.Ensure that your policy spells out that it is the nurse’s responsibilityto report any disciplinary action taken against his or her licenseover the course of the year. If the nurse does not report any actionto the HR department, they could be working on the floor, interact-ing with patients with a suspended or inactive license. This leavesyour patients vulnerable and your facility liable. “Conduct periodicchecks with your state board to make sure there are no nurses withrevoked or suspended licenses from your facility,” says Harrington.

Transforming the credentialing process at your facilityCreating a new credential-verification process for nurses may appearto be a daunting task. But as the Cullen case shows, it’s one that istoo important to ignore. Nurses, who often have the most direct con-tact with patients, should be subjected to the same scrutiny given tomembers of the medical staff such as advanced practice nurses, cer-tified nurse anesthetists, and physicians. “Make credentialing a cen-tralized and consistent process,” advises Harrington.

Making this change will entail an evaluation of staff and resourcesas well as a review of your facility’s bylaws. HR administrators shouldconsult the medical staff office since they most likely have an estab-lished credentialing process in place.

Strategically plan, develop, and train a department solely responsiblefor the review of nurses’, physicians’, and other health profession-als’ credentials during the application process, as well as through-out the year once you’ve hired them. Ensure this new process is con-sistent with your facility’s bylaws—if it’s not propose revisions tothe appropriate regulations.



This special report is published by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. • Copyright 2004 HCPro, Inc. All rightsreserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form orby any means, without prior written consent of HCPro or the Copyright Clearance Center at 978/750-8400. Please notify us immedi-ately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. Ifyou have questions, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected] • Opinionsexpressed are not necessarily those of the editors. Mention of products and services does not constitute endorsement. Advice givenis general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. HCPro, Inc., is not affili-ated in any way with the Joint Commission on Accreditation of Healthcare Organizations.

SR350408/04

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