The Stanley Shalom Zielony Institute for Nursing ... · moved under The Stanley Shalom Zielony Institute for Nursing Excellence umbrella, so too did the operating budget. Consolidating

Notable NursingFall 2014 | A Publication for Nurses by Nurses The Stanley Shalom Zielony Institute for Nursing Excellence

Feature Stories

Leading by Example: Nurse Leaders Model Importance of Unity — p. 1

Far Away, but Not Forgotten: Integration Efforts with Nurses Across Continents — p. 6

It All Comes Back to Communication — p. 8

Wound Care Affinity Group — p. 12

Also Inside

A Closer Look at Affinity Groups — p. 14

Sharing Best Practices — pp. 11, 15

Research News — pp. 16, 17

ONECleveland Clinic

This publication is printed on paper

certified to the standards of the Forest

Stewardship Council (FSC).

K. KELLY HANCOCK, MSN, RN, NE-BCExecutive Chief Nursing OfficerCleveland Clinic Health SystemChief Nursing Officer, Main Campus

Dear Colleagues and Friends,

Welcome to our fall 2014 edition of Notable Nursing. In this issue, we are excited to share with you an overview of our system integration efforts of the last five-plus years. It was in 2009 that The Stanley Shalom Zielony Institute for Nursing Excellence was centralized, and we set out to fully standardize policies and practices across our many Cleveland Clinic hospitals.

We start this issue with a closer look at how nursing leadership came together to create a strategic plan to develop nursing practices and care delivery models that could be understood and applied globally. Read about this in our “Leading by Example” article on the next page. Our feature on page 12 takes a deep dive into how we are integrating wound care protocols across the system. Wound Care is one of nine affinity groups across our hospitals created to bring each specialty care area together to standardize practices and protocols.

We also take a closer look at how we have been able to integrate the practices of our faraway hospitals in Florida and Abu Dhabi even as we allow for differences in state policies and a country’s culture. Later in the issue, we hear from Staffing Resources on how the team has worked to centralize all staffing practices to ensure the best in patient care while realizing big cost savings. And finally, our page 8 feature on communications takes you inside our vital and continuously evolving website where nursing is staying connected across facilities, cities and even continents.

Also in this issue, we have our regular Research and Best Practices columns in which we share exciting new research developments and some of our most successful best practices making an impact on patient care.

From implementing innovations and patient care protocols to standardizing our purchasing policies across the system, nursing leadership and all nursing staff came together to create unity and consistency. Integration has been about steering our nursing professionals and nursing practices in the same direction and working together at all levels — in a phrase: to truly be “One Cleveland Clinic” in all our nursing endeavors.

I hope this issue gives you ideas for innovation in your own setting. Please contact us to share your activities or to explore how we can work together to advance our vital profession. You can reach us at [email protected] look forward to hearing from you.

Table of Contents

Feature Articles

p. 01 Leading by Example:Cleveland Clinic’s Nursing Leaders Work Hand in Hand, Modeling the Importance of Unity for Frontline Staff

p. 04 Streamlining External Staffing:Standardizing the Approach to Hiring External Agency Staff Results in Huge Savings

p. 06 Integration Efforts Ensure That Cleveland Clinic Nurses Working Outside of Northeast Ohio Remain an Integral Part of the Team

p. 08 Using the Power of the Web to Unify Across Hospitals, States and Even Continents

p. 12 Wound Care Affinity Group Focuses on Consistency and Collaboration Across the Health System

Best Practices

p. 11 Falls Are Down: Unit-SpecificNursing Councils Reduce Patient Falls by as Much as 30 Percent

p. 15 Nurse Devises Simple Way toControl a Prolapsed Stoma

Research

p. 16 Chemotherapy Nurses Don’tFollow Safety Guidelines as Often as They Think

p. 17 Diabetes Outcomes ImproveWhen APNs Are Involved in Care

Back Page

Awards

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216.448.1039 Notable Nursing Fall 2014

Nurses in the thoracic surgery step-down unit at Cleveland Clinic’s main campus regularly gather

around a whiteboard for team huddles. The dry erase board is imprinted with an image of the Zielony

Nursing Institute’s Professional Practice Model (PPM), which is divided into four guiding principles:

quality and patient safety, professional development and education, research and evidence-based

practice, and healing environment. The nurse manager adds key discussion points to the appropriate

quadrant.

The PPM board is not unique to the thoracic surgery step-down unit. All nursing units and inpatient

areas across the health system rely on the visual management tool. “The whiteboards take our

Professional Practice Model and make it come alive,” says K. Kelly Hancock, MSN, RN, NE-BC,

Executive Chief Nursing Officer. Whiteboards serve another purpose, too: They help rally nurses

across the system behind the PPM.

Established in 2008, the Zielony Nursing Institute comprises 12,000 nurses and more than 4,000

support caregivers. It strives to create and uphold the image of “one Cleveland Clinic nurse,” says

Hancock. “If you are a patient and enter any of our hospitals or family health and surgery centers, you

should expect to receive the same level of care and witness the same level of professionalism from

any Cleveland Clinic nurse.”

Leading by ExampleCleveland Clinic’s Nursing Leaders Work Hand in Hand, Modeling the Importance of Unity for Frontline Staff

Spearheading the drive toward a unified nursing depart-

ment are approximately 350 nurse leaders, starting with

Hancock, eight associate chief nursing officers (ACNOs)

and 11 chief nursing officers (CNOs) at community hospi-

tals and other Cleveland Clinic healthcare facilities. Under

Hancock’s guidance, this core leadership team adopts prac-

tices and policies and steers all Cleveland Clinic nurses in

the same direction.

Appointing systemwide ACNOs

Prior to formation of the Zielony Institute, nurses

functioned independently by hospital, with CNOs reporting

to hospital CEOs. “There were different cultures at each

system hospital, and we had duplication and variation in

nursing-related resources,” says Hancock. “What really

stood out was the lack of a unified practice model for

nursing. There was no sense of a team.”

In 2008, Cleveland Clinic CEO and President Toby Cosgrove,

MD, appointed an executive chief nursing officer to lead the

Nursing Institute and changed the reporting structure so

that CNOs report to this executive CNO, with a dotted line

to their local CEOs. Nursing leaders, managers and direc-

tors from across the system partook in a strategic planning

forum, and subsequent quarterly leadership sessions, to

create a mission, vision and values. “We considered where

we needed to be as a group and how we wanted to get there,”

says Jacqueline Nowlin, MBA, BSN, RN, NEA-BC, Director

of Nursing at Lakewood Hospital, a Cleveland Clinic com-

munity hospital. “The strategic planning forum helped

bring nurses at each hospital together under one leadership

team.”

When pondering how to integrate thousands of nurses from

multiple facilities, nursing leaders at the forum initially

focused on three fundamental areas of nursing — clinical

practice, informatics and education. The Zielony Nursing

Institute created associate chief nursing officer positions

corresponding with each of those areas. ACNOs support

integration in their respective areas across the health

system.

For instance, the ACNO for clinical practice moved multiple

policies and procedures from all Cleveland Clinic facilities

to one common platform. “Standardization decreases the

variation, which hopefully impacts outcomes from a quality

perspective,” says Hancock. She cites central line placement

and care as an example. “No matter what ICU a nurse works

in, you can be assured the protocol for taking care of the

patient with a central line is standardized.” The same holds

Jacqueline Nowlin,

MBA, BSN, RN,

NEA-BC

Sheila Miller, MSN, MBA, RN

4Ways to Foster Unity

Talking about an interconnected nursing team is one thing. Making it happen is another. Here are four examples of programs, groups or events put into place by nursing leaders to foster cohesiveness among Cleveland Clinic nurses.

Affinity Groups These groups of specialty nurses from throughout the health system represent nine key areas, including critical care, emergency services, oncology and rehabilitation. Affinity groups convey information systemwide, throughout each department, to standardize nursing practices. (Read about the Wound Care Affinity Group on page 12.)

Nursing Leadership Summit Held each July, this leadership conference provides the executive CNO, ACNOs, CNOs, nurse managers and clinical nurse specialists a venue to brainstorm on strategic themes and plan for the future. The summit features presentations by renowned healthcare leaders, such as Tim Porter-O’Grady and Patricia Benner.

Nursing Excellence Awards The systemwide awards are divided into two groups: enterprise and local. Awardees, nursing leaders and other dignitaries celebrate honorees from across the healthcare system at an annual ceremony.

Nursing Residency Program Cleveland Clinic developed and launched its own nurse residency program on Jan. 1, 2014, to help bridge the education-to-practice gap in nursing. All new nursing graduates who are hired by the health system must participate in the program, which focuses on competency and uses simulation as one method to achieve goals.

clevelandclinic.org/notable

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true for administering medication, changing dressings,

using restraints and any other task performed by nurses.

Today, ACNOs represent the following areas:

• Ambulatory Services

• Emergency Services

• Informatics

• Nursing Education and Professional Development

• Nursing Quality and Practice

• Cleveland Clinic Main Campus

• Research and Innovation

• Surgical Services

Establishing a council of leaders

“ACNOs act as cross-pollinators,” says Sheila Miller, MSN,

MBA, RN. She is CNO of South Pointe Hospital, a Cleveland

Clinic community hospital. “They bring expertise around

a particular body of work, then take those best practices

and cross-pollinate them across the enterprise.” They are

When nursing at all Cleveland Clinic facilities moved under The Stanley Shalom Zielony Institute for Nursing Excellence umbrella, so too did the operating budget. Consolidating finances allows the institute to look at costs across all its facilities and make sound decisions concerning staffing, pay practices, supplies, capital budget procurement and so on. “We wanted to make sure we weren’t addressing each nursing area individually and in a silo,” says Chad Minor, Institute Administrator and Finance Director. “When we begin the annual operating budget process, we approach it from a system perspective to ensure consistency across all hospitals.”

The first thing the finance team did when the budget became centralized was look at all the detailed cost centers to get an accurate view of nursing expenses at each facility. The team examined labor expenses, which account for 89 percent of costs, and nonlabor expenses such as supplies. It took a year to get expenses mapped to the appropriate areas. Now each nursing unit at every facility has its own cost center, which includes only nursing expenses.

aided by the systemwide Nurse Practice Council and Affinity

Groups, both of which develop and implement standards of

care, policies and procedures.

Nursing leaders model the importance of collaboration

and interconnectedness by serving on the CNO Council.

Hancock, the ACNOs and hospital CNOs meet twice a

month to get an update on nursing initiatives, share best

practices and receive a financial overview. They also approve

any initiatives or changes to policies and procedures

recommended by the Nurse Practice Council and Affinity

Groups, then make sure the information gets disseminated

to frontline staff through the intranet, newsletters, huddles

and a variety of communications.

“With the support of the CNOs and ACNOs driving

integration, we’re able to be as successful as we are today,”

says Hancock. “It has a positive impact on employee

engagement and patient outcomes.”

Email comments to [email protected].

Next, Minor and his team developed uniform naming conventions. “All nursing cost center descriptions begin with ‘NRS,’” he says. “Anybody, anywhere — whether a CNO, the hospital COO or someone in finance — can quickly identify cost centers that the Nursing Institute manages.” Finally, the institute developed service-line reporting that allows leaders to assess how the entire health system is doing from a nursing standpoint as well as a fiscal breakdown by hospital.

Minor says the advantages of a centralized budget became evident last year. “As we began to see changes in the industry materialize, everyone’s focus was on identifying opportunities to improve quality while reducing costs,” he says. In 2013, the Zielony Nursing Institute removed $30 million from its budget. One of the biggest cost-saving decisions was to eliminate weekender pay.

Under the weekender program, when nurses worked two 12-hour weekend shifts, they received pay for an additional eight hours, bringing their total hours to 32 per week, which made them

eligible for full-time benefits. The Nursing Institute changed its policy to pay nurses only for hours worked; however it “grandfathered” in benefits for existing weekender nurses.

Nursing leaders relied on a multipart communica-tion plan to explain weekend changes to frontline staff. First, frontline leaders were informed to get their buy-in. Next, Executive Chief Nursing Officer K. Kelly Hancock, MSN, RN, NE-BC, held a town hall meeting to present the policy and the reasons behind it. “We were transparent about changes in healthcare today,” says Hancock. “We need to be more efficient and provide quality care that’s more affordable to our patients.” Ultimately, frontline staff understood that eliminating weekender pay saved jobs, minimized layoffs and preserved the number of caregivers at the bedside.

Consolidating Nursing’s Operating Budget

Chad Minor


The Stanley Shalom Zielony Institute for Nursing Excellence clevelandclinic.org/notable

4

“We wanted to make sure we were optimizing resources we

currently had before moving forward with external agency

staffing,” says Duffy, MSM, RN, Director of Cleveland Clinic

Nurse Recruitment and Cleveland Clinic Staffing Resources.

So in the fall of 2012, Cleveland Clinic Staffing Resources

undertook a project to standardize requesting, selecting,

onboarding and training of external agency staff. To keep

hospitals and nurse managers involved in the project work

processes, Duffy and Sasala, Department Work Leader

for Staffing Resources, began by conducting in-person

interviews with staffing office managers from Cleveland

Clinic’s main campus and each of its eight community

hospitals. Their initial goal was to learn the process each

facility followed when hiring external agency personnel.

“We quickly found out that no one was doing exactly the

same thing,” says Sasala. “So we developed a phased

approach to coordinate external staffing.”

Phase I Standardize Forms & Approval Process

In November 2012, Cleveland Clinic Staffing Resources

took over responsibility for all long-term requests for RNs

and LPNs as well as extension requests. Requests from

all community hospitals went through Staffing Resources

while main campus continued to work through its staffing

office.

One of the project goals was to ensure that everyone un-

derstood the fiscal ramifications of hiring external agency

personnel. Sasala and her staffing coordinator counterpart

Donna Arnold developed a standard request form that

requires approval from unit managers, nurse managers,

nursing directors and CNOs. “We wanted to make sure that

we had the correct approvals and everyone was aware of

who would be brought in and what the process would be,”

says Sasala.

The approval form requires a review of current resources

and internal PRN nurse options. Simply by implementing

this form, Duffy and her peers noticed a shift in thinking.

“Instead of going right for the gusto — making the quick

call to an external agency and requesting a nurse — we were

able to fill a large percentage of the gaps with nurses from

our float pool,” says Duffy.

Phase II Coordinate Time Cards, Invoicing & Per Diem Requests

During the initial interviews with hospital personnel, Duffy

and Sasala discovered that there were opportunities to

enhance efficiencies with further review and approval of

agency time cards and invoices. “Without a standardized

and consistent process in place, the previous process

opened up the potential for risk. We needed to make sure

that we were good stewards of our resources,” says Duffy.

In March 2013, Cleveland Clinic Staffing Resources insti-

tuted a time card approval process for unit managers. Each

week, nurse managers log onto the ShiftWise™ work man-

agement system, review the hours worked by external per-

sonnel and approve hours worked. “We then had the peace

of mind that we were paying the correct amount for the

correct time worked, and we had an audit trail to prove it,”

says Sasala. The process also revealed some time card fraud,

which provided Sasala and Duffy the opportunity to provide

S t r e a m l i n i n g E x t e r n a l S t a f f i n g

Standardizing the Approach to Hiring External Agency Staff Results in Huge Savings

Prior to 2012, when a Cleveland Clinic nursing unit needed an agency nurse, the nurse manager or hospital staffing office typically reached out to an external staffing agency. This struck Jennifer Sasala and Meg Duffy, who work in Cleveland Clinic Staffing Resources, as inefficient and uneconomical. They thought a standardized approach to external agency staffing could streamline the process, save money and encourage nursing units to consider the institute’s enterprise float pool of more than 200 caregivers. The team brought the idea to nursing leadership and got the green light to go ahead with centralizing the process.

Meg Duffy, MSM, RN

4


5


Contracting with personnel from an external agency isn’t as simple as placing a phone call, then welcoming the nurse. Cleveland Clinic uses a systematic approach, developed by the hospital’s Staffing Resources Department. “External agency personnel are brought on board with the same expectations and requirements as Cleveland Clinic caregivers,” says Jennifer Sasala, Department Work Leader for Staffing Resources.

When a nursing unit requests a long-term contract, staffing coordinators match the requirements with the appropriate external agency personnel. Then, using a detailed checklist developed internally, they perform more than 50 tasks, including the following:

3 Verify and print the nurse’s licensure

3 Send offer letter to the agency

3 Schedule the nurse for testing (EKG, Metidose and Performance-Based Development System)

3 Receive statement of good health

3 Obtain Cleveland Clinic contractor ID

3 Set up nurse to complete COMET (Cleveland Clinic’s Center for Online Medical Education and Training)

3 Email agency/nurse itinerary, Cleveland Clinic expectations and required forms (confidentiality, emergency contact, etc.)

3 Conduct background checks and fingerprinting

3 Forward unit management team an FAQ document to review onboarding expectations and unit responsibilities

3 Schedule three-day nursing orientation

3 Schedule unit orientation

Cleveland Clinic Staffing Resources has similar checklists for ongoing monitoring of external personnel as well as the exit process.

additional education through an FAQ document on the

importance of responsibilities and efficiency when external

agency personnel is at a Cleveland Clinic facility.

In addition, Staffing Resources established batch invoicing

and a formalized plan for signing invoices. Each week,

Sasala and Arnold receive and process all invoices from

external agencies. The Zielony Nursing Institute set up

a separate cost center for external staffing agencies to

more easily track costs. “This helped our relationship with

Cleveland Clinic health system managers as well as external

agencies because they now were getting paid in a more

timely fashion,” says Sasala.

Phase III Unite Staffing Personnel & Assemble Documentation

In April 2013, the Cleveland Clinic Staffing Resources office

became the central point of contact for all Nursing Institute

external agency requests for all health system hospitals and

regional medical practices. “Everything now goes through

one door, which was a huge undertaking because there were

so many requests from both community hospitals and main

campus,” says Sasala.

The team developed additional forms to streamline the

process and created an external agency binder to maintain

templates. Forms include everything from long-term

contract request forms to performance evaluation forms.

The team also created a personnel checklist that covers all

phases of onboarding, file creation, ongoing requirements

and the exit process. “It’s a complete walk-through from

start to finish,” says Sasala. Staffing Resources uses the

binder to ensure all potential external personnel meet not

only the requirements of the unit where they will work, but

also adhere to standards set by The Joint Commission and

the Ohio Hospital Association.

The standardization process was laborious and challeng-

ing. “When we set out, it was difficult,” admits Duffy. “We

weren’t saying to managers, ‘No, you can’t use external

agencies.’ It was about how we could assist them in bring-

ing in the right resources and having an efficient staffing

model.”

So far, the system is working well. In 2012, the Zielony

Nursing Institute spent $4.9 million on external agency

personnel. That number plummeted to $1.5 million in 2013

and was only $130,360 through the first five months of 2014.

“We’ve been able to mobilize our own staffing resources

and offset a lot of external agency activity,” says Duffy. “And

while the process is about gaining efficiencies, it is first and

foremost about keeping patients safe and providing the

highest quality of care; essentially, living our ‘Patients First’

guiding principle.”


In 2012, the Zielony Nursing Institute spent

$4.9 million on external agency personnel. That

number plummeted to $1.5 million in 2013.

Onboarding External Personnel

5

Notable Nursing Fall 2014


6

Offering long-distance learning is just one of many ways

the Zielony Nursing Institute ensures that nurses outside

of Northeast Ohio receive the same access to professional

development, resources, clinical best practices and more.

Cleveland Clinic nurses are on the same team, whether they

work at main campus, more than a thousand miles away

at Cleveland Clinic Florida or across oceans at Cleveland

Clinic Abu Dhabi.

Communication is key

Making sure that nurses in long-distance locations remain

in the loop begins with nursing leadership, including

Executive CNO K. Kelly Hancock, MSN, RN, NE-BC, and

Cleveland Clinic’s eight associate chief nursing officers.

“They set the tone for integration and make sure everybody

has a voice at every level,” says Kerry Major, MSN, RN, NE-

BC, Chief Nursing Officer at Cleveland Clinic Florida. “If you

don’t have leadership that supports that philosophy, then

all the emails in the world aren’t going to help you be part of

the enterprise.”

Ms. Major points to the recent rollout of the nurse

residency program as an example. At the beginning of the

year, Cleveland Clinic unveiled its own program to bridge

the education-to-practice gap in nursing. It’s a radical

transformation in the way the health system onboards

and trains new graduates, concentrating on competency

and simulation. Major and her colleagues collaborated

with a team from Nursing Education and Professional

Development, led by Associate Chief Nursing Officer Joan

Kavanagh, MSN, RN, NEA-BC. Six nursing directors from

Cleveland Clinic Florida worked with Kavanagh to develop

a timeline for instituting the residency program. Then staff

from Ohio traveled to Florida to assist with the first cohort.

From the time the 150-bed hospital in Weston, Florida

joined the Cleveland Clinic health system in 2006, its nurses

have felt included. When the Zielony Nursing Institute was

formed in 2008, nurses from Florida joined in strategic

planning. “My leadership team and I were involved in the

integration from the very beginning,” says Major. “We were

active participants in the strategy around what the Nursing

Institute would look like” — which is to say, what her team

would look like.

Keeping the lines of communication open is key. Nursing

teams use a host of tools, including video conferences,

texts, emails, conference calls and instant messages. “It’s

a constant dialogue,” says Major. “Over the years, we have

built up networks with our peers in Ohio, and no one here is

hesitant to reach out to them.”

When Cleveland Clinic Florida began its quest for Pathway

to Excellence® Program designation, the coordinator was in

constant contact with those who handled the designation

process at the health system’s four Pathway to Excellence

hospitals. “They were instrumental in helping us put our

application together and successfully receive designation in

May,” says Major. The process also was made easier because

the Florida hospital adheres to the same policies and

procedures as all Cleveland Clinic hospitals.

Following policies, Respecting cultures

Representatives from Cleveland Clinic Florida are

members of the systemwide Policies and Procedures

Committee, giving them a voice in the development and

implementation of guidelines that affect bedside nursing.

All policies and procedures are available online on the

nursing intranet, making them easy to access for any

Integration Efforts Ensure That Cleveland Clinic Nurses Working

Outside of Northeast Ohio Remain an Integral Part of the Team

In 2010, the Zielony Nursing Institute launched the Vascular Access Resource Nurse (VARN) program aimed at increasing knowledge of best practices in vascular access. Hundreds of nurses throughout the health system enrolled in the intensive eight-hour education program, held at Cleveland Clinic’s main campus. Although nurses at Cleveland Clinic Florida could not readily attend the class in person, they were not left out — 30 nurses participated through video conferencing.

7


Cleveland Clinic facility. This was especially helpful to

Randall Steven Hudspeth, PhD, MSN, MBA, RN, when he

became CNO of Cleveland Clinic Abu Dhabi in 2011. (He’s

now a consultant.)

The hospital in the United Arab Emirates (UAE) will open in

March 2015. Hudspeth’s role during the three-plus years he

served as CNO included building relationships within Abu

Dhabi and the UAE, interacting with the construction team,

and developing and executing the recruitment plan for

more than 1,000 clinical caregivers.

In May of this year, Ann Williamson, PhD, RN, NEA-BC,

took over as CNO at Cleveland Clinic Abu Dhabi (CCAD).

A key attraction for her was the strong enterprise nursing

leadership and the team at Cleveland Clinic, and the sense

that CCAD would be an international replication of the very

best that the health system has to offer. Williamson has

already spent concentrated time at main campus and has

plunged into the challenges of finalizing the orientation/

onboarding processes, in collaboration with Cleveland

Clinic leadership. When CCAD opens, caregivers will be

fully prepared and patients will have the best opportunity

for excellent outcomes.

Since January, Cleveland Clinic Abu Dhabi has hired

approximately 750 clinical staff from North America,

Europe, Australia, New Zealand, India, the Philippines and

the Middle East. “We’re not telling them how to be a nurse

or allied health provider (AHP) — we’re telling them how

they’ll be a nurse/AHP here,” Hudspeth says. “And we’re

using Cleveland Clinic’s fundamental tools to do that,”

Williamson adds. This includes practice protocols, the Epic

electronic medical records system and the Cleveland Clinic

model of care.

While much of this framework will remain intact at the 350-

bed hospital in Abu Dhabi, some things had to be changed

to meet laws in the UAE or to respect the Middle Eastern

culture. For this reason, Hudspeth oversaw the arduous

task of reviewing all Cleveland Clinic protocols. Some were

edited for minor reasons, such as semantic differences.

For example, any references to “elevators” were changed

to “lifts.” Other alterations impacted treatment: Certain

medications used in the U.S. are not available in the UAE.

These kinds of changes aren’t made only at international

healthcare facilities. Cleveland Clinic Florida has adapted

policies too, primarily to meet state regulations. For

instance, the State of Florida requires that patient care

policies be reviewed annually, but this is not a requirement

in Ohio. So the Florida hospital’s policies are on a different

review cycle.

Perhaps the largest changes at Cleveland Clinic Abu

Dhabi were made because the vast majority of citizens are

Muslim. “We took Cleveland Clinic’s model of care and

added on nuances for the Middle East using a framework

called the Crescent of Care, which guides the care of Arab

Muslim patients,” says Hudspeth. Individualization to the

environment of care is important, so in Abu Dhabi, if a

patient is nearing death, the nursing staff may be requested

to reposition the bed to face the holy city of Mecca.

Embracing One Cleveland Clinic

But the overarching goal of providing quality, relationship-

based care remains identical. “The relationships you have

with patients are the same whether you are on the Cleveland

Ohio main campus, in Florida or in Abu Dhabi,” says

Williamson.

The Zielony Nursing Institute strives to keep its nursing

leaders and frontline staff at all facilities abreast of any

initiatives aimed at keeping patients safe, providing a

healing environment, promoting professional development

and supporting evidence-based practice. “We truly feel a part

of the enterprise,” says Major. “We are one Cleveland Clinic.”


Joan Kavanagh, MSN, RN,

NEA-BC

Kerry Major, MSN, RN,

NE-BC

Ann Williamson, PhD, RN,

NEA-BC


8

ONEUsing the Power of the Web

to Unify Across Hospitals,

States and Even Continents

8

9


ONERallying nearly 12,000 nurses across a main campus, eight

system hospitals and two faraway hospitals — in Florida

and Abu Dhabi — would mean building a platform that

could reach every last one of them. And it would mean

finding creative ways to engage with nurses to build a sense

of unified purpose.

“The nursing intranet,” says Mandy Barney, Marketing

Manager for nursing, “is the foundation to our house. We

built everything else on top of it.”

“The intranet site has created great enthusiasm,” says

Nelita Zytkowski, DNP, MS, NEA-BC, RN-BC, Associate Chief

Nursing Officer, Office of Informatics, who oversees the

team responsible for updating the nursing intranet.

Since 2009, when overhaul of the intranet site began, it has

improved and grown exponentially. It went from a static

website to a leader-driven, user-friendly website complete

with news feeds, videos, shared governance documents,

research posters, a nursing innovation center, career and

educational opportunities, organizational charts, an events

calendar and more.

It is the one place where nurses can stay informed about

nursing efforts across the system and across the field

of nursing. And importantly, it is a place for two-way

communication where nurses can provide their feedback

and learn more about their colleagues’ efforts.

“It has become the go-to place for need-to-know informa-

tion,” says Barney. “Nurses are busy and don’t have a lot of

time to spend online, so you have to give them content that

is timely and relevant.”

When nursing leadership set out to integrate the Zielony Nursing Institute’s policies and practices across the entire Cleveland Clinic health system, it was apparent that strong central communication was the most critical part of the plan if they were to achieve success.


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Providing engaging content

Today, the content-rich site is designed around Cleveland

Clinic’s Professional Practice Model, and it has an average

of 16,000 visits from nurses across the system every week.

“Our centralized communications ensure that we are not

only delivering the right message, but also continuing

to support our culture of shared governance,” says Joan

Kavanagh, MSN, RN, NEA-BC, Associate Chief Nursing

Officer. “It is so important to hear and honor the voices of

our nurses.”

With all roads leading to the nursing intranet, Marketing

is able to track and measure readership to find out what

nurses find most valuable. “We are always listening to

feedback so we can continue to engage nurses and give

them what they need,” Barney adds.

This year, the most highly trafficked time on the site was

during National Nurses Week in May. Celebratory events

were featured and a series was posted called “Generations of

Nurses,” which highlighted stories about Cleveland Clinic

nurses who were related. Nurses also had the opportunity

to send fellow colleagues flowers and ecard thank yous in

honor of the special week; and they were invited to post

nursing messages and photos on Twitter, Instagram and

Facebook.

Another great advantage of this virtual communication

tool is the ability to connect all of nursing with nursing

leadership. In the past year, Executive Chief Nursing

Officer K. Kelly Hancock, MSN, RN, NE-BC, launched

her “Momentum Series.” In these five-minute videos,

she and guest nurses talk candidly to viewers about the

latest nursing initiatives to keep everyone informed.

Hancock does this regularly in addition to her bimonthly

e-newsletter, which is sent to all nurses with links back to

the intranet — always for more information.

Kavanagh believes that streamlined communications

have been instrumental in facilitating a “culture of unity”

across all nursing units in the system. “Effective, timely

internal communication is the key driver in building trust

and commitment,” she says. Cleveland Clinic’s Nursing

Institute has seen tremendous gains on this based on

results from the Gallup employee engagement survey. In

2013, there was a 92 percent survey participation rate across

the institute, and engagement scores jumped from the 38th

to the 61st percentile from 2008 to 2013.

“In this time of rapid and intense change, our communica-

tions had to evolve from merely conveying information to

exchanging information and involving our nurses as strate-

gic business partners,” says Kavanagh. “All of our intranet

communications have strengthened nurses’ identification

with our Nursing Institute’s mission and strategic goals.”

Ultimately, with the help of the intranet, the primary goal

is being achieved every day: more connectivity and more

streamlined policies and practices — all of which allows

Cleveland Clinic nurses to provide the very best in patient

care.


Reaching Bedside Nurseswith Smartphones

The proliferation of smartphones made text messaging a natural next step in enhanced central communications. In 2014, more than 900nurses opted to receive a weekly text message on their personal cell phones. The messages include news updates, event and conference information, giveaways, and inspirational messages designed to enhance engagement. This form of communication has become especially helpful to bedside nurses who don’t have immediate access to a computer.

Centralization of

NURSING RECOGNITION

As nursing worked to build central communications across the system, it became apparent that other nursing programs needed to be centralized too. One of these was the annual nursing awards.

One of Cleveland Clinic’s most notable recognition programs — the annual Nurses Week awards — underwent an overhaul in 2012. “The goal was to bring consistency to how we celebrate and recognize staff,” says Sue Collier, DNP, RN, NEA-BC, Vice President, Nursing and Chief Nursing Officer, Cleveland Clinic Hillcrest Hospital. Dr. Collier worked with a nursing committee from across the system to rewrite the awards.

The change meant that each hospital would use the same criteria to recognize nurses locally, and it meant adding new awards to honor nurses across the system with the “Enterprise” awards. “This standardization has provided us with a shared definition of excellence,” says Dr. Collier. “This empowers us to raise the bar across the health system and focus on our mission to continuously improve the care of our patients.”

11


Falls Are Down:

Unit-Specific Nursing Councils Reduce

Patient Falls by as Much as 30 Percent

Best PRACTICES

The nursing staff at Cleveland Clinic’s Lutheran Hospital

was following all the guidelines for preventing patient

falls. So why was the hospital’s fall rate still the highest in

Cleveland Clinic’s healthcare system, with more than four

falls per 1,000 patient days?

“Our staff had begun to accept that ‘our patients just

fall,’” says Denise Minor, DNP, RN, NEA-BC, Chief Nursing

Officer (pictured). “But data showed that the falls weren’t

all happening in our geriatric psychiatry unit, where you’d

expect a higher fall risk. Nor were they all happening at

night, as was a common assumption.”

Lutheran Hospital needed a culture change. And the change

began with forming a multidisciplinary fall prevention

committee.

Four types of falls

“Preventing falls isn’t just a nursing issue,” says Dr. Minor.

“Our fall prevention committee included representatives

from radiology, pharmacy, rehab, facilities management

and environmental services — all departments that could

send employees into patient rooms.”

A committee member from facilities management used

a slip meter to measure how slippery hospital floors were

and studied handrails and shower designs. Pharmacists

explored links between falls and specific medications.

Physical therapists provided nurses with advanced training

on patient mobility.

But the turning point came when committee members

attended a fall-reduction webinar by the Institute for

Healthcare Improvement. Their main takeaway was a new

way of classifying falls, using four categories:

• Intentional

• Accidental

• Anticipated physiological

• Unanticipated physiological

“We found that 53 percent of our falls were ‘anticipated

physiological,’ meaning they were caused by something

related to the patient’s disease process,” says Dr. Minor.

“That indicated we should be able to preempt falls for

patients with certain conditions.”

The committee learned even more when they categorized

falls within each unit.

“Although the vast majority of falls in medical and surgical

units were ‘anticipated physiological,’ that wasn’t the case

in our behavioral health units,” says Dr. Minor. “No wonder

that general ‘best practices’ weren’t preventing falls. Each

unit needed a customized action plan.”

Customizing plans for each unit

Knowing unit-specific data empowered nursing managers

and sparked staff discussions about fall prevention. Each

unit began its own council of frontline nurses to develop fall

prevention tactics.

“Nurses in our medical unit devised a ‘No-Nurse Nurses

Station,’ where nurses were permitted in the station only to

speak with a physician or nurse practitioner, answer phone

calls, print documents or attend daily shift huddles,” says

Dr. Minor. “Otherwise, they were to be in the hallway or

patient rooms. As a result, the unit’s fall rate decreased 27

percent.”

In the geriatric psychiatry unit, nurses began a more

thorough shift-change procedure and began positioning

more nurses in halls and common areas. That unit’s fall rate

decreased 30 percent. And in one year, Lutheran Hospital’s

overall fall rate decreased 13 percent.

“Sorting falls into the four categories was a game changer

for us,” says Dr. Minor. “And customizing plans for patient

populations in each unit was powerful. Fall rates decreased

most once we involved our frontline nurses.”


Yellow, nonskid slippers? Check.

Yellow wristbands? Check.

Signs outside rooms of high-risk patients? Check.

11


12

Consistency and collaboration are shaping prevention and

treatment efforts for hospital-acquired pressure ulcers

(HAPUs) at Cleveland Clinic. This is no small task, as the

health system consists of a main campus, numerous local

community hospitals, one Florida hospital and post-acute

care services. That’s where the Wound Care Affinity Group

comes in. The group, comprising wound care-focused

nurses, ensures that nursing teams have the tools and

resources they need to provide consistently high-quality,

evidence-based skin and wound care.

Wound Care Affinity Group Focuses on Consistency and Collaboration Across the Health System

HAPU Prevention Efforts Top Priority List

The Wound Care Affinity Group, which includes co-

chairs from main campus and representatives from each

community hospital or center, was born from Cleveland

Clinic’s Nursing Affinity Group model. Nurses focus on

delivering standardized care in all health system locations

in various specialty areas (see sidebar on page 14).

Shaping a culture of prevention through early interventions

“The Wound Care Affinity Group developed unified skin

care protocols based on evidence-based research,” says

Mary Montague, MSN, APRN, ACNS-BC, CWOCN, Co-

chair of the Wound Care Consult Team, Nursing Quality

Assurance. “We created standards of practice and meet

regularly to revise protocols and policies as needed.”

Group members also:

• Serve as content experts for nursing skin and pressure

ulcer (PU) initiatives

• Provide a structure for PU prevalency monitoring

• Select products and ensure that all locations use the same

products

“Wound care nurses provide value to patient care and to

the organization through the reduction of HAPUs in all

settings,” says Mary Ann Sammon, BSN, WOCN, CWCN,

who is Co-chair of the Wound Care Consult Team. “This

is accomplished by ensuring that wound and skin care

protocols reflect contemporary nursing evidence-based

practice, that frontline staff has the tools they need to

provide basic and preventive care, and that specialty-trained

nurses are available for complex wound management.”

A proactive approach is increasingly important to hospitals

and health systems across the country, given the Agency

for Healthcare Research & Quality guidelines that make

stage III, stage IV, unstageable and deep tissue injury

(DTI) reportable patient safety indicators. “HAPU quality

metrics are now tied to reimbursement, with the Centers

for Medicare & Medicaid Services no longer reimbursing

institutions for hospital-acquired stage III and stage IV

pressure ulcers,” Montague says. “These publically reported

Study Examines Predictors of HAPUs in Patients with Vascular Disease

In a nurse-led research study within Cleveland Clinic’s Vascular Surgery Step-down Unit, nurses are taking a closer look at key predictors of HAPUs. Researchers previously identified nine factors that placed patients at high risk for HAPUs and are validating their earlier findings in a new cohort of patients. Now that the validation study is near completion, further research will center on developing interventions to reduce HAPUs in patients that are high risk based on the nomogram risk score, and determining the effectiveness of interventions.

“Through a literature review, we found many HAPU risk factors, however, most factors were only found in one or a few research reports, and some factors could not be generalized to a non-studied population. Little research was available for patients admitted with a diagnosis of peripheral vascular disease,” says Tonya Moyse, BSN, RN, who is the study’s principal investigator and assistant nurse manager in the unit.

Validating 10 potential predictors

Although the validation study kicked off in early 2013, the initial research dates back to 2009. The initial research identified nine predictors of HAPUs. History of diabetes mellitus was added after further analyses. “Our validation study findings — based on medical records from a little over 900 patients — supported the 10-factor HAPU risk score as a reliable tool that is ready to be used clinically,” Moyse says.

13


metrics also affect how patients view us and how we’re

ranked nationally compared to other institutions.”

Multispecialty approach

Increasingly, HAPU interventions hinge on a multispecialty

approach to care. In critical care and cardiac care units,

nursing administrators, wound care nurses, vascular

surgery and plastic surgery are rounding together two times

per week to evaluate any patients with a suspected stage

III or greater PU, including DTIs as recently defined by the

National PU Advisory Panel.

“Our goal is to reach a consensus regarding staging,

preventive measures and treatments,” says Shannon Pengel,

MSN, RN, NE-BC, Clinical Nursing Director for the Heart &

Vascular Institute and Critical Care Nursing.

“We want to ensure that we are staging appropriately from

the beginning, since HAPUs — especially DTIs — can

sometimes be a very subjective assessment,” Pengel says.

“The combined perspectives from this multidisciplinary

approach create balance and objectivity.” For example,

sometimes a maroon or purple area that initially looks like a

DTI might have a vascular cause.

Cleveland Clinic’s Skin Care Resource Nurse (SCRN) program, which meets monthly, consists of specially trained

bedside nurses from 40 units who learn about the latest updates in wound care. Like the Wound Care Affinity Group,

the SCRN program focuses on standardizing the delivery of optimal care. “They take what they learn back to the units

so everyone has the information,” says Mary Ann Sammon, BSN, WOCN, CWCN, Co-Chair of the Wound Care Consult

Team. “We discuss issues related to standardizing processes, including staging, documentation and education.” At a

recent SCRN meeting, pictured here, representatives learned about preventive efforts taking place in the OR during

longer cardiac surgeries that involve applying foam dressings to patients’ sacrum and heels.

1414

On the main campus, the skin assessment team often

follows patients for up to two weeks to see how the

suspected wound progresses or how it resolves. “What we

are seeing is that areas of initial concern often don’t evolve

into anything,” Pengel says. Preventing and effectively

treating HAPUs hinges on consistency and coordination of

care across the health system. “Constant assessment of the

skin from the time of admission to the time of discharge

— including any time in the operating room — is critical,”

Pengel says.

Although data collection will be ongoing for another year

or two, data from early quality reports are showing that

patient safety indicators, reported in six-week periods,

appear to improve by as much as 50 percent. “We hope

what we’re learning on main campus could eventually

become a standard of practice throughout the system,”

Pengel says.

Initiatives to decrease HAPUs

Ongoing initiatives that have the potential for broad

application throughout the health system and to other

hospitals include:

• Results of a research study that validated 10 predictors of

HAPU in patients with vascular disease (see sidebar on

page 12)

• A nursing quality assurance-led protocol in which

preventive rounds are completed on patients in the

medical intensive care and inpatient palliative care units

who have not developed a HAPU but are at high risk,

based on a Braden score of 18 or less.

Another way in which Cleveland Clinic is standardizing

care is through the development of a PU prevention and

treatment care path. Cleveland Clinic is developing

condition-specific care paths for each of the health system’s

clinical institutes, including Nursing. The initiative

emphasizes value-oriented care by using process-based

tools that operationalize evidence-based practice guidelines

and guide clinical work flow. The PU care path is scheduled

for completion by the end of 2014, and it will be integrated

into the electronic medical record system.

Cleveland Clinic’s emphasis on consistent, high-quality

care can be easily summed up: “Anytime you can prevent

a HAPU, it’s good for the patient and good for the health

system,” Sammon says.


A Closer Look at Affinity GroupsCleveland Clinic’s Nursing Institute created affinity groups dedicated to standardization of best practices and nursing care across the health system. Each group is led by a specialty nurse from the designated area. Nurse members focus on excellence in clinical practices through collaboration, communication and networking. Further, they keep current in research literature to promote evidence-based practices.

Emergency Services After implementing ED nurse-initiated protocols, the group aim is to sustain door-to-provider time at an average of 14 minutes at each site. Currently, the group is rolling out “My Emergency Department Plan of Care,” which provides information about all aspects of care, from pain control and safety to wait times and ancillary testing. It is given to patients and/or family members upon arrival to the emergency department.

Women and Children’s The first affinity group to begin policy integration efforts, this team includes all women’s and children’s patient care areas. Over the past three years, the team has integrated 55 protocols/procedures for all mother/baby, newborn intensive care and pediatrics units.

Critical Care The group is currently piloting an innovative eHospital program at three system hospitals that is designed to be a resource to critical care unit personnel. The program involves remote telemonitoring of ICU patients throughout the night. Monitoring includes direct observation of patients and hemodynamic values, ability to view radiology images and laboratory values, medical support, and entering orders. The group hosted its first Nursing Summit this spring.

Acute Care Medical-surgical patients represent the largest patient population across the health system, and this group meets regularly to share successes and address issues. Some topics discussed by the team include bed resource management, “colleagues in care” that represents the staffing model, hospital length of stay, and nurse-physician communication.

Oncology The group finalized several standard operating procedures, including pregnancy assessment, chemotherapy administration and assess-ment documentation. Members also developed a standardized oncology-specific template for patient education to ensure all oncology sites relay healthcare information consistently throughout the health system.

Behavioral Health After implementing psychiatric core measures, this group developed processes to ensure adherence to measures. Currently the group is working with Nursing Informatics to improve flow sheet documentation and with Nursing Education to develop a “behavioral health focus day” for newly hired nurse graduates participating in the nurse residency program.

Surgical Services Several projects are in progress, including standardization of job codes, documentation and policies as well as definitions (numerator/denominator) of performance measures for starting first cases on-time and turnaround times. Further, the group completed standardization of a lapa-roscopic cholecystectomy custom pack and is standardizing the total knee replacement custom pack.

Rehabilitation The Rehab Affinity Group was formed in 2014. Since forming, members aligned policies and procedures that include autonomic dysreflexia, and bowel and bladder care for patients undergoing inpatient rehabilitation.

The Stanley Shalom Zielony Institute for Nursing Excellence

15


Best PRACTICES

Executive EditorNancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC, FAHA, FCCM ASSOCIATE CHIEF NURSING OFFICER, OFFICE OF NURSING RESEARCH AND INNOVATION

Address comments on Notable Nursing to Nancy M. Albert, [email protected].

Editorial Board

Sue Collier, DNP, RN, NEA-BC CHIEF NURSING OFFICER, HILLCREST HOSPITAL

Janet Fuchs, MSN, MBA, NEA-BC ASSOCIATE CHIEF NURSING OFFICER, AMBULATORY NURSING

Joan Kavanagh, MSN, RN, NEA-BC ASSOCIATE CHIEF NURSING OFFICER, OFFICE OF NURSING EDUCATION AND PROFESSIONAL DEVELOPMENT

Mavis Kramer, MBA, BSN, RN, CCRN NURSE MANAGER, LAKEWOOD HOSPITAL

Meredith Lahl, MSN, PCNS-BC, CPON SENIOR DIRECTOR, ADVANCED PRACTICE NURSING

Sandra Maag, BSN, RN NURSE MANAGER, NURSING QUALITY

Mary Beth Modic, DNP, RN, CDE NURSING EDUCATION, MAIN CAMPUS

Ingrid Muir, MBA, BSN, RN NURSING DIRECTOR, MEDICINE INSTITUTE AND ENDOCRINOLOGY & METABOLISM INSTITUTE

Mary A. Noonen, BSN, RN-BC NURSING EDUCATION, SOUTH POINTE HOSPITAL

Christine Szweda, MS, BSN, RN SENIOR DIRECTOR, NURSING EDUCATION

Jennifer Van Dyk, DNP, RN DIRECTOR, NURSING EDUCATION

Linnea VanBlarcum, MSN, RN, ACNS-BC PATIENT CARE SERVICES, LUTHERAN HOSPITAL

Dana Wade, MSN, RN, CNS-BC, CPHQ, NEA-BC ASSOCIATE CHIEF NURSING OFFICER, OFFICE OF NURSING QUALITY AND PRACTICE

Susan Wilson, BSN, RN, CCRN NURSE MANAGER, MAIN CAMPUS

Marianela (Nelita) Zytkowski, DNP, MS, NEA-BC, RN-BC, FHIMSS ASSOCIATE CHIEF NURSING OFFICER, OFFICE OF NURSING INFORMATICS

Adrienne Russ MANAGING EDITOR

Amy Buskey-Wood ART DIRECTOR

PhotographyRUSSELL LEE, TOM MERCE, STEPHEN TRAVARCA, WILLIE McALLISTER, DON GERDA, JOHN STILLMAN

Mandy Barney, MBA MARKETING MANAGER

Visit clevelandclinic.org/notable and click on the “Notable Nursing” tab to add yourself or someone else to the mailing list, change your address or subscribe to the electronic form of this newsletter.

Wound ostomy continence (WOC) nurse Linda Coulter, MS, BSN, RN, CWOCN

(pictured), remembers the look on the young patient’s face. He was very ill, and

his prognosis wasn’t good. He was disheartened by having an ostomy and even

more upset when he developed a prolapsed stoma.

“I could reduce his stoma temporarily, but it would come out again whenever

he’d walk around,” says Coulter. “At one point, he wrapped an elastic bandage

around his belly to hold in the stoma. It didn’t work. In desperation, his mother

asked me, ‘Isn’t there anything else we can do?’”

That’s when Coulter got the idea for a stoma “cap.” Using gauze, an ostomy

belt and the convex wafer from an ostomy pouch — supplies readily available

from a WOC nursing formulary — Coulter pieced together a temporary fix. It’s

an alternative to waiting several weeks for custom-tailored belts with prolapse

straps. While those belts are more durable, they can be expensive, not to mention

too late for critically ill patients or those nearing surgery.

“A few weeks later, I ran into the patient’s mother,” says Coulter. “She said, ‘You

know that thing you did? It’s still working!’”

An innovation is born

Coulter described her stoma cap idea to her Cleveland Clinic colleagues, who

since have used it successfully with other patients. One patient was able to

become more active and perform better at work without worrying about his

stoma prolapsing. It gave him an extra degree of confidence, says Coulter, who

now is pursuing a quantitative research study to support outcomes of the cap’s

anecdotal successes.

The concept earned Coulter a 2014 nursing innovation award at Cleveland Clinic.

The stoma cap is a five-step process that can be created by a single nurse at

the bedside, after collecting supplies. Sometimes, a stoma cap can contain a

prolapse for weeks, until the patient’s prolapse belt arrives or the patient has

stoma reversal or revision surgery.

However, it does not work for everyone, notes Coulter. The cap may not stay in

place over prolapsed stomas that don’t reduce easily. And caps seem to work

better with ileostomies and other ostomies in which effluent is in a thinner,

liquid form rather than with colostomies where larger-volume, solid evacuations

may be inhibited by the cap.

“Prolapsed stomas aren’t necessarily painful, but their appearance can be quite

alarming to patients,” says Coulter. “It’s good to offer patients an immediate,

although temporary, solution that can ease their distress and improve their

quality of life.”


Nurse Devises Simple Way to

Control a Prolapsed Stoma


1616

Female nurses working on units that administer chemo-

therapy are often worried about keeping themselves and

their babies safe if they become pregnant. “We believe that

the national safety recommendations, if followed, will pro-

vide an adequate level of protection,” says Christina Colvin,

MSN, RN, AOCNS, Clinical Nurse Specialist in the Nursing

Institute’s Office of Nursing Education and Professional

Practice.

To learn more, Colvin decided to explore the literature for

evidence on safety for chemotherapy nurses, pregnant or

not. She found studies that showed that some pharmacists

who were exposed to certain drugs had miscarriages or had

babies with developmental delays; however, the research

was conducted in the 1970s, before PPE was incorporated

into the workplace.

Further, current studies were not based on first-hand ob-

servations of PPE use, only on retrospective data from ques-

tionnaires. Colvin decided to conduct a study that used

both a self-assessment questionnaire and direct observa-

tion of nurses preparing, administering and discarding

chemotherapy agents at Cleveland Clinic’s main campus.

The study took place at the 76-chair infusion suite. The

primary goal was to find out if nurses followed safety guide-

lines as often as they self-reported that they did.

Twenty-two cases of chemotherapy handling were

observed and 12 of 20 ambulatory nurses completed self-

assessments. Of 16 safe-handling practices, nurses were

observed to complete only one behavior 100 percent of

the time — that was washing hands after disconnecting

chemotherapy infusion.

“Adherence to occupational safe handling of chemotherapy

guidelines did not match expectations and varied from self-

assessments,” Colvin says. “Our research results raise ques-

tions about the intensity of adherence to current PPE guide-

lines and nurse safety if guidelines were relaxed slightly.

Another thought is to study how current recommendations

were developed [for example, expert opinion or high-quality

research evidence] and advocate for guidelines that ensure

nurse safety based on only high quality evidence.”

Colvin says her work points to the importance of nurses

being aware that PPE use is not designed only to protect

them but also to protect the work environment that

involves many healthcare workers, patients and families.

For example, double gloving can inhibit a nurse’s manual

dexterity, but it allows for removal of the outer glove when

needed to touch a pump to program it. This stops the

spread of chemicals onto surfaces where other people will

encounter them. The next person who touches the pump

may then go to input information into a shared computer,

further spreading contamination.

“For chemotherapy nurses, PPE is the equivalent of a lead

shield in radiology. There is no known ‘safe’ exposure to

chemotherapy for employees, so the goal for workers is

to not have any exposure to it. This sets the bar incredibly

high,” Colvin says.

Next, Colvin hopes to perform swab analyses of the

chemotherapy suite to determine the rate of chemotherapy

exposure in the environment.


Chemotherapy nurses have many tools to protect themselves from exposure to hazardous drugs in their work, such as access to personal protective equipment (PPE) — gloves, gowns and robust education programs. However, a nursing research study shows they may not always use available resources.

Research

Chemotherapy Nurses Don’t Follow Safety Guidelines as Often as They Think

How does quality of care compare — specifically in patients

with type 2 diabetes mellitus — when APNs and IMPs

manage patients using the Chronic Care Model versus

when IMPs manage patients alone? That’s what Patricia A.

Marin, DNP, NP-C, of Cleveland Clinic’s Medicine Institute

intended to discover in a research study assessing longitudi-

nal differences in levels of hemoglobin A1c (HbA1c).

Procedure

Using administrative/clinical databases at a Northeast Ohio

ambulatory medical center, data were retrieved for diabetes

patients, ages 18 to 85, treated two or more times from 2007

to 2010. To be included in the study, there needed to be at

least one visit six months after the initial visit of record and

at least two HbA1c levels recorded during that time period.

HbA1c levels of patients treated by an IMP alone were

compared with those treated by both an APN and IMP.

Results

• At baseline, patients managed by both APNs and IMPs

had higher HbA1c levels than patients managed by IMPs

alone. Compared with baseline, the groups had similar

reductions in HbA1c levels at 6, 12 and 24 months.

• However, within groups, patients managed by IMPs

alone had similar HbA1c levels at 6, 12 and 24 months

compared with baseline. Patients managed by both APNs

and IMPs had significantly lower HbA1c levels at 6 months

compared with baseline; and their HbA1c levels tended to

be lower at 12 months as well.

In analysis, patients (APNs and IMPs versus IMPs alone)

were matched on three characteristics: age, race and gender

in a 1:2 fashion so that for every one patient managed by

both an APN and IMP, there were two patients included

from the IMP alone group. In the matched sets of patients,

those managed by the APN and IMP had significant

reductions in 6- and 12-month HbA1c levels compared

with baseline, and HbA1c levels tended to be lower at 24

months. For patients managed by IMPs alone, there were no

differences in HbA1c levels over time.

These results provide evidence that an APN care provider

who uses the Chronic Care Model to manage patients with

diabetes may be more successful in normalizing HbA1c

levels over time.

However, because only one APN was involved in this

research study, further research is needed by other APNs

who provide independent care to patients with chronic

diabetes.

Beyond diabetes?

“As more patients flow into the U.S. healthcare system due

to the Affordable Care Act, and as the prevalence of chronic

conditions in the U.S. continues to grow — particularly

among the elderly — we need to explore innovative ways to

provide quality care,” says Dr. Marin.

The medical status of adults with one or more chronic

medical disorders may be stabilized by APN services that

include patient education on medications and lifestyle

modifications as well as individualized care plans.

“In this study, an APN who used a chronic disease man-

agement model within an internal medicine department

had similar outcomes to IMPs,” says Dr. Marin. “And when

data were analyzed within groups, APN care was associated

with lower HbA1c levels. Thus, APN-delivered healthcare

contributes importantly to health promotion and quality

outcomes.”


Research

Diabetes Outcomes Improve When APNs Are Involved in Care

The Chronic Care Model is a vetted approach to reducing morbidity and mortality from chronic conditions, such as diabetes. Advanced practice nurses (APNs), collaborating with internal medicine physicians (IMPs), play an important role in the model’s success.

17

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Stay Connected to Cleveland Clinic

Awardsfor the advanced practice nurse is offered in partnership by Duke University School of Medicine, Duke University School of Nursing and Johnson & Johnson.

Julie Green, RN, from the short-stay unit at Cleveland Clinic’s main campus has been recognized for outstanding professional achievement as the winner of the 2014 Academy of Medical-Surgical Nurses (AMSN) Clinical Practice Award.

In September, Cleveland Clinic Florida nurse practitioner Debra Hain, PhD, APRN, ANP-BC, GNP-BC, FAANP, was presented with the 2014 GAPNA Award for Excellence in Research. The award is from the Gerontological Advanced Practice Nurses Association.

Cleveland Clinic Florida and Lutheran Hospital achieved Pathway to Excellence® Program designation from the American Nurses Credentialing Center. The designation came in May 2014 and June 2014 respectively, and they join Cleveland Clinic’s Euclid, Lakewood, Marymount and South Pointe hospitals in receiving this distinction.

Cheryl Cairns, MSN, PNP, Community Pediatrics; Carrie Cuomo, MSN, ACPNP, Cleveland Clinic Children’s; and Anne Vanderbilt, MSN, CNS, CNP, of Cleveland Clinic’s Center for Geriatric Medicine, have been selected as fellows for the Duke-Johnson & Johnson Nurse Leadership Program. This one-year leadership development experience

The Cleveland Clinic Way

By Toby Cosgrove, MD,

CEO and President of

Cleveland Clinic

Great things happen when a medical center puts patients first. Visit clevelandclinic.org/ClevelandClinicWayfor details or to order a copy.

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