Bringing Nurses to the Table

Although the need to escalate care when a patient’s condition is deteriorating is fundamental to safety and outcomes, there are numerous barriers to this critical practice, ranging from clinical inexperience to high staff workload and fear of criticism by senior colleagues.

“Before care escalation can happen, nursing caregivers must recognize that patients are beginning to deteriorate,” says Maureen A. Schaupp, MSN, APRN-CNP, Executive Director, Associate Chief Nursing Officer Advanced Practice Nursing, Nursing Quality and Practice at Cleveland Clinic.

“Recognition usually involves a combination of patient factors, including vital signs and lab work trending in the wrong direction. Once a problem is recognized, clinical inpatient nurses are responsible for escalating concerns to the appropriate provider group to ensure patients receive proper care.”

Two years ago, nursing leaders at Cleveland Clinic set out to better understand if caregivers within the healthcare system felt equipped to identify and communicate changes in patients’ conditions to appropriate clinical leaders. The team partnered with the Cleveland Clinic Alliance for Patient and Caregiver Safety, which is certified as a Patient Safety Organization (PSO) by the Agency for Healthcare Research and Quality (created under the Patient Safety and Quality Act of 2005). PSOs gather and analyze data voluntarily collected by providers to improve patient safety and healthcare quality.

“Encouraging a safety-focused culture empowers our nurses to escalate concerns without hesitation and reinforces team collaboration,” says Christine M. Pokryfky, BSN, RN, JD, Program Manager, Patient Safety Organization, Cleveland Clinic Alliance for Patient and Caregiver Safety.

Identifying opportunities

Among the activities coordinated by PSOs are “Safe Tables” — confidential forums where healthcare professionals engage in robust discussions about patient safety issues.

“Safe Tables provide a venue for caregivers to speak openly and freely about concerns related to all sorts of safety topics they encounter day to day,” says Pokryfky. “It allows the healthcare organization to learn from caregivers and make improvements.”

In 2023, Cleveland Clinic selected escalation of care as a topic for Safe Tables based on results of a previous year’s caregiver engagement survey. One of the questions asked caregivers how they felt about their ability to challenge the decisions and actions of those with more authority.

“The feedback was not as favorable as we would have liked, so we identified an opportunity to collaborate with nurses,” says Schaupp. “Our nurses may have a wonderful ability to recognize patient deterioration, but if they find it difficult to escalate care, patient outcomes can be less than optimal.”

Creating action plans

The Cleveland Clinic Alliance for Patient and Caregiver Safety held Safe Table
discussions at 15 U.S. hospitals within the healthcare system, which were attended by 241 nursing professionals representing all care areas and shifts.
The PSO and nursing content experts developed four open-ended questions to
guide discussions.

“We wanted to hear directly from the nurses if they felt there was a hesitancy to escalate care and, if so, why?” says Schaupp. “For example, was there a barrier to communication? Were they unsure who to call? Did they previously experience a negative interaction with a provider?”

The PSO analyzed the qualitative information gathered before sorting it into themes pervasive across the healthcare system.

“The nursing executive team created action plans in concert with our caregivers and other stakeholders based on feedback we received,” says Schaupp. “Feedback was robust because caregivers felt psychologically safe to speak up during the Safe Table activities.”

One of the overarching areas the team focused on was ensuring there was
a clear escalation pathway in every unit within the organization. Due to the
confidentiality of Safe Tables, nursing leaders don’t share specific details about their discussions. Leader discretion about what is shared contributes to the success of Safe Tables — and also Cleveland Clinic’s commitment to improving escalation-of-care efforts.

“Safe Tables have been a wonderful tool to help us dig a little bit deeper into
our caregivers’ needs,” says Schaupp. “This approach allowed the nursing
leadership team to key in on areas where we could help caregivers, remove barriers and make sure they felt like they could question those with more authority.”

The strategy worked. “By the time we conducted our caregiver engagement
survey in 2024, our scores for the question related to the ability to challenge
the decisions and actions of those with more authority improved,” she adds.

Three tips to improve escalation of care

Schaupp and Pokryfky offer the following advice to other nursing leaders:

• Prioritize timely escalation of care. “Essential to delivering high-quality, high-reliability care are the following three elements: Have the right protocols, policies and procedures in place; educate caregivers; and promote open communication in a psychologically safe environment,” says Pokryfky.

• Lean into the culture. “Nurses need the tools to feel confident escalating
their concerns, but it’s equally important to make sure they know they are
supported by all leaders within their organization when these situations arise,” says Schaupp. “The culture at the top is what makes things run smoothly.”

• Be open to vulnerability. “Our nursing leadership team was willing to be vulnerable and ask our bedside caregivers what was going on at the patient
level,” says Schaupp. “I think it was well worth it because we came away from the Safe Tables experience stronger than when we started. Our nurses are now better equipped to escalate treatment, and our patients are getting the care they need.”

Focusing on escalation of care has also reinforced Cleveland Clinic’s team of
teams approach, Pokryfky says. “The safety culture is so important, and it needs to be pervasive across the entirety of the enterprise,” she adds. “This was a wonderful step by nursing leadership to show they really care about the perspectives of the nursing caregivers at the bedside.”

Safe Tables 2025

The Cleveland Clinic Alliance for Patient and Caregiver Safety’s first Safe Tables forum focused on central line-associated bloodstream infections, followed by discussions on escalation of care in 2023.

This year, the Patient Safety Organization will host quarterly Safe Tables at the healthcare organization’s U.S. hospitals for all caregivers, including nurses, physicians, advanced practice providers, environmental services personnel, social workers, risk managers, case managers, transporters and others.

The 2025 topics are:

Q1: Medication Safety and Reconciliation
Q2: Preventing Burnout and Promoting Mental Health Well-Being in Healthcare Teams
Q3: Bridging Gaps in Care: A Safety-Focused Discussion
Q4: Enhancing Telemetry Safety and Alarm Management