Nursing and the Journey to High Reliability

Nurses are key to interprofessional collaborative practice

By Kelly Hancock, DNP, RN, NE-BC

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As more healthcare organizations like Cleveland Clinic work on the journey to high reliability, exceptional nursing has never been more imperative.

Nurses are key to two of the foundational components of high reliability environments – quality and safety. As part of their jobs, nurses continuously work to understand, acquire, develop and practice the skills needed to improve patient care. Thus, they are constantly helping shape and advance quality and safety processes and outcomes.

In Cleveland Clinic’s own journey to high reliability, the nurses of the Stanley Shalom Zielony Institute for Nursing Excellence have been key players in our organization’s progress.

System-wide role models in collaboration and communication

The first phase of our health system’s journey has been centered on creating a culture that drives and supports high reliability.

According to experts, cultures of high reliability are designed to build trust among caregivers, identify opportunities for improvement, and capitalize on those opportunities to advance evidence-based practice. They encourage health teams to work together to create and lead change that positively impacts how care is delivered, and they welcome ongoing quality improvement.

When successful, high reliability cultures directly lead to better health outcomes and patient experiences, improved efficiency and job satisfaction.

For the past two years, Cleveland Clinic’s nursing institute has been focused on improving and enhancing interprofessional collaborations and communication – areas that are pivotal to attaining a highly reliable culture.

Through Cleveland Clinic’s Solutions for Value Enhancements (SolVE) program and Continuous Improvement (CI) initiative, our nurses have been helping establish a team-based competency and shared foundation for clinical practice that is built on collaboration and communication.

  • SolVE is a three-month experiential course that teaches clinicians structured ways to make clinical changes to improve patient care. Intended for multi-disciplinary teams, it includes classroom and application time as well as peer coaching. It combines training with a positive quality improvement experience.
  • Similarly, Cleveland Clinic’s CI initiative is focused on improving quality and safety to achieve desired outcomes. It encourages care teams to renew their focus on quality and safety by incorporating a structured planning approach that assesses and evaluates current practice, systems and processes, and overall healthcare delivery.

Nurse-led projects improve interprofessional practice

While many of our nurse managers admit that the thought of participation in these programs was overwhelming at first, those who have completed them agree the reward was well worth it.

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Across the health system, nurse-led relationship-based improvement projects have impacted caregiver teams in welcoming ongoing quality improvement, achieving excellence in quality and safety, and improving patient-centered care delivery. Two examples, include:

Willoughby Family Health Center Pediatrics

Standing up as one of the first nurse-led SolVE projects, nurses in the pediatric department at Willoughby Family Health Center knew they needed to improve transitions of care processes from pediatric to adult care. They also knew interprofessional collaboration was going to be imperative to their work.

To begin, they obtained leadership support, evaluated survey data, researched national data and best practices, and created and worked through process maps. They worked closely with numerous physicians, registered nurses, advanced practice registered nurses and health unit coordinators, as well as information technology, billing and coding, and call center caregivers.

Their work revealed several findings, including that providers were sometimes reluctant to let go of patients or they weren’t fully aware of national guidelines for transition. By collaborating and communicating with the entire caregiver team, the nurses leading the project initiated a new process for transition based on the “6 Core Elements of Transition” from the national organization Got Transition.

They have since been working to evolve the transition process, address hidden challenges and collect data. Pilots are currently in place in several Cleveland Clinic family health center locations.

Pediatric Post-Anesthesia Care Unit

In 2015, nurses in the pediatric Post-Anesthesia Care Unit (PACU) were encountering noticeable delays in pain medication orders for post-operative patients. They knew they needed to find the root cause of the issue to properly keep their patients safe and minimize patient pain.

Turning their challenge into a SolVE project, they began building research and relationships. They looked at hundreds of patient charts, called upon other children’s hospitals across the nation for advice, collaborated with anesthesia caregivers, quality directors, nurses, pharmacists and other caregivers, and created a process map that identified barriers to patient care. They used a fishbone diagram to help determine potential solutions.

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Some of the team’s most significant findings came from newfound collaboration with their anesthesia colleagues. They learned that the pharmacy department had its own stipulations and regulations for medication delivery. They also learned anesthesiologist caregivers didn’t have access to computers in the operating rooms to immediately enter orders. And they learned there were often technology delays between order-entry and the medication-dispensing machine.

As a result, there was an average 17-minute delay for placement of pain medication orders once a patient was in the PACU.

The team devised and implemented simple changes, such as adding a direct link for order-entry by anesthesiologists in the computer system. They also made not-so-simple changes like creating a new “no transfer without orders” policy – a significant culture change on the unit.

The enhanced interprofessional collaborative practice – paid off. Very quickly, the 17-minute delay in pain medication orders became a zero-minute delay.

Additionally, since the project ended and the new interventions have been incorporated into daily patient care, average length of stay has decreased by 42.9 minutes, unit costs have been reduced by roughly $80,000 annually, and both employee engagement and patient/parent satisfaction have improved.

A new age of care

Without question, interprofessional collaborative practice is an important part of becoming a high reliability organization. When caregivers communicate, they can see opportunities and challenges through the “lens” of other care professionals. They can better recognize the value each caregiver brings to the table, remove silos, enhance teamwork, solve challenges and improve patient care.

To help attain cultures of high reliability, nurse leaders should encourage nursing caregivers to pursue work that impacts interprofessional collaboration and communication to propel team-based care and help deliver sustainability and structure to care delivery.

Kelly Hancock is the Executive Chief Nursing Officer of the Cleveland Clinic Health System, and Chief Nursing Officer of Cleveland Clinic Main Campus.

Follow Kelly on Twitter at @kkellyhancock.