In the chaotic, high-stakes emergency department (ED) environment, it's tough to consistently hit every item on the ever-growing quality metrics checklist.
And even when you do, you may not have time to document that care thoroughly. After all, these are life-and-death situations we're dealing with!
Unfortunately, these "misses" can have real-life consequences for our patients. And in this era of value-based reimbursement, inaccurate or incomplete documentation can depress quality scores and incur financial penalties for the hospital.
We know because we've been there. The Providence Holy Cross Medical Center
ED in Mission Hills, Calif., has a longstanding reputation for quality and efficiency. But in recent years, rising volumes — particularly among higher-acuity patients — made it tougher to consistently meet regulatory standards and implement best practices. What's more, our documentation didn't reflect the high quality of the care we provided.
So, to address this issue, we created a new role — a quality nurse, or QRN. Having this quality champion on every shift has helped us to greatly improve clinical care and regulatory compliance. This is especially true in cases of sepsis, stroke, STEMI, and other complex conditions.
Here's how we did it. The following is adapted from a poster presentation at Vituity’s 2016 Annual Meeting.
Why a Quality Nurse?
Following best practices set down by the Joint Commission, Centers for Medicare and Medicaid Services (CMS), and other agencies benefits all patients. However, regulators have focused special efforts on certain high-risk conditions. Examples include stroke, sepsis, and STEMI. There are also many rules pertaining to procedural sedation, pain management, and the use of physical restraints.
Beginning around 2010, Providence Holy Cross Medical Center’s ED experienced a 52 percent rise in patient volume over a five-year period. This included an increase in the proportion of high-acuity patients.
As a result, our nurses struggled to adjust their practice to ever-evolving quality standards. They also faced challenges around accurately and consistently documenting the level of care rendered.
The nursing staff discussed these challenges with their leaders, who understood their need for additional support. From that meeting, the concept of a quality nurse was born.
We envisioned the QRN as working in conjunction with the charge nurse to review patient charts in real time and immediately address any "misses" related to quality measures or documentation. This would allow us to correct any missteps while the patient was still in the department. We hoped that this timely feedback would boost our quality scores.
Other goals of the program included:
- Fostering a supportive and safe nursing environment
- Developing in-house quality champions to promote best practices and improve patient outcomes
- Staffing an additional nurse to help with surges, codes, and complex cases
Before diving into the planning stage, our team conducted a literature review. As of 2015, we found no other organizations using an ED nurse in this capacity. We were even more excited to pilot our idea knowing that our quality nurse program might be the first of its kind.
How We Did It
Our ED nursing team developed a detailed position description for the QRN. We also put together a quick reference guide that outlined the best practices and regulatory requirements we're all held accountable for. The QRN refers to this manual when reviewing documentation, and it's turned out to be a great resource for our entire staff.
While we envisioned the more senior RNs taking on the QRN role, we actually trained everyone in our department to do the job. As a result, our nurses made a huge leap forward in their understanding of quality metrics and regulatory requirements. And it's easier to accept feedback from the QRN when you understand the process yourself.
We piloted the QRN program for three months beginning in March 2015. We'd just completed a three-month audit of our pain management practice and had solid data to work from. So we decided to focus on pain management during the trial period.
The pilot was a success. Real-time chart reviews led to changes in observed practice. Not only did nurses complete more 30-minute reassessments of pain patients, they were documenting this step more consistently.
Nurses also appreciated having an extra set of hands. The QRN was always available to help when the ED got crowded, a patient coded, or a complex case strained our staff resources.
Based on this successful pilot, we decided to expand the QRN role. To make this happen, we gathered pre-implementation data on sepsis, STEMI, and stroke care as well as restraint use. We then tracked these quality metrics over time to validate a change in practice.
Some Numbers We Like
Having a QRN perform chart reviews and provide backup staffing yielded major improvements in clinical documentation and care of high-acuity patients.
Completion of restraint flow sheets increased from 60 percent to more than 90 percent between January 2015 and September 2016.
Door-to-needle time (a metric for stroke patients receiving tPA injections) decreased from about 90 minutes to less than 40 minutes between February 2016 and September 2016.
And pain reassessment documentation jumped from approximately 80 percent (at the end of the three-month pilot) to nearly 100 percent within five months.
Incorporating the QRN into the Holy Cross ED’s staffing matrix has enhanced patient care and outcomes. It's also improved our clinical documentation, helping us meet regulatory benchmarks and capture more reimbursement for our hospital.
Professional development has been another benefit of the QRN program. All of our nurses have deepened their knowledge of and appreciation for quality, regulatory compliance, and evidence-based practice. As a team, we are more diligent about seeking out new advances and best practices for the benefit of patients.
Having a QRN also changed the culture of our department. Instead of waiting for directions from nursing leadership, staff now help their peers. They remind one another to meet metrics and document care appropriately. And they're more open to receiving feedback when a metric is missed.
Finally, having an extra set of hands on each shift has allowed us to launch new quality initiatives. For example, the QRN now performs callbacks, which is a huge satisfier for our patients.
Getting this program up and running took time and effort. But two years later, it pretty much runs itself. The charge nurse no longer assigns the QRN because everyone is trained in this role and happy to volunteer.
In summary, we encourage you to give the quality nurse role a try. It's definitely done a lot of good for our department, hospital, and patients.