4/24/2019 1 CNM SYMPOSIUM 2019 Beyond Nutrition: Trends in Healthcare CNMs Should Know Sherri Jones, MS, MBA, RDN, LDN, SSGB, FAND Senior Improvement Specialist, UPMC Shadyside CNM Symposium 2019 Disclosures • Senior Improvement Specialist Position is grant funded by the Shadyside Hospital Foundation • Member of the Academy’s Definition of Terms Workgroup • Member of the Academy’s Quality Leader Alliance • Chapter author of “The Clinical Nutrition Manager’s Handbook” – but no royalties from sales 1 2
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Beyond Nutrition:Trends in Healthcare CNMs Should Know
“The overriding concern of hospital executives is to assure safe and high
quality care,” says Deborah J. Bowen, FACHE, CAE, President
and CEO of ACHE.
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Trends: Topics Addressed Today…
•Patient Experience
•Quality
• Safety
•Regulatory
•Magnet Recognition – Nursing Excellence
•RDN Careers
Connection to CNMs
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Trend: Patient Experience – Consumerism Press Ganey researchers surveyed >1,000 adults responsible for household health care decisions
Findings provided 6 critical insights:
1. Patient experience is more influential than other marketing strategies in predicting brand loyalty
2. Consumers turn to the Internet before turning to family and friends
3. Consumers no longer blindly follow primary care referrals
4. Consumer choice is influenced by both positive and negative comments
5. Consumers value online patient ratings and reviews
6. Consumers seek patient ratings and reviews when researching a physician
Reference: Press Ganey White Paper. Consumerism: The role of patient experience in brand management and patient acquisition. 2018.
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Trend: Hospital Quality Ratings Programs
•CMS Overall Hospital Quality Star Rating
•CMS HCAHPS Patient Experience Star Rating
• Leapfrog Top Hospitals
• Leapfrog Hospital Safety Grades
•US News’ Best Hospitals
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CMS Overall Hospital Star Ratings• Originally launched July 2016 to:
• Help patients choose a hospital based on quality performance
• Summarize wide range of measures into a single metric
• Finally updated on February 28, 2019 after a 14‐month delay
• Considering further revision to replace the latent variable model possibly in 2020
• Hospitals receive 1‐star to 5‐stars based on overall performance
• Use composite of 9‐60 distinct quality metrics from:
• Hospital Inpatient Quality Reporting Program (IQR)
• Hospital Outpatient Quality Reporting Program (OQR)
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CMS Overall Hospital Star Ratings
Scores based on hospital performance in 7 different categories (below)
Category Weight Metrics Examples No. of Metrics
1) Mortality 22% 30‐day mortality rate from dx: MI/CAGB 7
2) Readmissions 22% 30‐day mortality rate from dx: MI/CAGB 8
3) Safety of Care 22% CAUTI, C‐Diff, etc. 9
4) Patient Experience 22% Communication w/ MD, Communication w/ RN 11
5) Effectiveness of Care 4% Patient offered flu vaccine 10
6) Timeliness of Care 4% Time in ED from arrival to discharge 7
7) Efficient Use of Medical Imaging 4% Assess the clinical necessity of imaging 5
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CMS HCAHPS Patient Experience Star Rating
• Published on Hospital Compare website to help patients choose a hospital based on patient experience + Updated Quarterly
• Ratings derived from HCAHPS survey administered post discharge
• A summary star rating assigned for each hospital based on:• Statistical method applied to consider distribution and clustering of responses
• Adjusted for patient mix, survey mode, and quarterly weighting
• Stars assigned for 11 HCAHPS categories
HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems
Communication with Nurses Communication about medications Quietness of hosp. environment
Communication with Doctors Discharge information Rate Hospital 0‐10
Responsiveness of hosp. staff Care transition Recommend the Hospital
Pain Management Cleanliness of hosp. environment
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Leapfrog Group Rating Programs
• National nonprofit organization founded in 2000 by large employers and other healthcare purchasers to inform Value Based Purchasing
• Reports data on almost 2,000 hospitals, with partnerships in 36 states
• 2 Programs Reported:
1) Leapfrog Hospital Survey Top Hospitals
2) Leapfrog Hospital Safety Grade
• Driving a movement for “giant leaps” forward in the quality and safety of American health care
For more information: www.leapfroggroup.org
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Leapfrog Top Hospitals
• Hospitals voluntarily submit data through the Leapfrog Hospital Survey• Free annual survey open from April 1 to Dec. 31
• Survey covers a variety of quality, safety, and resource use (efficiency) measures
• 28 measures across 6 domains (med safety, inpatient care management, infections, maternity care, pediatric care, inpatient surgery)
• Recognizes acute‐care top hospitals compared to their peer categories
• Conditions to be named a ‘Top Hospital’
1) VBP score ranked within top 10% of their category 4) Comply with Leapfrog’s never events policy
2) Meet/achieve progress with CPOE 5) Receive an ‘A’ for Leapfrog’s Safety Grade
3) Meet standard for ICU MD staffing 6) Satisfy Leapfrog’s Selection Committee review
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Leapfrog Hospital Safety Grade
• Hospitals with available data are given grades regardless of participation in the Leapfrog Hospital Survey
• Safety Grade includes data from: CMS, Leapfrog Survey if available, and American Hospital Association’s annual survey
• Exclusively covers safety (accidents, injuries, and errors)
• Measures divided into 2 groups each being 50% of total score:
• Process/Structure measures CPOE, hand hygiene, barcode medication admin., etc.
• Outcome measures Pressure ulcers, CAUTIs, SSIs, falls, etc.
• Assigns letter grade of A through F based on overall safety performance
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US News’ Best Hospitals
• Annual published listings:• Honor Roll – top 20 hospitals delivering quality care in many specialties
• Specialty Rankings – separate lists in 16 specialties
• Works with market research firm (RTI) to complete the rankings
• Data used for ranking comes from several sources• American Hospital Association Annual Survey, ANCC Nurse Magnet hospitals, NIH‐designated Cancer Centers, physician surveys, CMS’s Standard Analytical Files, patient safety measures
• Measures are categorized and weighted
Structure – 30% Process – 32.5% Outcome – 37.5%
*NOTE: There’s also a separate US News’ Best Children’s Hospital List
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Trend: Regulatory ‐ The Joint Commission (TJC)
• SAFER Matrix effective Jan. 1, 2017
• SAFER = Survey Analysis for Evaluating RiskTM
• Replaces previous scoring methodology
• Provides visual representation of survey findings
• RFIs plotted on Matrix according to likelihood to cause harm + scope (prevalence)
• Placement determines level of detail required for RFI’s Evidence of Standards Compliance follow‐up
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Additional Elements
Requires:
• Written Plans of Correction (POC)
• Documentation Evidence of
• Policies
• Staff education/in‐servicing with signatures
• Meeting agendas/minutes
• Logs
• Auditing for compliance (ongoing)
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Accreditation Requirement Categories
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Sample: 2018 UPMC PUH/SHY Results
Resulted in:
Preliminary Denial of Accreditation
Required follow‐up activity
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Trend: Patient Safety ‐ TJC Sentinel Events
• TJC formed sentinel event policy in 1996 to help hospitals improve safety and learn from events
• Sentinel Event = a patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm and the need for life‐sustaining intervention
• Majority of events are voluntarily self‐reported by organizations
Alert 53: Tubing Misconnections August 20, 2014 TJC sentinel event alert with transitioning to new ISO
tubing connector standards
• Tubing misconnections cause severe patient injury and death, since tubes with different functions can easily be connected using luerconnectors, or connections can be “rigged” (constructed) using adapters, tubing or catheters
• Why new ISO (International Organization for Standardization) tubing connector standards were developed for manufacturers
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Alert 58: Inadequate Handoff CommunicationSeptember 12, 2017 TJC sentinel alert on handoff communication
• Hand‐off = transfer/acceptance of patient care responsibility achieved through passing patient‐specific info from one caregiver to another or from one team to another for purpose of ensuring continuity and safety of patient’s care
• Common problem regarding hand‐offs, or hand‐overs, centers on communication: expectations can be out of balance between sender of info and receiver
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Result of Poor Hand‐off Communication
Example:
Quality Leader Alliance Quickinar
QI Project related to
Nursing Bedside Shift Report
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Clinical Nutrition Handoff Considerations
When there is…
• Change of nutrition risk (high/low) – NDTR to RDN and vice versa
• Transfers to other units or levels of care (ICU)
• Schedule coverage – vacations/holidays/weekends
• Transfer of setting – to Nursing Home, Hospice, Home Health, etc.
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Trend: Quality and Workforce Integration
• Healthcare organizations support the IHI’s Triple Aim
• In today’s Value‐Based Purchasing environment it’s been challenging to balance:
• National Association for Healthcare Quality (NAHQ) and the Accountable Care Learning Collaborative (ACLC) aim to improve healthcare by building workforce and organizational QI competencies
Reference: White Paper.: The Road to Healthcare Value Is Driven by Quality Workforce Integration. NAHQ and ACLC. December 2018.
Care Quality
Cost
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Quality Workforce Integration
• NAHQ conducted a member survey in Nov./Dec. 2018
• 268 healthcare quality professionals in US completed survey
• Responded to 2 open‐ended questions:
• “If you could do one thing to improve quality at your organization what would it be?”
• Only 33% said all staff receive training and education on quality within their healthcare organization
• “Who in your organization receives education and training on healthcare quality?”
• Nearly half (47%) said their healthcare organization needs to align all healthcare professionals
• Focus on mutual respect, autonomy, and shared values
• Promote highest standards of care
• Adoption of safe practices
• Higher support for evidence‐based practice
• Better patient outcomes
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Magnet Components/Model
Five Components:
1. Transformational Leadership
2. Structural Empowerment
3. Exemplary Professional Practice
4. New Knowledge, Innovation, & Improvements
5. Empirical Outcomes (Quality Results)
What can CNMs learn/incorporate from each?
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Transformational Leadership
The CNO in a Magnet‐recognized organization is a knowledgeable, transformational leader who develops a strong vision…and strategic and quality plans in leading nursing services.
• Nurse leaders lead effectively through change
• CNO is a strategic partner in the organization’s decision‐making
• CNO advocates for ongoing leadership development of all nurses, with a focus on mentoring and succession planning
Example Exemplar TL7:Provide one example, with supporting evidence, of succession‐planning activities for the nurse manager role.
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How Can RDNs Support Succession Planning?
• Do you have a clinical nutrition succession plan in place?
• What is the plan to train/develop for YOUR replacement?
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Structural Empowerment
Magnet structural environments are generally flat…[with] nurses…involved in shared governance, decision‐making structures that establish standards of practice and address opportunities for improvement.
• Clinical nurses are involved in interprofessional decision‐making groups at the organization level
• Healthcare organization supports nurses’ participation in local, regional, national, or international professional organizations
Example Exemplar SE2EOb:Provide one example, with supporting evidence, of an improved patient outcome associated with the application of nursing standards of practice implemented due to a clinical nurse’s participation in a nursing professional organization.
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How Can RDNs Support Structural Empowerment?
At your organization level:
• Shared Leadership Councils
• Interdisciplinary
• Professional Practice Councils
• Frontline staff
• Both RDNs/NDTRs
• Varying years of experience
• Varying specialties
At the National Level:
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Exemplary Professional Practice
Exemplary professional practice in Magnet‐recognized organizations is evidenced by effective care services, interprofessional collaboration, and high quality patient outcomes.
• Nurses create partnerships with patients and families to establish goals and plans for patient‐centered care
• Nurses are involved in interprofessional collaborative practice to ensure care coordination and continuity of care
Example Exemplar EP7EO:Provide one example, with supporting evidence, of an improved outcome associated with an interprofessional quality improvement activity, led or co‐led by a nurse.
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How Can RDNs Support Exemplary Practice?
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New Knowledge, Innovation, & Improvements
Magnet‐recognized organizations conscientiously integrate evidence‐based practice and research into clinical and operational processes.
• Organization supports the advancement of nursing research
• Clinical nurses evaluate and use evidence‐based findings in their practice
• Innovation in nursing is supported and encouraged
Example Exemplar NK3:Provide one example, with supporting evidence, of a clinical nurses’ use of evidence‐based practice to revise an existing practice within the organization.
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How Can RDNs Support Evidence‐Based Practice?
Formerly known as the Dietetics Practice Based Research Network (DPBRN)
Academy’s Standards of Excellence was modeled from:
• Nursing Magnet Recognition Program
• Malcom Baldrige National Quality Award
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Last Trend: For Your Consideration…
• Inspirational RDN trailblazers
• Janel Welch, MS, MPA, RDN, CDN, FAND, CPHQ, QIP St. Ann’s Community
• Linda Kluge, RD, LD, CPHQ Alliant Health Solutions
• Lauren Melnick, MS, RD, LD Cleveland Clinic
• Laura Jeffers, Med, RD, LD Cleveland Clinic
•My position as a Senior Improvement Specialist
Dietitians working in non‐traditional RDN positions within healthcare
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Janel Welch, MS, MPA, RDN, CDN, FAND, CPHQ, QIP
Director of Quality and Risk Management; Corporate Compliance OfficerSt. Ann’s Community
• Number of Years in Current Position3 years
• What made you pursue your current position in a non‐traditional RDN role?“As a CNM at my organization, I was looking to enhance my leadership skills and pursued a Master’s in Public Administration. I had the opportunity to be involved in a Lean Six Sigma Yellow Belt Project and really enjoyed the experience. I began participating in more and more quality initiatives and a position within the Operational Process Improvement Department became available. I never thought I would actually get the position. But I did and my journey beyond the traditional scope a Dietitian began.”
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Janel Welch, MS, MPA, RDN, CDN, FAND, CPHQ, QIP
continued…
• What do you like most about your current position? “What I love the most about my position is having the opportunity to help other departments provide high quality care to the residents we care for across the continuum of healthcare. The regulations and requirements are always changing and the opportunities for improvement are endless. I recently was able to hire another FTE in my department and I hired an RDN who was looking to gain more experience inproject management.”
• What advice would you give to RDNs who are thinking about pursuing non‐traditional RDN positions within healthcare organizations?“The advice I would give …is to just go for it. We are well equipped for success. RDNs are highly educated, hard working, dedicated, and self‐driven making them able to adapt to new opportunities and experiences. We have the clinical, analytical and leadership skills necessary to be successful. Best of luck on your journey!”
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Linda I. Kluge, RD, LD, CPHQExecutive DirectorAlliant Health Solutions, Inc.
Laura A. Jeffers, MEd, RD, LDProject Manager, Community Care Cleveland Clinic
• Number of Years in Current Position9 Months
Prior had 2 years in Quality Improvement + 12 years in Nutrition Therapy
• What made you pursue your current position in a non‐traditional RDN role?“I no longer had the passion I once did for the work and was bored in the role. I did not feel excited about the initiatives being rolled out in the Center for Human Nutrition and I knew that I had so much more to give the Cleveland Clinic. I wanted to be a part of something bigger and help make a difference with our patients.”
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Laura A. Jeffers, MEd, RD, LDcontinued…
• What do you find exciting about your current position? “I am involved in rolling out framework in our population health model – Cleveland Clinic Community Care. We are creating new ways to take care of patients and manage populations. I get to help plan and implement programs that are making a difference for our caregivers, providers and patients.”
• What advice would you give to RDNs who are thinking about pursuing non‐traditional RDN positions within healthcare organizations?• “Be sure you are ready for the next step – moving away from nutrition”
• “Have coffee chats with individuals across your organization to learn what else goes on outside of nutrition”
• “Figure out what lights you up and go for it!”
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My Current Role
• Position: Senior Improvement Specialist• Department: Patient Safety and Innovation• Supervisor: Lisa Donahue, DNP, RN, CPPS• Responsibilities:Assist with QI Projects + Tests of ChangeMentor/Coach + My Nursing Career project mentor
Magnet Writing Team
Shared Leadership Council Facilitation + SupportSupport to Committees: Skin Care, Sepsis, Surgical Services
Quality and Safety Fair Judging Coordinate the annual Communication Conference
Command Center assistance PRN
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My Motivation and Journey
• Comfortable in CNM role – needed a challenge
• As a CNM and volunteer work in Academy roles – developed a strong business acumen and leadership skillset
• Thought Mantra – “Why is it always nurses? Why not a dietitian?”
• Precedent set – previous non‐nurse Improvement Specialists
• Developed a reputation at hospital and rapport with my future/current boss
• Scariest career move I’ve made to date
• First 3 years continued to question my decision
• Comfort level now – learning so much about healthcare
Don’t know what’s next…stay tuned!
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My Learnings – From Personal Experience
• Form relationships with leaders outside the Food and Nutrition Department
• Be a member of hospital‐wide councils, committees, workgroups
• Speak up in meetings to show you are engaged/interested
• Volunteer for any hospital initiatives
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My Learnings – From Personal Experience
• Participate in any award programs, health fairs, QI fairs, etc.
• Promote and share your/your staff’s great work and accomplishments
• Let your leadership and business acumen skills shine through
• Pursue any professional development opportunities offered
• Form
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“Nothing ventured, nothing gained.”
‐ Benjamin Franklin
"If you are interested in trying something new that's a nontraditional RDN position, why not give it a try. You just might be pleasantly surprised at how successfully you master it and prove to others in your organization that
