Sharon Je ff er sPhebe Searcey

Kathy Boyle

Carol HerringKathleen Lester

Hillarie Goetz-SmithPolly Nelson

Centralized Video MonitoringFor M e n t Safely: A Denyer

Health Lean JourneyEXECUTIVE SUMMARY

The demand for certitied nurs-ing assistant (CNA) statt usedas 1:1 sitters for safetyenhancement and fall preven-tion can be costly.

Through Lean thinking andtools and brainstorming, lead-ers at Denver Health conceptu-alized the centralized videomonitoring (CVM) program forpatient safety.

The CVM program reallocatedthe underutilized talents of CNAsitters as video monitoring tech-nicians (VMT) to meet the chal-lenge of delivering high-quality,cost-effective patient care.

Implementing the CVM pro-gram required tight connectionsand collaboration with a multi-disciplinary team of individuals.

Actual program performanceexceeded the initial projectedbenefits.The CVM program supports thehigh level of vigilance requiredby nursing statf to ensurepatient safety and quality.

NOTE: Please see the following page forauthors' biographical information andacknowledgments.

THE CORE OF SUCCESSFUL HEALTHcare delivery systems is theability to deliver care in asafe, injury-free environ-

ment for patients and staff usingcurrent protocols and proven sci-ence (Evans & Lindsay, 2011). TheJoint Commission (TJC) identifiedinjury from falls as one of the safe-ty concerns when a patient is hos-pitalized (Inouye, Brown, & Tinetti,2009). Within the hospital setting"accidental falls are the common-est reported patient safety inci-dent in hospitals" (Oliver, 2008, p.1774) and approximately 2% to12% of patients experience atleast one fall during their hospitalstay (Coussement et al., 2008). Interms of the financial burden, by2020, the nationwide cost of fallsis projected to be more than $43.8billion (Quigley, Neily, Watson,Wright, & Strobel, 2007). To ad-dress the challenging impact offalls on patients and organiza-tions, TJC added the requirementof a fall-reduction program witheffectiveness evaluated as the 9thNational Patient Safety Coal in2005, and elevated it to a TJCStandard in 2010 (Jorgensen, 2011).Furthermore, the Centers forMedicare & Medicaid Servicescreated guidelines related to

patient safety and reduced finan-cial reimbursement for injuriesresulting from falls occurring dur-ing a patient's hospital stay(Department of Health and HumanServices, 2010).

When evaluating quality andorganizational performance, healthcare organizations look toward theAgency for Healthcare Researchand Quality and other organiza-tions such as TJC for publishedstandards of care such as NationalPatient Safety Coals, competen-cies, and standards of practice. AtDenver Health (DH), in 2009, fallrates continued to remain abovenational benchmarks despite theimplementation of a comprehen-sive fall-prevention program. Theuse of yellow arm bands, signage,risk-score associated interven-tions, and a validated risk-to-fallassessment tool did not result in adesired decrease in fall rates. Inresponse, DH implemented anhourly rounding fall-preventionprogram based on an evidence-based program developed and stud-ied by the Studer Croup (Meade,Bursell, & Ketelsen, 2006). How-ever, the demand for certified nurs-ing assistant (CNA) staff as 1:1 sit-ters for safety enhancement and fallprevention and the cost of sitters

NURSING ECONOMIC$/November-December 2013/Vol. 31/No. 6

Figure 1.Denver Heaith Anaiysis of Demand for Sitters (Juiy 2010 - December 2011)

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SHARON JEFFERS, MBA, PMP, is Program Manager and Lean Black Belt, eHealthServices/Information Technology, Denver Health and Hospital Authority, Denver, CO.

PHEBE SEARCEY, MSN, RN, is Clinical Nurse Educator, Nursing Support Services,Denver Health and Hospital Authority, Denver, CO.

KATHY BOYLE, PhD, RN, is Chief Nursing Officer and Lean Black Belt, Denver HealthAdministration, Denver Health and Hospital Authority, Denver, CO.

CAROL HERRING, MA, RN, is Quality Initiatives Coordinator, Nursing Management,Denver Health and Hospital Authority, Denver, CO.

KATHLEEN LESTER, BS, BSN, RN-BC, is Clinical Nurse Educator, Denver Health andHospital Authority, Denver, CO.

HILLARIE GOETZ-SMITH, BSN, RN, is Clinical Nurse Educator, Denver Health andHospital Authority, Denver, CO.

POLLY NELSON, RN, is Nurse Program Manager - Float Pool and Lean Black Belt,Nursing Support Services, Denver Health and Hospital Authority, Denver, CO.

ACKNOWLEDGMENTS: The authors vi ish to thank Patricia Tillapaugh, MBA, RN; QuinDavis, BSN, RN; Denise Johnson, BS; Kim Carroll, BSN, RN; Joseph Gerardi, BSN, MHA;Wayne Struhinger, BMET; Susan Van Dyk, MAHRD, MAM, BSN, RN; Lee Ann Kane,MSN, RN; Kelly Murphy, BS, CNA; Jacob Pratt, BS, CNA; Rachel Cutierrez, CNA; MikeJames, CNA; Brad Barney, CNA; Lauren Corray, CNA; Mike O'Malley, ACFO; Patti BlairThompson, RN; Sarah Radunsky; and Jeff Pelot, CTO, FHIMSS, for their support on thisproject.

continued to trend upwards asshown in Figure 1. In response,other innovative ways to monitorpatients' safety and use resourcesmore efficiently were explored.DH's use of Lean thinking andtools (Radnor, Holweg, & Waring,2012) and brainstorming sessionswere used to conceptualize thecentralized video monitoring (CA^)program for patient safety. Thepurpose of this article is to des-cribe CVM as an innovative ap-proach to address the organiza-tional demand to ensure patientsafety at reduced operational ex-penses. Implementation of theCVM program reallocates theunderutilized talents of 1:1 CNAsitters as video monitoring techni-cians (VMT) to meet the challengeof delivering high-quality, cost-effective patient care.

NURSING ECONOMIC$/November-December 2013A/ol. 31/No. 6

BackgroundEounded more than 150 years

ago, Denver Health, a 525-bed acutecare facility, serves the people ofDenver, the state of Colorado, andthe Rocky Mountain region. Theintegrated health care system in-cludes a level I trauma center,Denver's 911 Emergency Manage-ment System, a paramedic divi-sion, eight family health centers,15 school-based health centers,the Rocky Mountain Poison andDrug Center, NurseLine, correc-tional care, Denver CARES (a 100-bed detox facility), Denver PublicHealth, and the Rocky MountainCenter for Medical Response toTerrorism, Mass Casualties, andEpidemics. Denver Health, anaspiring Magnet® facility, is thelargest provider of care in the statefor the uninsured and Medicaidpopulations as well as a majorprovider for the Child HealthPlan. Approximately 42% of DHpatients are uninsured, and un-compensated care for uninsuredpatients exceeded $450 million in2011 and more than $4 billionsince 1991.

In a society characterized byfiat revenues and increasing costs,health care organizations mustmake the most of their invest-ments in people, process, andtechnology by threading qualityand organizational performancethroughout their organizations.Denver Health is not immune tothe changing and uncertain econo-my, and executive leadershipstates quality initiatives are anintegral part of health care opera-tions and provide processes andtactics that address the challengesfacing health care organizations.In 2005, DH embarked on a Leantransformation journey, a para-digm-shifting organizational beha-vior change initiative to create anew model for health care deliv-ery and build a mature organiza-tional culture committed to reduc-ing waste while perfecting thepatient experience and becominga model for the nation. Denver

Health's leadership driven initia-tive, "Cetting It Right and Per-fecting the Patient Experience,"utilizes Lean principles in allaspects of the organization. Leanis an integrated system of princi-ples, practices, tools, and tech-niques focused on reducing waste,synchronizing workflows, andmanaging variability in produc-tion fiows (Radnor et al, 2012).Lean gives organizations a system-afic approach and tools to drive outwaste from overproduction, mo-tion, rework, waiting, transporta-tion, intellect, inventory, and pro-cessing (Yousri, Khan, Chakrabarti,Eernandes, & Wahab, 2011). Theresult is standard work that addsadditional value fo processes andworkflows that serve the cus-tomer's needs. Lean's strength toorganizations is built from thecommon set of standard solutionsand a focus on the customer andthe entire value chain (De Koning,Verver, Van Den Heuvel, Does, &Bisgaard, 2006).

The Lean transformation jour-ney started with the first BlackBelt training program designed tobuild core competency in the useof Lean tools and principles. Inthe spring of 2005, multiple valuestream analyses aligned effortswith core value stream businessobjectives and resulted in the firstrapid improvement events (RIE) inJune 2005. In April 2006, DH esta-blished a Lean Systems Improve-ment (LSI) department to commitdedicated resources to focus onLean initiatives. In August 2006,DH recognized the first confirmedfinancial returns. Momentum andcommitments from all levels ofthe organization continued topush this effort forward. In thespring of 2007, DH conducted thefirst internal Black Belt trainingprogram and had engaged morethan 20% of fhe organization'semployees in some type of Leanquality initiative. Cumulative fig-ures published from the LSIdepartment in June 2012 con-firmed Lean had taken hold as evi-denced by 400 RIEs with more

than 2,000 employee participantsfrom over 220 departmentsaligned with 16 corporate valuestreams. Lean "brings action andintuition to the table, quicklyattacking low hanging fruit withKaizen events" (Smith, 2003, p. 1).The Lean process fits health careby leveraging an intuitive tool setof Lean principles and a two-pronged approach to organizationchange through facilitated RIEevents and trained DH Lean BlackBelts. Lean provides meaningfulemployee engagement, initial rapidresults, and the power to changeculture across the organization.Through June 30, 2012, organiza-tional Lean financial impact hasreached $171 million. Lean trans-formations occur daily in the DHsystem. The CVM program is anexample of Lean at work, identify-ing and eliminating waste withinan increasing sitter population,through the utilization of CVM todeliver continuous patient safetywhile decreasing personnelexpenditures.

Literature ReviewDenver Health's CVM program

research produced limited pub-lished content on the use of videosurveillance monitoring in a pa-tient care setting to support pa-tient safety initiatives. A Boston-based hospital pilot-tested videomonitoring to "collect reliabledata for use in quality improve-ment" ("Video Monitoring," 2005,p. 8). This type of monitoringfocused on staff performance andfacility security. In 2009, OchsnerMedical Center in New Orleans,LA, implemented a small-scale24-hour camera surveillance pro-gram on a 34-bed internal medi-cine unit with success, "reducingtheir sifter cosf from $960 for fourpatients to $240 for four patients"(Coodleft, Robinson, Carson, &Landry, 2009, p. 21). Rochefort,Ward, Ritchie, Cirard, and Tamblyn(2011) supported arguments thatsitter usage and increasing sittercosts cannot be associated directlywith specific patient health condi-

NURSING ECONOMIC$/November-December2013A/ol. 31/No. 6

tions. However, sitters have beenused historically as a tool toincrease patient safety in thosepatients with at-risk characteris-tics. "To our knowledge, no priorstudy has documented the factorsthat are associated with higher sit-ter use costs" (Rochefort et al.,2011, p. 2). Rochefort and col-leagues (2011) also reported annu-al sitter costs in U.S. hospitals canreach as high as $3 million. Mosthospitals have adopted technolo-gy such as bed alarms, chairalarms, restraints, and unlicensedassistive personnel as part of acomprehensive patient safety pro-gram (Wiggins, Welp, & Rutledge,2012).

In 2009, the Nursing Execu-tive Center published a case studyfrom Poudre Valley Hospital inFort Collins, CO, discussing theirvideo surveillance deploymentwithin a single neurosciencesunit. Poudre Valley's use of cam-eras for all patients assessed ashigh risk for falls resulted in "a fallreduction from 23.5 falls per yearto 2 in the first year after imple-mentation" (Nursing ExecutiveCenter, 2009, p. 130). DenverHealth was faced with similarchallenges with staff providingpatient and family-centered carewith safety as a primary focus. Inan effort to keep patients safe,there are times when staff isrequired to intervene and redirectpatients. For example, patientswith a traumatic brain injury maytry to pull out intravenouscatheters or have a propensity tofall. These patient behaviorsrequire staff interventions to keeppatients safe. A sitter's responsi-bility is to keep the patient in lineof sight at all times and to inter-vene when necessary (Harding,2010). The CVM team visitedPoudre Valley to learn from theirsuccesses and look for a Leanmethod to apply their findings ona larger, centralized scale.

Health care organizations ex-perience tremendous pressure tochange to keep pace with ad-vances in technology, medical

practice, and the better-informedpatient population. Advancedtechnologies and increased costsdue to operational inefficienciesimpact all areas of health careorganizations (De Koning et al.,2006). The CVM program teamfocused on using technology andLean with the premise the wholeis greater than the sum of its partsand implemented a CVM programthat is patient centered, timely,efficient, technologically advanc-ed, and expanded the hospital'scurrent investment in the fall-pre-vention program. Lean initiatives"become a formidable tool forattacking the problems that en-large the difference between annu-al revenues and the bottom line"(Smith, 2003, p. 1). Organizationalbehavior initiatives, such as Lean,combined with leading edge, cen-tralized video technology, provid-ed a formidable solution in DH'sacute care setting.

Intervention and ProgrammingImplementing the CVM pro-

gram required tight connectionsand collaboration with a multidis-ciplinary team of individuals rep-resenting nursing administration,acute care nursing managementand staff, nursing support servicesmanagement and staff, biomédicalservices, information technology,legal, regulatory, quality and pa-tient safety, and vendor partners.Denver Health assigned a projectmanager to coordinate workefforts across the departmentalareas and to help streamline theimplementation steps. Informa-tion technology resources facilitat-ed the selection of a video tech-nology solution that supported theminimum requirements for con-tinuous monitoring without re-cording with video image, quality,and patient visualization in bothhigh and low light settings. Con-struction of a monitoring room or"command center" provided videomonitoring staff with a central-ized, secure space to perform themonitoring job functions. Com-munication between care provi-

ders required the expansion of thenurse call system to the central-ized monitoring room to provideproactive, immediate audio con-tact with unit nursing staff andpatients. Finally, camera installa-tion on all acute care unitsrequired closure of patient roomswith minimal impact to patientcensus.

Following many planningmeetings and site visits the previ-ous year, CVM program imple-mentation began in September2010. Before implementation,clinical nurse educators createdworking documents such as flowsheets for documentation, admitand discharge logs, and a resourcemanual for staff. The resourcemanual provided VMTs with keyoperational guidelines on theCVM and nurse call systems,workflow and downtime algo-rithms, and contact informationfor support staff. Training andeducation of the staff occurredthrough "at the elbow" hands-onuse of software and equipment,discussion of standard workflows,and job simulation. Competencyevaluation tools were used to vali-date the VMT knowledge andunderstanding of the system andprocesses being implemented. An-cillary staff were educated regard-ing the surveillance program andreassured their own performancewas not being evaluated. An ad-ministrative procedure was draft-ed and approved by the legaldepartment. Consent for videomonitoring was part of the generalconsent form and did not require aseparate consent. After repeateddiscussions between the nursingand legal departments, the legaldepartment stood firm on thedecision patients could refusevideo monitoring, and when thisoccurred, they would be providedwith 1:1 CNA sitters due to thenewness of this type of program ina clinical setting.

After the preliminary stepswere in place, the implementationteam executed a small, focusedpilot on one of the acute care '

NURSING ECONOMICS/November-December 2013A/ol. 31/No. 6 Q

units. During the first week of theprogram implementation, the pilotwas limited to day shift monitor-ing to provide better support forthe pilot staff and to facilitate pro-gram feedback and lessons learned.The CVM room was staffed at alltimes with two CNAs, also refer-red to as VMTs. Patients enrolledin the pilot were consented and anin-room sitter remained in placefor the first week. During the pilot,the average census of patientsmonitored was 8-10. Status meet-ings were held daily includingstaff from the pilot unit, CVMroom, information technology,and the nurse call system repre-sentative. The meetings were usedto evaluate program effectivenessand provide process and proce-dure feedback. After the firstweek, the pilot was expanded to24/7 coverage with an increase inthe number of patients on videomonitoring. The CVM programpilot expanded quickly to addi-tional floors with full implementa-tion across all acute care units byDecember 2010.

The current CVM programmonitors 8-18 patients from sevenacute care units, with an averagedaily program census of 12 pa-tients. Two VMTs continue to staffin the CVM room 24/7 post pilot.The inpatient nursing float poolmanagement team provides theorientation and staffing and main-tains competencies for all CNAs inthe centralized monitoring room.The VMTs are scheduled for 12-hour shifts with relief breaks pro-vided by the acute care unit CNAson a rotating basis. The VMTswork together as a team to monitorfor patient activity, communicatewith patient and unit staff, andtroubleshoot and provide inter-ventions as necessary. Documen-tation occurs in real-time on avideo monitoring technician worklog (see Figure 2), and resultingdocumentation is transferred tothe patient's electronic medicalrecord at 2-hour increments.

A VMT's shift begins with aformal hand-off of information

Figure 2.CVM Video Monitoring Technician Work Log

Patient Label Date:Room No:

D iVIeets Sitter CriteriaD Patient with Sitter

DReportTime:

RN Fall

CNA f'o^S^tf^'Flight

Dx Pullina linesSeizures SMT initials

from the previous shift. The VMTsin the monitoring room give reporton each patient to incoming staffand round on each nursing unit tocollect patient census reports andestablish communication withunit staff. Each shift, the unitcharge nurse responsible for CVMpatients calls report to the VMTsto confirm the correct patients areon camera and are being moni-tored for the correct identifiedrisks. Two patient identifiers andthe specific criteria that catego-rized the patient as at risk occurupon patient admission, uponreturn from patient transport fromoff-unit locations, or at a change inlevel of care or risk criteria. TheVMTs are responsible for followup with the charge nurse and bed-side RN for clarification, verifica-tion, and updates as needed. Keyvideo monitoring processes in-cluding admission to program,escalation procedures, and down-time operations are formalized as

Lean standard work to ensure thesame workflow is followed inde-pendent of the individual staffperforming the same job function.

The CVM program was metwith skepticism initially by nurs-ing unit managers and staff.However, shortly after implemen-tation, the value of the programbecame apparent and is nowwidely accepted. "Initially I wasvery skeptical and not at all a fan,but they (the cameras) have provedmuch more helpful than I anticipat-ed. When (video monitoring) CNAsspeak to the patients, we hear itand can go in before anythingactually happens. Much like a bedalarm, it gives us an extra 60 sec-ond warning before a fall," stateda nurse manager. A CNA and VMTnoted, "This has been a great wayto enhance patient safety whilemaintaining privacy. "

NURSiNG ECONOMICS/November-December 2013/Vol. 31/No. 6

Outcomes and ImplicationsFor Future Practice

The benefits of this programexpanded beyond the originalexpectations. The program wasoriginally implemented to in-crease patient safety, decreasefalls, and prevent elopement. Thebenefits included increased pa-tient satisfaction, decreased inter-ruptions in therapy, added staffsafety, and improved time to rec-ognize seizures through limited

seizure monitoring. The VMTskeep a log of "Creat Saves" torecord informal feedback for re-porting of improved outcomes as aresult of VMT interventions (seeFigure 3). The first 3 months ofVMT interventions contributed tothe prevention of 57 falls, sevenoxygen therapy disruptions, and10 IV catheter pulls. Additionally,the CVM program facilitated afaster transition of two patientsfrom an in-room sitter to CVM,and subsequent placement to a

Figure 3.Centralized Video iVIonitoring 'Great Saves'

"Patient started to roll out of bed, monitor alert called, staff responded quickly. Thepatient did not fall."

"Patient having a grand-mal seizure, RN walked into room, pressed tracker (staffassist) - no response. We called the front desk to get extra staff to help. Sitterappointed to patient for remainder of shift v(/ith camera assist."

"Patient very agitated and restless not redirectable. Patient on edge of bed startingto stand. Monitor alert called, within 5 seconds staff in room to catch patient andhelp untangle patient from oxygen. Patient did not fall."

skilled nmrsing facility. Another ofthe benefits is the ability for thestaff to have a "second pair ofeyes," increasing both staff andpatient safety.

Additional unintended bene-fits occurred related to staff safety.An informal survey of staff indi-cated the CVM program helpedprovide security to staff whenworking with more challengingpatients. For example, a patient ona mental health hold was assigneda sitter and was additionallyassigned to the video monitoringteam. The VMTs noticed thepatient fidgeting with his sock andnotified the 1:1 sitter of the behav-ior. Upon further investigation,the patient was found to have asmall weapon hidden in his sock.The patient became aggressivewith the weapon with the inten-tion to cause harm to staff. TheVMTs notified the unit of the needfor staff assistance and helparrived for the sitter without harm

Figure 4.Denver Heaith Acute Care CNA Usage Resuits

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NURSING ECONOMICS/November-December 2013A/ol. 31/No. 6

Figure 5.Denver Heaith Centraiized Video IVionitoring iJtiiization (Juiy 2010 - June 2012)

• Sitter Rooms

Monthly Summary

— Monitored-Only Rooms • CNA Savings

Jul |Aug Sep Oct Nov | Dec

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Jan|Feb|Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2011

Jan Feb Mar Apr May Jun

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occurring to the staff or patient.The program has also assisted intimely identification of patientneeds, such as the patient whoneeds assistance with meals, or apatient struggling to replace anoxygen cannula.

The CVM program had animmediate and significant impactto Denver Health's operations andmission of providing "Level OneCare for All." Prior to implement-ing this program, conservativeestimates of 1:1 sitter use were ashigh as 30 sitter patients per day(average of 11 - 1:1 sitter rooms/day). Of those, more than 50% ofthe sitters were a combination ofregular DH CNA staff at $14.51/hour and contracted agency CNAstaff at $23/hour. The CVM pro-gram goals included two primary"target state" metrics: (a) decrease1:1 sitter observation by a mini-mum of 50% per day or six pa-tients with 1:1 sitters per day, and(b) decrease hospital fall rates to

under National Database of Nur-sing Quality Indicators (NDNQI)benchmarks. The projected pro-gram return on investment, ex-cluding the initial technologyinvestments, was estimated at$381,323.

Actual program performancehas exceeded the initial projectedbenefits. Figure 4 shows actualCNA expenses in most periodswere lower than baseline expens-es even during periods of in-creased CNA usage. Within thefirst quarter of operation, the$392,000 cumulative VMT defer-red staff savings exceeded theoriginal technology investment of$305,000, passing the programbreakeven point. As of June 2012,with just over a year and a half ofoperation, the CVM program hasaffected more than $2.02 millionin deferred cost savings (seeFigure 5). The deferred savings arerepresented by the costs associat-ed with "Monitored Only Rooms"

where a 1:1 sitter was replacedwith CVM minus the cost of twoVMT CNAs required to staff theCVM monitoring room. An aver-age cost of $14.51 per hour perCNA or $696.46 per day was usedin these deferred savings calcula-tions. Future discussion willdetermine the feasibility of build-ing monitoring costs into patientcharges. Within the first 3 monthsof operation, 57 falls were pre-vented with a potential minimumsavings of $24,225. Following thefirst quarter of CVM implementa-tion, acute care units experiencedtheir highest percentage of NDNQIfall compliance since the programimplementation, with 75% of thenursing units meeting or exceed-ing the benchmark mean for thesecond quarter 2011 (see Figure6). This is the best performance in2 years, and the overall trend foracute care falls per 1,000 patientdays continues to decrease postimplementation (see Figure 7).

NURSING ECONOMIC$/November-December 2013/Voi. 31/No. 6

Figure 6.Denver Health Acute Care Performance Against National

Benchmarl<s - Acute Care Fails

Acute Care Percent of Units at or Better than the National Benchmarkfor Falls per 1,000 Patient Days

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Figure 7.Denver Heaith Acute Care Fail Trend (Q1 2012 - Q1 2012)

Acute Care Falls per 1,000 Patient Days

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A secondary goal of the pro-gram was to reduce the number ofpatient elopements. The camera'sview of the patient's bed and sur-rounding area is static, so at theonset of the program, it was dis-covered the patient who is at riskfor elopement could move outsideof the camera's range and not beattempting to elope. Consequentlypatients who are at risk for elope-ment but do not meet other quali-

fying criteria are no longer placedon video monitoring.

Nursing leaders continue tolook for opportunities and learnfrom the CVM program as a fallcannot always be prevented evenwhen a patient is on video moni-toring. Some patients are impul-sive, move quickly, and do notadhere to direction provided bythe VMT staff. In these situations,VMTs immediately notify unit

staff who respond quickly to pre-vent patienf fall or injury. Ad-ditionally, patients with commu-nication challenges including lan-guage barriers and hearing losscould not be instructed and redi-rected utilizing the integratednurse call system. These patientsare monitored by an in-room sit-ter. The CVM program team con-tinues to seek ways fo expandCVM to this population.

The Denver Health Lean im-provement story is rooted in themission of serving all of fhe peo-ple of Denver, including disadvan-faged and vulnerable populations.Additional resources are alwaysneeded to meet the demands forhealth care delivery. The funda-mental improvement question forDH has always been, "How canmore people be served with ourlimited resources?" The CVM pro-gram supports the high level ofvigilance required by nursing stafffo ensure patient safety and quali-ty (Matsuo et al, 2008). The DHstory is one of continuous growthand maturation while identifyingand eliminating waste in thedelivery of health care. The invest-menf in the CVM Lean initiativehas paid off for Denver Health andhealth care organizations are look-ing closely at operationalizing thesuccesses at Denver Health. $

REFERENCESCoussement, J., Paepe, L., Schwendimaim,

R., Denhaerynck, K., Dejaeger, E., &Milisen, K. (2008). Interventions forpreventing falls in acute- and chronic-care hospitals; A systematic reviewand meta analysis. Journal of Amen-can Geriatrics Society, 56(1), 29-36.doi:10.1111/j.l532-5415.2007.01508.x

Department of Health and Human Ser-vices. Centers for Medicare and Medi-caid Services. (2010). Proposals forimproving quality of care during inpa-tient stays in acute care hospitals inthe fiscal year 2011 notice of pro-posed rulemaking. Medicare FactSheet. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-S er vice-Pay ment/AcutelnpatientPPS/downloads/FSQ09JPLTCHll_NPRM041910.pdf

De Koning, H., Verver, J.P., Van DenHeuvel, J., Does, R.J., & Bisgaard, S.(2006). Lean six sigma in healthcare.

NURSING ECONOMICS/November-December 2013A/ol. 31/No. 6

Journal for Healthcare Quality 28(2),4-11. doi:10.1111/j.1945-1474.2006.tb00596.x

Evans, J.R., & Lindsay, W.M. (2011). Mana-ging for quality and performanceexcellence (8th ed.). Mason, OH:South-Western Cengage Learning.

Goodlett, D., Robinson, C, Carson, P. &Landry, L. (2009). Focusing on videosurveillance to reduce falls. Nur-sing2009, 39(2), 20-21. doi:10.1097/Ol.NURSE.0000345233.09590.79

Harding, A. (2010). Observation assistants:Sitter effectiveness and industrymeasures. Nursing Economics, 2(5),330-336.

Inouye, S.K., Brown, C.J., & Tinetti, M.E.(2009). Medicare nonpayment, hospi-tal falls, and unintended conse-quences. The New England Journal ofMedicine, 360, 2390-2393. doi:10.1056/NEJMp0900963

Jorgensen, J. (2011). Reducing patient falls:A call to action. Special Supplementto American Nurse Today, 6(2).

Matsuo, A., Shimomura, W., Motas, M.,Kamikawa, C, Guy, S., & Kooker, B.(2008). Better patient surveillance:How a wireless monitoring systemhelped staff decrease patient falls andimprove patient satisfaction on onemedical/surgical unit. Nursing Man-agement, 39(12), 14-18. doi:10.1097/Ol.NUMA.0000342684.87516.24

Meade, CM., Bursell, A.L., & Ketelsen, L.(2006). Effects of nursing rounds onpatients' call light use, satisfaction,and safety. American Journal of Nurs-ing, 306(9), 58-70. doi:10.1097/00000446-200609000-00029

Nursing Executive Center. (2009).Envisioning the future nursing organ-ization: High-risk video surveillance.Washington, DC: The Advisory BoardCompany.

Ohver, D. (2008). Evidence for fall preven-tion in hospitals. Journal of American

Geriatrics Society, 56(9), 1774-1775.doi:10.1111/j.l532-5415.2008.01830.x

Quigley, P., Neily, J., Watson, M., Wright,M., & Strobel, K. (2007). Measuringfall program outcomes. The OnlineJournal of Issues in Nursing, 32(2), 8.Retrieved from http://www.mu'sing-world.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volumel22007/No2May07/ArticlePreviousTopic/MeasuringFallProgramOutcomes.html

Radnor, Z.J., Holweg, M., & Waring, J.(2012). Lean in healthcare: The unful-filled promise? Social Science SrMedicine, 74(3), 364-371. doi:10.1016/j.socscimed.2011.02.011.

Rochefort, CM., Ward, L., Ritchie, J.A.,Girard, N., & Tamblyn, R.M. (2011).Patient and nurse staffing characteris-tics associated with high sitter usecosts. Journal of Advanced Nursing,24, 1-10. doi:10.1111/j.1365-2648.2011.05864.x

Smith, B. (2003, April). Lean and six sigma- a one-two punch. Quality Progress,37-41. Retrieved from http://www.tbmcg.com/acrobat/press_public/QP_-_Lean_and_Six_Sigma_-_One_Two_Punch.pdf

Video monitoring provides new source ofdata. (2005). Health Facilities Manage-ment, 38(12), 8.

Wiggins, A., Welp, C, & Rutledge, D.N.(2012). Reconceptualizing patientsafety attendants. Nursing Manage-ment, 43(5), 25-27. doi:10.1097/01.NUMA.0000413652.57719.6b

Yousri, TA., Khan, Z., Chakrabarti, D.,Fernandes, R., & Wahab, K. (2011).Lean thinking: Can it improve the out-come of fracture neck of femur pa-tients in a district general hospital?Injury: International Journal of theCare of the Injured, 42(11), 1234-1237.doi:10.1016/j.injury.2010.11.024

Health Policy and Politicscontinued from page 308

REFERENCESBeauchamp, D. (1976). Public health as social justice. Inquiry, 13, 3-14.Dorfman, L., Wallack, L., & Woodruff, K. (2005). More than a message: Framing public

health advocacy to change corporate practices. Health Education &• Behavior, 5.2(3),320-336.

Hooks, N. (2013, September 10). What is the best way to get rid of Obamacare? The LasCruses Sun-News. Retrieved from http://wvvrw.lcsun-news.com/las_cruces-opinion/ci_24276500/what-is-best-way-get-rid-obamacare

Krugman, P. (2013, October 6). Despite COP's best efforts, Obamacare is here to stay.Honolulu Star-Advertiser, p. F4.

Newport, F. (2013). Approval of Affordable Care Act inches up. Callop Politics. Retrievedfrom http://www.gallup.com/poll/l65548/approval-affordable-care-act-inches.aspx

Turner, C. (2013, September 30) Obamacare not ready for prime time: Opposing view. USAToday. Retrieved from http://www.usatoday.com/story/opinion/2013/09/30/obamacare-affordable-care-act-galen-institute-editorials-debates/2899003

USA Today Editorial Board. (2013, September 30). Mend Obamacare, don't end it: Ourview. USA Today. Retrieved from http://www.usatoday.com/story/opinion/2013/09/30/obamacare-health-refonn-exchanges-insurance-editorlals-debates/2899141/

An Interview with LindaAiken - Part 2continued from page 276

REFERENCESAiken, L.H., Cimiotti, J.R, Sloane, D.M.,

Smith, H.L., Flynn, L., & Neff, D.F.(2011). Effects of nurse staffing andnurse education on patient deaths inhospitals with different nurse workenvironments. Medical Care, 49(12),1047-1053. doi:10.1097/MLR.0b013e3182330b6e

Aiken, L.H., Clarke, S.P., Sloane, D.M.,Sochalski, J., & Silber, J.H. (2002).Hospital nurse staffing and patientmortality, nurse burnout, and job dis-satisfaction. JAMA, 288(16), 1987-1993.

Aiken, L.H., Shang, J., Xue, Y, & Sloane,D.M. (2013). Hospital use of agency-employed supplemental nurses andpatient mortality and failure to res-cue. Health Services Research, 48(3),931-948. doi:10.1111/1475-6773.12018

Kerfoot, K.M., & Douglas, K.S. (2013). Theimpact of research on staffing: Aninterview with Linda Aiken — Part 1.Nursing Economics, 33(5), 216-220,253.

Neff, D.F., Cimiotti, J., Sloane, D.M., &Aiken, L.H. (2013). Utilization of non-US educated nurses in US hospitals:Implications for hospital mortality.International Journal of Quality inHealth Care, 25(4), 366-372. doi:10.1093/intqhc/mzt042

Tubbs-Cooley, H.L., Cimiotti, J.P, Silber,J.H., Sloane, D.M., & Aiken, L.H.2013). An observational study ofnurse staffing ratios and hospitalreadmission among children admittedfor common conditions. BMJ Quality&• Safety, 22(9), 735-742. doi:10.1136/bmjqs-2012-001610

Xue, Y, Smith, J., Freund, D.A., & Aiken,L.H. (2012). Supplemental nurses arejust as educated, slightly less experi-enced, and more diverse compared topermanent nurses. Health Affairs(Millwood), 33(11), 2510-2517. doi:10.1377/hlthaff.2011.1297

Wiltse Nicely, K.L., Sloane, D.M., & Aiken,L.H. (2013). Lower mortality forabdominal aortic aneurysm repair inhigh-volume hospitals is contingentupon nurse staffing. Health ServicesResearch, 48(3), 972-991. doi:10.1111/1475-6773.12004

NURSING ECONOMICS/November-December 2013A/ol. 31/No. 6

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