7.9 Provide examples of nurse involvement in evidence-based quality initiatives to improve coordination and delivery of care across the continuum of services.

Nursing practice at Massachusetts General Hospital (MGH) is guided by knowledge and

built on the spirit of inquiry. A principle that guides practice states – we are ever alert for opportunities to

improve patient care: we provide care based on the latest research findings. Following are examples of evidence-

based quality initiatives

Nurses Improving Care for Health System Elders (NICHE)

At MGH, 41% of all inpatient admissions and 40% of outpatient visits are for patients over

the age of 65. This data excludes OB and Pediatric patients. To enhance current programs and to

prepare for the growing population of the frail elderly, MGH participates in Nurses to Improve the

Care of Health System Elders (NICHE). This nationally recognized evidence-based program,

developed by the John A. Hartford Foundation Institute for Geriatric Nursing at New York

University, focuses on the prevention and better management of syndromes common to the

hospitalized older adult. At MGH, NICHE is called 65plus to reflect the interdisciplinary nature of

the program for patient and family-centered care.

The 65plus at MGH is an interdisciplinary team of Nursing Directors, Staff Nurses, Nurse

Practitioners, Clinical Nurse Specialists, Associate Chief Nurses, Social Workers, Physical Therapists,

Physicians and Chaplain working to identify, evaluate and implement strategies to advance clinical

practice in the care of older patients across the continuum. The team, with a nurse as the project

manager, approached NICHE in two phases. Phase I of this initiative evaluated the current state of

geriatric care at MGH, in order to make recommendations for future program directives.

Phase II: Program

Development

Geriatric Institutional Assessment Profile (GIAP)

Identification of Experts

Institutional Inventory

Gaps & Opportunities

What is in place?

Pharmacists, Case Managers, Dieticians, Physicians, Chaplains, Interpreters

Therapists & Social Workers

Nurses

Disciplines w/ board certification

Staff who are certified

Ways to promote

certification

Development of Mission

Guiding Principles

Vision

Our Name

NICHE Phase I

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During Phase I, the mission and guiding principles for the program were developed and an

organizational assessment was completed. Additionally, the new name, 65plus, was developed and

tested with visitors, patients and families to validate the interdisciplinary and broad reaching

approach to care that this program will offer.

65plus Mission

To ensure the optimum health and well-being of older adults by creating a comprehensive program of

care that addresses the physical, spiritual and emotional needs of the individual, while respecting their values,

beliefs and background.

65plus Guiding Principles

Patient Centered Care - We recognize the importance of having older adults participate in the decisions

affecting their care. Through an interdisciplinary delivery care model, health care providers will work with the

individual and family to promote wellness and prevent functional decline by providing a consistent and

comprehensive standard of quality, ethical and sensitive care to all older adults.

Environment of Care - The environment in which care is delivered promotes the safety, comfort and

optimal treatment of older adults by providing physical space, equipment and systems that meet the

individual’s physical, emotional and spiritual needs.

Evidence-Based Care -We understand the importance of developing and implementing research-based

programs and protocols that are specific to the care of older adults. Our care will reflect the understanding and

knowledge of age-related changes, using current scientific evidence and best practice as the basis of all

recommendations and care provided.

The NICHE Geriatric Institutional Assessment Profile (GIAP) provided the assessment tool

for the program. Using the GIAP, staff completed an interdisciplinary assessment of staff

knowledge, perceptions and practices related to caring for older adults and their families. 1072 staff

including Staff Nurses, Physical Therapists, Occupational and Respiratory Therapists, Speech-

Language Pathologists, Case Managers, Primary Care Physicians, Chaplains, Social Workers,

Pharmacists, Dieticians and Interpreters completed the survey to reflect a broad organizational

perspective on both, staff perceptions of care and the care environment.

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In addition to the GIAP, the team completed an institutional inventory to identify existing

policies and procedures, clinical guidelines, staff education and other resources and programs

available to meet the needs of older patients and their families. Twenty-two care topics were

assessed including; common geriatric syndromes and subjects that focus on the spiritual, financial

and medical-legal aspects of patient care needs.

Phase I of the NICHE has been completed. The team successfully assessed the staff’s

knowledge, perceptions and practices related to caring for older adults and their families. Outcomes

for Phase I include the:

• Identification of staff perceptions regarding the care of older adults,

• Identification of strengths in clinical practices and services,

• Identification of gaps in clinical practices and services, and

• Development of a mission, principles and a new name: 65plus - tailoring healthcare for today’s

older adult - to articulate MGH’s values regarding the care for older adults.

Based on the work of the NICHE/65plus team, this initiative has moved from an

organizational assessment to developing and implementing strategies to advance clinical practice in

the care of older patients. To support the implementation, a new role was created for a Geriatric

Nurse Specialist (attachment 7.9.a) to manage and lead the development and implementation of

clinical practice changes for the organization. The Geriatric Nurse Specialist will report directly to

the Associate Chief Nurse leading the program and will be responsible for working with other

nursing leaders and program directors in Patient Care Services in overseeing the development of the

program. A doctorally prepared nurse was hired for this position and started in this new role in

August 2007.

Tracheostomy Quality Team (TQT)

The Tracheostomy Quality Team (TQT) was established in 2005 to enhance the quality and

safety of care of the tracheotomy patient. With more than 700 tracheostomy patients on general

care units annually, an interdisciplinary TQT was formed through the hospital’s Surgical Clinical

Practice Management team to ensure safe, high quality airway-management for these patients on all

units.

The TQT mission is to assist medical & surgical floors with timely and effective management of in-

patients with tracheostomy tubes through education & training. TQT members include Clinical Nurse

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Specialists from the Respiratory Acute Care Unit and the Thoracic Surgery Unit, a Respiratory

Therapist and a Speech-Language Pathologist.

To improve coordination of services and delivery of care, tracheostomy algorithms for

ventilated and non-ventilated patients were developed to provide a framework for the

interdisciplinary team. While algorithms identify steps to help patients move toward tracheal de-

cannulation while assessing key indicators; such as, secretion clearance, adequate gas exchange,

aspiration potential, swallowing issues, vocal strength and wound concerns. The algorithm guides

care, but it is the input from all disciplines that is essential to ensuring positive outcomes for

tracheostomized patients throughout the hospital. The goal of TQT is to support the care team in

providing safe, high-quality care for this specialized patient population.

To evaluate the effectiveness of the program, a recent pilot study of 100 patients with new

tracheostomies was conducted. Outcomes from the study demonstrated the need for increased

education around some bedside care and technology issues for the nursing and respiratory therapy

staff. Based on these findings, the TQT initiated two initiatives to improve the quality of care for

these patients.

First, a role for Respiratory Therapists specially trained and dedicated to the care of

tracheostomy patients was created. This team of dedicated Respiratory Therapists follows this

patient population on a daily basis, which has made significant improvements in the trajectory from

placement to de-cannulation. Secondly, the TQT developed an e-mail communication tool to

support the clinical staff on the general patient care units. This daily e-mail communication tool

(attachment 7.9.b) was developed to inform clinical leadership of the identity and location of airway-

management tracheostomy patients on their respective units. Included in the emails are attachments

and links to resources and materials that focus on optimizing care for this population.

The goal for TQT is to improve the quality of life for patients with a tracheostomy through

education and multi-disciplinary contributions. Attachment 7.9.c is a clinical narrative from March

2007, describing the role of the TQT from a team member’s experience with a patient. Finally,

current data for the TQT program shows:

♦ The TQT members are working closely to improve overall care of the respiratory

compromised patient and

♦ Daily numbers of tracheostomy patients on general care units have significantly

decreased by approximately 25% with the TQT development of the new Respiratory

Tracheostomy Therapist role.

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Anticoagulation Management Services

In 2003, research published by a MGH physician, Challenges to the Effective Use of Unfractionated

Heparin in the Hospitalized Management of Acute Thrombosis (EM Hylek, et al. Arch Intern Med, March,

2003) identified quality and efficiency gaps in processes to deliver anticoagulation to patients as they

transitioned from the hospital to home care. The results of this study prompted the formation of an

interdisciplinary team to address these deficiencies and make recommendations for improvements in

practices in the delivery of anticoagulation services to patients at MGH.

As a direct result of this work, the Anticoagulation Management Services (AMS), co-directed

by a Nursing Director and Medical Director, was created as a comprehensive, evidence-based

program to monitor, manage and educate patients who require anticoagulation therapy. The goals

for AMS are:

♦ To provide safe, effective, timely, efficient and equitable anticoagulation care for

patients,

♦ To create a relationship-based care delivery model, and

♦ To design and implement effective support systems and workflow processes.

Patients are referred to the program from both outpatient and inpatient settings when they are

discharged from the hospital with a new order for anticoagulation therapy or when they are referred

by their primary care provider for long-term maintenance therapy. AMS also provides transitional

care for initiation and continuation of interrupted therapy. In doing so, AMS provides monitoring,

assessment, and dosing for patients at home in collaboration with Partners Home Care. Patients are

then admitted or returned to the maintenance program or their local medical provider.

There are approximately 4,000 patients in the maintenance program. The primary

population served is adults, many of who are over 75 and who reside in the metropolitan and

suburban Boston areas. The acuity of patients admitted to AMS is generally high. Patients have

complex medical and post-surgical problems requiring anticoagulation therapy. Diagnoses include:

deep vein thrombosis, stroke, atrial fibrillation, multiple cardiac conditions including valve

replacement, at risk oncology patients, and hematologic coagulopathies. Some of the more

commonly identified nursing diagnoses are Imbalanced Nutrition, Risk for Injury, Noncompliance,

Knowledge Deficit, Anxiety, and Ineffective Health Maintenance.

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The staff includes a Medical and Nursing Director, Clinical Nurse Specialist, Registered

Nurses and Patient Service Coordinators providing administrative support to the clinicians. The

nursing staff works in collaboration with the patients’ Physicians, Community-based Nurses, Case

Managers, Pharmacists, Interpreters, the patients and their families, and other disciplines based on

patient care needs.

Computerized and hand-held algorithms support frequent assessments by skilled AMS

Primary Nurses. Practice is based on evidence-based guidelines, such as those recommended by the

ACCP Conference on Antithrombotic and Thrombolytic Therapy. Review of clinical records occurs

on an ongoing basis to assure patient compliance, to verify appropriateness of continued

anticoagulation therapy and to assess any thromboembolitic or hemorrhagic complications and gain

knowledge from these events.

The unit budget is prepared and negotiated annually prior to the beginning of the fiscal year

using current and historical data and trends in volume (workload), as well as, resource utilization in

concert with unit, departmental and hospital goals and projections (personnel budget). Performance

against budget is reviewed monthly (FTE and financial reports). Budgets are adjusted during the

fiscal year as needed based on major changes in activity, resource requirements, goals or projections.

AMS Primary Nurses complete unit-based orientation and related competencies that focus upon

the care of patients with complex anticoagulation management needs. Newly hired RN staff

function under the supervision of a Registered Nurse preceptor throughout the orientation period.

The preceptor facilitates and monitors this process through direct supervision, coaching,

consultation, and collaboration with program leadership. Attachment 7.9.d is a clinical narrative

from a Staff Nurse describing the role of a primary nurse on AMS.

Since its inception, AMS continuously works to improve the quality of services provided to

patients and families. A progress report delivered to senior hospital leaders in January 2006 and

follow up in December 2006 outlined the following accomplishments for the program:

♦ A transition to four new evidence-based clinical pathways for patients on

anticoagulation therapy,

♦ Introduction of a new computer decision support tool with a warfarin dose adjustor,

♦ Transition from functional to primary care nursing using a relationship-based model of

care,

♦ Integration of the hospital’s Patient Registration System into the practice to support

outpatient visits,

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♦ Development of practice guidelines for patient self-testing, and

♦ Development of quality performance measures to support practice decisions.

The program has also shown consistent and significant growth and development in FY06.

There has been a 13% growth in referrals and a 3% growth in active patients, with a 37% increase in

patients on the inpatient discharge pathway.

Bedside Family-Center Rounding

MassGeneral Hospital for Children adopted the philosophy and model of family-centered

care in 2000. The Pediatric Clinical Performance Management (CPM) Committee uses their patient

satisfaction scores to monitor and evaluate how family-centered care is integrated into their practice.

Although patient satisfaction scores are 92%, the team’s inability to quantitatively measure both

performance and associated importance of specific family-centered concepts has hindered their

efforts to initiate system improvements that can effectively impact the care of children and their

families.

The importance of parental satisfaction has been supported in the literature. However, it is

noted that parental perception does not always equate to health care professionals’ perception of

various dimensions care in the healthcare setting; this disparity often inhibits improvement in health

care systems. (Bragadottir and Reed, 2002) Although parents, healthcare practitioners and hospital

administration are committed to the same goal of appropriate healthcare for children, they often

may have very diverse views on the meaning and practice of family-centered care.

In 2005, the Pediatric Clinical Nurse Specialist received an Yvonne L. Munn Research Grant

Award to conduct a customer satisfaction survey to study this issue. “Family-Centered Care at

MassGeneral Hospital for Children: How are we doing and just how important is it?” looked at the similarities

and differences in how parents and staff rate the performance and importance of key components

of family-centered care at MassGeneral Hospital for Children. Survey results showed that families’

satisfaction scores were lower than the clinicians in most areas. When topics were ranked for

importance, families rated scores higher or the same as the healthcare providers. The three issues

with the lowest satisfaction scores and highest importance for both groups were: communication,

information sharing and parent-to-parent networking.

Based on these outcomes, Bedside Family-Centered Rounding, a pilot quality improvement

initiative was launched on June 25, 2007. The goal of this pilot is to improve communication and to

keep information flowing between families and healthcare providers. The pilot is being conducted

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with the Medical Pediatric Team on Ellison 17, the Infant and Toddler Unit and Ellison 18, the

School Age and Adolescent Unit. Parents and with the parent’s permission, children, are now invited

to join Physicians, Staff Nurses and the Clinical Nurse Specialist on routine morning rounds.

Children between the ages of 15 and 17 may attend without the parent present, if parents agree.

Attachment 7.9.e is a copy of the team’s daily quality performance report sheet to help guide

their daily performance. A formal evaluation of the pilot will take place in 6-weeks, with plans to

repeat the customer satisfaction survey with parents and clinicians to compare pre and post

implementation results.

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Attachment 7.9.a

MASSACHUSETTS GENERAL HOSPITAL Patience Care Services

Role Description: Geriatric Nurse Specialist

Meeting the needs of older patients will become increasingly important as our population continues to age. The Department of Patient Care Services at Massachusetts General Hospital has initiated a plan to enhance our current programs, as we prepare for the growing population of older adults. Working collaboratively with leaders in the department and reporting to the Associate Chief Nurse, the Geriatric Nurse Specialist will be responsible for developing a strategic plan to facilitate system-wide advancements in the care of older adults in the hospital setting and through the transition of care across settings. The Geriatric Nurse Specialist is a master’s prepared nurse with expertise in gerontology, who promotes competent, compassionate and professional nursing care for patients/families across the continuum and who demonstrates strong leadership qualities and has program development and management skills that will help to facilitate culture change across the organization. The role includes program development, clinical practice, teaching, consultation and research. The Geriatric Nurse Specialist’s spheres of influence include the patient and family, nursing personnel and other health care practitioners and organizational systems. Principal Duties And Responsibilities

Clinical Practice

Demonstrates excellence in clinical practice focused on the care of older adults. Supports independent nursing practice of professional nurses through collaborative, consultative,

and role modeling activities. Analyzes clinical and non-clinical variables to anticipate care needs and predict responses for

older adult patients. Identifies current trends in gerontology and its implications for clinical practice. Integrates competencies of care for the older adult into existing nursing practices, policies and

procedures to promote the progression of patients along the continuum of care. Takes the lead in identifying new technology, nursing theories, evidence based research findings

and experiential knowledge to improve nursing practice in the care of older adults. Designs, implements and evaluates guidelines, protocols, and standards to appropriately assess

and care for older adults Identifies ethical issues in nursing practice and guides staff and other providers in application of

ethical concepts to patient care issues. Identifies and recommends innovative approaches to solving complex problems related to the

care of older adults Education

Develops, implements, and evaluates core curriculum and educational programs focused on the care management needs of older adults.

Develops, implements, and evaluates educational programs based upon assessed learning needs of patients, families, and staff.

Designs educational programs for staff at the department or interdepartmental level.

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Attachment 7.9.a continued

Coaches peers and staff in analyzing practice and assessing their level of practice within the Clinical Recognition Program. .

Facilitates the acquisition of advanced clinical skills in staff nurses, and graduate students through role modeling, practice, and consultation in the clinical setting.

Collaborates with The Institute for Professional Development on the development, implementation, and evaluation of central orientation, training, and continuing education programs.

Consultation

Provides expert consultation to patients, families, nurses, and other health providers to promote positive patient care outcomes.

Initiates, facilitates and develops interdisciplinary collaboration. Provides consultation at the unit, program, service, administrative, and community level(s). Analyzes and evaluates the effectiveness of the consultative process.

Research/Research Utilization

Takes the lead in designing and implementing research activities that will positively affect patient care and patient care outcomes.

Uses nursing theories and research findings to plan, design, evaluate nursing practice and to generate researchable clinical problems.

Initiates, or participates in quality assurance and performance improvement activities for evaluation of structure, process, and outcome criteria as it relates to clinical practice.

Utilizes scientific method in collecting data on clinical practice issues. Professional Leadership

Collaborates with leaders and members of the 65 Plus committee to set goals and plan the strategic direction of the program.

Forms collaborative relationships with the interdisciplinary team and other departments within and outside the MGH community to promote excellence in clinical practice focused on the care of the older adult patient.

Leads or participates in departmental and/or hospital committees. Partners with Nursing Administrative Faculty and the Institute for Professional Development to

facilitate programs and activities that support the organizational mission and goals. Clinical Leadership

Leads or participates in performance improvement activities at the organizational and departmental levels.

Collaborates with the nursing leaders and members of the 65 Plus interdisciplinary team in identifying and evaluating the learning needs of staff.

Collaborates with the nursing leaders and members of the 65 Plus interdisciplinary team in the development and implementation of a plan to meet the ongoing professional development needs of staff.

Integrates systems thinking, ethical reasoning, and problem solving in identifying interventions that facilitate quality, cost-effective patient care outcomes.

Professional Development

Engages in self-performance appraisal on an annual basis, identifying areas of strength as well as areas for professional and practice development.

Identifies individual learning needs and goals and develops a plan to meet them. Maintains clinical knowledge and skills based upon current nursing and health care practices.

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Participates in the appropriate peer and leadership meetings that address professional development and foster peer support and networking.

Attachment 7.9.a continued

Maintain membership in one or more professional nursing organizations. Promotes the role of the Geriatric Nurse Specialist through professional organization

involvement, presentations, and publication.

Qualifications and Skills

Master’s degree in Nursing is required. Current licensure as a registered nurse in the Commonwealth of Massachusetts. Relevant professional experience in gerontology nursing. Certification in gerontology is required at the time of hire or will be required within one year of

hire. Must be self-directed and have the ability to work independently Strong organizational and time management skills Ability to work with others to create organizational change

Terms of Employment

Full time position. (Will consider part time options in collaboration with another nurse)

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Attachment 7.9.b From: MGH Tracheostomy Sent: Tuesday, February 20, 2007 11:00 AM To: Jeffries, Marian, R.N. Subject: Tracheostomy

The links below direct you to information resources that can assist you in the care of your tracheostomy patients. Among the documents available is a checklist for safe room set-up & an algorithm for assessing clinical progress. In addition, the Respiratory Therapist responsible for care of patients with a tracheostomy can be reached on Pager 2- 4294. Questions related to tracheostomy care should be directed to the respiratory therapist carrying this pager. All Tracheostomy Resources Checklist for Safe Room Set-Up Clinical Progress Algorithm

Patient Problem List for Tracheostomy / Discharging a patient with a Tracheostomy

The information transmitted in this email is intended only for the person or entity to which it is addressed and may contain confidential and/or privileged material. Any review, retransmission, dissemination or other use of or taking of any action in reliance upon, this information by persons or entities other than the intended recipient is prohibited. If you received this email in error, please contact the sender and delete the material from any computer.

The following patient(s) on your unit have a tracheostomy:

Med Rec # Patient Name Admit Date Location 1111110 2/4/2007 EL 19

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Attachment 7.9.c

Clinical Narrative by the Tracheostomy Quality Team March 1, 2007

Mr. H was an active 76-year-old man who had been involved in a motor vehicle accident that resulted in

facial fractures, a loss of teeth, and a loss of vision in his left eye. In addition to limited vision, Mr. H was hard of

hearing, unable to speak, smell, taste, or eat. Now hospitalized for oral surgery to correct his facial injuries, he had a

tracheostomy tube fitted to his hearing aids and was placed in a private room on a general care unit for pain and

airway management.

When the Tracheostomy Quality Team first encountered Mr. H, he was in bed, mildly discouraged about his

condition, and frustrated with his lack of ability to communicate clearly. Mrs. H was supportive, but concerned about

her husband’s condition and declining optimism. Mr. H wasn’t able to swallow his saliva; he was suctioning his mouth

with a suction wand he clutched in his hand.

His nurse was trying to meet his needs, but having cared for only one trached patient previously, she was

overwhelmed by the complexity of his situation. After introducing ourselves to the nurse, Mr. H, and his wife, we

assessed Mr. H, suctioned him, evaluated his trach pressure, obtained a replacement cannula for his appliance, and

made sure all the necessary equipment was at his bedside. We assured Mr. H that his oxygen needs were being met,

but his secretions were too copious to alter his care at that time.

Our goal was to help mobilize him, expand his lung volumes, prevent atelectasis and hopefully help him cough

up secretions independently. We suggested that staff assess Mr. H’s suctioning needs more frequently, monitor his pain,

and increase the frequency of his mouth care. These measures seemed to comfort him. After conveying this information

to the nurse and the unit respiratory therapist and documenting our findings in Mr. H’s record, we moved on to our

next patient.

A few days later when we returned to Mr. H’s room to assess his progress, he was experiencing some distress.

His temperature was 100 and he had been started on antibiotics for an apparent infiltrate. He was wheezing audibly

with each deep breath, and his breath sounds were decreased markedly on the left side. The unit clinical nurse specialist

and the Tracheostomy Quality Team worked together to develop a plan of care to address the increased acuity of Mr.

H’s condition. We reviewed bedside practices and reinforced airway-management with unit staff, and the clinical nurse

specialist was now engaged to follow up with staff and Mr. H.

Mr. H was reassured by the presence of the team, and we immediately started him on a nebulizer treatment.

Sitting with him at eye level and speaking to him about his care and the plan to remove his trach tube before being

discharged was a pivotal point for Mr. H. He needed that hope that the airway tube wasn’t going to be necessary

forever. He grabbed our hands individually and mouthed the words, “Thank you.” Following the nebulizer treatment,

Mr. H was suctioned for secretions and his oxygen mask put back on. We reminded him that keeping the oxygen

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Attachment 7.9.c continued

mask on helped keep his secretions less viscous. Having more fluid secretions enabled him to have a clear airway and

stronger cough.

Our speech-language pathologist assessed Mr. H’s ability to swallow, and realized that with some exercises

and support he’d be able to regain this ability quickly. Essentially, he had forgotten how to swallow. Once we re-

established his ability to swallow and cough effectively, he became a candidate for a smaller tracheostomy tube. A

surgical consult was arranged to down-size his tracheostomy tube to facilitate secretion-clearance.

We reviewed care of the tracheal opening with his nurse, and an official speech language consult was requested

to begin strengthening the muscles in his neck. A physical therapy consult was requested to address Mr. H’s fear of

mobilization. It was wonderful to see Mr. H’s vitality return the very next day. He literally turned around overnight.

He was able to communicate that his fear of moving was really a fear of occluding his airway and suffocating. Mr. H’s

tracheostomy was down-sized, and his secretions were more controlled after the speech-language consult. He was able to

swallow his saliva once again. The skin around his trach site improved, and he was able to ambulate in the hallway

with assistance.

After a brief, but successful speaking-valve trial, Mr. H was decannulated and able to go to a rehabilitation

facility before being discharged home. It is a privilege to care for patients who literally have no voice and help them move

forward in their recovery. We will continue to assess practice, improve quality, and monitor the care of tracheostomized

patients to improve outcomes. Tracheal downsizing and decannulation, the use of speaking valves, preventing

aspiration, and the early placement or discharge of tracheostomized patients are realistic goals of the Tracheostomy

Quality Team. By reviewing each case individually, assessing options, implementing a realistic care plan, and involving

the patient and family in the multidisciplinary team, we will continue to improve outcomes and ‘give voice’ to this silent

population

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Attachment 7.9.d

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Attachment 7.9.e

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