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Letter to the Editor

The Influence of Quality Improvement Efforts on Patient Outcomes And Nursing Work: A Perspective from Chief Nursing Officers at Three Large Health Systems

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Marla Weston, PhD, RN, FAAN
Darryl W. Roberts, PhD, MS, RN

Abstract

Quality and performance improvement initiatives are driving significant changes in the United States healthcare system. In anticipation of the full implementation of national health reform over the next several years, the pace of these changes has been increasing. The goals of these quality initiatives mirror the National Quality Strategy's three aims which developed out of the Institute for Healthcare Improvement’s triple aim of improving the patient care experience, improving the population’s health, and reducing healthcare costs. Projects are underway across the United States to achieve these aims. In this article, Chief Nursing Officers of three of the nation’s largest healthcare systems, the Department of Veterans Affairs, Kaiser Permanente, and Ascension Health, have outlined their organizations’ quality and performance improvement initiatives. Their forward-thinking projects broadly address several aspects of healthcare, including reduction of hospital-acquired conditions, patient engagement, and the integration of mobile technologies and other informatics solutions to improve clinical workflows and increase registered nurses’ access to knowledge resources. The article then offers a brief analysis and conclusion of these three exemplars. The projects span the information systems life cycle: some are well established and continuing to improve, others have been recently implemented, and still others planned for implementation in the near future.

Citation: Weston, M., Roberts, D., (September 30, 2013) "The Influence of Quality Improvement Efforts on Patient Outcomes And Nursing Work: A Perspective from Chief Nursing Officers at Three Large Health Systems" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 3, Manuscript 2.

DOI: 10.3912/OJIN.Vol18No03Man02

Key words: quality, National Quality Strategy, patient outcomes, performance improvement, nursing workflow

Quality and performance improvement initiatives are driving significant changes in the United States healthcare system. Quality and performance improvement initiatives are driving significant changes in the United States (U.S) healthcare system. In anticipation of the full implementation of national health reform over the next several years, the pace of these changes has been increasing. The goals of these quality initiatives mirror the National Quality Strategy's three aims, which include Better Care, Healthy People/Healthy Communities, and Affordable Care (U.S. Department of Health and Human Services, 2012). These objectives evolved out of the Institute for Healthcare Improvement’s triple aim of improving the patient care experience, improving the population’s health, and reducing healthcare costs (Berwick, Nolan, & Whittington, 2008). Achieving these aims will require a concerted effort in four measurable focus areas: care coordination and patient safety; increased access to and use of preventive health services; better care for at risk populations; and enhanced patient & caregiver experience of care. The Centers for Medicare and Medicaid Services measure achievement of these four areas through the formation and monitoring of accountable care organizations (ACOs) that measure and report 33 quality measures. ACOs have launched projects across the U.S. that maximize the use of health information technology (IT) and informatics solutions to smooth workflows and increase efficiency of nursing care.

In this article, Chief Nursing Officers of three of the nation’s largest healthcare systems have outlined their organizations’ quality and performance improvement initiatives. These organizations include the Department of Veterans Affairs (VA), Kaiser Permanente (KP), and Ascension Health, which together employ about 200,000 nurses at 277 acute care hospitals and other settings. Their forward-thinking projects broadly address several aspects of healthcare, including reduction of hospital-acquired conditions (HACs), patient engagement, and the integration of mobile technologies and other informatics solutions to improve clinical workflows and increase registered nurses’ access to knowledge resources. The projects span the information systems life cycle: some are well established and continuing to improve, others have been recently implemented, and still others are planned for implementation in the near future.

In the vignettes that follow, nurse leaders from each system provide a brief overview of the projects and their influence on patient outcomes and nursing workflow. After these vignettes, we highlight aspects of these projects that registered nurses (RNs) working outside of these systems could employ to improve their practices and their patients’ outcomes.

The Department of Veterans Affairs: Supporting Patient-Centeredness Through Technology

The Department of Veterans Affairs Healthcare System includes 152 hospital facilities and 989 outpatient clinics (fiscal year 2012); making it the largest integrated healthcare system with 323,733 employees and 81,989 nursing employees (25 percent of the Veteran’s Health Administration workforce). In FY 2012, there were over 8.7 million enrollees in the VA healthcare system. VA reorganized several years ago, creating the Office of Informatics and Analytics. Informatics is the link between clinical expertise, technology, and information flow.

The vision of this organization is to support veteran patient engagement and to transform healthcare through technology, making it more efficient, effective, and patient-centered. Patients need to be engaged and included in their care, patient information needs to be quickly accessible to providers within and between facilities, and the healthcare workforce needs tools to help them efficiently manage patient care.

Patient Engagement

The VA has actively implemented technology to foster patient engagement, through access to their health information. The VA has actively implemented technology to foster patient engagement, through access to their health information. This is a critical step in supporting patients as active healthcare partners. In 2010, the VA Blue Button was released, offering several patient engagement features that include the ability to access and download personal health information to foster continuity of care, which includes a Continuity of Care document. The patient can authorize access to the information for both VA and community providers. This project incorporates recognized industry standards to support the exchange of information between providers and healthcare systems. A recent addition to Blue Button in 2012 was VA Open Notes, which allows veterans to view progress notes, in an effort to foster discussion with providers and enhance patient engagement. Another emerging patient engagement technology initiative is being adopted from the GetWellNetwork to promote and support a national strategy and approach to providing inpatient-centered tools and resources across VA. Although this work is in its infancy, the outcome is to improve patient access to education and the healthcare team, thereby increasing satisfaction among veterans and their families.

Using Data to Support Clinical Decision Making and Quality Care

Staff nurses need IT tools that support patient care. These tools include documentation systems that support nursing workflow, and clinical decision support (CDS) built into the documentation, and data to monitor improvements.

Capture of clinical measures relies on the ability to obtain data through standardized documentation, which is difficult given the variety of clinical applications currently used across the VA. One of the identified nurse-sensitive measures of clinical quality is prevention of hospital-acquired pressure ulcers. In 2008, a standardized electronic skin risk documentation tool was developed, with the assistance of nursing subject matter experts, to guide staff nurses in documentation of critical assessments. CDS was provided through embedded links within the tool to information sources. Key mandatory fields prevented nurses from inadvertently skipping important data elements. Branching logic meant that sections of the template only appeared as needed, based on the nurse’s documentation. In addition, key information documented on a prior assessment appeared within the next reassessment tool, alerting a new caregiver to the presence of skin breakdown. Skin risk quality and outcomes indicators were created based on tagged data elements. Monthly reports by discharged patients and nursing unit are now compared and trended by the facility, region, or enterprise. Reports include patient-level information for authorized users, to assist in data validation processes. Based on feedback from report users, new ‘daily’ skin reports were developed in late 2011, to provide actionable information on current inpatients by nursing unit, and their status related to risk assessment, skin inspection, and burden of pressure ulcers. Facilities use the data to determine staff educational needs, monitor improvement processes and track hospital-acquired pressure ulcer trends.

Supply and Equipment Tracking

Inefficiencies in communication and location affect both nurses and patients. Inefficiencies in communication and location affect both nurses and patients. Time spent hunting for supplies and equipment impact the available time for patient care. Patient flow is impacted, inconveniencing the patient and wasting valuable time, when nurses must wait for exam or treatment rooms to open, or a patient bed needs to be located when the unit has no available space. The VA is poised to release a nationally integrated, enterprise Real Time Locator System (RTLS) over the next five years. The RTLS solution combines tags, hardware, and software that allows users to interact with the RTLS data. This has significant implications for streamlining nursing and patient workflow. Individual VA RTLS databases will be aggregated to provide an enterprise-wide view of the data using predictive analysis and business intelligence tools.

The initial focus for the projects will include equipment tracking, temperature monitoring, catheter lab supply management, and sterile process workflow. Additional enhancements expected in the future include hand hygiene, patient elopement and wandering, and emergency and surgical workflow. The intent is to increase efficiency while decreasing operational costs with the ultimate goal of positively influencing effective delivery and quality of healthcare services to veterans and their families.

Patient Safety and Increased Workflow Proficiency

Point of care bar code scanning technology provides enhanced patient safety and patient care. Bar Code Medication Administration (BCMA) was first implemented in the VA in 1995 to improve the accuracy of the medication administration process. Positive patient identification ensures the veteran receives ‘the right drug at the right time to the right patient.’ All inpatient care areas in VA use positive patient identification at the point of care to document activities associated with BCMA. Point of care bar code scanning technology provides enhanced patient safety and patient care. As each patient wristband and medication is scanned, BCMA validates the medication is ordered, timely, and in the correct dosage. By doing so, the rate of medication errors has decreased across VA.

BCMA allows for real-time documentation at the point of care to improve accuracy and make medication administration data more immediately available for other clinicians. Studies have demonstrated a reduction in nursing time on medication administration activities using BCMA. Nurses are satisfied with BCMA because it is safer for patients, user-friendly, and effective in reducing medication errors.

Starting this year in VA, BCMA technology will be expanded to the outpatient setting. Future bar-coding projects include scanning of laboratory specimens and blood administration. All of these expansion projects will continue to make patient care safer and improve the workflow of VA employees.

Kaiser Permanente: Employing Innovations to Improve Nursing Care and Patient Outcomes

Kaiser Permanente is an integrated healthcare delivery system composed of 37 hospitals, over 600 outpatient facilities, and 49,000 nurses across 9 states and the District of Columbia. KP is also the nation’s largest non-profit health plan with 9 million members. The Permanente Medical Groups have a shared mission and governance with the hospitals and close alignment with contract hospitals in regions that do not have inpatient facilities. KP has the largest private electronic health record (EHR) reaching Stage 7 of the HIMSS Analytics Electronic Medical Record Adoption Model (HIMSS Analytics, 2013). As a nation, the U.S. is at the beginning of this journey, with only 1.9% of hospitals at Stage 7 at the end of 2012. KP is ahead of the curve in the implementation and optimization of the EHR allowing it to leverage real-time data, advanced analytics, performance improvement, and patient engagement to support true clinical transformation.

Nursing SmartCARE: A Strategic Roadmap for Enabling Extraordinary Care

When implementing technology in the inpatient environment it is critical to prioritize how the technology will be used and how it will affect nursing workflow. In 2010, nurse executives partnered with nurse informaticians to develop a SmartCARE strategy for transforming care with the use of technology to improve quality outcomes and clinician efficiency. Utilizing video ethnography and input from bedside nurses the team set the following goals:

  • Simplify the nurse’s path
  • Support the nurse with knowledge
  • Reduce non-value added tasks

The SmartCARE Strategy was informed by a series of 20 interviews with key leaders across the organization from Patient Care Services, Quality, IT, physician colleagues, and executive sponsors. During a facilitated visioning session and heat map exercises, key technology priorities identified to support bedside nurses were Rapid Sign On to the EHR; Clinical Intelligence Dashboards; Clinical Logistics/Situational Awareness; and Mobility.

KP recognizes that health IT will be a differentiator in improving the goal of the triple aim. When implementing technology in the inpatient environment it is critical to prioritize how the technology will be used and how it will affect nursing workflow. This concept of a ‘socio-technical system’ is described in the IOM report, Health IT and Patient Safety: Building Safer Systems for Better Care, and represents a cornerstone for care transformation.

Using Data to Support Clinical Decision Making and Quality Care

Nurses have a key role in delivery of high quality patient care and EHRs should support clinical decision-making and professional practice. Nursing leaders across KP’s four inpatient regions have collaboratively built CDS tools within the EHR to support evidence-based practice and individualized care. Since 2010, KP has been leveraging CDS and data mining to support the prevention of pressure ulcers.

Hospital associated pressure ulcers (HAPUs) are the most frequent medical error, costing the U.S. $3.2 billion annually (Van Den Bos et al, 2011). The prevention of HAPUs requires a comprehensive and interdisciplinary approach. The EHR supports the documentation of evidence based care by cascading the bundle of interventions into the nurse’s electronic flowsheet for patients at risk. After extensive root cause analyses it was determined that nurses needed a real time reminder to turn/reposition patients at risk for skin breakdown.

Best practice alerts can support nurse decision making if they are appropriate, timely, and not excessive. Best practice alerts can support nurse decision making if they are appropriate, timely, and not excessive. A best practice advisory was implemented to alert nurses if documentation was not up to date. Feedback from bedside nurses was positive, and 100% of hospitals in the Southern California region that piloted the alert demonstrated a statistically significant improvement in pressure ulcer prevention documentation six months after implementation continued improvement in HAPU incidence. Other examples of CDS include cascading of interventions into the flowsheet based on the selection of individualized care plans and predictive analytics to identify patients at risk for falls and falls with injury.

Nurse informaticians partnered with nurse leaders and bedside nurses to transition from retrospective reports and chart audits to real time data for clinical decision-making and prevention of adverse events. One example of this is the Clinical Care Dashboard that is built within the EHR and displays clinical and quality indicators dynamically for all patients on a nursing unit. These indicators include fall risk; pressure ulcer risk; prevention of catheter-associated infections; vaccine reminders prior to discharge; and pain reassessment timeliness. The dashboard is real time and actionable; nurses can click the hyperlink to open to the patient’s record to the appropriate flowsheet template. The ability to see data in real time supports the individual nurse caring for the patient as well as the charge nurse or nurse manager who is monitoring the care of all patients on the unit.

Improving Communication with Mobile Technology

...nurses have a key role in designing and implementing the new models of care and the requisite technology solutions to improve quality outcomes. Communication among care providers, and with patients, is complex. Often, the nurse is the human information integrator resulting in multiple interruptions and gaps in care coordination. U.S. hospitals waste over $12 billion annually because of communication inefficiency among care providers (Kleinberg, 2013). Mobility was identified as a priority for the Nursing SmartCARE Strategy and the team is collaborating with IT and wireless communication experts to overcome challenges in the hospital and across the continuum of care. Most nurses and healthcare consumers use smart phones to talk, text, and access information in their personal lives. Healthcare organizations are starting to evaluate how mobile communication devices can support voice communication, clinician to clinician secure messaging, alarm management, access to clinical references and task list prioritization. KP is developing a comprehensive unified communication strategy for nurses with a technology infrastructure that is flexible and device agnostic. The goals are to improve patient safety and clinician efficiency.

As the nation moves towards outcomes-based measures in Stages 2 and 3 of Meaningful Use, healthcare organizations will need to demonstrate improvement in quality, safety, and efficiency. While health IT is expected to support this vision, many of these benefits have yet to be realized. Nurses are at the forefront of this transformational change. As the largest workforce within the healthcare delivery system, nurses have a key role in designing and implementing the new models of care and the requisite technology solutions to improve quality outcomes.

Ascension Health: A Successful, Continuous Journey to Improve Healthcare Quality

Ascension Health Quality Journey

Ascension Health is transforming healthcare by providing the highest quality care to all, with special attention to those who are poor and vulnerable. Ascension Health, which provided $1.3 billion in care to persons living in poverty and community benefit programs last year, is the nation’s largest Catholic and nonprofit health system. The mission-focused health ministry employs more than 150,000 associates, serving in more than 1,500 locations in 23 states and the District of Columbia.

Since 2003 when Ascension Health committed to its “Call to Action for Healthcare That Is Safe,” associates in its hospitals and related healthcare facilities have continuously sought to eliminate preventable injuries and deaths through eight Priorities for Action (falls, fall injuries, pressure ulcers, perinatal safety, nosocomial infections, perioperative safety, Joint Commission national patient safety goals, adverse drug events). The Priorities for Action had remarkable results, exceeding by three times the primary goal for reducing preventable mortality. By becoming a high-reliability healthcare system, Ascension Health will consistently deliver safe, reliable, proven methods of care through expert nursing and medical interventions in a team approach based on patients’ needs and preferences.

Ascension Health has 88 acute and critical access hospitals that are eligible to participate in the Centers for Medicare and Medicaid EHR Program. At this time, all but seven critical access hospitals are expected to transition to the American Recovery and Reinvestment Act Meaningful Use Stage 2 in federal fiscal year 2014 or 2015. The hospitals plan to upgrade to 2014 certified electronic health record technology from a variety of vendors to comply with the Stage 2 measures. In addition, many of the eligible hospitals must implement key new functionality to meet the Stage 2 measures, including BCMA and patient portals.

Ascension Health also has more than 2,000 eligible professionals, upwards of 700 of who have attested to Meaningful Use Stage 1 and therefore will be transitioning to Stage 2 in calendar year 2014 or 2015. Many of our eligible professionals also will be implementing new technology, including the patient portal, in order to meet the Stage 2 measures.

Closed Loop Medication Delivery: Reducing Harm and Improving Workflow

Errors are potentiated by the lack of process and technology integration across this workflow constellation. In 2006, the Institute of Medicine (IOM) report “Preventing Medication Errors” estimated that a hospital patient is subject to at least one medication error per day (IOM, 2006). These errors arise within all aspects of medication administration workflow, including medication ordering; pharmacy provisioning and unit-based medication storage; and nurse-to-patient medication transfer (including infusion management). Errors are potentiated by the lack of process and technology integration across this workflow constellation.

Impacting this baseline performance can affect as much as 17-20% of nursing time, and it requires that nurses work with an interdisciplinary team comprised of pharmacy, medicine, informatics, and supply/resource decisions (Hendrich, Chow, Skiercynski, & Lu, 2008). A “roadmap” is helpful to guide capital allocations that will solidify a vision and funding approach that implements a suite of integrated medication administration technologies, evidence-based practices, and adaptation of clinical behaviors to leverage those technologies optimally. The collective result of that vision and strategy is a Closed Loop Medication Administration System (CLMDS; see Figure 1). CLMDS will improve medication safety by reducing errors at each phase of the medication process: procurement, prescribing, transcribing, dispensing, administration and monitoring (Hendrich, Chow, & Goshert, 2009). In each phase, there are opportunities for increased safety through automation, technology, and workflow improvements that require assessment and evaluation to determine impact on value, quality, and safety.

Figure 1

 

NOTE: Figure created by the authors

...some nurses organized their schedules around patients, whereas others organized based on tasks, such as medication delivery. We preformed an ethnography study of nursing behaviors related to medication administration. Researchers shadowed nurses and recorded behaviors related to medication administration. Initial observations found that most nurses used the automated medication cabinet, whereas about one-third of nurses recorded all medications on their “brains” (handheld devices) at the start of their shift and then used this information to pull all medications at the same time. Similarly, some nurses charted medications as they administered them, whereas a few charted all medications once they completed administration for all patients. These findings illustrate how some nurses organized their schedules around patients, whereas others organized based on tasks, such as medication delivery.

Both of the behaviors identified above (pulling multiple medications at once and visiting other patient rooms prior to administering medications) directly predispose nurses to medication administration errors and do not support a high reliability medication administration process. In evaluating risk mitigation strategies, we concluded that, given the human factor influences observed, the only technology mitigation that could reasonably be expected to minimize risk was BCMA. This conclusion led us to a major shift in our previously defined technology implementation roadmap; a planned smart infusion pump implementation was postponed to allow acceleration of BCMA implementation, which was originally sequenced to follow smart pump deployment.

Nurses cited instant real-time charting as a key time saver. Post implementation, ethnographic researchers again shadowed nurses who used workstations on wheels (WOWs) integrated with hand held scanners.  They reported an overwhelmingly positive impact on nursing workflow. The carts provided storage for frequently used items, reducing the need to travel for supplies, and a surface for nurses on which to work. Nurses cited instant real-time charting as a key time saver. Use of the WOWs also allowed nurses to spend more time in the patients’ rooms, thereby reducing interruptions during medication administration, increasing opportunity for patient education, improving charting activity and accuracy, reducing the number of uncharted medications, and, in the nurses’ opinions, improving patient care overall. Information hand-off during shift changes was also found to be easier and more accurate. More of these types of pre- and post- studies are needed.

Small Tests of Change: Using an App to Target Hospital-Acquired Conditions

By creating a system-wide mobile application (app) that provides a modern approach to sharing, spreading, and adopting relevant patient safety information, Ascension Health has demonstrated its interest in being viewed as an innovative leader in healthcare and the use of technology. The “Partners in Excellence App,” which is available through the Apple App and Google Play stores, was developed by nurses and physicians with frontline caregivers in mind (App; Figure 2).

Figure 2

NOTE: Figure created by the authors and included with permission of Ascension Health

The app features quick-hitting facts on various hospital-acquired conditions, including adverse drug events (ADEs); obstetrical adverse events (eliminating early elective deliveries); catheter-associated urinary tract infection (CAUTI); central line-associated bloodstream infections (CLABSI); surgical site infections (SSI); injuries from falls and immobility (IFI); pressure ulcers; ventilator-associated pneumonia (VAP); venous thromboembolism (VTE); and preventing readmissions. Many of these are nurse sensitive measures and are heavily influenced by nursing practice, such as pressure ulcers, falls, CAUTI and more. Keeping pace with today’s fast track healthcare environment, the app provides the 80 percent of Ascension Health associates who deliver care the opportunity to quickly and accurately receive vital patient safety information in a handheld “smart” device regardless of care location.

Nurses have a vital role, along with all care team members, to incorporate technologies that have demonstrated their “true” positive impact on workflow, safety, efficiency, and cost. Managing costs will require this level of careful evaluation to assure that work environments support care provider with real-time data and knowledge so they can provide safe, holistic care to each patient, every time.

Analysis

Each healthcare system has outlined several initiatives to achieve the aims of the National Quality Strategy through improvements in nursing care efficiency, patient engagement, and access to knowledge. Of the identified projects, VA’s use of BCMA in congruence with its effective EHR represents the longest standing initiative. Reports on its effectiveness show reductions in medication error rates ranging from 60% to 93% (Rivish & Moneda, 2010). Such improvements are well documented in other institutions following VA’s lead (see Rack, Dudjak, & Wolf, 2012; Poon et al., 2010; DeYoung, VanderKooi, & Barletta, 2009).

One of the benefits of BCMA is that it improves nursing workflow during medication administration by decreasing opportunities for error through workarounds. BCMA does not eliminate workarounds altogether (Rack et al., 2012). For this reason, Ascension Health has accelerated implementation of its BCMA program. This acceleration boldly sidetracked a smart infusion pump implementation in a pragmatic move that placed improvements in patient safety over meeting established timelines set in a corporate roadmap. These types of priority changes are consistent with the broad shift in healthcare’s broad shift to lean techniques that emphasize agility over established corporate implementation schedules, particularly when those improvements affect patient safety and nursing efficiency (Johnson, Smith, & Mastro, 2012; Swick, Doulaveris, & Christensen, 2012).

Recently, the American Nurses Association (ANA; 2013) endorsed the Office of the National Coordinator of Health IT (ONC) Blue Button campaign. Blue Button encourages patients to exercise their legal rights to access their health records (Ricciardi, Mostashari, Murphy, Daniel, & Siminerio, 2013). Like BCMA, Blue Button started at the VA, met with significant success among the veterans they serve, and is now spreading across the national healthcare landscape. The ANA role in the campaign is to encourage registered nurses to act as role models to patients by accessing their own records, using them to create their own personal health records, and use their experiences to encourage family members, community members, and patients to follow suit.

KP has been working very hard to improve patient care and the nursing processes that support that care. As stated in their vignette, KP is a national leader in EHR implementation and use. That base provides them with the ability to expand their nurses’ access to knowledge resources through SmartCARE. This nursing-focused initiative grew from a multi-disciplinary approach to improve clinician workflow through scientific investigation and integration of tools developed in the KP EHR. Giving nurses access to CDS tools integrated into the documentation modules that nurses use every day; real-time dashboards useful at multiple levels (clinician at the point of care to the director of nursing); and data mining technologies that analyze trends in nursing care effectiveness has allowed KP to demonstrate significant improvements in the incidence of pressure ulcers, falls, and other HACs.

Ascension Health showed its ability to reduce errors by applying the findings of scientific research to the daily work of nursing care. Their findings have allowed Ascension’s nurses to improve the medication administration process, which both saved time and improved patient safety. Like VA and KP, Ascension benefitted from the diligent application of EHR technology, adding the use of smartphones and workstations on wheels to increase the amount of time nurses could spend doing what they do best—delivering care to their patients. Integration of smartphones did not stop at reducing medication errors. Instead, Ascension integrated the smartphone into the reduction of nurse-sensitive HACs, giving nurses access to information about the effectiveness of the care they provide.

Conclusion

Quality and performance improvement initiatives will continue to be a feature of the healthcare landscape. The three large healthcare systems that contributed descriptions of their organizational initiatives to this article have made substantive strides toward achieving the National Quality Strategy aims. Each of them accomplished this in a different way, but with similarly positive results. Registered nurses, nurse managers, and nurse executives at systems throughout the U.S. could adopt some or all of these initiatives to achieve their own organizational goals, including improvements in patient outcomes, nurse workflow efficiency, and cost savings.

Many smaller systems have implemented innovations that have made similar, impressive improvements. To continue to develop quality and safety measures, it is important for nurses to share these innovations through conference presentations, posters, and publications to help others learn about successful initiatives. Quality and performance improvement initiatives will continue to be a feature of the healthcare landscape. It is our hope that the descriptions provided here, and a growing body of similar resources in the literature, will assist healthcare systems as they develop and implement the tools needed to provide excellent care.

Acknowledgement: The authors thank the following colleagues who provided exemplars from three health systems, respectively: Cathy Rick, Murielle Beene, Mimi Haberfelde, Toni Phillips, Pam Pickett, and Lynn Shuler (Veterans Health Administration); Ann O’Brien and Marilyn Chow (Kaiser Permanente); Ann Hendrich, Deborah Rapp, and Susan Wilson (Ascension Health System).

Authors

Marla Weston, PhD, RN, FAAN
Email: marla.weston@ana.org

Marla Weston, PhD, RN, FAAN is the chief executive officer of both the American Nurses Association (ANA) and the American Nurses Foundation (ANF), and a recognized nurse leader with more than 30 years diverse management experience in healthcare operations. Prior to joining ANA in 2009, she served at the U.S. Department of Veterans Affairs in the Veterans Healthcare Administration (VHA), first as program director in the Office of Nursing Services, and then as deputy chief officer in the agency’s Workforce Management and Consulting Office. At the VHA, she oversaw policies, programs, and initiatives that provided support for VHA employees and was responsible for improving nurse retention and promoting nursing as an attractive career choice. Weston also served four years as the executive director of the Arizona Nurses Association. During her tenure, membership in the association increased by 24 percent and revenues rose by 109 percent. Dr. Weston has been widely recognized for her leadership for nurses, including being inducted as a member in the American Academy of Nursing in October 2012.

Darryl W. Roberts, PhD, MS, RN
Email: darryl.roberts@ana.org

Darryl W. Roberts, PhD, MS, RN is a Senior Policy Fellow at the American Nurses Association (ANA). In addition, he is an adjunct professor at Stevenson University School of Graduate and Professional Studies and at the University of Baltimore College of Public Affairs. He has been a nurse with 25 years of experience in such diverse areas as chronic pulmonary care, hospice, mental health, informatics, health care quality, and the learning healthcare system. He earned graduate degrees in Nursing Informatics and Policy Sciences from the University of Maryland School of Nursing and the University of Maryland Baltimore County (UMBC), respectively. He later earned a PhD in Public Policy Evaluation from UMBC. As evaluation scientist, nurse informatician, clinical researcher, policy advisor, and university educator, Dr. Roberts gives a unique perspective to health care and nursing. In his several roles, he has the privilege of investigating, acting on, advocating for, and teaching about the confluences of healthcare, health information technology, health policy, and health care quality. The body of his work has been captured in numerous publications, as well as presentations at research and professional conferences nationally and internationally.

References

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HIMSS Analytics. (2013). Electronic medical record adoption model (EMRAMSM). Retrieved from www.himssanalytics.org/emram/emram.aspx

Hendrich, A.C., Chow, M. P., Skierczynski, B. A., & Lu, Z. (2008). A 36-hospital time and motion study: How do medical-surgical nurses spend their time? The Permanente Journal, 12(3), 25.

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Poon, E. G., Keohane, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., ... & Gandhi, T. K. (2010). Effect of bar-code technology on the safety of medication administration. New England Journal of Medicine, 362(18), 1698-1707.

Rack, L. L., Dudjak, L. A., & Wolf, G. A. (2012). Study of nurse workarounds in a hospital using bar code medication administration system. Journal of Nursing Care Quality, 27(3), 232-239.

Ricciardi, L., Mostashari, F., Murphy, J., Daniel, J. G., & Siminerio, E. P. (2013). A national action plan to support consumer engagement via e-health. Health Affairs, 32(2), 376-384.

Rivish, V., & Moneda, M. (2010). Medication administration pre and post BCMA at the VA medical center. Online Journal of Nursing Informatics (OJNI), 14(1).

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© 2013 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2013


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