Allegheny General Hospital and SEIU Healthcare PA RNs
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Allegheny General Hospital and SEIU Healthcare PA RNs

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Outline for Discussion. Background on Quality Improvement Structures at Unit and Hospital LevelSuccessful Work ProjectsNurse Collaboration Council (NCC)Approach and OutcomesCollaboration Project ? Length of Stay (LOS)Lessons LearnedNext Steps. Background . Allegheny General HospitalLevel 1 T
Allegheny General Hospital and SEIU Healthcare PA RNs

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1. Allegheny General Hospital and SEIU Healthcare PA RNs Image that comes to my mind recently is of a playground see-saw, where you know that you need both unit level and hospital level activity but you need to find that right balance so that in the case of the playground when I was growing up that someone would fly off the other end, or in this case that one or the other doesn?t stop happening. Image that comes to my mind recently is of a playground see-saw, where you know that you need both unit level and hospital level activity but you need to find that right balance so that in the case of the playground when I was growing up that someone would fly off the other end, or in this case that one or the other doesn?t stop happening.

2. Outline for Discussion Background on Quality Improvement Structures at Unit and Hospital Level Successful Work Projects Nurse Collaboration Council (NCC) Approach and Outcomes Collaboration Project ? Length of Stay (LOS) Lessons Learned Next Steps

3. Background Allegheny General Hospital Level 1 Trauma Center Academic Medical Center Flagship of West Penn Allegheny Health System 1,500 RNs represented by SEIU Healthcare PA 7 years the Union (SEIU Healthcare PA) and management have been working on quality improvement process at the unit level and hospital level Allegheny General Hospital Level 1 Trauma Center, Academic Medical center Flagship of the West Penn Allegheny Health System (6 other hospitals) 1,400 RNs at AGH Had a structure for both in the last 3 contracts: Nurse Collaboration Council (hospital level) and Patient Care Committees (unit level) Health system with strong reputation but with significant financial challenges 7 years the Union (SEIU Healthcare PA) and management have been working on quality improvement process at the unit level and hospital level Allegheny General Hospital Level 1 Trauma Center, Academic Medical center Flagship of the West Penn Allegheny Health System (6 other hospitals) 1,400 RNs at AGH Had a structure for both in the last 3 contracts: Nurse Collaboration Council (hospital level) and Patient Care Committees (unit level) Health system with strong reputation but with significant financial challenges

4. Background 7 years ?hospital level? and ?unit level? structures in contract Patient Care Committees (PCC) Nurse Collaboration Council (NCC) Been working on collaborative quality improvement work for 7 years where we have had some unit level and hospital level structures in the contract. Been named different things along the way but for the past 2 contracts we have had the NCC which operates at the hospital level and the PCCs which are the unit level structures In the past couple of years a shared governance structure has been created called the Professional Practice Partnership which also operates on a hospital level and which we had to work to figure out how to coordinate those activities with the PCC and NCC at the unit and hospital level. Been working on collaborative quality improvement work for 7 years where we have had some unit level and hospital level structures in the contract. Been named different things along the way but for the past 2 contracts we have had the NCC which operates at the hospital level and the PCCs which are the unit level structures In the past couple of years a shared governance structure has been created called the Professional Practice Partnership which also operates on a hospital level and which we had to work to figure out how to coordinate those activities with the PCC and NCC at the unit and hospital level.

5. Patient Care Committees Unit Level Structure Structure can vary but includes staff RNs and nurse manager and Division Director Monthly meetings for 1 hour on unit Shared Goals for Effective PCC Led by staff RNs Collaboration on agenda with manager and staff RN Communication of process and outcomes Patient Care Committees: Unit level--- varies in structure but includes staff RNs, manager, division director, staff of union 1 hour meetings on the unit; monthlyPatient Care Committees: Unit level--- varies in structure but includes staff RNs, manager, division director, staff of union 1 hour meetings on the unit; monthly

6. Balancing Unit and Hospital Work: Previous ?Theory? Union?s focus was on expanding unit level committees Way to engage nurses and build union?focusing on ?RN concerns? Way to ?respond to issues? Have ?problems? filter up from PCCs to NCC Start with a few successful PCCs and then expand outward Train RNs in a basic ?evidenced based approach? around the issues that nurses wanted to address Previous theory and efforts around quality improvement process Union?s focus was on unit level issues Way to engage nurses and build union?focus on ?RN concerns? Way to ?respond to issues? Way to respond to ratio concerns and to build from ratios to other/ ?systems? issues Goal was to get some successful PCCs and then expand outward Goal was to use an ?evidenced based approach? around the issue that nurses wanted to address Previous theory and efforts around quality improvement process Union?s focus was on unit level issues Way to engage nurses and build union?focus on ?RN concerns? Way to ?respond to issues? Way to respond to ratio concerns and to build from ratios to other/ ?systems? issues Goal was to get some successful PCCs and then expand outward Goal was to use an ?evidenced based approach? around the issue that nurses wanted to address

7. EARLY RESULTS Handful of units with strong and sustainable PCCs Several other units with PCCs that started and then faded Lack of collaboration and sustainability for the PCCs Frustration between Union and Management? Mistrust Where did this leave us? Generally with both side being reactive Bouncing back and forth between unit level and hospital level without clear path and without clear expectations or sharing of strategy on either side Lack of clarity led to more independent operations between union and management Lack of trust and just general frustration Note: Ratio implementation helped us move on to other issues And both sides were persistent? and kept focused on the broader goals Where did this leave us? Generally with both side being reactive Bouncing back and forth between unit level and hospital level without clear path and without clear expectations or sharing of strategy on either side Lack of clarity led to more independent operations between union and management Lack of trust and just general frustration Note: Ratio implementation helped us move on to other issues And both sides were persistent? and kept focused on the broader goals

8. Examples of PCC work 9A Evidence Based Project on Remote Telemetry Patients Neuro ICU Building a new ICU design 8C Grab n Go Respiratory Bags As I mentioned we did have some units that during these years developed some strong unit level committees that were transformative and made operational impacts. Neuro ICU 9A 8C Had other units that took on various PCCs at various points in time (11C-medical, 10C, 6A oncology, ER) but were not sustained As I mentioned we did have some units that during these years developed some strong unit level committees that were transformative and made operational impacts. Neuro ICU 9A 8C Had other units that took on various PCCs at various points in time (11C-medical, 10C, 6A oncology, ER) but were not sustained

9. Nurse Collaboration Council 7 staff RNs and 7 nurse managers and union staff representatives Monthly Meeting 4 hours (used to be 1 hour before most recent contract) Purpose: The parties acknowledge and agree that the Nurse Collaboration Council (NCC) shall oversee the work of the PCCs in the following relevant strategic initiatives as described below: 1) Achieving excellence in patient care and service 2) Nursing retention and recruitment 3) Workplace Health and Safety 4) Operational and Quality Initiatives and Patient Flow 5) Professional Education and Training 6) Advancement of the art and science of nursing 7) Pursuing relevant grants or examining important developments in industry standards (e.g. Health Information Technology) 8) Helping achieve organizational goals and directives Nurse Collaboration Council: that oversees unit level committees and also focuses on hospital level issues, 7RNs and 7 managers and then staff of the Union In past met for just 1 hour a month but moved to 4 hours in this most recent contract The contract spells out a broad framework for the NCC but is oversees the unit level work and focus on some broad goals outlined belowNurse Collaboration Council: that oversees unit level committees and also focuses on hospital level issues, 7RNs and 7 managers and then staff of the Union In past met for just 1 hour a month but moved to 4 hours in this most recent contract The contract spells out a broad framework for the NCC but is oversees the unit level work and focus on some broad goals outlined below

10. Balancing Unit Level and Hospital Level: Challenges Easier to get started and get some results Easier to innovate pilots Good way for RNs to see the ?action? Takes time and energy to make sustainable Need time and energy to share results Across Hospitals Several ?unique? goals make it harder to get ?hospital? focus Solutions may lie at Hospital Level I wanted to take a minute to reflect on some of the challenges with balancing unit level activity based on our original theory of focusing primarily on the unit level. Easier to get unit level committee started though still need capacity to make sustainable, to expand, share results Unit level projects are great to pilot innovation that can be replicated, though several independent focuses harder to tie into core hospital goals Unit level is easier way to get RNs feeling like something is happening though solution may often lie at hospital level. Capacity: Takes a lot of time and energy to focus nurses on an evidenced based process and follow through and to get to the point of a ?self-sustaining? committee. The challenges with unit level activities didn?t mean that we abandoned it or just put it to the side. It does mean that in a system with financial challenges that we had to re-think our strategy. I wanted to take a minute to reflect on some of the challenges with balancing unit level activity based on our original theory of focusing primarily on the unit level. Easier to get unit level committee started though still need capacity to make sustainable, to expand, share results Unit level projects are great to pilot innovation that can be replicated, though several independent focuses harder to tie into core hospital goals Unit level is easier way to get RNs feeling like something is happening though solution may often lie at hospital level. Capacity: Takes a lot of time and energy to focus nurses on an evidenced based process and follow through and to get to the point of a ?self-sustaining? committee. The challenges with unit level activities didn?t mean that we abandoned it or just put it to the side. It does mean that in a system with financial challenges that we had to re-think our strategy.

11. Nursing as Strategic Partners Contract Negotiations More explicit discussion of goals and theory Less focus on specific structures or answers but did make some changes (longer meetings, budget time and resources for ?sharing? and training) Retreat Continued to share independent and common goals and vision Identified a joint ?umbrella? project that both sides have a strong stake in Past summer at contract negotiations realized that we had an opportunity to do more strategic work since we had moved beyond ?ratios? question To move beyond past challenges decided before we gave ?proposals? at the bargaining table decided to just have RNs and management involved in this work in the past share explicitly our vision, frustrations, and thoughts for moving forward (did this over 2 close to 2 hour sessions) Identified a share vision and goals and desire of RNs to help carry out managements strategic goals and discovered management was really open to making these structures that had not been working as well as hoped to be able to work better. Maintained previous NCC and PCC structure and added some other opportunities for sharing, longer meeting for NCC etc. Held an 8 hour off-site retreat to in part flesh out our ?theory? on approaching this work and the ?unit v. hospital? level balancing act Focus on issue that resonates with RNs and also that is strategic for management to build deeper collaboration: Length of Stay as the general framework or primary focus Past summer at contract negotiations realized that we had an opportunity to do more strategic work since we had moved beyond ?ratios? question To move beyond past challenges decided before we gave ?proposals? at the bargaining table decided to just have RNs and management involved in this work in the past share explicitly our vision, frustrations, and thoughts for moving forward (did this over 2 close to 2 hour sessions) Identified a share vision and goals and desire of RNs to help carry out managements strategic goals and discovered management was really open to making these structures that had not been working as well as hoped to be able to work better. Maintained previous NCC and PCC structure and added some other opportunities for sharing, longer meeting for NCC etc. Held an 8 hour off-site retreat to in part flesh out our ?theory? on approaching this work and the ?unit v. hospital? level balancing act Focus on issue that resonates with RNs and also that is strategic for management to build deeper collaboration: Length of Stay as the general framework or primary focus

12. Implementing New Strategies for Success Choosing Joint Project for Organizational Success Length of Stay Don?t Rush the Unit Level Develop clearer, collaborative strategy on PCC sustainability Maintain focus on evidenced based nursing and also balance with Hospital level strategic goals Engage RNs at Unit Level ? ?Walk Around? Process Length of stay project was a good project to tackle because the ?Board? and thus nursing administration was focused on this Is both a hospital level (?systems? issue) and also there are processes and opportunities to engage RNs at the unit level for some of the solutions Don?t Rush the Unit level PCCs?take our time to really have a plan and strategy and resources from union and management (support the ones currently going or where opportunity arises-- ED, Case Management) Have had explicit discussions at recent NCC meetings: What is the vision? Shared vision for the PCCs: Evidenced Based Nursing and also a mix of both ?unit level? matters and also sharing of strategic quality goals of the hospital and why Inventorying what is currently happening at unit levels (union staff person and manager) Joint discussion on what makes PCCs effective and what are goal is around the unit level activity and how it ties to the hospital level. At same time we can?t just sit in a meeting with the NCC and really make changes. To achieve the goal we need to ?engage? a broader group of RNs at the unit level around quality improvement Length of stay project was a good project to tackle because the ?Board? and thus nursing administration was focused on this Is both a hospital level (?systems? issue) and also there are processes and opportunities to engage RNs at the unit level for some of the solutions Don?t Rush the Unit level PCCs?take our time to really have a plan and strategy and resources from union and management (support the ones currently going or where opportunity arises-- ED, Case Management) Have had explicit discussions at recent NCC meetings: What is the vision? Shared vision for the PCCs: Evidenced Based Nursing and also a mix of both ?unit level? matters and also sharing of strategic quality goals of the hospital and why Inventorying what is currently happening at unit levels (union staff person and manager) Joint discussion on what makes PCCs effective and what are goal is around the unit level activity and how it ties to the hospital level. At same time we can?t just sit in a meeting with the NCC and really make changes. To achieve the goal we need to ?engage? a broader group of RNs at the unit level around quality improvement

13. Walk Around Process Manager and Staff RN from NCC visit all units in day and engage in structured discussion/data collection with RNs and Manager Initial Walk Around to gather initial data from RNs on What barriers do nurses encounter that impact patient flow? What impacts LOS on your unit? Well received Walk Around: Staff nurse from NCC and manager from the NCC walk around the hospital in a day and spend 20 minutes on each unit and pull in staff RNs working and manager to do some ?data collection? Did this a few other times in the past around other issues: good way to build trust as union willing to take on challenges from staff RNs with management and vice-versa Initial Walk Around to gather data on ?barriers to patient flow? What processes or barriers do nurses encounter that impact patient flow? What impacts LOS on your unit? Diagnostic Testing Impact? Walk Around: Staff nurse from NCC and manager from the NCC walk around the hospital in a day and spend 20 minutes on each unit and pull in staff RNs working and manager to do some ?data collection? Did this a few other times in the past around other issues: good way to build trust as union willing to take on challenges from staff RNs with management and vice-versa Initial Walk Around to gather data on ?barriers to patient flow? What processes or barriers do nurses encounter that impact patient flow? What impacts LOS on your unit? Diagnostic Testing Impact?

14. Walk Around Assessment Initial Data led to Action Plan for NCC at Hospital Level Nurse Aide Consistency project Pilot on monitor tech team devoted to transport for testing procedures Case Management simple process improvements?paperwork, ancillary support Another Walk Around to continue to Build RN Engagement around our NCC Initiatives ?LOS target? in computer charting system Initial walk around lead to various initiatives Nurse Aide Survey Kim B?s initiative?pilot on monitor techs and testing Case Management process improvements?paperwork, computer work etc. Initial walk around lead to various initiatives Nurse Aide Survey Kim B?s initiative?pilot on monitor techs and testing Case Management process improvements?paperwork, computer work etc.

15. ?Walk Around? Part 2 Continue to Engage RNs at Unit Level Update RNs on NCC work Educate RNs on importance of Length of Stay Verbal Survey Analysis of Feedback Again, while having discussions at the hospital level NCC committee and following up some of the initial ideas, we didn?t want to just sit back and not engage RNs at the unit level. We would have liked to have had strong, active, self-sustaining PCCs at the Unit level that could have just put some of these items on their agenda. But we didn?t and we didn?t want to ?force? that knowing how hard it is to get started and how damaging it can be if not successful out of the gate. So we decided to do another ?walk-around? to make sure we were engaging RNs at the unit level in the meantime. Again, while having discussions at the hospital level NCC committee and following up some of the initial ideas, we didn?t want to just sit back and not engage RNs at the unit level. We would have liked to have had strong, active, self-sustaining PCCs at the Unit level that could have just put some of these items on their agenda. But we didn?t and we didn?t want to ?force? that knowing how hard it is to get started and how damaging it can be if not successful out of the gate. So we decided to do another ?walk-around? to make sure we were engaging RNs at the unit level in the meantime.

16. LOS Walk Around Findings

17. Summary of Lessons Learned Need to have both unit level and hospital level activity happening Can?t be one or the other Explicitly collaborate between Union and Management on the strategy for that balance Best if they complement one another At some point hospital level work can help to drive the unit level work Fostering unit level engagement around issues such as we heard today

18. Next Steps Implement ideas from ?Walk-Arounds? Refine and Develop PCC strategy Enhanced coordination of the PCC and NCC Unit level RN engagement/education while building PCCs ?Walk arounds? and all other trainings that we have identified that will sustain our work and attain our vision


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