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Allegheny General Hospital and SEIU Healthcare PA RNs. Balancing Unit and Hospital Quality Improvement Collaborative Work. Outline for Discussion. Background on Quality Improvement Structures at Unit and Hospital Level Previous Theory and Outcomes Pivot Point

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Allegheny General Hospital and SEIU Healthcare PA RNs

Balancing Unit and Hospital Quality Improvement Collaborative Work

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Outline for Discussion

  • Background on Quality Improvement Structures at Unit and Hospital Level

  • Previous Theory and Outcomes

  • Pivot Point

  • New Approach and Initial Outcomes

  • Summary of Lessons Learned

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Allegheny General Hospital

  • Level 1 Trauma Center

  • Academic Medical Center

  • Flagship of West Penn Allegheny Health System

  • 1,400 RNs represented by SEIU Healthcare PA

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7 years “hospital level” and “unit level” structures in contract

  • Nurse Collaboration Council (NCC)

  • Patient Care Committees (PCCs)

  • Professional Practice Partnership (2 years)

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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

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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

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Professional Practice Partnership

  • Shared Governance Structure

    • 6 Hospital Level Councils with formalized structure and participation guidelines

  • Coordination of PPP and PCC in CBA

    • PCCs are “work-engine” of PPP/unit level connection

    • PPP councils are tools of the PCC

    • “Coordinating Council of PPP includes NCC chair staff RN chair”

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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

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  • Handful of units with strong and sustainable PCCs

  • Several other units with PCCs that started and then faded

  • Lack of collaboration and coordination with NCC, PPP, PCCs

  • Frustration between Union and Management– Mistrust

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Examples of PCC work

  • 9A

    • Evidence Based Project on Remote Telemetry Patients

  • Neuro ICU

    • Evidence Based Project related to Pharmacy Process

    • Addressed “pulling” issues and general work environment issues in 2 different physical locations of same unit

  • 8C

    • Ratios

    • Grab n Go Respiratory Bags

    • Regular Staff Huddles

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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

Balancing Unit Level and Hospital Level: Challenges

Challenges for Unit Level

Arguments for Focus on Unit Level

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  • 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

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New Approach to Balancing Unit Level and Hospital Level

  • Umbrella Project at Hospital Level

    • 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

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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?

    • Diagnostic Testing Impact?

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Walk Around Process

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 other Hospital Initiatives

    • “LOS target” in computer charting system

  • Starting to find ways that PPP can be helpful tool in carrying out NCC/PCC work

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“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

    • Have you noticed that on sunrise now it indicates information on Length of Stay and expected discharge date?

    • Given that RNs play a critical role in the coordination of care and discharge, how could that information be useful for RNs?

    • Do you have any other ideas on what could change to help improve patient flow and more timely discharge of patients?

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Initial Outcomes

  • Had RNs look at “countdown” tool

    • Example: On 6C, 3 out 5 in an assignment were already beyond discharge target, nurses not really focused on

    • Led to a discussion about role of RNs and Aides which tied to work in progress around Nurse aide role

  • More “data” and ideas on LOS and patient flow

    • Information to help shape other pilot projects

    • Idea for changing taping of report on transfers between units

    • RNs to round with physicians on units

  • Opportunities to explain to RNs about PCCs

    • 6C boomerang re-admissions

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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

  • In the mean time have a plan to continue to “engage” RNs at the unit level

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Next Steps

  • Implement ideas from both “Walk-Arounds”

  • Refine and Develop PCC strategy

  • Enhanced coordination of PPP and PCCs/NCC

  • Unit level RN engagement/education while building PCCs

    • “Walk around” and other trainings