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The Roots of Peer Review

The following is an excerpt from Nursing Peer Review, Second Edition

Medical staffs have been peer reviewing their cases for decades, and as fellow professionals, we must hold ourselves to the same high standards. Nurses are professionals who must hold each other accountable and evaluate patient care so we can eliminate system and human errors. Nurses are no different than physicians in this way.

 

An early crusader for quality improvement, E. A. Codman helped develop the concept of outcomes management in patient care. He was a proponent of peer review and quality programs for healthcare delivered at the hospital level.

 

Practicing in the early 20th century, Codman was a founder of the American College of Surgeons and its Hospital Standardization Program. Eventually, that program would morph into what we know today as The Joint Commission. His statement from 1916 calling for review and transparency are as relevant today as they were a hundred years ago:
I am called eccentric for saying in public that hospitals, if they wish to be sure of improvement, must find out what their results are, must analyze their results to find their strong and weak points, must compare their results with those of other hospitals, must care for cases that they can care for well and avoid attempting to care for cases which they are not qualified to care for well, must welcome publicity, not only for their successes, but for their errors. Such opinions will not be eccentric a few years hence.

—E. A. Codman, A Study in Hospital Efficiency, 1916

 

Codman would likely be happy to see today that the practice of physicians reviewing the work of other physicians—peer review—is a common practice and is considered to be a crucial element of ensuring that quality medical care is provided to patients.

 

That element is just as crucial in the nursing profession. The major reason for implementing a peer review process is to improve patient care. If nothing else, peer review is the right thing to do to protect the patient from potential harm. It is just a matter of time before external accreditation agencies, the government, and your hospital will require a formal peer review process of nurses.

 

More and more, healthcare organizations are required to be transparent about quality performance metrics. While the information that is publically reported is aggregate data, it is important for the healthcare organization to know person-specific performance data so that they can drive improved patient outcomes.

 

Typically, the outliers or underperformers are a small number of nurses who may not know they are not performing to the standard of care. It is important to give them specific and periodic performance feedback so that they can adjust their care model. Additionally, providing performance data to nurses helps them understand where they rank among their peers. When doing so, it is important to report the data in an anonymous way so that each nurse is uniquely identified using a coding system. This can be useful when metrics are performance based and specific in nature. Transparency is the way of the future, and moving in that direction will help the nursing infrastructure catch up with performance models used by physicians.

 

The goals and benefits of peer review include:

  • Improving the quality of care provided by individual nurses
  • Monitoring the performance of nurses
  • Identifying opportunities for performance improvement
  • Identifying system-wide issues
  • Identifying educational needs of nurses

If the process of peer review is to be effective, then a formal structure must be created to allow for the tracking and trending of information and the identification of potential system or human failures. Case review is useful for this, as it presents opportunities to identify failures through investigation so nurses and other team members can correct them before injury occurs in another patient or patients.

The key to nurse retention

The following is an excerpt from Essential Skills for Nurse Managers.

Put aside all the tips and tools for retention for a moment and remember this:

Of 1,500 nurses surveyed, their #1 incentive was noted to be personal recognition by their manager.

Imagine you are a staff member who helped out the department by covering an extra shift due to a sick call. Sure, at the end of the pay period they will be smiling with the overtime in their check. Do you know what will make them smile just as much, or for some even more? If the next time they worked an envelope was in their mailbox or locker and inside was a single wrapped life saver with a note signed by their manager that simply read:

  • Many thanks for helping out by picking up the extra shift. You are a life saver!

After much conflict in the department related to precepting issues and a lack of interest among the staff to contribute to the ongoing educational needs of the new graduate staff, one employee stepped forward to offer to assist. He understood there was no extra pay differential for taking on this challenge when he agreed to the role. However, that did not matter because he found in his locker an envelope with a single wrapped “treasures” chocolate candy and a note from the manager that read:

  • Many thanks for volunteering to work with our new grads—we treasure you as part of our team!

Sometimes a trip down the candy aisle at the grocery store with a pad of paper is not about the eating; instead, it is about creating a memorable message that means something to an employee. Be sure that part of your retention strategies include your “shining stars.” Many managers assume these high-level performers do not need or desire recognition or praise; this is far from the truth. They may want to be recognized in different ways from the rest of the staff, but they still deserve to be reminded of the vital role they hold in the department. Sometimes the employees we desire to hold on to the most are the ones for which we use the least retention efforts. Do not make this mistake and be alert to the fact that many assumptions are made about top performers.

Rewards for employees should match and be in line with how and what they contribute to the department/organization. Just because employees perform well does not mean they are easy to get along with, welcoming to new hires, etc. And always remember that current performance may not be an indicator for future potential in a “shining star” Schmidt (2010). Be sure to balance your attention and recognition efforts among all of the team members, shining stars or not.

Include cultural diversity training in orientation

Healthcare professionals have varied views about what the term cultural diversity means and the actual purpose of cultural diversity training. They may believe that such training is initiated primarily to help them avoid professional and legal problems rather than improve patient care (Nisha et al 2007). Others are genuinely concerned about being culturally sensitive when working with patients and collaborating with colleagues. NPD practitioners know that the primary purposes of cultural diversity education are to improve:

  • Healthcare professional–patient communication
  • Healthcare professional–family communication
  • Communication among healthcare professionals
  • Patient and family outcomes

Cultural diversity education is also a requirement of some accrediting agencies.  However, this is not the primary purpose of such education. Your cultural diversity programming should be practical and based on evidence that directs its design.

It is not easy to add more content to an orientation program. However, cultural awareness will help new employees to assimilate into the organization. Role play, discussion, and distance-learning techniques can all be used to provide basic information. Allow time for in-person discussion as well. Include information about how cultural differences manifest themselves in patients, visitors, and colleagues and present learners with scenarios that require them to make choices based on cultural appropriateness.

What topics should you include as part of diversity education?

It is not possible to include all aspects of multiple cultures in a diversity program. However, if cultural diversity is part of your competency program, you can regularly add material about aspects of various cultures.

The following is information to include in your initial training:

  • How do members of this culture communicate? What significance do body language, gestures, tone of voice, and eye contact have? Which family members take the lead in communicating with people outside of their culture?
  • What specific family/gender issues exist? What is the woman’s role? How are major decisions made?
  • What role does religion play?
  • How is pain expressed?
  • What are common health practices (e.g., alternative medicine, herbal medicine, home
    remedies, etc.)?
  • How do families deal with pregnancy and births?
  • Is there a standard work ethic valued in the culture? How are specific occupations viewed
    in terms of respectability, financial need, and appropriateness?
  • Are there dietary restrictions associated with this culture?
  • Are there specific political beliefs that influence people of this culture?
  • Are there specific conflicts between certain cultural groups that may surface within your organization?

Source: Staff Development Made Simple

Privacy and social media in the nursing unit

We all consider our privacy to be sacrosanct, a cocoon in which we wrap ourselves to feel safe and in control. We value our personal space and believe that others have an obligation to respect our wishes in regard to what is commonly known and what we wish to keep private.

Your role as a manager means you have become the “Privacy Police.” It is your job to protect the privacy of your staff, the hospital, your patients, and yourself. This juggling act is made more difficult by the fact that privacy is a very fragile commodity these days, and we have far less influence than we had previously thought. Large leaks of personal data in the online environment have made privacy a matter of public commentary and personal challenge.

The word “privacy” has been part of our lives back to our earliest moments of awareness, when we were told that “some things are private” or “do not talk about that at school; it is private.” However, as we swept into the 21st century, the term “privacy” began to take on a new meaning or perhaps to lose its meaning entirely. Invasive social media and the unrelenting celebrity-chasing paparazzi have somewhat neutralized the concept of privacy, making it largely a word with diminishing relevance in today’s world. Yet, on your unit, the idea of privacy remains important and fundamental to your staff and patients.

We consider privacy to be freedom from unwanted invasive scrutiny. Young people today hear about hacking and high-level release of private information, and they accept it as a natural part of life. Privacy has become relative to the degree of interest in your business and your ability to keep others out of it. Your young nurses were raised in a world calling for more transparency with decreasing value on personal privacy; these are often the values they bring to your unit when they are hired.

As a manager, you are faced with a boatload of privacy rules and regulations that fall to you for enforcement. You must ensure that your unit protocols are protecting personal health information largely driven by the Health Insurance Portability and Accountability Act of 1996 (HIPAA; U.S Department of Health and Human Services, 2015). HIPAA applies to all healthcare personnel and providers. Your manager role means you must ensure your nursing staff understands and complies with rules about documentation, photography, telephone release of information, and the media’s need to know.

You can help your staff understand release of patient information, for example, by identifying who is nonessential and who is on a “need-to-know” basis. Make sure they understand the boundaries and then ensure that they adhere.

You also need to help Boomers grasp how social media really works. Many of them get on sites in order to keep up with younger family members. They may not understand the insidious seepage of information based on the link provided by these sites. Your younger nurses might provide information to the more senior members, helping them understand the full impact of such platforms as Facebook, Twitter, and others. But do not assume that everyone just naturally knows the privacy limitations on your unit; annual review of current privacy standards is a good time to emphasize how this information helps protect the hospital as well as the individual nurse from legal repercussions.

Frank, open conversations about the right to privacy can move it from a gray area for social media followers into a priority for all activities on the unit.

Source: Managing the Intergenerational Nursing Team

House calls can benefit patients and cut costs

Two of the lasting images of early healthcare professionals is the doctor with their big bag making house calls and a midwife rushing to a family home to facilitate a birth. As healthcare has advanced, we’ve moved away from this home-based model toward the consolidated approach of the modern hospital. However, some practices have returned to house calls, with some positive results.

Independence at Home, a program created by the Centers for Medicare and Medicaid Services (CMS), seeks to identify patients that would benefit from homecare or cannot be helped in a hospital setting. The project sends mobile interdisciplinary healthcare teams, lead by physicians and nurse practitioner, out to the homes of these patients and provide care.

According to a recent Medscape article, the program reports a few different benefits. The patients receive more attention and care from providers, and the setting can foster trust between patient and provider. Hospitals and nursing homes can be difficult places for many patients, and they would prefer to get treatment in their homes. Terminal patients particularly benefit from this; as one provider notes, hospitals are not where people want to die.

The providers benefit from the more personalized patient relationship as well, but there are also financial incentives for homecare. CMS reports that they saved $25 million by using this system and $11.7 million of that went back to the providers. Because the system targets some of the most expensive Medicare patients, hospitals can save a lot by providing in-home care in this system. In addition to the CMS program, Veterans Affairs Medical Centers report that providing home care for some of their patients cost 12% less than standard care.

CMS adopts 2012 Life Safety Code®

Editor’s Note: This originally appeared in the OSHA Healthcare Advisor.

In a highly-anticipated move expected to significantly affect the regulatory rules that hospitals and other healthcare facilities are held to, the Centers for Medicare & Medicaid Services (CMS) has officially adopted the 2012 edition of the Life Safety Code® (LSC).

CMS has confirmed that the final rule adopts updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the LSC as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code.

Healthcare providers affected by this rule must comply with all regulations by July 4—60 days from the publication date of the rule in the Federal Register.

The adoption of the rule has long been anticipated, as the LSC, which governs fire safety regulations in U.S. hospitals, is updated every three years, and CMS has not formally adopted a new update since 2003, when it adopted the 2000 edition. As a result, CMS surveyors have been holding healthcare facilities to different standards to other regulatory agencies that have gradually adopted provisions of the new LSC in their survey requirements.

Some of the main changes required under the final rule include:

  • Healthcare facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years. after the rule’s effective date.
  • Healthcare facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
  • The provisions offer long-term care facilities greater flexibility in what they can place in corridors. Currently, they cannot include benches or other seating areas because of fire code requirements limiting potential barriers to firefighters. Moving forward, LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms.
  • Fireplaces will be permitted in smoke compartments without a one-hour fire wall rating, which makes a facility more home-like for residents.
  • For ASCs, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.

Visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-10043.pdf to read the full final rule.

View the CMS press release here: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-05-03.html

Newly promoted leaders need support too

Many companies have clear guidelines for onboarding a new hire; they often have formal training, manuals, and extra resources to help them adjust to their new responsibilities. However, many nurse leaders are promoted from within, and their training path is often less clear. As a new study suggests, the training process for internal promotions is often inadequate, and internal hires require just as much support as external ones.

Michael Watkins wrote in the Harvard Business Review about this issue, and coined the term “inboarding” to describe the process of training internal hires for their new position. About two thirds of the new hires in his study were internal; 70% of them said that their transition was as difficult as joining a new company, and 35% found the transition more difficult. This results in unnecessary failures and difficulties for the organization.

Watkins identifies the lack of support given to inboarding as one of the main reasons for this disparity. So how can an organization make inboarding easier? To start, leaders should adopt a common methodology when approaching new hires. This includes using the same framework and tools for all leadership transitions. Watkins also suggests performing a risk assessment for transitions: identify the potential difficulties (such as relocation, new business divisions, or shifts in work culture) and provide additional support for those risks. This might sound simple, but changing an organization’s culture can be difficult and the first step is identifying that internal hires need the same support as external hires.

Did you receive formal training when you got your first leadership position? Did you feel prepared for your new responsibilities? Let us know in the comments, or take our Strategies for Nurse Managers Poll.

Featured Webcast: Millennial Nurse Retention: Bridging the Generation Gap

Wednesday, April 20, 2016

In 2015, the number of millennials in the workplace surpassed baby boomers as the largest segment of workers. This future generation of nurses has very different career expectations than the generations before them. Millennials expect more feedback, greater collaboration, interaction with nurse leaders, an 8-hour workday and better work-life balance. Unlike their parents, they rarely intend to stay with one employer for their entire career—or possibly even more than a few years.

The shift in attitude has many organizations struggling to retain millennials and learning to adjust management strategies to accommodate their unique style. Join Kathy Bonser, Vice President of Nursing and CNO at SSM Health DePaul as she discusses the importance of leveraging the differences to create a win-win environment for staff and frontline leaders.

Take part in this live 60-minute webcast to:

  • Uncover how making changes in leadership behaviors can bridge the generation gap
  • Discover new onboarding processes that support the growing millennial workforce
  • Devise a structured approach to providing regular employee feedback
  • Understand the importance and value of engaging millennials early and often

Agenda:

  • Improving nurse retention, especially in the first year after hire
  • Understand communication preferences
    • Text or call? How to decide
    • Use of social media
  • The importance of strong onboarding and engagement processes
    • Scheduled touchpoints
    • Celebration of milestones
    • The need for performance feedback
  • The need for transparency
    • Explaining the why behind decisions
    • Seeking out nurse feedback and acting on it
    • Shedding light on how their contributions make a difference
  • Live Q&A

HCPro is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. HCPro provides 1.0 nursing contact hours for this educational activity.

For more information or to register for the webcast, click here.

Getting nurses from bedside to the boardroom

Last week, we discussed some of the benefits of having nurses in executive positions. It is crucial to bring a myriad of perspectives to these positions, and nurses are significantly underrepresented in hospital leadership. This week, Becker’s Hospital Review has offered up some tips about how nurses can prepare for hospital board seats.

The first thing an aspiring nurse should consider is the core competencies of the hospital board. This can be a little different for each hospital, so having a specific facility or type of facility in mind would be helpful; if you can find a facility that matches your nursing specialty, even better. Often, boards have lists of competencies, so not having the right core skills can sink an application right away.

Once you establish the required skills would need, you can begin working towards that goal. Many nurses don’t have opportunities to develop governance skills on the job, so it might be helpful to look outside the hospital for that. Volunteer board positions in their community or at a nonprofit organization can be a great way to get experience in governance and make nurses more appealing candidates for board positions.

Connections are key in this process as well. Nurses should meet with board members and the chair if possible, to better understand the board’s mission and how they might align with it. These relationships can be crucial to obtaining a board position, but also to keep it. Board members can become mentors that can teach nurses how to navigate their new responsibilities and help them through the gauntlet of new board membership.

How rethinking reviews can boost staff morale

Performance review time is never easy. Managers have the uncomfortable task of assessing their team, and the staff is uneasy about what a poor review could mean for their career; if a review goes poorly, it can lead to tension and dissatisfaction long after the review. A new study in The Nursing Management Journal proposes a new way of approaching performance reviews that could make the process a little easier on everyone.

A task force of nurse leaders from a Magnet® recognized hospital system sought to make their process more objective after receiving staff feedback that their performance reviews were too subjective. Previously, the nurse manager would evaluate staff based on the fulfillment of their job description, meeting performance outcomes, and following care commitment guidelines. The team revised the RN job description to better fit the staff’s responsibilities, then created performance metrics based around the revised job description. They hoped that this would provide the staff with measurable results for their performance review and tangible goals for improvement.

The staff responded to this new criteria-based model for reviews. The surveyed nurses said that the new system was more transparent and consistent, and they liked that the results were evidence-based and didn’t hinge on personal bias. Overall, 71.7% of the surveyed staff felt the new process accurately reflected their performance, versus the 37.8% under the previous method. So while performance reviews will always be a headache, perhaps moving to a criteria-based model will help ease the pain.

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