How CUSP Enables Nurse Empowerment (Transcript)

November 15, 2011

Operator: Excuse me, everyone and thank you for holding. Please be aware that each of your lines is in a listen-only mode. At the conclusion of today’s presentation, we will open the floor for questions. At that time, instructions will be given as to the procedure to follow if you would like to ask a question. I would now like to turn the call over to Mari Franks. Ma’am, you may begin.

Mari Franks: Thank you so much, Stella, and good afternoon, everyone. And good morning, I guess, to a few of you still. My name is Mari Franks. I am with HRET, and thank you for joining this CLABSI supplemental call. The title of today’s call is “How CUSP Enables Nurse Empowerment.” And we’re ecstatic to have both Pat Posa and Joanne Timmell joining us today. First we’re going to have Pat Posa speak to us. And Pat has held various roles in health care in her 31 years of practice, including clinical care staff nurse, manager, educator, and director of nursing, and administrator of an outpatient multispecialty primary care clinic. Her current position is a system performance improvement leader for St. Joseph Mercy Health System in Ann Arbor, Michigan. Her role is to oversee quality and patient safety in the critical care areas for four hospitals and implementation of a program to manage severe sepsis and septic shock throughout each of the hospitals. Pat received her BSN from Wayne State University in Detroit, Michigan, and her master’s in health care administration from Central Michigan University.

And our second speaker following Pat will be Joanne Timmell. Joanne is currently the nurse manager of the surgical oncology unit at Johns Hopkins Hospital and has been in her role for 7 years. About 6 years ago, she and Peter Pronovost and others began a CUSP program on that unit, and from that work were able to implement a daily goals program in a non-ICU setting as well as other patient safety initiatives. Joanne received her master’s in nursing and health systems management from Johns Hopkins University, and her BSN from Towson University. She was board certified as a nurse executive in 2007. Joanne loves to travel in her spare time and is restoring a historic home built in 1840. Both of her children are now off at college. So with that I’m going to turn the call to Pat Posa. And just to note, everyone should have received the slide deck from your State lead, and you should have that in front of you, and our speakers will take you through that slide deck. So without further ado, Pat.

Pat Posa Well, thank you very much. I’m excited to be here and really excited to be presenting with Joanne. Just a few fun facts about me, I’m from a family of 12, Brady Bunch times two. I have four kids and a grandson, and I have two daughters that will graduate as nurses in May, so I’m very excited and proud about that. But today we’re going to talk about how CUSP enables nurse empowerment. So I’m going to move to actually Slide 3 in the deck just to do a quick review so we’re all on the same page. We’re talking about the different components of CUSP and then how CUSP can empower nursing. CUSP is the Comprehensive Unit-based Safety Program that was started at Johns Hopkins and that we have implemented in the State of Michigan through our Keystone Project starting in 2004. The first step is to form a CUSP team with executive sponsorship, having the executives round on a regular basis on the unit, measuring your unit culture, educating on the science of safety, identifying defects a variety of ways, one of those using a staff safety assessment tool. And then prioritizing those defects, making sure that you continue to learn from defects at least every quarter, and then implementing team and communication tools.

Well, how is CUSP different than other tools that we’ve used for patient safety? CUSP is driven by frontline nurses, and that’s what makes it different. CUSP identifies problem areas. So other tools that we use, and throughout my 31 years in practice we’ve had a lot of different things that we’ve used -- continuous quality improvement, Six Sigma, Lean -- those help improve processes and systems which are important to improve patient safety. But CUSP helps us identify problem areas, so it helps us look at what the staff think are patient care issues versus what managers and directors might think are the priority areas. And so it really empowers the frontline staff, and here I’m going to focus on the frontline staff nurses, but we’re looking at the whole team. CUSP involves everyone that currently practices in your unit. So if you’re in an ICU, that might include a respiratory therapist, techs, unit clerks or unit secretaries, as well as physical therapy and any other role that might be a part of your unit, as well as residents, mid-level providers, and physicians. CUSP improvement tools are designed for bedside caregivers, easy for busy staff to use, and it allows the unit to drive its own quality. CUSP can complement the other quality tools, and you’ll find that you need a whole bunch of tools in your toolkit to be able to deal with the complexity and the challenges we that face in health care today.

So moving onto the next slide, I’m just going to share a little bit about St. Joseph’s Mercy Hospital’s journey. This hospital is part of a health care system, but this hospital is a tertiary center. It’s a trauma center. It’s 450 beds, and it has 47 ICU beds, sees about 90,000 visits per year in the ER. We began in 2003 on our CUSP journey with our statewide ICU collaborative, the Keystone ICU, where the Michigan Hospital Association partnered with Johns Hopkins through an AHRQ grant. We got our multidisciplinary team together, our Keystone team. We meet twice a month, and we still meet monthly. One of those meetings each month we’re focusing on sepsis and the other are all of our other patient safety and CUSP initiatives. We do an annual assessment of our culture. With the staff working with the unit leadership team to develop action plans to improve the culture. We do quarterly executive rounds. We have an executive that’s adopted each of the units in the hospital and even some of our diagnostic areas: Hemodialysis, cath lab, et cetera. We learn from defects which is very important, and we continue to embed this strategy, this tool, into our daily work. And I’m going to talk a little bit more in detail about that. And then the final piece of CUSP is teamwork and communication tools. And we’ve implemented multidisciplinary rounds with daily goals in our ICU and working on standardizing that outside of the ICU. I’m not going to focus on that today. Another thing we’re doing to improve communication is, house-wide, we are putting all staff over a 3-year period through crucial conversations training. But what I’d like to focus on in addition to learn from defects over the next 10 minutes or so is structured huddle.

So, learn from defects tool, I’m sure all of you are familiar with it. This slide on Slide 6 is a snapshot of a badge card that Duke University’s patient safety program has put the learn from defects tool onto the badge card. And if you remember, the key components to the learn from defect process is to first talk about what was the defect, a brief description of what happened, and then talk about with the staff: Why did it happen, what contributed to it happening, and what prevented it from maybe reaching the patient, if you’re talking about a near-miss, or what minimized the risk to the patient. And you’re going to look with a system lens at why things happened. What contributed to this defect from happening? Staffing, workload, environmental reasons, caregiver factors, policy and procedures or lack thereof, et cetera. And then work on what can we do to reduce the risk of this reoccurring in a different patient with different caregivers. How will we know if the risk was reduced? So how are we going to measure if we’re resolving this defect? And who do we want to share this learning with? So this is actually something that we are now in the process of passing out to every staff, and we’re trying to incorporate this problem-solving strategy any time we have something occur on the unit that isn’t what we had planned -- so any defect. And I know Joanne in her presentation is really going to talk more specifically about application of the learning from defects tool.

So if you move to Slide 7, I’m going to focus on one strategy that we’ve been using to engage in sustained nurse involvement in CUSP. And we’re doing that through huddles. And so “huddles” has become a very generic term for a variety of strategies to improve patient safety. I know we had implemented a couple years ago, every time a patient falls, we do a post-fall huddle. And now we’re incorporating that learn from defects tool as the framework for those post-fall huddles. But we actually looked at some work that was being done at Virginia Mason Hospital in the State of Washington, and they had implemented structured huddles. And what that does is it enables the team to have frequent but short briefings so all of the staff can stay informed, review work, make plans, and move ahead rapidly, allowing for fuller participation of the frontline staff. I know in our CUSP teams we have one or two staff from each of our ICUs for our ICU CUSP team. But that’s not all of the staff. I mean we have probably close 150 to 200 FTEs between our ICUs. So, by bringing the huddles onboard, the issues and problems get exposed to many more staff, and it helps us keep the momentum going.

So if you move to the next slide, our huddle process centers around a huddle board. And let me just orientate you to this huddle board that’s on Slide 8. So there are six components to this huddle board. The top three components are metrics. And so all of the work that you’re doing, the quality plan or the goals for the hospital as well as the goals for the unit -- core measures, patient satisfaction, et cetera -- come down to the unit level. And each unit then defines what things they want to work on in three categories. We’ve chosen at our organization that metric one needs to focus on quality and safety, and that metric two should focus on a patient satisfaction area, and metric three focus on operations. And this isn’t surgery. It’s operations in the unit, efficiencies, et cetera. And so each of our units has a unit leadership team that includes a medical physician leadership for the unit, nursing leadership, a clinical nurse leader who’s an RN in an advanced degree, and a system performance improvement leader like myself that brings a bunch of process improvement tools to the team. And so that group picks out, based on feedback from the staff, based on pay for performance performance priorities, core measures, they decide on the metrics. And those metrics are decided upon, and I’m going to show you some examples, and then they go on the huddle board. The daily critical communication is the center section and underneath the metrics, this is where the nurse manager, or the clinical leader, or the medical director might write information that needs to be shared. And we’ll show you some examples of that. And then on the left at the bottom, there’s an area for information. Currently, our executive administration sends out a game plan each week with key messages that need to be communicated from the top to the frontline staff, and so that gets posted there on some of the units or at least gets shared at the huddles. And then the final section, which is the most important section, is the ideas in motion. And this is when each of the metrics gets discussed, if we haven’t met the metrics, we have a defect identified. And we talk to the team about why did we not meet that metric and what we can do to meet it the next time. And that’s where the ideas in motion come in -- very important. So we’re doing a little learn from defects each time we huddle.

So how do we do it? Well the huddles occur on every shift. Each of the units have decided when. Sometimes they’re at the beginning of the shift or mid-shift. They last probably about 10 minutes, and they’re led by a member of the unit leadership team initially and then other clinical staff. At the end of each of the huddles, after the metrics have been discussed and any of the communication and there’s been brainstorming, we also spend a few minutes on improving the team’s situational awareness. So we talk about any new admissions coming in that have come in this morning. We ask the staff, “Has anybody’s patients changed that we need to worry about?” or maybe offer assistance if anybody’s assignment’s too heavy or needs some help, anybody that’s at safety risk, fall, travelling off the unit, any other issue that might be occurring. Just to give an idea of what’s going on in the rest of the unit.

You go to the next couple slides, there’s some examples of each of our huddle boards. And I’m not going to spend too much time because I want to leave time for Joanne. So this is our surgical ICU huddle board. You can see the quality metric — and I’m on Slide 9 — was sepsis. We have implemented the Surviving Sepsis Campaign bundle, and we attempt to get our patients resuscitated in less than 4 hours. And so you can see on this day -- and this metric was updated every day -- two out of the three patients that had come in the day before had met their metric, but one didn’t. So the team discussed that, and actually the first idea in motion was to deal with one of the reasons why we didn’t meet the metric. Under patient satisfaction, we were doing reassessment of pain after a pain med was given. You can see we weren’t very successful. And then we began to decrease our ICU length of stay as an operations metric. We used early recognition of delirium as we were implementing the CAM-ICU. This was fairly early on when we were implementing it, so you can see we didn’t have good compliance. But we improved each of these metrics, and probably once a month we change the metrics as we’ve reached our goals. You can see we also had some information related to skin on the left. So this can be used in an ICU. This is an example of a surgical unit huddle board dealing with hand hygiene, pain control, and discharging by 11. You can see under the critical communications they identified patients that were at fall risk, that had bed alarms in two of the rooms, and a patient with restraints. And if you look at — well, I thought I had another one, but it looks like I don’t. So you can see that you can do this on any area, and this really brings that learning and ownership of the quality and safety goals down to the frontline staff. The nurses are the people that are doing the work. They’re the best to know what’s preventing them from getting things done as well as being able to problem solve how to make it better. And we’ve seen phenomenal improvement in our metrics as we’ve taken this down to the staff, and it improves a lot more rapidly.

So, lessons to bring home to your hospital: If you want more information on huddles, I would be happy to send you the templates, et cetera, that we’ve used. But leveraging the nursing staff and their knowledge and empowering them by bringing huddles into place, by having them be a part of the CUSP team, by meeting monthly, and allowing the nurse to take responsibility for identifying problems and giving them a forum and strategy to solve them through the CUSP team, learning from defects tool, and structured huddles. So all of these things have helped empower the frontline nurses to help us problem solve. So, we are in a unique situation in health care, and I love this quote from Dr. Atul Gawande. “In medicine, as in any profession, we must grapple with systems, resources, and circumstances, people, and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, and we must improve.” And CUSP is definitely a way to be able to identify those problems and continue to improve.

I’d like to turn it over now to Joanne Timmell, and she’s going to talk to you about nurse empowerment through CUSP and learning from defects at Johns Hopkins.

Joanne Timmell: Hi, everybody. My name is Joanne. And, Pat, that was really excellent. Since we haven’t really spoken much in the past, I was so impressed with all that you had to say on here, a little bit more about those huddles, and there’s also a lot that you say that I would have said also. So I think the fact that we have a lot of convictions in common is sort of indicative of what works.

So, I’m starting on Slide 14. One of the things that I felt that was important to stress is that there are certain beliefs or unit-based cultures that predispose for success. And you really need the hospital leadership, unit-based leadership, to belief that the staff who are giving direct care to the patients are the best people able to identify those impediments to safe care. And you also have to have created a culture where the staff really embrace patient-centered care so that the concerns that they’re going to be raising are what impact the patient. Although I don’t think you can separate out nurse satisfaction from patient satisfaction because one impacts on the other. I think that the focus of CUSP has got to be patient centered. You also need a unit manager who has a participative leadership style and is willing to be transparent, willing for staff to speak up, is not going to be embarrassed if people bring up something that she or he isn’t proud of, that kind of thing. We’ve found that the setting is extremely important. We tried to have our CUSP meetings in the conference room which is only 100 feet from the unit, and the staff were not really willing to leave the unit to attend the meeting, and so we couldn’t get this strong response. So we instead moved the meeting to a small report room which gets very crowded when we have 30 people attend our CUSP meetings. But, the fact that we continue to maintain those kinds of numbers, around 30, that shows that people are willing to be crammed in a tiny room if they feel that their voice is being heard. We started out with trying to invite anybody that we could possibly think might be involved or interested. So we invited the pharmacy, social work, rehab staff, the chaplain, housekeeping environmental services, of course, we have our nurse practitioners and PAs, the residents, attendings, and some representatives of hospital administration.

My first suggestion is to define CUSP for your setting. I’m moving on to Slide 15. What is it that you hope to achieve? And I, as the nurse manager, had two goals. One is I really wanted to improve patient safety, but, two, I wanted also to give the nurses a voice where some of their concerns could actually be addressed and fixed. Too often, nurses spend tons of energy complaining, griping, voicing problems without it being in a setting where they can actually change things. That’s one of the things I think is the beauty of CUSP is you pair the nurses who are giving direct care with someone who is powerful enough in the organization to help move bureaucracy, move impediments so that concerns can be addressed. With our unit, we started out with a potluck dinner. Everybody brought something, including wine, and we had talks about the science of safety which moved everything from just being about how you feel about things but that there’s actually measureable science about what contributes to a safe patient environment versus what you just have gut feelings about. And then at Hopkins there’s a strong conviction that you start out with the question of “How will the next patient be harmed on our unit?” And they ask every participant to put in writing what they believe is their answer. It’s a little awkward because people don’t want to believe that the next patient will be harmed or they don’t want to put it on paper, that kind of thing. But it forces some focused thinking about that.

Moving on to slide 16, something I need to interject since the very topic of this session is how CUSP empowers nurses, I think it’s fair to say that it wouldn’t necessarily empower nurses if there isn’t any power experienced through the sharing and through the followup of the events that are brought up. So, what I included at the bottom of the slide is that nurses will only be empowered if they’re actually given power to change things. And they probably oftentimes need assistance with that in that their efforts are often concentrated on a few patients, and they see the system problems but don’t necessarily know how to address changing the system. So by pairing a physician champion, a hospital executive, and the staff, then you have somebody looking at things from the microcosm and then from a big macro overview. In those settings, the staff concerns shouldn’t be minimized or explained away but, rather, affirmed. And it allows nurses to develop their voice and share specific instances. Usually what I do prior to the meeting, I hear a zillion concerns over the course of a month, and the ones that are striking I often encourage people to be willing to speak up at the CUSP meeting. And just by saying, “Go ahead. Share your story you were telling me about X, Y, Z,” they will then feel the freedom to talk about that. And in general, you have to have a culture that speaks up about patient safety.

So to tell you a little bit about our story at Johns Hopkins, I came on as nurse manager 7 years ago to a 54-bed general surgery unit, which is mostly surgical oncology. That 54-bed unit was three separate pavilions, and nurses and assistance personnel could be assigned to any one of those three pavilions on any day. And that meant there were over 100 staff members on this one unit. We also had eight surgical teams represented, probably five residents on each team as well as their associated attendings. And in an effort to try to get a patient into a bed as quickly as possible, any patient could end up in any of those 54 beds. So you never developed an expertise on a certain kind of care nor did the nurses have an opportunity to develop relationships with the medical staff. And, lastly, the nurses didn’t have an opportunity to develop relationships with the patients because they could get moved around. And what it did was it fostered tremendous dissatisfaction with the nurses as well as a difficulty holding people accountable for poor performance. If someone did something on one unit, well, maybe the next day when they showed up on unit two, you wouldn’t know about that so you couldn’t say, “Hey, this is happening again.” The patients were very frustrated because it was just a quiet kind of chaos. They were very frustrated with not knowing what the plan of care was, and they took out that frustration through anger at the nurses. The nurses were very unhappy, and they felt powerless. So what it did was the strong nurses -- the high-achieving nurses, the nurses that wanted to improve or do better -- ended up leaving and the poor performers stayed put. So it was quite challenging. To be honest with you, this was my second time as a nurse manager. One had been 15 years before, and I was quite surprised both at dissatisfaction but also what I saw as not high quality.

So the first thing that we did was we proposed dividing up the three units into three separate units so that there would be smaller staff and greater accountability, and you could encourage the poor performers to leave and empower the strong performers. So that happened relatively quickly. But then hand-in-hand with that, we proposed that we would cohort a particular type of patient on each of the three pavilions. So our pavilion decided to concentrate on pancreatic and liver cancer patients, even though it’s in the GI setting hepatic and biliary patients. That way, the nurses could get expert but, more importantly, the team of doctors managing those patients would have a home base. Hopkins is absolutely huge in terms of its physical campus, and it could be that a resident who was responding to a critical situation or a concerning situation with a patient, it could take 15 minutes to walk from one set of patients to another. And that was very frustrating to the residents. So by having all their patients in one setting, one, they would get to know the nursing staff, the nurses would get to know the physicians, and, two, they would be there. So when a medium or minor problem occurred, you could just step out to the station and talk it over, and it promoted tremendous collaboration. And lastly, by focusing on one particular cohort of patients, then when that team rounded, nursing could join that and then they could engage in a joint nurse-physician discussion about the plan of care. Previously we would have eight different teams showing up a 5:30, 6 a.m., and nurses didn’t know which group to join. It was very disjointed, so they essentially gave up joining the rounds. And at this point we’ve been going strong for over 4 years and they still attend, not just attend but participate in joint rounding.

We also developed a written daily goal sheet which was helpful to focus communication, to say, “This is what’s going to happen today.” And we translate that written daily goal that is for the health care team. We discuss that with the patient and then put that in patient-centered language on their whiteboard that, “We’re going to focus on X, Y, Z today.” Sorry my phone is ringing. I’m going to try to ignore that. So on rounds, we also developed some concrete ways of communicating with the team about nonurgent communication rather than paging them. The docs were very stressed out. They might get hundreds of pages in the course of 24 hours, and it was all reactive. They couldn’t move ahead. So we had one doctor, one of our residents that was involved in this change, state that his experience went from he was having 60 pages a day on his shift to it went down to two. Now that might be an excellent example. It might be exaggerated. But that was his experience that he was having face-to-face communication with the nurses. There was an agreed-upon sense of a plan, and people didn’t have to call him to clarify this, to clarify that. Also, one really strong way that we promoted empowerment of the nurses is that, once a month, we host a breakfast for the new team of residents, and the nursing staff are able to say, “This is the way we do things on our unit. If you have a stat order, we don’t just put it in the computerized order set, but rather we expect you to either call us or come and see us in person and talk to us about something stat. We expect that you would, when you arrive on the unit to do rounds, that you let us know that you’re here because we want to participate and we have some important information to contribute.” And so we set down the guidelines, and when that happens, it’s very easy to hold people accountable to that kind of communication, that kind of teamwork.

So moving on to slide 19, at our CUSP meetings, which we hold once a month, the nurses have a way of voicing their concerns that aren’t being solved on a day-to-day basis. So these tend to be system issues. Some of the things that have recently come up are some problems with having medications available when they’re due, so that’s a pharmacy and nursing interaction systems problem. We had some significant, significant pain issues for patients who are operated in the outpatient setting and then, for some reason, needed to be admitted. We have tried to work out some issues, and this is ongoing communication between the PACU nursing staff and the inpatient nursing staff. In today’s economy, there’s a great pressure for operating on as many people as possible and moving them through the OR to either the PACU or to the ICU and then on to the unit. And if discharges are slow, there’s just a lot of mutual stress that we put on each other, and we’re trying to work that out. We have had some recent turnover with an increased number of newer staff with some medication errors. And we’re also doing a lot of technological changes here as we get prepared to move into a new building, and that, I think, is contributing to stress on the staff on the unit. So we are doing what Pat was talking about, analyzing a defect or about medication errors. And another example is July 1 when the new rulings went in for residents’ hours, ACGME restrictions, one of the things that the residents brought up was that they did not feel that their class which explained the new provider order entry system that it gave them enough skill in learning how to enter specific orders on their patients. So the nursing staff volunteered to create a support team with nurses out of the numbers out of direct patient care to be a support to the residents. That was a really neat unit-based initiative. And we also came up with some other strategies. We have an increased nurse practitioner staff, and I think that hospital administration heard these issues, that we needed to have somebody to address patient care issues on the unit, especially when the surgeons are in the OR. And, again, because in the surgical unit we always have pain control issues, so right now we have a new group of patients brand new to us with islet cell transplants that have chronic pancreatitis, and they have a great deal of pain, and we’re working on solving those issues.

Moving on to slide 20, what I wrote as best practices. We absolutely need an essentially tripartite group of people who fully embrace the concept of CUSP. I don’t think that you can have a CUSP team that’s successful unless you have all three aspects of this. So you need support from nursing, from physicians, whether it be surgeons or medical docs, and from the hospital administration because it’s often the hospital administration that is going to control the funding for certain initiatives. Although we’ve done a lot of things that have required very low cost, so that’s interesting. Secondly, someone might have to be dedicated to sending out reminders, and not just by email but also on the unit that day: “Okay at 3 o’clock we’re going to have our CUSP meeting.” Then at 2 o’clock, you’re going to remind everybody that at 3 o’clock we’re going to have our CUSP meeting. Then you go around and see if anybody needs any assistance to be able to be available at 3 o’clock. So it’s pretty energy intensive for me as nurse manager. But I think that, again, if we focus on what matters to the nurse at the bedside, then they are very invested in attending and in participating. I think if you have these metrics that are handed down that you need to improve, it’s hard to get nurses to buy-in. But if they get to address, not just verbalize about their problem, but actually see efforts at solving this problem, I think you’ll have buy-in and that will be what’s empowering, the actual resolution of some problems.

So, on slide 21 I recommend that if you’re finding that your nursing staff is not engaged, then ask them why. Ask them why. My example about if you’re trying to lower CLABSI rate as an example, and you’re asking just the nurses to do more but they find that they can’t do more, then address why they can’t do more. I know that nurses are going to care about central line-associated blood stream infections. It’s very clear that this is life threatening to patients. However, maybe they care more about Mr. Jones, that he not get a central line infection, end up septic, end up in the ICU on a vent. They may care more about that than a number that you have a 1 percent CLABSI rate or something lower than that. And lastly, try to find at the beginning some low-hanging fruit that will be easy to fix. We recently had a medication error that involved in a mix-up between a high-concentration PCA cassette and a standard concentration. So one of our recommended fixes is “Let’s have red labels on the high concentration, green labels on low concentration, and white labels for the standard concentration.” And that will significantly help.”

So that’s the end of my presentation. I would like to say that I have seen some CUSP groups not work well, and would like say that you have to have some secure leaders that are willing to see issues aired in front of the physicians and administration and be willing not to be defensive, not to need to fix the problem instantly but rather to engage in some analysis to see what’s contributing to that. But it’s been very, very satisfying for me and for my staff to participate in that. So I guess we have a question time now.

Mari Franks: Wonderful. Thank you so much, Joanne and Pat, for your wonderful presentations. A very, very important topic here, and I hope that everyone on the call enjoyed that as much as I did and found it beneficial. So at this time, operator, would you mind opening the lines for questions?

Operator: At this time we will open the lines for questions. If you would like to ask a question, please press the star key followed by the one key on your touchtone phone now. Questions will be taken in the order they are received. If at any time you would like to remove yourself from the questioning queue, please press star two. And, once again, to ask a question that’s star one. Our first question comes from Craig Pennington with Ochsner Hospital.

Craig Pennington: Good afternoon, and thank you. I’m in infection control and I play kind of a peripheral part in some of the CUSP teams. How do we encourage new nurses to start asking questions or be more involved in advocating for their patients?

Pat Posa: Joanne, do you want to take that or do you want me to?

Joanne Timmell: Sure, I’d be glad to.

Pat Posa: Go ahead.

Joanne Timmell: I hire almost all new grads. And I like doing that because they’re idealistic and energetic, and I have the opportunity to influence them. But I guess I would first say I don’t think they’re ready to speak up until at least 6 months to a year of experience. I mean, I don’t object to them speaking up, but I think they’re just totally task focused. They just need to figure out, “How can I possibly get to all my patients and give them the attention that they need, the medications that they need?” I had one nurse tell me after a year that she felt like she had had blinders on, like horse blinders, and then all of a sudden at a year those blinders fell away, and she noticed that there were other nurses she was working with and there were other issues going on. But she just had tunnel vision and she couldn’t see it. But after that, after they’ve mastered at least the day-to-day routine, I guess creating opportunities for speaking up so that you end up discussing patient-centered conversations rather than what’s happening on the latest reality T.V. or something like that, I think will help them speak up.

Craig Pennington: Okay.

Pat Posa: And I can add to that. One of the things, as Joanne alluded to, is you also have to have an environment where they feel comfortable speaking up. They clearly have to have enough skill to know, “I should be speaking up.” But you have to create that psychological safety that, “If I speak up, I know I’m not going to get torn down.” And so we have to be very cautious, as Joanne had said, when the executive is asking for comments and feedback to not become defensive and try and give quick answers but to truly listen. And I think that’s creating that environment so when the staff express a concern that they’re greeted with, “Yes, tell me more about that,” and, “I hear what you’re saying.” And that it’s genuine listening and respecting and valuing each of their inputs. Some of the strategies that we’ve used on our multidisciplinary rounds is clearly defining the nurse’s role. And we actually did a survey. We had the nurses do a survey on the leadership of each attending when they were leading rounds and asked them questions, “Did you feel like your input was valued?” et cetera, and showed that to each of the attendings. And it was eye opening for them because they didn’t realize that maybe that’s how they were coming across. And so really being able to give feedback to each other and giving them some structured time to speak up, and that’s what also the huddle process has provided for us is it’s structured time. So the person leading the huddle has to make sure that they are making it inclusive, and if you look at the verbal and nonverbal behavior of people, listening feedback from them. So people begin to feel comfortable saying, “Yeah, they do want to hear it.”

Craig Pennington: It seems like it could be just a wonderful educational moment. And too often, from what I’ve observed, is sometimes the physicians get defensive because they think that they’re being questioned or their care is being questioned by a nurse no less.

Pat Posa: Yes, and I’ve been a manager in the past, and just one of the expectations is putting out clear expectations to the physicians that round on the unit is that the expectation we have for our nursing staff is that they understand all of the treatment strategies and interventions that they’re going to be required to do. And we would expect them to ask if they don’t understand why it’s happening. And so if that is made clear as an expectation that we have for the nursing staff and that’s shared with the physicians, then they’re going to be less likely to be defensive. Then if you hear that they are defensive, it’s then having that conversation with that physician and repromoting the expectations that you have for the nursing staff. And to create that culture of safety, really anybody should have the ability to ask “why” to anybody. There’s no hierarchy here. The housekeeper, if they notice someone not putting on gloves and a gown in an isolation room, should be able to say something, and so we have to be able to get to that.

Craig Pennington: Absolutely. Sorry for dominating the conversation here. I’ll listen now.

Pat Posa: That’s okay.

Joanne Timmell: Thanks.

Operator: Our next question comes from Louise Saladino with Durham Regional.

Louise Saladino: Hi. We are having initial success. We started our CUSP program in August. And I was just wondering if you all have decided on some form of empowerment tool to help gauge your actual nurse empowerment. I mean our feedback from the staff are positive. We plan on using our SAQ responses as one of our metrics. But I was just wondering from an empowerment standpoint if you have a tool that you’ve considered.

Pat Posa: Joanne, do you have?

Joanne Timmell: Yes, that’s a good question. Yes, we rely heavily on our SAQ scores, which indicate the perceived level of teamwork, job satisfaction, attention to safety. But we also use the NDNQI which is National Database of Nursing Quality Indicators. And those are some really important questions, and we do that as an institution. And also as an institution, we participate in the Gallup Employee Engagement Survey. We did away with employee satisfaction. And just for example, in that survey it asks: One, my coworkers are committed to high-quality care. Two, my opinion counts at work. So it’s not specifically for clinical staff but definitely gets those metrics.

Pat Posa: Yes, and I would agree with Joanne that we use our SAQ. We use our Employee Engagement Survey. And then I had just shared that when we were doing multidisciplinary rounds, we evaluated each of the team member’s perception of the leadership and how their opinion was valued during rounds. And we’ve done a survey of the staff on huddles. Now, mind you, it’s not a validated tool, but we’ll send out a Survey Monkey survey and ask questions: Do you feel like you can speak up? Do you feel comfortable sharing your ideas at huddle? So we’ve done it with each of the initiatives, but not specifically. In general we’re using our SAQ and our Employee Engagement Survey.

Louise Saladino: Okay, thanks. And to the other gentleman’s point, we have about seven new graduates in the unit right now and part of the engagement for them was including them in the executive walk arounds. And I think that really goes a long way to letting them see the openness, that the rest of the staff are willing to discuss some of their concerns. And then, of course, time will allow them to see that it is the type of environment to be able to speak up.

Pat Posa: Thank you for sharing that.

Operator: Our next question comes for John Zondlo with Presbyterian Healthcare.

John Zondlo: Good afternoon. I have a question primarily, I think, for Joanne and possibly Pat. But I want some more detail on the monthly CUSP meetings that you talked about. How long do they run? I assume is it you encourage nurses who are not working on the shift to come in? Do you pay them for that? Are they required to attend?

Pat Posa: Joanne, go ahead first.

Joanne Timmell: Okay, I’ll speak for ours. Anybody is welcome to attend. And occasionally I may have a leadership meeting or something like that which I will tack onto the time for the CUSP so that that group could attend. But, in general, we would just try to encourage the people who are currently working to attend the meeting. That meeting usually goes for about an hour. Well, it’s a challenge to get our executive and our physician and me all free for an hour, so wherever we can find an hour we will do it. But it also tends to be around 3 in the afternoon which tends to be a better time for the nursing staff than something earlier in the morning. So, again what I find is going around maybe three times over the course of the day: “Is there anything I can do to help so that you can be free to go to the CUSP meeting?” And it just gets people thinking, “I want to aggregate my work so that I can be able to step away from patient care to be free for this meeting.”

John Zondlo: So, do the physicians on the unit also attend the meeting? Or the physician champion?

Joanne Timmell: The physician champion always attends, and, actually, our executive also happens to be a physician. But the residents do if they’re on the unit. Oftentimes they may be in surgery. And then, at that point, we also have the mid-levels that are attending. We call that our PAs and nurse practitioners.

Pat Posa:  And we approach it just a little bit different. So we pick a 2-hour period twice a month, and we’ve identified two or three staff from each of the ICUs, so we do a combined one so we can standardize things throughout our ICUs. And so we do both the safety piece, the learning from defects, as well as the technical work of implementing CLABSI prevention and VAP and other ICU initiatives. So we have physicians there from each of the units, residents, mid-level providers, nursing staff, respiratory, pharmacy, and we do it in a 2-hour block. And so they’re paid for it. We make it at the end of the shift, and that’s worked well. And that’s why the huddles really complement this work because then more people can be involved in a lot that we’re doing where we just can’t get people off the unit for long periods of time.

John Zondlo: Thank you.

Operator: Our next question comes from Lola Tweet with Avera.

Lola Tweet: Hi, thank you. This is a great presentation. A couple questions on the huddle board. Where do you put those? Are they right on the unit where they’re in visible sight for all disciplines plus patients and families? Do you have a small room or another area that you put this in where it’s seen daily, like in a lounge? Just some thoughts a little bit on the huddle board -- very unique idea.

Pat Posa: So we put them similar to what Joanne was describing that people crowd into the little room because it’s close. We have it right outside in the unit so that people can still listen for alarms and bells and whistles while they’re at the huddle. And so when we do a huddle in our ICU, the rounding team comes to it, so the physicians, the mid-level providers, as well as all the nursing staff. And so we might have 10 or 15 people huddled around that huddle board. And it’s front and center, out in the open. At first, we were concerned that people would write funny things on it or what would the patients think. But our focus is transparency, and so if the family or anybody asks, we tell them.

Lola Tweet: Thank you.

Operator: Once again, if you’d like to ask a question that’s star one on your touchstone phone now. Our next question comes from Pamela Lewis with Wayne Memorial Hospital.

Pamela Lewis: With the huddle boards out front and center, how do you handle confidentiality or HIPAA?

Pat Posa: So, as you can see from the examples, there really isn’t any patient-specific information so, it’s no HIPAA violation. It’s generic. The metrics are groups of patients, and so you really couldn’t identify any particular patient from what’s written on the board.

Pamela Lewis: Okay. Thank you.

Pat Posa: You’re welcome.

Mari Franks: And this is Mari. I know we’re at the top of the hour, and I want to be cognizant of everyone’s time. So operator, if we have one more question we’ll take it, but if not we should wrap things up.

Operator: At this time I’m showing there are no further questions.

Mari Franks: Excellent. Well, I think that this presentation has been very informative, and thank you both to Joanne and Pat. And again, we encourage you here at HRET to fill out the survey that is at the end of all of your PowerPoint presentations. We really look at that feedback and want to keep improving and bringing you presentations like the ones today. We are grateful for Pat and Joanne’s time, and we look forward to having a supplemental call here in a few months. We’re not going to plan to have one in December but look forward to starting them up again in January. So at this time, Joanne and Pat, thank you again.

Pat Posa: Well, thank you for having us.

Joanne Timmell: Thanks, Mari.

Pat Posa: Thank you for allowing us to share our stories.

Mari Franks: Absolutely. And if anyone has questions for them, feel free to email myself, Mari Franks. My email address is mfranks, F-R-A-N-K-S at A-H-A dot org, and I’ll be happy to relay any questions you may have to either of our presenters. So with that, thanks everyone, and have a great afternoon.



Page last reviewed April 2013
Page originally created April 2013
Internet Citation: How CUSP Enables Nurse Empowerment (Transcript). Content last reviewed April 2013. Agency for Healthcare Research and Quality, Rockville, MD.