Running Head: THE CLINICAL NURSE LEADERS ROLE IN BRIDGING

The Clinical Nurse Leaders Role in Bridging the Healthcare Quality Chasm Melissa Alberto UCLA School of Nursing NUR 269, Fall 2013 October 18, 2013

THE CLINICAL NURSE LEADERS ROLE IN BRIDGING

Great strides have been made in medical advancements; however, implementation of these findings into clinical practice has failed. The current healthcare system struggles to utilize this new information to provide effective treatments for patients; in fact, it is causing harm to patients more often than it should. Therefore, the Institute of Medicine (2009) issued a report entitled, Crossing the Quality Chasm: A New Health System in the 21st Century, to provide recommendations on how the United States (U.S.) can transform its healthcare system to bridge the gap between knowledge and application and to improve the quality of healthcare. There are several factors that contribute to the problems seen in the quality of healthcare. Firstly, there is an immense amount of new medical knowledge and technology being produced every day due to increased investments in research and development. Furthermore, this knowledge and technology is growing more complex. Although these findings are seen as a huge stride for healthcare, it cannot be translated by health professionals as fast as the new knowledge and technology is being produced (IOM, 2009). The inability to distribute new information and technology to the public nearly renders it useless and fails to improve the quality of healthcare. Secondly, as a result of these medical advancements, people are now living longer and the prevalence of chronic illness has increased. The number of adults 65 years and older increased from 35.1 million in 2000 to 41.4 million in 2011 (Administration on Aging, 2012). In 2005, 133 million Americans had at least one chronic illness and by 2020, it is estimated to increase to 157 million (Wu & Green, 2000). Caring for the chronically ill is a collaborative process amongst different healthcare providers to develop an appropriate care plan. In addition, it takes a lot of communication and coordination to provide continuity of care (IOM, 2009). The complexity of chronically ill patients condition and care plans can result in many these patients to become lost in the shuffle, which decreases their quality of care.

THE CLINICAL NURSE LEADERS ROLE IN BRIDGING

Thirdly, the manner in which healthcare and treatment are delivered to patients is poorly organized because of the healthcare systems fragmented structure and overly complex processes. The healthcare delivery process requires unnecessary steps and handoffs that slow down the process and decrease safety (IOM, 2009). The lack of efficiency leaves room for errors and wastes resources. Furthermore, our current healthcare system does not have the mechanisms to coordinate the array of services needed by those with multiple chronic illnesses (IOM, 2009). As mentioned before the lack of coordination and follow-up can be detrimental to the quality of care for patients with chronic illnesses. Lastly, there are limitations on accessing health information on the internet. As of 2010, over 228 million American adults have access to the internet (U.S. Census Bureau, 2012). The internet serves as a good resource for information and an estimated 70 million Americans seek health information and advice on the internet (Cain, Mittman, Sarasohn-Kahn, & Wayne, 2000). However, limitations such as privacy issues, inconsistent information, and lack of organizational interest in investing in information technology have prevented the internet in becoming a potential healthcare resource (IOM, 2009). Thus, the gap between medical knowledge and technology from the people remains. The factors that contribute to the problems in the quality of healthcare will continue to widen the chasm unless we can change our healthcare system to bridge the gap. The Institute of Medicine (2009) report describes six areas that the U.S. needs to improve upon in order to achieve quality healthcare: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability. In a high-quality healthcare system, provided care is safe and would not inflict injury to the patient. For example, the implementation of a time out before a procedure can prevent possible mistakes such as performing the wrong procedure on a patient (Mulloy &

THE CLINICAL NURSE LEADERS ROLE IN BRIDGING

Hughes, 2008). In addition, care is effective because it has been thoroughly deliberated using science-based knowledge to ensure that it provides more benefits than harms to the patient; for example, encouraging postoperative patients to use the incentive spirometer in order to improve lung function decreased pulmonary complications and length of stay in the hospital (Westwood et. al., 2007). Furthermore, a high-quality healthcare system provides patient-centered care, which guarantees that medical professionals are sensitive to the needs and values of the patient when considering what methods are appropriate in managing disease. For instance, Krist et. al. (2012) found that providing an interactive and patient-centered preventative health record to patients increased the number of patients undergoing preventative cancer screening. Also, all processes must be timely and conducted in a manner that prevents hindrance in delivering care as in implementing a set interval for nurse rounding can reduce patients call light use and increase patient satisfaction (Meade, Bursell, & Ketelsen, 2006). Efficient care provides prompt services while preserving resources such as energy, equipment, and supply. The Meade, Bursell, & Ketelsen (2006) study demonstrated that set interval for nurse rounding was a more efficient use of their time because the nurses only visited their patients once to take care of all of their needs rather than answer multiple call lights. Lastly, a quality healthcare system provides medical services that are equitable, which means that the services make no bias in who receives care regardless of the patients gender, ethnicity, geographic location, and socio-economical status. One idea that can help reduce health disparities in breast cancer screening in African American women is going out in the community and collaborating with religious leaders who have an impact on this population (Sabatino, 2012). The role of the clinical nurse leader (CNL) was developed by the American Association of Colleges of Nursing (2007) to help transform our current healthcare system. The CNL is

THE CLINICAL NURSE LEADERS ROLE IN BRIDGING

trained in several core competencies that can be used to address the aims previously described above. For example, the CNL is trained to use their critical thinking and assessment skills to identify problems, gather and analyze data, develop interventions, and evaluate these interventions (AACN, 2007). A prime example of this process is demonstrated by Neiman, Rannie, Thrasher, Terry, & Kahn (2011). To address the growing number of falls during hospitalization, they developed a fall-risk assessment tool that was incorporated into the electronic medical record and an IM SAFE fall prevention program. The assessment tool categorized patients as low-risk, moderate-risk, or high-risk. Personalized interventions were based on the patients fall risk. In addition, the program provided educational materials to the staff, patients, and family members both in English and Spanish. The impact of the program was evaluated by comparing the monthly fall rates. After sixteen months of implementation, the study found a decrease in fall rate from 0.67 falls per 1,000 patients to 0.57 falls per 1,000 patients (p=0.048) (Neiman et. al., 2011). This study demonstrated with the implementation of this assessment tool and prevention program the hospital was able to reduce harm to its patients and improve the quality of care. This study addresses many of the goals of the IOM report; more specifically, the implementation of the fall-risk assessment tool and fall prevention program was shown to be effective in reducing the amount of falls and ensuring the safety of patients during their hospitalization. Furthermore, the fall-risk assessment tools allowed for patient-centered care by categorizing patients and implementing fall prevention interventions that addresses the patients needs. Since the assessment tool was available in the electronic medical record, the fall risk assessment is readily available to health care providers and interventions can be implemented in a timely manner. In addition, by preventing falls, additional costs for fall injuries can be avoided;

THE CLINICAL NURSE LEADERS ROLE IN BRIDGING

thereby, demonstrating the efficiency of the fall prevention program. Finally, the program demonstrated equitability in care by providing educational materials to the patients and their family members both in English and Spanish. Like Neiman et. al. (2009), the CNL can identify a problem on the unit, develop or research possible interventions, implement the intervention on the unit, and evaluate the outcomes. By implementing evidence-based interventions on the unit, the CNL can achieve safe, effective, patient-centered, timely, efficient, and equitable care for their patients. The CNL can bridge the chasm between knowledge and application. The CNL can help transform the U.S. healthcare system to provide exceptional quality of care, the care that Americans expect and deserve.

THE CLINICAL NURSE LEADERS ROLE IN BRIDGING

Reference Administration of Aging. (2012). A profile of older Americans: 2012. Retrieved from http://www.aoa.gov/Aging_Statistics/Profile/2012/docs/2012profile.pdf American Association of Colleges of Nursing. (2007). White paper on the education and role of the clinical nurse leader. Retrieved from http://www.aacn.nche.edu/publications/whitepapers/ClinicalNurseLeader.pdf Cain, M. M., Mittman, R., Sarasohn-Kahn, J., & Wayne, J. C. (2000). Health e-people: The online consumer experience. Oakland, CA: Institute for the Future, California Health Care Foundation. Retrieved from http://books.nap.edu/catalog.php?record_id=10027 Institute of Medicine. (2001). Executive summary: Crossing the quality chasm. Washington, D.C.: National Academies Press. Retrieved from http://books.nap.edu/catalog.php?record_id=10027 Krist, A., Woolf, S., Rothemich, S., Johnson, R., Peele, J., Cunningham, T., ... Matzke, G. (2012). Interactive preventive health record to enhance delivery of recommended care: A randomized trial. Annals of Family Medicine, 10, 312-319. doi:10.1370/afm.1383 Meade, C., Bursell, A., & Ketelsen, L. (2006). Effects of nursing rounds on patients' call light use, satisfaction, and safety: Scheduling regular nursing rounds to deal with patients' more mundane and common problems can return the call light to its rightful status as a lifeline. American Journal of Nursing, 106(9), 58-71. Retrieved from http://journals.lww.com/ajnonline/pages/default.aspx Mulloy, D. F., & Hughes, R. G. (2008). Wrong-site surgery: A preventable medical error. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses.

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Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2678/ Neiman, J., Rannie, M., Thrasher, J., Terry, K., & Kahn, M. G. (2011). Development, implementation, and evaluation of a comprehensive fall risk program. Journal for Specialists in Pediatric Nursing, 16(2), 130-139. doi:10.1111/j.1744-6155.2011.00277.x Sabatino, S., Lawrence, B., Elder, R., Mercer, S., Wilson, K., Devinney, B., Glanz, K. (2012). Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: Nine updated systematic reviews for the guide to community preventive services. American Journal of Preventive Medicine, 43, 97-118. doi: 10.1016/j.amepre.2012.04.009 Westwood, K., Griffin, M., Roberts, K., Williams, M., Yoong, K., & Digger, T. (2007). Incentive spirometry decreases respiratory complications following major abdominal surgery. The Surgeon, 5, 339-342. Retrieved from http://www.journals.elsevier.com/thesurgeon/ Wu, S. Y., & Green, A. (2000). Projection of chronic illness prevalence and cost inflation. Santa Monica, CA: RAND Health. Retrieved from http://www.cdc.gov/chronicdisease/overview/index.htm U.S. Census Bureau. (2012). Statistical Abstract of the United States: 2012. Retrieved from http://www.census.gov/prod/2011pubs/12statab/infocomm.pdf