Shared Governance in Practice: RNs Improving Patient's Surgical Preparation through Standardization and Collaboration

Our organization is a safety-net hospital and the only level I adult and pediatric trauma center in our state. We are licensed for approximately 400 inpatient beds and perform more than 600 planned (non-emergent) surgeries per month. In 2015, our outpatient surgical clinic managers noticed they were experiencing lower than expected CG-CAHPS scores, and there were anecdotal reports of “regular” cancellations of surgeries due to patients not following pre-op NPO instruction. Our facility is scheduled to adopt a single unified EHR in 2020, but currently we work in a mosaic model that does not always allow for seamless communication between the inpatient and outpatient records. As a result of this complicating factor, we were unable to provide data to address this issue. With a focus on improved patient safety and experience, a work group was formed to review the literature and perioperative best practices, followed by a gap analysis of pre-op teaching practices and preparation among the 10 surgical clinics. We found significant gaps in the essential components of documentation, variability in messaging, and lack of physician engagement and understanding of the role of the RN in clinic. There was also scope of practice and safety concerns identified with some historical support staff.

The work group that formed was made up of the ambulatory nursing administrator, clinic managers, assistant nurse managers, and some frontline staff nurses. This group worked in collaboration with colleagues from quality improvement, inpatient nursing, pre-anesthesia, social work, pharmacy, and med-op clearance physicians to address specific pre-operative policies and practices. The first task that was undertaken was to identify priority safety issues and set teaching and documentation standards based on current best practice and regulatory requirements.

We conducted a patient survey that measured perception and depth of understanding of one of the critical components of pre-operative teaching. Even at the earliest point of the project, patients had a 74% perception that they were getting adequate pre-op teaching, despite chart reviews that did not support that perception. A survey of clinic nurses at that same time showed that only 43% of nurses strongly agreed that they had a strong impact on their patient’s outcomes

In early 2018, we adopted pre-operative teaching standards and relaunched efforts to link assessments in a shared electronic form. We now measure the compliance of clinic nurses in following the documentation standards. Over a 10-month period, compliance has gone from 19% to 58%. Clinics that have fewer RNs to help with patent education have met with leadership to adopt other strategies in their practice in order to meet the same standard.

The process taken to review best practice, set standards, and track compliance has been reflected in our CG-CAPHS scores and surgical cancellations data. Our work group has proven invaluable as a forum for process improvement and shared governance for our surgical practices. We have developed tools and processes to communicate information that will improve discharge readiness, decrease unnecessary length of stay, and decrease readmissions.