Purpose: The purpose of this initiative was to increase clinical staff awareness on the potential risk of medication administration error (MAE), to improve staff’ behaviors, and to reduce MAEs.
Description: MAEs, although, common and preventable, may lead to adverse drug events, costing the patient and the organization. It is reported approximately that four in 10 patients are harmed in primary and outpatient health care settings, with up to 80 percent of those MAEs being preventable (Finnegan, 2020). Similarly, at Community Healthcare Network, MAEs – although common – could have been prevented.
To help prevent the MAE occurrences at CHN, an interdisciplinary team of nurse leaders, nursing front-line staff, and clinicians implemented a multifaceted process improvement approach. This multifaceted process improvement comprised the creation of electronic medication for single and multi-dose vaccination vials, the implementation of two-staff verification for medication administration, the weekly audit of medication expiration, the random audit of the medication management process by central leadership, a fishbone focused on the causes of the medication errors, and staff training and education. The effectiveness of this approach is continuously being monitored.
Evaluation/outcome: A month into the implementation process, which was rolled out in February 2020, a remarkable MAE reduction of 40% was noted when comparing the months of March 2019 and March 2020. Additionally, when comparing the time period of March through October 2019 and 2020, a reduction of 33 percent in MAE was noticed.
Although systematic reviews stipulate that there is not enough data to support the impact of two-staff verification in preventing medication errors, this pilot study reveals that multifaceted strategies to support safe medication administration may reduce medication administration errors.
1. Finnergan, J. (2020, January 28). 4 in 10 patients harmed by medical errors in primary and outpatient settings. Fierce Healthcare. https://www.fiercehealthcare.com/practices/medical-errors-globally-as-many-as-4-10-patients-harmed-primary-and-outpatient-settings
2. Koyama, A. K., Maddox, C.-S. S., Bucknall, T., & Westbrook, J. (2020). Effectiveness of double checking to reduce medication administration errors: A systematic review. BMJ, 29, 595-603. http://dx.doi.org/10.1136/bmjqs-2019-009552
The purpose of an advanced practice provider (APP) council is to provide a platform for APPs to identify and impact patient care and outcomes through trust, interconnection, and collaboration. The mother of modern management declared that a leader’s most important role is to develop other leaders and their sense of power (Follett, 1924). Presented in this abstract is a plan to promote the empowerment of APPs through the implementation and evaluation of an APP council focused on increasing the social capital of APPs. The United States health care system is transitioning from fee-for-service based care to value-based quality care. APPs play a valuable role in providing vital care to patients in care coordination, including annual wellness visits, sick visits, and post-operative care. Health care leaders must offer ways for APPs to obtain and sustain the support that promotes professional practice environments (Buckler, 2019; Kirkman, Wilkinson, & Scahill, 2019). Specific outcomes include achieving quality improvements, leading change, applying current evidence-based practices, supporting compliance with APP rules and regulation requirements, addressing issues of concern, and unifying the organization. This council development is program implementation and evaluation. The methods to implement the project included 1) structure: identify APPs employed at the organization, establish a steering committee of APPs to guide the development of the council, reserve time to meet, send invitations, plan agenda items, and classify the placement of the council within the organizational structure; 2) process: design and distribute pre- and post-needs assessment surveys, conduct APP council meetings; 3) outcome: pre- and post-survey data results, initiatives established through the council, number of APP attendants, and transitions of practice initiatives including compliance with APP rules and regulatory requirements. As health care continues to evolve, the roles and responsibilities of APPs continue to change. It is crucial for health care leaders to support and empower other health care leaders, such as APPs, to engage in their work environments to impact patient safety and outcomes. Implementing an APP focused council provides an opportunity to build social capital among APPs within the organization’s medical practice.
1. Buckler, L.T. (2019). Building a home for advanced practice: An academic health care system experience. VOICE of Nursing Leadership, 17(3), 12-14.
2. Follett, M.P. (1924). The Creative Experience. New York, NY: Longmans, Green.
3. Kirkman, A., Wilkinson, J., & Scahill, S. (2018). Thinking about health care differently: Nurse practitioners in primary health care as social entrepreneurs. Journal of Primary Health Care, 10(4), 331-337. doi:101071/HC18053
Introduction: In 2017, Massachusetts Department of Public Health (DPH) sent a circular to all clinician practices approving medical assistants (MA) to administer vaccines. This approval for MAs to legally administer vaccines was new for the state of Massachusetts. Our large ambulatory care center with inconsistent practice expectations met this change by standardizing practices and successfully creating a comprehensive plan of qualifying, validating, training, and empowering their medical assistants to function at the top of their scope of practice.
Background: The DPH circular provided criteria regarding the recommended guidelines for education, experience, and training which allowed medical assistants to administer vaccines and the provision of supervision to adhere to in order to justify this practice. The multi-specialty ambulatory care center was comprised of several smaller and larger primary care practices acquired at various times to become one large entity. Prior to the application of this project, practices among the various sites ranged from some sites allowing MAs to administer vaccines, while other sites that did not.
Objective: The updated state guideline would ensure that patients would have easy access to vaccinations and that only select qualified medical assistants with validated vaccine training and skills could administer vaccines. The goal was to empower and train the current medical assistant workforce to safely administer vaccines while allowing them to practice to their full scope. Additional sub-goals included retention of staff and employee satisfaction.
Methods: Extensive collaboration and employee records documentation was required to ensure compliance with law and standardization. The plan was to integrate this practice not only with the current staff, but also in onboarding new MAs. Key stakeholders included legal, human resources (HR), safety, infection control, and practice leaders/administrators. This project required top leadership buy-in at all levels!
The project was implemented in four steps:
1) Identify MAs who qualify per state regulation to safely administer vaccines: implemented through legally vetted attestation forms, and processes which identified the MAs into two state approved categories.
2) Train the identified MA’s to administer vaccines: implemented by creating a comprehensive vaccine curriculum which included web-based online learning platform, in-person class, simulation of vaccine skills, and vaccine administration documentation. Curriculum included safe medication administration, handling and storage, adverse reaction identification, and recognizing and reporting unsafe practices.
3) Trained MAs required nurse validation of vaccine skills in supervised settings: implemented by requiring nurses to supervise and validate ten vaccine administrations during flu visits prior to MAs administering vaccines on their own.
4) Document successful candidates in centralized HR records: on completion, the manager/supervisor sends the names of successful candidates to be stored in the centralized HR system.
Outcome: By 11/05/2020, 30 MAs completed all the requirements, and another 24 have been scheduled for training. New processes were put in place including, a new job title, new list in HR for MAs eligible to administer vaccines, and new ID badges. They supported staffing by reducing workload on nurses. Supervisory requirements met at each site to keep patients safe, and MAs empowered with practice change.
Problem: Paper-informed consent forms are associated with incomplete and or inaccurate information such as missing signatures and incorrect patient identification. The Food and Drug Administration’s bioresearch monitoring program audit for the 2019 fiscal year lists failure to obtain informed consent requirements as one of the most common violations (2%) by clinical investigators in clinical trials. In a selected practice site, approximately 440 (2%) out of 25,000 paper informed consents were returned by the medical records department to clinicians in 2019 due to incomplete and or inaccurate information. This resulted in significant delays in the start of clinical trials, incurring additional time and effort for participants and clinicians to correct and or re-consent.
Purpose: The purpose of this quality improvement project is to implement electronic informed consent for research participants in the adult oncology, allergy and infectious disease, and diabetes, digestive, and kidney diseases outpatient clinics in a clinical research hospital.
Methods: Pre-implementation surveys were administered to clinicians (n=43) to obtain baseline perceptions on using paper versus electronic consents. The clinicians were then trained remotely on using electronic consent for signatures. Paper consents were replaced with electronic consents for specific protocol studies (n=8), followed by a post-implementation survey to compare clinicians’ preferences and satisfaction.
Preliminary results: Preliminary results show an increase in the mean percentage of confirmed electronic informed consents accessible in the electronic health record within one day of signing by clinicians. However, the results of the project have not yet been completed. The plan will be to discuss the findings for documentation of informed consent, timeframe for accessibility of confirmed consents in the electronic health record, and clinician satisfaction with using electronic informed consent.
Preliminary conclusions: Preliminary conclusions show that replacing paper with electronic informed consent appears to improve documentation. However, the results of the project have not yet been completed, and therefore conclusions cannot be drawn at this time.
Background: Our nation’s underserved communities face rising costs, and declining life expectancies. In response, health care stakeholders seek to integrate primary care (PC) and public health (PH) nurses to meet these rising challenges. Navigating this convergence requires ambulatory care registered nurses (RNs) to execute both upstream and downstream nursing actions. Applying up-to-date knowledge of the integration of public health and primary care is vital to nurses in these settings, to improve health outcomes of their individual patients and their patient populations.
Learning outcomes: After a review of this poster, participants will be able to 1) describe the content of two newly developed modules that integrates PH and PC competencies for RNs in ambulatory care settings and 2) describe the post-module survey results.
Methods: An interprofessional team utilized an existing academic-practice partnership in a large local PH department and two federally qualified health centers (FQHCs) to develop 14 modules that integrate PC and PH content. 56 nursing contact hours were obtained using a free online platform, MoodleTM. The topics are 1) precepting, 2) PC, 3) PH, 4) integration of primary care and public health, 5) transitions of care and chronic disease management, 6) mental health and substance abuse, 7) cultural competence, 8) social determinants of health, 9) program development, 10) ambulatory care, 11) hospice and palliative care, 12) quality improvement, 13) population health, and 14) interprofessional education. Modules 3 and 4 cover PC and PH integration. Participants complete online surveys using Qualtrics® before and after the online training modules. Data will assess competence and application of PC/PH nursing integration.
Results: Two modules will be summarized with exemplars. Module 3 describes a) the tier 1, II, and III of PH nursing competencies and how they apply to practice, research, policy development and education; b) the council of linkages and its role between academics and PH practice; and c) PH nursing’s contribution to a healthy Michigan. Module 4 describes a) the reasons for the integration of PH and PC, b) the differences in how integration is defined, c) the World Health Organization’s (WHO) suggestions for how to integrate public health and primary care, and d) roles nurses play in the integration of public health and primary care. The modules were beta-tested by seven RNs with expertise in PC or PH in year one and year two of our grant, with two RNs from FQHC centers and five RNs from the PH department. Preliminary post-module qualitative and quantitative survey results from these beta testers will be provided. The final modules are being shared with a larger audience in our three partner sites and our college of nursing; we will provide outcomes from these additional RNs.
Conclusions: Public health and primary care academic-practice partnerships can enhance ambulatory care nurses’ knowledge, skills, and actions to improve population health. Nurses in both primary care as well as public health who apply knowledge of their respective specialties' value will launch both upstream and downstream actions to improve their patients’ and communities’ health.
Background: Networking is a critical component of professional development for nursing that promotes career growth, advances evidence best practice, builds relationships, and provides opportunities for nurses to collaborate with colleagues outside of their department or organization. Our American Academy of Ambulatory Care Nursing (AAACN) state-wide local networking group (LNG) has worked to create networking opportunities for nurses, grow membership, and establish a leadership and succession planning. With only 12 LNGs listed by AAACN, more are needed in order to meet this growing need for ambulatory care nurses.
Purpose/learning objectives: Our poster will allow the learner to a) understand how an AAACN LNG can enhance ambulatory care nurses’ ability to network professionally; b) analyze the relationship of leadership expansion, comprehensive bylaws development, and succession planning to long-term LNG success; c) analyze the tools and methods used to expand the LNG over time; and d) apply tools and methods to the create a successful LNG.
Description: Established in 2013 by a small group of ambulatory care nurses, our state-wide LNG was galvanized with bylaws outlining the organization’s purpose and mission. After a period of waning activity with only the LNG chair leading the organization, revitalization occurred by LNG leadership leaning on evidence in the literature to define and establish a board of directors filled by volunteer LNG members. The newly developed board of directors worked to determine the needs of ambulatory care nurses within the state. Members were surveyed on their learning needs and desires of the organization to determine the direction of the LNG. The board worked to officiate LNG membership and re-establish regular meetings for members to participate in networking events. Membership events were held with plans to recruit members and increase networking opportunities. The LNG experienced an increase in membership applications during the COVID-19 pandemic, demonstrating an increased desire for nurses to network and participate in learning opportunities. With expansion of LNG membership, the board sought to expand the LNG bylaws using the structure and language of the AAACN bylaws as a guide. However, the AAACN is a robust organization versus our LNG in its infancy, resulting in modifications or exclusions of certain content from the AAACN bylaws to fit the needs of our LNG. The resulting bylaws included structure surrounding operations, responsibilities of leadership positions, election processes, and membership eligibility. Ultimately, the focus of the board of directors during the advancement of the LNG bylaws was to generate sustainability of the organization and create longevity beyond the members of the founding board.
Outcome and conclusion: Creation of an LNG board of directors ensures sustainability of the organization and support of future LNG leadership. The work of LNG leadership and the new board of directors has led to a community of over 300 members, with nearly 90 members added in the year 2020 alone. LNG meetings in the last year provided a venue to network and receive education, with significantly positive feedback from members. Our work can be used to guide successful establishment and growth of other LNGs to benefit ambulatory care nurses.
Despite cabinets full of safety needle options, staff were still experiencing needlestick injuries. Propelled by a desire to improve safety and needlestick injury (NSI) data, a plan was initiated to enhance and standardize sharps at a 32-site ambulatory care organization.
In 2000, the Occupational Safety and Health Administration (OSHA) Needlestick Safety and Prevention Act was established as was the work of “Safe Needles Save Lives,” a campaign launched by the American Nurses Association and signed into law on November 6, 2000. This act requires the use of “safety-engineered devices or sharps” engineered sharps injury protection (SESIPs). Congress felt that a modification to OSHA's bloodborne pathogens standard was appropriate and set forth in greater detail OSHA's requirement for employers to identify, evaluate, and implement safer medical devices.
Inventory at sites and departments within the organization uncovered various safety needles, up to five different types. Despite having these safety needles readily available, staff were experiencing NSI on average of 33 per year. The needles were evaluated and it was recognized that all had different safety mechanisms. Safety mechanisms on sharps have improved over the years. Were these safety needles up to current standards? Another concern was the lack of uniformity throughout the sites. Staff deployed to a different site might encounter a needle with an unfamiliar safety mechanism for which they had not been trained.
Based on research on the different safety mechanisms available, the organization selected a retracting syringe to trial at three internal medicine department locations over a three-month period. The trial resulted in a 98% favorable response from staff. Finding a safer product accomplished one part of the mission to decrease NSI. It was decided to also standardize the needles used on pre-filled syringes, and a retractable needle was selected. Enlisting the support of the VP of ambulatory care services and the purchasing department, bumpers were placed within the ordering system to facilitate ordering of the new safer needles instead of the vast selection of needles previously available.
Ensuring that staff became knowledgeable of the product change and were properly trained on the use of the safety mechanism was a priority. A multifaceted training plan was implemented. An introductory notice of the change was sent electronically and included brief training videos for the products. A team of nurse educators then deployed to the sites to provide training sessions with key stakeholders who would become the trainers in their departments. Additional “‘elbow” support was provided to staff on an ad hoc basis.
Staff were encouraged to report concerns, which included the needle not retracting properly and the needle becoming detached during use. All were investigated, and the majority were related to improper use of the safety mechanism, and remediation was provided.
The response to the new products has exceeded expectations. Staff voice increased sense of safety when using products that retract in the patient and the potential for decreased NSI. There is confidence that the data, once available, will support this.
In today’s health care arena, hospitals struggle to meet the established Medicare reimbursement requirements for providing safe and comprehensive care to admitted patients. This has resulted in patients being discharged even faster than in previous times in order to conform to the Centers for Medicare & Medicaid Services’ Hospital Readmission Reduction Program (HRRP) which was implemented in 2012. This reimbursement schedule for allowable hospital days is based on diagnosis codes which penalize hospitals up to 3% of operational diagnosis-related groups (DRGs). This loss in revenue occurs when hospitals are penalized financially if the patient is readmitted for any cause within 30 days following discharge from an inpatient stay.
One method of readmission reduction that has gained the attention of hospital leaders is called mobile integrated health care (MIH). In this program, local emergency medical services (EMS) staffed with paramedics, a resource already well established in almost every community and available 24/7, are trained to emergently assess a patient’s condition. Some hospital systems and EMS companies have empowered this resource to expand their capabilities to treat chronic patients in their home to reduce emergency department (ED) congestion and readmissions. This has helped to relieve access issues by getting patients seen when they need a provider; it has reduced the overuse of ED resources, and generated better patient outcomes. Published research has discussed the benefits of home care conducted by paramedics leading to improved patient care through monitoring, education, and faster access to health care.
By adding nurses and clinic staff into the workflow, we were able to streamline the criteria review for admitted chronic disease patients which reduced the paramedics’ workload and allowed them greater productivity in the field. This retrospective study reviewed a sample of 320 congestive heart failure (CHF) patients who were seen for an exacerbation of their chronic disease symptoms in the ED and either released home or admitted for an inpatient stay. Their ED and physician office visits were tracked for 90 days both prior and after an admission for those who entered the home visit program and those who refused the program. The same parameters were utilized to compare the MIH program before and after the added clinic staff assistance.
Purpose: The purpose of this study was to evaluate a newly designed online educational module on the use of telehealth nursing in ambulatory care settings. Bachelor of nursing (BSN) students who completed the module rated their overall knowledge of the content and their perceived abilities to actualize the content, manage clients, and educate and mentor others. The development of the module was supported by the CARES Act supplemental funding for NEPQR program to prevent, prepare, and respond to COVID-19.
Background/significance: Telehealth nursing has become an essential skill for nurses due to COVID-19; however, training resources remain scarce for pre-licensure nursing students. To meet this need, an online module was developed, implemented, and evaluated in a BSN program at a large academic university in fall 2020. The module focused on 1) the definition of telehealth nursing, 2) professional telehealth communication strategies, 3) handling difficult situations, 4) use of medical interpreters, and 5) telephone triage. The triage section emphasized the nurses’ scope of practice and the use of decision support tools. The self-paced interactive online module included two exemplar case studies to demonstrate the promotion of diversity, equity, and inclusion using telehealth nursing and a downloadable toolkit.
Methods: The BSN students were asked to participate in an anonymous 6-question mixed-method survey upon completion of the online module about telehealth nursing. The participating students rated their pre- and post-module abilities to actualize the training content, level of comfort managing clients, overall knowledge, and ability to educate others about telehealth nursing using a 5-point Likert scale (1=low, 5=high). The survey also included a free-response feedback item. The survey responses were compared using a paired T-test. Study procedures were approved by the university’s institutional review board.
Results: 13 of the 83 students (16%) agreed to participate in the study. Overall, the students’ self-rated post-module expertise was significantly higher for all questions compared to the pre-module expertise (p < 0.05). On average, the students rated their post-module abilities to actualize the training content higher by 1.3 points (95% CI: 0.7-1.9), as well as the abilities to manage clients (1.4 points, 95% CI: 0.9-1.9), level of comfort (1.5 points, 95% CI: 1.0-2.1), overall knowledge (1.3 points, 95% CI: 0.8-1.8), and ability to educate others about telehealth nursing (1.1 points, 95% CI: 0.6-1.5) compared to their pre-module levels, respectively. The qualitative responses described the case studies and interactive learning platform as helpful and provided technical usability feedback such as playback speed and glitches.
Conclusions/implications: The telehealth nursing online module improved the BSN students’ perceived abilities to actualize the content, manage clients, educate, and mentor others and overall knowledge about telehealth nursing in ambulatory care settings. Additional educational resources are needed to equip nurses to deliver high-quality care and meet the increasing demand for telehealth nursing.
The COVID-19 pandemic has increased demand for primary care services while limiting clinic and provider ability to accept new patients. As demand for primary care grows, new models are urgently needed that can increase access to care while efficiently identifying and addressing care gaps.
The MAHEC Family Health Center new-to-practice adult 18+ patient visit process was identified as an opportunity to improve clinic efficiency and increase scheduling capacity with RN same day pre-visit planning. Due to the pandemic, new-patient-to-clinic visits mid-year 2020 were scheduled as telehealth encounters only.
Consistent reduction in provider time from 40 minutes to 20 minutes for a new-to-practice adult 18+ encounter would allow for an additional scheduling slot opportunity. Adding at least one new to practice adult patient scheduled encounter per day for the four telehealth service-assigned providers would significantly increase new-to-clinic patient access.
A same-day pre-visit planning workflow was developed that uses the RN to full practice scope, provides consistency in assessment and charting, and provides an opportunity for the RN to share information in the SBAR format to the provider. The RN scope of practice introduces robust assessment capabilities to efficiently identify patient needs and care gaps while meeting identified MAHEC provider needs for consistency in medication review and review of systems. Data was collected over the course of 35 patient encounters including provider time in visit, gaps in care identified and addressed, and RN and provider collaboration with warm handoff.
The initiative demonstrated that provider time in telehealth new-adult patient encounters can be reduced below 40 minutes while increasing consistency in recognizing and closing gaps in care. Utilizing RNs for new patient intake provides the scope of practice element necessary for ensuring consistency in medication review and review of systems components of the work-up. Workflow standardization was shown to be crucial for consistency in data gathering, risk assessment screening, and EHR documentation. RN handoff communication to the patient’s provider increased provider perceived ability to focus on the patient’s primary reason for visit and to perform diagnostic work and planning. Study data has informed MAHEC Family Medicine clinical leadership decisions in the development of patient intake standardized EHR documentation accompanied by job aids and training for all clinical staff and providers.
This RN-led process increased access for patients, consistently identified and closed gaps in care, and increased collaboration between clinical staff and providers.
The authors wish to thank Suzanne Shapiro and Brenda Benik for their assistance with the presentation.