In 2010, inspired by statistics from Robert Wood Johnson Foundation, Winston-Salem, N.C.-based Novant Health leaders decided to investigate the amount of time the system's nurses were actually spending at the bedside during their 12-hour shifts.
"We discovered that we weren't that different from the rest of healthcare organizations," says Sallye Liner, RN, Novant's chief clinical officer. "They were spending two-and-a-half to three hours on direct care. They're working hard. They're just engaged in activities that didn't have them performing at the top of their license. "
Novant's leaders brought together a group of nurses from across the health system's then-13 hospitals to further investigate the issue and come up with a solution. Ms. Liner says the nurses identified four major types of activities that accounted for most of their time away from the patient: hunting for and gathering supplies (such as IV poles), retrieving medications, care planning, and the process of admitting the patient (including the necessary paperwork concerning patient history, medications and other documentation).
Ms. Liner says Novant Health then decided to set an ambitious goal: having nurses spend 70 percent of their time in a patient's room. "Over the course of the last three years following that, we've worked on care team models that included having the nurse define what the top of their license performance would look like," she says. "It was clear that we would need a team of people wrapped around nurses to make sure all of the needs of the patient were met."
In line with that discovery, Novant brought in certified nursing assistants and had them take over many of the activities that were keeping nurses away from the bedside. Furthermore, the implementation of an electronic medical record freed medical unit secretaries from transcribing orders. "Now we have a safer system where the doctor enters the orders directly into the computer," Ms. Liner says. "So medical unit secretaries could take on more of a role of support for the clinical staff."
Additionally, the health system implemented processes such as placing monitors in patients' rooms so nurses could document there. "Rather than having to run around and have hard copy things, they could turn a monitor around and show [the patient] their medications they're going to be going home on," Ms. Liner says. "It became a great tool to engage the patient in dialogue about their care."
Novant also had pharmacy techs pull needed medications and place them in patient rooms so that nurses wouldn't have to go looking for them. All of the care process improvements were incorporated into the system's EMR, Ms. Liner says. "We were really able to accelerate time with the patient by hardwiring activities into the EMR," she says.
The system originally put the reforms in motion in 51 of its nursing units and now has the changes implemented in all of its now 15 hospitals. Novant nurses now spend 72 percent of their time in patient rooms, Ms. Liner says.
And more direct care time isn't the only positive consequence of the improvement effort. Ms. Liner says Novant has also seen reductions in falls and an increase in patient satisfaction now that nurses are more routinely available. Nurse turnover rates and infections are also down. Ms. Liner says these developments played a definite part in seven Novant Health hospitals achieving Magnet recognition from the American Nurses Credentialing Center in April.
To other organizations aspiring to achieve similar results, Ms. Liner advises engaging frontline nurses early on and involving them in the development of the care model design. "We are proud of the fact that we had our nurses engaged early," she says. "I encourage and offer that as a first step that they take."
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