Incorporating Microsystems and Quality Improvement into the CNL Curriculum

1. Incorporating Microsystems and Quality Improvement into the CNL Curriculum Sally Gerard, DNP, RN, CDE, CNL Assistant Professor Fairfield University

2. Welcome To Fairfield Univesity

3. Fairfield University • Jesuit University founded in 1942. • Located in Fairfield CT, one hour north of NYC • 35 undergraduate majors and 35 graduate programs. • Began enrolling women in 1970 with the founding of the School of Nursing. • Current undergrads approx 4,000 and 1,000 graduates.

4. Faculty • 14 Full time faculty with some Visiting faculty and adjuncts. • Full time faculty teach in graduate and undergrad • VA Academy faculty for post BS accelerated nursing degree. Faculty retreat to examine the CNL and vote for moving forward

5. Learning Curve • Microsystem : “where patients and providers meet” (Nelson et. al. 2002) • To achieve organizational results, we must optimize the performance of each microsystem (McKeon et al 2009). • A comprehensive understanding of the microsystem is integral to the success of the CNL success

6. Faculty Development • CNL Essentials integrated with MSN essentials • Microsystems literature • Quality and safety initiatives • Focused group for CNL Task Force • National conferences • Publications

7. Continued Development and Exposure • The unique collaborative nature of the CNL vision set the stage for continued opportunities with faculty and partners. • All invited for continued opportunities with visiting faculty, lectures and student presentations. • Message to all was this curriculum strives to be among the country’s best and will continue to evolve into the future.

8. CNL Curriculum Core and Practice Courses • Epi and Health Promotion • Advanced Health Policy • Role Acquisition and Transition • Advanced Research • Adv. Health Assessment, Patho, Pharm CNL Courses: 521 Clinical Nursing Leadership (4cr) 522 Advanced Research and Informatics (3cr) 523 Quality Outcomes Management 1 (4cr) 524 Quality Outcomes Management 2 (7cr)

9. Practicum NS 523 & 524 Quality Outcomes Management 1&2 Clinical Nurse Leader Specialty Courses NS 521 Clinical Nursing Leadership (4 Cr) NS 522 Advanced Nursing Research And Informatics (3cr) Collaboration/Partnership development Strong Base of Core Studies 21 Credits Epidemiology, Adv. Health Assessment, Adv. Pharmacology Adv. Physiology, Adv. Health Policy, Adv. Research Role Acquisition/Transition Collaboration/Partnership Development 11 credits/376 Clinical Hours With Capstone & Partnership Collaboration CNL Curriculum 39 Credits

10. Incorporating MicrosystemsCORE Courses Microsystems • Role Acquisition and Transition • Epidemiology and Health promotion • Advanced Research • Advanced Health Policy

11. Microsystems into CNL Courses

12. Microsystems into CNL Courses: Revised

13. National Consultants • Especially helpful to have experts look at the proposed courses to operationalize the development of theory and skill needed to diagnose the microsystem, deploy resources and improve outcomes (McKeon, 2009). • Give an objective view of a work that is ‘owned’ by the faculty.

14. Curricular Activities to Support Microsystem Education • Introduce students to the BIG picture and the ‘micro’ picture. • Foundations of improvement science throughout healthcare and other industries. • IOM , IHI, Joint Commission • Kotter: Leading Change • Studer: Hardwiring for Excellence etc. • Nelson et al: Quality by Design

15. Curricular Activities to Support Microsystem Education • Now make it personal…. • Roberts (1995): A Primer on Personal Quality • How does Ben Franklin connect to the CNL? • Prochaska: (1992) In search of how people change: Applications to addictive behavior. • Applicable to all realms of humanness • Goal: Give students a wide foundation of ideas on quality as it applies to themselves, their patients and the world.

16. Staff • Staff focus • Education & • Training • Interdependence • of care team • Leadership • Leadership • Organizational • support Information & Information Technology • Performance • Performance • results • Process • improvement • Patients • Patient Focus • Community & • Market Focus High Performing Clinical Microsystems Quality by Design Nelson et al (2007) p. 21

17. Curricular Activities to Support Microsystem Education • Strong focus on Leadership: • How do you give CNL students an insight into the true leadership that impacts their microsystem? • Take a few minutes to brainstorm

18. Our Approach Visitors to Class • One established with very strong VISION and quality/safety program in place. • “Role of Nursing in Safety and Quality: To Collaborate with the interdisciplinary team to provide timely, safe, effective patient-centered care in an efficient and equitable manner.” Cooley Dickinson Hospital. • One new to the organization but with a proven track record. Onsite Appointments: with formal preparation • Group preparation • Individual coaching from faculty • Role play • formal template

19. Preparation Steps for Individual Interview 1. Preflight - Review your aim & interview guide/key questions 2. Taking Off - Establish purpose with respondent and rapport and appreciation for their participation. 3. Flying - Work your way through the interview guide covering the main topics and exploring promising leads and asking questions to clarify and to probe. 4. Landing - Ask your final question and remind the respondent of how results will be used and thank for participating. 5. Debriefing - Reflect on how the interview went - What might be done to improve the process and the method before conducting the next interview

20. Executive Summaries by Students • Preflight: I had studied everything I could get my hands on regarding the XXXX mission, strategic business plan, nursing strategic goals, nursing model, the newly implemented collaborative governance structure, and the administrative hierarchy of the hospital. Some of the material was very hard to access and I wondered why it wasn’t easier to find. I couldn’t help but feel that this information should be easier for staff nurses to obtain as a working knowledge of the business structure is imperative for practice. MJS

21. Executive Summaries by Students • Debrief. Immediately after finishing, I had a great feeling of accomplishment, having just spent an hour with the CNO of this huge institution. I was a bit disappointed that she didn’t bite more about the CNL role, as a few months ago I was present at a meeting where she referred to the fact that the institution is wrestling with where the CNL will fit into XXXX’s in the future. I wonder if with recent budget cuts, that issue has been tabled. I felt like I gave her plenty of opportunity to explore this with me but for whatever reason, she didn’t pursue this. I do at least feel that she would know that I could serve as a resource for her should she decide at a later date to explore this further. This was validated 5 days later when she emailed me with a link to an article she had read in a nursing administration journal about the role of the CNL. MJS

22. Executive Summaries by Students • LANDING: I soon realized the importance of having done a thorough preflight investigation pertaining to current safety and quality initiatives at the institution. This enabled me to follow the conversation, question appropriately and ask for specifics when needed. MS  • Seeing the institution through the eyes of a leader gave it a new perspective, one that I would not have achieved if not for the interview. The genuine interest and determination exhibited by XXXX in improving quality measures at this facility was both encouraging and invigorating.(MS)

23. Executive Summaries by Students • To my surprise I was welcomed and the interview was informative. It was a nice opportunity to learn about the hospital from the other side. Being a staff nurse I am concerned with my patients, their needs, and outcomes. During that day to day interaction I don’t often stop to think of the whole system. The administrators look at other angles and views. They view the picture through a much different lens. By doing this interview I got a glimpse through that lens for the first time. Getting an inside look at the big picture helped me understand why some of the changes occur. DM

24. Executive Summaries by Students • Preflight I am new to the organization in which I work and never had the opportunity to meet the members of the senior leadership team. ML • Landing . The DPH was at XXXXX when this interview took place and I was touched that she did not reschedule the interview and she gave me her full attention even though we were interrupted on one occasion. Lorrie had come in close to the end of the interview to let her know the exit/recap session was beginning in the board room. XXXX told Lorrie to let them know she would join them when our time was over. Being new to this organization I didn’t have any expectations going into this interview but when I left I had a sense of I made the right decision in deciding to join this team.ML

25. Final Impressions • How could the CNL be successful without this exposure, knowledge and understanding?

26. How do you assess your microsystem? • A clinical microsystem is a combination of a small group who work together on a regular basis to provide care to a subpopulation of patients who receive that care. (Nelson, Batalden, Godfrey 2007). • What approach can students use to learn all as much about the microsystem as possible?

27. 5 P’s Approach • Purpose • Patients • Processes • Professionals • Patterns • Resource- website clinicalmicrosystem.org

28. Mary’s Poster

29. Additional tools • Flow charts, Surveys • Observation experiences: at multiple levels of staff, management or preferably patient. • Fishbone diagram • Quality by Design (2007) Nelson, Batalden & Godfrey • Workbooks: www.clincalmicrosystem.org • Article: Teaching Clinical Nurse Leaders How to Diagnose The Clinical Microsystem. (2009) Leslie McKeon, et al. J of Professional Nursing 25(6)

30. Clinical Microsystem Name Organization Name NS521 Fairfield University School of Nursing Spring 2009 Name of Student and Acknowledgements The 5P assessment highlights and summary: Specific Aim Insert Fishbone : PDSA Measures: Theme: Global Aim: Key Lessons and Insights: Plan-Do-Study-Act (PDSA) PLAN: Insert FLOWCHART Contact Information

31. Key Aspects • Purpose communicated to the microsystem • Interdisciplinary approach • Reliable data that it relevant to the microsystem • A broad perspective of quality and improvement • CNL’s as informed leaders and advocates • Connection to the strategic goals of the institution

32. The Quest for Improvement(NS 523 and 524)Choose a model of improvement

33. Theme for Improvement • Based on your knowledge of the microsystem and the macrosystem- choose a theme for improvement • Include a global aim and a plan to get there. • Starts with a specific aim to build upon. • Include patient/family centered goals. Students complete in Leadership (521) and build on this for Quality Outcomes Management I &II (523 & 524)

34. Improvement Project within the Microsystem (NS 523&524) • The immersion experience- allows CNL student to be clinical change agents • Ambassadors of the new role • Hours spread over 2 semesters and include a clinically based mentor and faculty mentor. • Utilize broad program exposure with CNL specific content

35. Improvement Project within the Microsystem • Reassess or use process to assess a new microsystem. • Choose an improvement theme • Focus on a specific aim • Form a clinical microsystem team

36. Improvement Project within the Microsystem • CNL’s lead the microsystem improvement with inclusion of core aspects: • Patient centeredness • Safety • Sustainability • Interdisciplinary collaboration and input • Knowledge of relevant evidence and data (522)

37. Improvement Project within the Microsystem • CNL directs a clear timeline (NS 523) • Meeting skills utilize time efficiently and establish clear goals(NS 521). • Data to support outcomes is identified and clear on the outset (522).

38. Improvement Project within the Microsystem • Outcomes of improvement are disseminated back within the microsystem (NS 524): • Storyboards • Data walls • Internal sources • External sources • National publications

39. Improvement Project within the Microsystem • Presentations of completed projects, outcomes and story boards. • Patient centered outcomes • Successes and challenges Again, can this be part of a program which connects the work of CNL’s with the national movement of improvement?

40. Spotlight on CNL’s Work: Thus far! Showcase of CNL’s microsystem work to faculty, peers and organizational leaders. Incorporated work with a lecture from a national speaker on quality and safety! Dr. Jon Lloyd, Co-PI of a Robert Wood Johnson Foundation, Plexus Institute grant for “Reducing MRSA Infections in Hospitals Using the Positive Deviance Approach to Organizational Change,” 2006-2007. Six beta sites supported by the grant have achieved dramatic reductions in MRSA infection rates.

41. CNL Program Reaction • Student responses: • This program suits me and the work I do, and hope to do in the hospital. • This degree gives me the academic foundation for many opportunities. • I am still not sure.

42. CNL Program Reaction Healthcare organizations: • When can you start your project? • When do you graduate? • What support do you need?

43. Staff 521,523,524 • Staff focus • Education & • Training • Interdependence • of care team • Leadership 521 • Leadership • Organizational • support Information & Information Technology • Patients ALL • Patient Focus • Community & • Market Focus • Performance 523,524 • Performance • results • Process • improvement Incorporating Clinical Microsystems Into CNL Curriculum NS 522 Nelson et al, Quality By Design p. 21

44. The End Product • The CNL curriculum must prepare nurses with all the skills necessary to lead improvement within the microsystem and beyond. • Nurses must be learned members the “team” that redesigns healthcare for the future.

45. Final Question: Is the CNL curriculum for CNLs or vital for all?