Magnet. I'm gonna be kicking things off today and also help facilitate some of our Q&A at the end of the session. Just a few housekeeping items, too, as well. As a reminder, as it said in the chat, a recording of this webcast will be sent out within two business days, and during our presentation, you can also use the chat feature that should be up in front of you there to share your thoughts and reactions. We'll also have a Q&A box there, in which you can type out any questions you might have during or after the presentation. And we'll answer as many questions as we can at the end of the presentation, and then follow up with you offline on anything we can't cover during the webcast.
All right, so now I'd love to introduce our presenter, Theresa or Terry Anderson. Terry has a very robust and impressive resume with experiences across clinical care, academic education, staff development, advanced practice, nursing leadership, and quality performance improvement. With a background as a Magnet program director for a large hospital system and 19 years as a national consultant, she assists staff in identifying and navigating the economic, political, and philosophical barriers encountered within organizations as practice and culture changes occur. She has worked with over 175 hospitals and has assisted nearly 100 facilities to become Magnet designated. So when it comes to magnet, Terry definitely knows what she's talking about. In addition to her clinical achievements and consulting, Terry is a proven leader in a variety of business settings.
She was their primary founder and serves as Association Manager of the Nebraska Nurses Foundation, was a transformative president of the Nebraska Nurses Association, and has served as the chief nursing officer of two successful technology companies. Terry is also currently chair of the Strategic Planning Subcommittee of the University of Nebraska Medical Center Alumni Association Board. Leveraging these diverse experiences, Terry most recently founded Oculi Data in 2020. Oculi Data is a Nurse-Sensitive Indicator national benchmarking database company. The database is on the ANCC-accepted vendor list and is gaining a lot of traction among Magnet-designated hospitals looking for easy alternatives to their current Nurse-Sensitive Indicator database. All right, so without further ado, Terry, I'm gonna hand things over to you.
All right. Thank you so much, Billy, and, you know, that's a lot of stuff, and when you get... You've been in nursing as long as I have, you have a lot of stuff. It's, you know, I hope it means I know some stuff. I mean, that's what people are here for today. So-
Yes.
I'm very excited. I'd like to get a little bit of an idea of who we've got. We've got a lot of folks that have already joined us, and we're gonna do our first quick polling question. If you are already logged in, and if you wanna go ahead and answer the question here of as to which of these roles you have, that would be very helpful. We'll give that just a couple of minutes. Looks like we're kind of coming to the end of the folks that are able to do that right now. So I'm gonna go ahead and move on so we have plenty of time for our discussion. I'm gonna do a presentation.
As they said, get those questions in there, any comments, good, bad, or otherwise, we'd love to hear them, and we will give us plenty of time at the end for questions. So just kind of going ahead here, I know some of you are still answering, so our numbers might be changing here in just a little bit. But really, truly, we've got a nice mix. We've got a lot of patient experience folks with us. We've got some nursing folks, other support staff, and oh, it looks like we just have one or two, just a small percentage of frontline providers and then some others. So great, diverse group. Excited to see that we've got a lot of folks from different roles because I think this presentation will have different meaning for different people.
So with that, let's go ahead and head on into what we're doing. I think, Billy already introduced me. That's me. I'm a little—I'm smiling a little more today than I was the day we took the picture. But, as Billy said, I've been at this a long, long time, and I've been in a lot of hospitals, a lot of really good hospitals. When a hospital's going for Magnet, those of you that are from nursing or that know what Magnet is, and I'm impressed, I gotta say, with Billy. He and I chatted the other day, and he knows a lot about Magnet. You know, my son is my director of business operations, and, you know, he read the whole Magnet manual the first week he was on board with us.
So I'm pretty impressed with these young guys. They learn how to do Magnet and what it means to nursing pretty fast. So I'm gonna structure the presentation today around five nursing insights, and, you know, these are things that I have seen for years. These are things that I have taught in other ways. Some of this, the first time I ever taught it was at the first tech company I worked for, when the developers came to me and said, "Tell us about how nursing works," and, you know, how do you do that with a bunch of people that were not healthcare, and, you know, they're code developers? It was a challenge, but it made me think about what we do, and I think that's where we are today. So what is a nurse-sensitive indicator?
Just to set the bar for those of you that maybe are at different levels, not direct front line, a nurse-sensitive indicator is a tangible measure in the healthcare industry that specifically reflects the quality and impact of nursing care on patient outcomes. So there can be some confusion around this, but we really have two defining questions: Is it measurable? Now, there's lots of different kinds of data that we measure: nominal, ordinal, interval, for those of you that are, you know, statistic nuts. But, you know, nominal is stuff like yes or no. Did they have a fall with injury? Yes or no? You know, ordinal is information that we rank. Patient experience is that kind of a thing. You know, strongly agree, agree, you know, always. Those, they're ranked, but they don't have a definite equal division between any of them.
So then what, when you look at interval data, that's stuff like length of stay is in actual measures, days, and days have a specific interval, just like height and weight. So there's lots of different kinds of ways to measure nurse-sensitive indicators, and there's lots of different topics. Some of them are patient experience, some of them are patient safety. So I think understanding how does nursing impact that? I think that's our first, our first lesson really today. So let's move on to my nursing insight number two. To fully understand NSIs, and that's what we'll call them for the rest of the day here, NSIs, and we use that a lot at Oculi. We must first understand the business of nursing care.
So I'm gonna take you down a different kind of journey to think about nursing care, and I hope you like it because it's really has meaning to me. So the business of nursing care, what does a nurse really do? I know we've got some nurse personnel on this call looking at our quick little poll. We've got some patient experience folks, and, you know, I'm sure some of them are... Some of you are out talking to patients, you're doing rounding, you're doing shadowing, the things that we always do, executive leaders as well, some other support department staff, perhaps quality folks. But, you know, how many of you have had the chance, if you're not a nurse, to shadow a nurse? How many of you really look at what a nurse does all day, every day during their shift?
So this is just to kind of put the patient in the middle. You've got a nurse, and I'm gonna talk mostly about inpatient care, because inpatient care is really different from ambulatory. That would be another whole topic, because obviously, safety and patient experience are important in ambulatory as well. But let's just look at the kinds of things typical nurse does for a patient. Obviously, there's seldom a patient that's in the hospital that isn't taking some kind of medication. I mean, rarely you might have somebody, but for the most part, they've got something they took at home, and they came in, they took pain meds. There's lab tests. They may have to go down to imaging, X-ray. They may have to, you know, somebody may have to come up to them and do a test.
Ambulation, a lot of our patients, we can't let them go home till we know they can get up and walk to the bathroom on their own or, or walk so far down the, down the hall and back, right? So I think that's an, you know, another thing that takes nurse- nurses or nursing time. Family and visitors, how much is that gonna impact? Do those phone calls come directly to the nurse? You know, is there... Is she, he or she taking those calls and having to explain things to the patient? Do they have visitors show up? They need a chair. I mean, there's all kinds of things that happen. Treatments, you know, do we have dressing changes? Do we have to do breathing treatments? Do we have to help respiratory with that? Education, there's always that discharge piece.
What do they need to know when they get home? When's their next appointment? How do you use your crutches? There's just so much, and I haven't even mentioned charting. You know, documentation is so huge, it takes up so much of a nurse's time, and all of this is happening for this patient. So I mean, think about the workflow of a nurse to make all this happen. You know, everything's rolling along pretty good, right? So what happens if the nurse is taking care of five patients? So she's got her first patient, all is well. Well, then, you know, she's been assigned another one at the beginning of the day, and, you know, maybe she works ICU, and she's only gonna get two. That's pretty manageable.
Maybe she's in a step-down unit, and she's gonna get another one, or it's really busy, and we've got overflow, and they're coming in. Here's a fourth, here's a fifth. Look at the chaos that's going on here. We're assuming that all these little things and all this workflow for all these different patients is something that a nurse can just handle, right? And look at that. If it's all going well, it goes really well. But I'm gonna ask you a thought-provoking question here: How many of you have mastered the time management skills to manage these overlapping workflows? I mean, really, in the job that you do, do you... Maybe you switch gears a lot during the day, maybe you go from one topic to another quite a bit, but how many of you could concurrently manage all of this going on at one time?
How many of you, at the same time, that you're trying to manage this workload, how many of you can also maintain a high level of expertise, empathy, inclusion, and caring for every single patient and family member when this is happening? You know, maybe some of you have been servers in a really busy restaurant. You know, maybe you've worked at another job where you're managing customer service concurrently for lots of people. This is a tall, tall task, and everything that this nurse does, the business of nursing, is going to impact patient safety, and it's gonna impact patient satisfaction. But really, does the nurse do it alone? No! You know, I like to think about the nursing on... You know, I'm from Nebraska.
I don't know where many of you are calling in from, lots of other places, but, you know, here in Nebraska, you know, we're the frontier, we're the prairie. And, you know, there are still people I work with on the East Coast that think we still have, you know, covered wagons and cornfields everywhere. Not quite how it goes, right? Billy was raised in Nebraska. He's a-
Yes. Yeah.
He doesn't live here yet right now, but you know, I used to tell people it's kind of like a wagon wheel story. You know, the nursing's the hub of the wheel, and then all these other departments, these clinical folks that touch... And I've just got a few here, because I know there's case management, and there's so many more, but just for the sake of conversation here, think about each of these as the spoke of the wheel on a covered wagon. And, you know, the prairie, you know, the pioneers could have made it halfway across Nebraska, and, you know, you could lose a spoke here and there, right? You know, the wheel will keep going. But the nurse was the hub that held that on the wagon. If you lose too many of those spokes, you're done.
Well, it's the same way here. Nursing in business or nursing care, we have independent tasks, those of you that are nurses on the call, right? Things you can do by yourself. You can do nursing diagnosis, and you can do teaching, and comforting, and all the things that we do.... There's also those tasks, though, that are dependent. We have to depend on somebody else's actions to do them or permission to do them. Then there's the collaborative tasks that we have to do together, things like interprofessional rounding or treatments that we do at the same time or Code Blue, you know, cardiac arrest, those kinds of things, we all do it together.
These departments are extremely important because they need to be doing what they need to be doing for the nurse at this point as well, to make sure that, you know, are we really doing what it is that we say we're going to do here? At this point, I think we've got another polling question I wanna go to. Oh, no, I think that's the next slide. Let's move on to the next slide. A couple more. A lot of things can negatively impact this business, right? One missing medication. Let's think back to this chaos a minute ago, right? Oh, well, it's not gonna let me. Never mind. I don't wanna have to go through that five times. Forget it.
So, but you'll think back about the, you know, 1 missing medication for one of those five patients and, you know, the nurse went in to get that. Maybe it's in a med machine, you know, maybe it's a special order, whatever it is, and uh-oh, it isn't there. So now I've got other meds, I've got other patients, and, you know, it's gonna get in the way. Same thing, what if lab doesn't come when they're supposed to come, and then the doctor needs the lab result? Or what if that specimen is lost in the lab, or what if it clots? What if I go to get linen, and there's not enough clean linen left? What if the family calls, and that call comes right to me at the same time I'm getting somebody up to the bathroom?
This is the business of nursing. The business of nursing is chaotic enough when everything is perfect and going well. But all it takes is one or two of these for one or two or more patients, and you have got chaos that is multiplied times 10. So this is the business of nursing, and all of these things can negatively impact the business. So when we think about the business of nursing and nurse-sensitive indicators and this collaboration and these tasks that everybody does, providing support to frontline nurses is the essence of all outcomes. It really is the essence of all of them. And, you know, this, I can say this about nursing, you know, I'm kind of nurse-centric, and I'm biased. I've been a nurse 43 years. But does this also similarly apply to the business of respiratory therapy, ha- perhaps?
Not quite the same as nursing because you don't have that 24/7 accountability or that, you know, coordination piece for this patient, but it impacts all clinicians at the frontline. So quality measures suffer if the nurse can't efficiently conduct nurse business. Patient experience suffers if the nurse can't efficiently conduct nurse business. And then, ultimately, nurse engagement deteriorates from lack of support or feelings of lack of support, and then that results in turnover, and that impacts the outcomes even more. I call it the death spiral of staffing. When you get turnover started, then the people that remain, loyal as they are, they start to get dissatisfied, and that shows through to patients. Those of you in the PX space, you know it. You see it every single day, don't you? So I think this is where we have our next polling question.
So did you think about nursing care this way before today? Let's take some time and see who can, who can tell me that. I'm not seeing any responses. Do we have that polling question open and ready to roll? Oh, here it come. Here they come.
It looks like they're coming now.
I'm just in a hurry. High energy. This is new software for me, everyone, so I haven't worked with this platform before, so it's, it's been pretty fun to learn. Okay, I'm gonna go ahead... Oh, we're rolling. Everybody's answering this one. This is great. We've got a good, good majority coming in. I'll give it one more minute here. Okay, I'm gonna go ahead and see what our results are so far. So many of you, the majority of you, thought about nursing care this way before today. That's exciting! I didn't expect that because there's a percentage, almost a third here, based on these early results. Almost a third of you, though, never thought of it this way before.
So when I look at our demographic of who we've got attending, you know, maybe we're enlightening some folks here that maybe aren't in that clinical arena. Hope so. That's part of why we're here, right? Let's go. I've got another question for you right now. So will you think about it differently after today? This might be a moot point for those of you who already thought about it that way. Okay, looks like people are still coming in here. All right. When we get to a little over half, I'll go ahead and see where we're at. It looks like we're about there. Okay. Whoa, look at that! We've got a lot of people that are gonna think about it differently, even if they had thought about it before. So, hey, we've had a success, success number one.
You know-
Yes.
I'm excited about that. So let's go ahead and head into our next topic here. Nursing insight number three: nursing business disruption is inversely related to patient safety and experience excellence. I think everybody can probably understand and agree with that pretty easily. So here you go. If we can decrease this disruption to nursing business, and we could even call that clinical business, if that's, you know, if you're broader, you wanna include that whole clinical team, because we are collaborative, absolutely, 100%.
If that happens, if we decrease that disruption, logically, the patient safety and the patient experience should go up, and that's what I've seen in all my years of practice with all the dozens, if not hundreds of hospitals that I've been in, people I've talked to in the numerous workshops I taught when, you know, the 12 years I worked for ANA, ANCC, and taught people around the country, and literally from other countries. But, you know, that assumption holds true only if these other departments are doing what they need to do or are supported to do what they need to do. Think about it. You know, yes, we're decreasing the disruption of nursing, and the patient experience will go up, but there's only so much nursing can handle.
You know, it really is an impact if any of these things is changed or different, and we know that. You know, that's not rocket science. That's not something that we're gonna need to spend a lot of time on here. But from here, let's dig in a little bit more about these concepts. I'm gonna start with patient experience. Everybody in the patient experience group, and there's a lot of you here, that when we did the little poll, that, you know, you're from the patient experience department. Some of you may not recognize NPS. You know, that's...
It's been drilled into my head for numerous years, having worked as the CNO for a digital rounding company for six years and having launched hourly rounding and leader rounding at our system years ago, you know, 28 units plus five units in a research study concurrently across, you know, five facilities. It's one of my worst experiences, challenging for sure, back in the day. But the Net Promoter Score, that's typically, you know, measured on a scale of 0 to 10, how likely are you to recommend this product or company? That really is a gold standard, and I would venture to guess that, especially at the executive level, many folks will have their annual performance evaluation, will have an element of NPS in there.
There's obviously some other metrics for the success of the nursing strategic or the organization strategic plan related to the NPS. But now, that's kind of a high-level concept, and everybody knows that there are KPIs or key performance indicators that contribute to that NPS score. How likely are you to recommend? You know, that's that goes beyond, "I'm satisfied. I'm committed enough that I would tell a friend to come here, or a family member," right? If we look on the left side, it's the HCAHPS dimensions. And the HCAHPS dimensions, I chose these. There's probably other measurements out there. You know, I know NRC has measurements. They have questions. Everybody's got custom questions and, you know, whatever, but we know these are linked to reimbursement through the federal government. These domains are very important.
If you look at that, you can probably see, obviously, nursing has an impact on all of these, but none of them really directly relate to nursing except the top one, communication with nurses, and I think that that's an important thing to remember. Nurses can manage up others, if you use that terminology. In the same way, we expect our other colleagues to hopefully manage up nursing and to help to support a nurse who's super busy or whatever is going on. Quietness is a big deal. You know, a lot of times, nurses, like, you know, if things get quiet, they get to chatting with each other, and things can get noisy in the middle of the night. I wanna take us to the other side for just a minute. Magnet categories are where I live.
My husband jokes with me that I, you know, talk Magnet in my sleep, but this current 2023 manual is my sixth manual that I have worked with. My life's work has been nothing but Magnet since 2002 when I was diagnosed with a severe latex allergy and had to leave the bedside. And so it's really what I do. It's why I founded Oculi Data, so there would be an alternative for nurse-sensitive indicator benchmarking and not just the same one we've all had for 30, almost 30 years. But these nine categories, for those that aren't as familiar with Magnet, and, and hopefully most of you are, but you choose four of the nine, and then you have a series of crosswalk questions that the vendor has crosswalked with the ANCC staff that they feel meet the expectations, and it's pretty flexible.
At the unit level, you can choose... You know, you choose the categories, but you can choose the question within that category, and you can choose the benchmark comparison within that category. So it gives you a lot of flexibility to meet patient experience from a nursing perspective. But where I see problems is sometimes with some vendors, you have to purchase certain questions, and some organizations don't purchase them, and it limits the choices that you have to try to meet that Magnet expectation of outperforming five out of eight quarters of data with the national comparative benchmark mean or median to, you know, in a majority of your areas, 51% or higher. So that's really. Magnet's drilled that down, and they've, they're really looking at nurse-sensitive.
You know, at this point, you know, Billy and I talked a little bit beforehand, and Billy, why don't you tell us a little bit about kind of what you're seeing at NRC relative to Magnet and trends and whatever?
Yeah. So one thing I wanted to connect to is just the HCAHPS, the dimensions that you were speaking of. So as many people are probably already familiar with on the call, HCAHPS is making some changes in 2025 to the survey itself. The most impactful changes in terms of our Magnet partners is gonna be that the HCAHPS project team is gonna actually be removing five questions and adding eight questions. So just on that standard question set. So we're gonna be removing five and adding eight. Four of the five questions that are being removed are Magnet questions, aligned to Magnet categories, and so we'll continue to work closely with ANCC on those eight new questions to see what sort of Magnet categories we'll see reflected on those.
But that will be a little bit of a change for some of our partners that are maybe in their right now in their eight-quarter data collection window or will be in 2025, because they will have some questions that go away. We're working closely with ANCC, as I said, to make sure that we can crosswalk anything there for you, then with the new questions, that there's it's an easy submission process still. But yeah, that will be one of the bigger changes, just because we've been very used to the questions that are on the HCAHPS survey from a Magnet lens for years.
Yeah.
This really is the biggest change we've seen since the HCAHPS survey started to be fielded. So, wanted to mention that piece, and then the other part or component relating back to patient experience that I think we noticed when we work with many of our partners kind of relates back to that NPS sort of key metric tracking that you were talking about, Terry. Where, organization-wide or at the executive level, that NPS or those kind of overall rate sorts of questions are what are tracked and shared really transparently across the organization. But what we see sometimes is a disconnect for nurse leaders and nursing staff, is that-
Mm
... there's not as much transparency around the specific nurse questions that align with the Magnet categories. So maybe they're doing really well at an overall vantage point, but maybe there's some opportunity to grow or improve in some of those nurse questions that are aligned to those Magnet categories. And there's not always transparency with sharing that data across nurse leaders or nurse staff. So I know with some of our partners, what they've done to change that is start to make sure that we're also transparently sharing that Magnet information or those Magnet questions that we're tracking with nurse leaders and nursing staff as well.
And then they get to feel like they have a little bit more of a frontline preview of what that component really will look like when it comes to their Magnet submission. And they can either be dialed in to help focus on improvement, because they know that the scores maybe have opportunity for doing better, or they can give themselves a pat on the back and congratulate themselves as a team because they see that they're already doing well, and there's not gonna be a problem when it comes to submission time for patient experience. So yeah, just that overall transparency and making sure that we're using those Magnet questions to drive improvement in the same way that we're using that overall rate question to drive improvement.
So absolutely. What did I tell you about his knowledge of Magnet, you guys? I mean, I'm impressed with this.
Thank you.
I'm totally impressed. But I think what he leads us to on this also is, those of us that are already Magnet or are on the journey, the, the appraisers are drilling down on this stuff. They're expecting the staff at the unit level to be able to speak to patient safety metrics and patient experience metrics. They're, you know, they don't have to know exactly, you know, what percentage ranking we are this month, that kind of thing, but they do need to know if they're trending up and down. And if they haven't seen that data until all of a sudden, two months before the site visit, all of a sudden, these new graphs start showing up, or we start talking about it in huddle, they're kind of going: "Where did this stuff come from?" You know.
I think there's a really great piece in that. I'm gonna go ahead and go on. I have a real belief, this is my nursing insight number four, you know, I believe that relationships are the core element of positive patient experiences. The core element is our relationships. Around that end, as I mentioned, I was the chief nursing officer of a rounding company for six years. I just left that position back in 2023 because the database company was getting busy, and my Magnet consulting is very busy. One of the things that I worked with there was what we call the relationship wheel.
The relationship wheel was actually developed by Ray Page, who's the CEO and co-founder of Noble, where I worked, and they've given me permission to use this and talk about the work that we built here. You know, when you think about patient experience and relationships, one size does not fit all. Each care setting is unique and may require a very unique solution. I learned that when we were going in to implement rounding in these other places. It was important because, you know, we all understand about standard work. In fact, standard work is one of the S's on here when we think about that. But standard work has to be flexible enough that you can adapt it to an OB population versus a cancer population, versus a busy ED, versus OR.
You know, there's different things that we have to do. So I'm gonna just walk you through a few of these elements of the relationship wheel, because this is the formula, if you will. Relationships matter, and, you know, there are some of us that it's... You know, Billy and I, as you can already tell, we're pretty outgoing and pretty friendly people. You know, I talk to people on airplanes, in airports. I embarrass my husband often when we travel because I'm just that kind of a person. I can form a relationship very easily. But that's not a natural thing for everyone, especially a novice, who maybe is still learning, and they're not comfortable, they don't have that confidence. So we're gonna walk through.
For some people, building a relationship with patients, and they're gonna wanna hug them when they go home, like my mom always did, and, you know, they're gonna want all that, it's easy. But for other people, you gotta have a process to help them, and that's what this relationships model really does. So the relationship wheel, and you can read, I'm not gonna read you all these realistic expectations, executive support, buy-in, accountable metrics, et cetera. I wanna drill in on three of these right now. Executive support, if you don't have the top-level understanding what it is that you need, whether it's a patient experience, initiative, new, that's moving out, anything like, with, you know, improving the perceptions of the NPS score, whether it's that or any other process, you've really gotta have executive res-...
support, and I see that, you know, inherently I see it. Sometimes people say, "Oh, you know, we have an executive sponsor." Well, that executive sponsor signs off at the beginning, and you don't hear from them again, right? I think it's ongoing executive support, which means real time. Stay involved, know what's going on, and be ready to help the initiative move forward when things go off the rails a little. Leader buy-in, you know, we talk about buy-in, and it's a buzzword somewhat, but I think it really comes back down to unit level. Think back to the business of nursing, the business of clinician or clinical care. It's at the bedside, and it's... You've gotta have those leaders have gotta believe in those initiatives that you're doing.
The last one, I mean, these other things are important, but the last one, ongoing recognition. Now, you know, we had a lot, the pandemic did a lot. You know, probably it gave us this platform we're using today, 'cause we didn't do a lot of this, as much of this stuff, right, before the pandemic shut down the world. But when you think about it, nurses had a lot of recognition during that time. People were standing outside at 7:00 P.M., we're cheering them on, signs were outside, all of that. But this is a hard business. Even though we're past the pandemic and past all those surges, this is extremely hard.
Being a nurse and managing that chaotic workflow that we talked about, and trying to be empathetic, and supportive, and caring, and think about, be aware of the patient experience, it takes a lot. Nurses need real-time accountable validation that they're valued and that they absolutely, you know, the people want to recognize that they're here and what they're doing. That's true of any clinician. All of our clinicians were in a really hard spot during COVID, and that job is hard all the time. I mean, being honest, you know, the faint of heart do not stay in healthcare very long. You can't get into it for the hours or the money. You have to really get into it for the caring, and you have to have a commitment to that as your life's work.
So let's move to the second half of the wheel. I already mentioned standard work. I mentioned standard work and how it can't be the same for everyone, but I think the other thing I wanna talk about on this one, two of them, notable moments and hospitality mindset. Notable moments matter. They really do, and it's the little things sometimes in the right moment that make a difference. You know, when... And I have adult children, you know. I mentioned my son, he works for me, but, you know, when my daughter was a sophomore in high school, she had an emergency appendectomy. At 7:30 A.M., you know, we were waking up at home, and by 9:00 A.M., you know, the nurse recognized we needed something to happen.
By 9:00 A.M., they were prepping her for emergency surgery, and, you know, 9:30 A.M., 9:45 A.M., they're taking her back. Well, I've been an L and D nurse for 20 years. I used to be the one with the blue hat and the booties that would say, "We're gonna take good care of your patient, you know, your loved one, and, and, you know, we'll keep you, keep you in, in touch with what's happening." Well, they went through those doors, and I was on the outside, and it was horrible! I mean, it... I was just like the fear of God. My husband was seeing patients. He's, you know, couldn't get out of the dental clinic, and I'm there going, "What is...
What's going on?" But the fact that they understood how stressed I was, that they knew I'd had a sibling that died in surgery because of the history we gave them, they came out, and they talked to me. That was a touch point. That was a notable moment, and those things are more important than the wow experiences, and the scripting, and the AIDET, and all the stuff that we tell people to do for patient experience. We have to connect on that direct level. The other thought is hospitality mindset. Some of us are not warm and fuzzy all the time. Some of us are just introverts maybe. We are just direct. I have a good friend who grew up the youngest of, with five older brothers, and let me tell you, she's the most direct female I have ever worked with in my life ...
because she learned in a very masculine, dominant household that she better stick up for herself, or she might not even eat on a weekly basis. So absolutely, we have to help people practice hospitality. We have to help them to feel comfortable and confident in what they do. So relationships matter, and I think some of these things will help you hardwire whatever you're implementing, but it really, really will help with keeping the team together and moving forward to make your initiatives successful. Let's switch gears to patient safety, another one of my favorites. I grabbed a couple logos. Leapfrog's one that's out there. You know, there's the U.S. News & World Report Top 100. There's a lot of other logos. I just grabbed one, and of course, Magnet, being Magnet-recognized, that's another patient safety, patient excellence, you know, measurement.
But, you know, just like patient experience, we've got our, our gold standards, too. Some of you may recognize, the Joint Commission puts out every year their national patient safety goals. These happen to be the goals for 2024. Most of you, you know, we're already five months into this, so I'm sure you're already working on it. These are high level, again, sort of when you look, you know, look HCAHPS versus the Magnet categories. Now we're looking at, at national patient safety goals and the Joint Commission. If you look at these things, these are all things that our patients expect us to do, right? They expect us to identify the right person before they do things to us, or the right limb, or the right eye, or the right, you know, whatever. They expect us to give them medication safely.
They expect us not to make mistakes in surgery. This is minimal safety standards. Those of you that are here that know Magnet and know it well, when we look at the Magnet indicators, Magnet's drilled down on, again, nurse-sensitive. This is what Oculi does best. You know, we know that falls with injury and skin care, you know, Hospital-Acquired Pressure Injury, stage two, for those of you that don't know, means the skin is broken. I mean, so we've got a real, real injury here. You know, UTIs, other associated infections, you know, device-related safety issues, assaults on nursing personnel, which have gone up through the roof since COVID. You know, there's a lot of attention on workplace violence. I'm sure all of you are working on it, but it's, it's sort of the same thing.
You know, there's Joint Commission, the DNV, that's the minimum safety, keep us safe. Magnet is high-end, and, you know what? I just had a conversation. I sit on that alumni board, and we had our meeting last night, and we were reviewing survey data from all of the alumni that completed the survey about the UNMC, the Nebraska Medical Center, and we had some of these numbers. And, you know, one of the doctors on the group, he said, "You know, you know, this percentage doesn't look so good, but how do we compare to other universities? Are they also struggling with engaging their alumni?" It's the same thing here!
You know, you could decrease from 10 falls a month to 5 falls a month, thinking, "Man, we've improved by 50%," but if the rest of the countries only having 2 a month, you're out of the ballpark. You are going to strike out every time. So it's really, really important that we think about this in a different way. So let's move on to just another nursing insight here. This is the last one. Clinical practice and staffing are key elements that put patient safety and experience at risk. I know some of you are going, "Duh, Terry, of course, that's not rocket science." But I think related to these, I wanna talk about two specific things, and those two things are clinical practice and, and the environment, and a couple things.
So clinical practice, those of you that are clinicians, whether this is nursing or other clinical-based things, it really is. You know, these are the things, evidence-based practice. Are we doing what the research says works? Do we have open dialogue? A lot of places are using Just Culture. You know, speak up if you see something wrong. It works in the airline industry. It should work in healthcare. Patients obviously should be our priority. That's our business. That's who we serve, and these other things. But I wanna talk about empowering nurses, and this, again, would apply to empowering other clinicians. But when I taught workshops for 12 years for ANA, ANCC, nationally, all over, 200-300 people, sometimes in a big lecture hall, we taught Structural Empowerment, and you guys know Structural Empowerment that are Magnet folks.
But there's three elements of structural empowerment that we taught, and that is information, resources, and support, and that's the work of Rosabeth Moss Kanter, and she was a business researcher back in the 1970s. You know, I was born then. You know, that's how old I am. Some of you probably weren't even around. But she studied that in business, and then years later, Heather Laschinger is a nursing researcher, and she applied that same stuff to nursing and found it still to be important. Everybody wants the information they need to be able to do their job.
You know, we mentioned a few minutes ago a little bit about, you know, how if, if the census is up, or if the EVS worker is called out, or if respiratory's pulling your usual respiratory therapist, give me a heads-up on that first, because then I can be ready instead of calling the wrong number and not getting anybody to come do my ventilator settings. Resources, resources, resources, we've talked about that, those departments for sure. Support. How do I define support? Billy, how would you define support, right? People look at support differently. When I was a nurse manager, nurse director, you know, support meant, "You're gonna give me what I want. I get the Christmas hours," or, you know, "I'm being supported." Everybody defines it differently, just like everybody defines recognition differently. So I think that's important for us to think about.
If you're going to empower frontline caregivers, give them these three things. It's, it's all we all want. I mean, this works in every relationship, you know, in your, in your life: information, resources, and support, most things will go well. So I wanna talk, this is my last slide, and then just a couple things to tell you a little bit about Oculi. But I wanna talk about staffing because patient safety and nursing staffing go hand in hand, or clinical staffing. And there's these eight elements, and I won't spend too much time on them because we are getting close on the questions. I don't... I wanna give us time. But physical layout, you know, I went to a hospital that had a 100-bed medical surgery unit, and they were so excited about this state-of-the-art nursing hub in the middle.
Some of these nurses were putting on 15, 20 miles on their pedometers because everything was in the hub, and if they were assigned to that patient at the end, that was, I mean, all they did was walk back and forth to get everything. Competence. Novices take longer to do stuff than experts. Novices ask more questions than of the experts, so that really impacts everybody's efficiency in nursing business. Skill mix. "Sorry, we have to pull your nursing assistant or your tech over to the other floor to watch a suicidal or confused patient. That's a must. We'll just send you another nurse." Well, that's a body, but nurses don't do the same thing as techs. Nurses don't like to do the same thing as techs sometimes, and that doesn't always work, or vice versa. Acuity.
When the ED's backing up, we absolutely, we gotta get patients out of here. The first bed opens up, you might admit a patient that, that is borderline acceptable for a medical unit. Maybe should've been in a step-down, but we don't have another bed. That puts stress on staffing. Census. A nurse can only take care of so many patients. I mean, you look at that chaotic little picture we had earlier. How many more of those little workflows do you think we can add in before something gives? Resources, not gonna belabor that point again. Collaboration. You know, I used to tell a story: How long does it take to make an occupied bed, a nurse, by themselves? Quite a while. You know how fast two or three clinicians can make an occupied bed by collaborating? They just turn that patient-...
Wipe on the sheets, turn the patient, wipe on the sheets, put up the covers, and they're done. You know, that's the difference, and I've mentioned it before, the voice of nursing, and that voice is sometimes pretty subtle. You know, those of you that are in the executive level, I know we've got some of you here, you know, rounding is great, shadowing is better because you—what if you happen to come by when they're with a patient? What if you're a stranger, and they don't know who you are? I had the opportunity back in 2008, 16 years ago, I had the chance to visit with a, at a children's hospital in the Southeast, and they had me there for an assessment.
We went to dinner, and Keith was the CEO of this children's hospital, and we were, you know, having dinner, and he said, "You know what I learned?" He said, "They may be right." And I said, "Keith, what do you mean?" He said, "If they're talking about something, and it's rising to a certain level, don't discount it and say, 'Oh, the numbers say you've got enough staff or the numbers say X.' They may be right." And what he taught me is to listen to that. I still have that little yellow card that he pulled out of his wallet. He meant it. He had worked as an orderly in high school and college. He knew what frontline care was.
I want all of us to think about what we do in healthcare and in nursing, and clinicians and what we do, and I was so excited that a big percentage of you said you would think differently about the business of nursing, and I hope that some of these tactics I've given you will be very helpful. So, Oculi Data is an NSI benchmarking company. I think we can stop right here. Just that's our webpage. You can contact us through that and learn a little more about us if you're interested. I wanna save time for questions. Let's go ahead.
Yeah, okay. Thank you so much, Terry. So yeah, the first question it looks like we had come in is, "If we're already facing that death spiral of staffing that you talked about, what are some ways that health systems can look to stop that from happening if it's already started or to even maybe be preemptive?
Well, yeah, and it is the death spiral. I agree with you. One of the things that we hate... a word we hate to hear, especially at the upper echelons, is agency. And the other one we hate to hear, you know, contract staff. I think the best way, once it starts, you have to do everything you can possibly do to listen, recognize, and support the people who are still there because they begin to get discouraged. At the beginning, the first couple people leave, and it's not a big deal, and then two more people leave, and you know, they're not all leaving 'cause it's a bad thing. It's not because your environment's bad. Maybe there's four people out on maternity leave at the same time. That happened to me in L&D.
You know, I've gotta keep the nurses, you know, at the bedside somehow there, but, you know, that's the life cycle of a new nurse. You know, they're young, coming out of college, and they meet people. They may have significant others, and off you go. But support, that initial support, and you may have to bring in agency. You may have to pay up front to really get a satisfaction. I believe in internal resource pools, internal agencies, if you will. A lot of people have gone to that after COVID. I've got a lot of my Magnet clients that they have their own resource pools across large systems, and they pay them like they would an agency person because it's valuable to them to say, "Well, we're gonna pay an outsider the same thing.
Why not pay one of our seasoned staff to be that same kind of person?" Some of them actually plug them in for 13-week stints or five weeks or whatever, to cover a specific opening that they know they're gonna have. The second thing I would recommend is over hire. Executives hate to hear that too. But it takes... From the minute a nurse says, "You know, we're leaving, my husband or spouse, wife, is being relocated, my significant other, we're being relocated," sometimes they don't let them even go start to hire till the day they go, they leave. It's 30 days. They have to give notice at their other hospital if you bring over an experienced nurse. It's 16 weeks sometimes to get a new grad oriented.
Hire, over hire, and create your own resource pool so you can cover that stuff and over hire to the pool. That's what I recommend, and that's what I see working.
Yep. Thanks, Terry. Another question we had come in is, "What are your thoughts on the role of a librarian within the team?" This person-
Oh
... sits on a nursing research council, and so just having that librarian role in the nurse rounding workflow.
You know, that, that's a question that in 19 years of doing this nationally, I've never heard that one before. You know, honestly, that's very interesting. I think that a librarian to support nursing in developing their Evidence-Based Practice, I have not had a librarian to sit in. Some of it depends on whether you have evidence-based resources, clinical support within your EMR. You know, some of those things you can get. I won't mention company names, but you know, you can click on a button, and it'll bring up policies and procedures and Evidence-Based Practice bundles and those things. I think some of it's about the access. Obviously, teaching hospitals, academic medical centers, cutting-edge, innovative cancer therapies or innovative surgical, you need somebody that can help you look at the evidence.
If the goal here is for me to say, "Yes, the speaker on the call said you should have your librarian" - I think the librarian should 100% be on your research and evidence-based practice committee, and I think that librarians should, if not be part of a clinical team, shadow and understand the work of clinicians. That way, they'll be able to do real searches that make a difference if you're looking for evidence.
Yeah.
I don't know where you're from-
Well, we got one-
I love the idea.
... one question you've ever had. Yeah.
Yeah, that's great.
So, yes, we got another question here: "So my current executive team believes improving the patient experience is playing the game. They believe other facilities are gaming the HCAHPS system somehow. Have you been able to positively influence executive teams that feel this way regarding surveys and patient experience, to try to help them understand that it really... like, the bigger picture?
... yes, too, people are gaming. Yes, some people don't get it, and I can't measure how much impact I've had, but I can tell you from experience, pre and post, with executives that I've challenged them, if you will. Executive rounding has a place. You know, my friends at Noble would tell me that, for sure. Executive rounding has a place. Leader rounding has a place. I'm a firm believer in shadowing. You know, when an executive gets out of his office, his or her office, and they get out there, and they literally spend time, you know, if your executive team doesn't believe that certain things are impacting patient experience and HCAHPS scores, then they need to walk in the shoes of that nurse or that respiratory therapist or whomever, for a minimum of four hours.
You can't walk through and you have a quick chat at the nurse station. You can change the culture of the executive suite if the executive suite understands clinical. Now, we have a lot of nurses that are moving into executive roles now. I see that all over the place. I see a lot of folks that have been nurses and worked their way up, and now they're the CEO. They get it, but it's also, you start to forget 'cause you get busy.
Yeah.
That's what I would say is, get them out there so they can really hear, and they may be right. They need to listen. They may be right.
Kind of a similar question here. So, this person feels like they have the information, but the resources and support for our nurses are lacking. "What do you find are the most effective ways to get buy-in from leadership, providing the resources and support we need? I'd love if we overhired, but I don't know how to convince the decision makers." I think a lot of this really relates to what you just answered, probably, Terry, with the rounding and getting those key decision makers on the floor so that they actually are getting a good grasp of the culture and see what it's like at the bedside.
I would agree with you, Billy. I think that it is difficult, what information, you know... How do we all feel if we're getting the same canned message every time? "Census is high today. Do your best. We love you. Thank you to the clinical team for pitching in." You know, you can hear that only so many times, and you're like, "You know, you can take your clinical support and put it where the sun doesn't shine," right? So I mean, you've got to back some of this up. I can tell you another quick story. 16, 18 years ago, I start...
It was 2008, 2010, somewhere around there, 16, 18 years ago, whatever, and I went to visit two hospitals 30 miles apart in a huge medical center, I mean, city, huge metropolitan area, both owned by the same hospital corporation. And one of them, the staffing was at the 10th to 15th decile. And the first one I went to: "We don't have enough staff, we don't have enough staff, we don't have enough staff, we don't have enough staff," yada, yada, yada. Everybody talked about it. The clinical supervisors talked about it. The chief nurse even said, "We don't have enough staff. We don't have enough staff." But then the numbers, they're like, "Well, but that's the numbers. Everybody's got them." I'm like, "This system is really screwed up because they're not staffing 15%." You know, go back to my, you know, census.
It doesn't work. You gotta have more resources. And I was thinking, "How am I gonna tell the exec team at the end of the day?" So I got to the end of that one, then had a day in between, went across town, went to the other hospital, same exact staffing model, same exact model, same 10%-15% nursing, you know, percentile, you know, by the hour, by the hours, by the rank. Those nurses are like: "How's your staffing? I was expecting terrible." "Oh, God, we have great staffing. We have fabulous staffing!
Mm.
I went, "What the heck is going on here?" As my little five-year-old niece would say, "What the stupid heck, Aunt Terry?" You know, but it was the resources around them. They didn't have to go look for a medication. They didn't have... You know, they always had housekeeping staff. You know, they always had, you know, lab did what lab could do and freed them up. They didn't have very many nurses, but man, oh, man, those nurses felt like they were ruling the roost, and they were. And they had really strong shared governance. So it does work. Surround them, start one department at a time, and I have found that. Where do you start? What's the biggest pain point? Do we make sure EVS is staffed all the time? Is it a pharmacy issue? Fix one at a time.
Get that one... Use your relationship wheel. Get that new process in there, and really make sure you've got buy-in at all levels, et cetera. Then you go to the next one. You give yourself two to three years doing that, six months at a time, you're gonna have one of the best cultures, clinical cultures in the country. I've seen it happen, and I've advised it to people. That's the fun part of being about a consultant.
Yes.
You get to steal from one to another.
Yes, and see if it actually works, 'cause you have-
Yeah
... to continue those relationships, yeah.
Exactly.
All right, I think we've got time for one more, Terry. So one other question we had was: would a nurse scientist have a role as a nursing leader to help effect clinical change?
A nurse scientist, meaning a research scientist, I'm assuming, a nurse scientist, and the answer to that is absolutely yes. We actually, Oculi, we have a 14-hospital system that works for, with us, and actually, their nursing scientist is actually the chair of their nursing quality committee at the system level. And she, her expertise as a nurse scientist with both evidence-based practice and research has enabled us, her generosity in giving information to us as a newer company, we haven't been around, you know, since 1998, like others I could mention. But, you know, her, her knowledge and her ability as a scientist to walk people through biostatistics and the evidence that's needed to convince people why to make a change, absolutely. A PhD, and, you know, we could have another whole conversation on DNPs versus PhDs versus EdDs.
Mm.
That's another whole talk, but absolutely, nurse scientists can make a difference. Clinical nurse leaders make a difference. I have a hospital I work with, every inpatient unit has a clinical nurse leader, and part of their job is quality, evidence-based practice, mentoring, and support for the nurses on that unit.
Yeah.
It's wonderful.
Using that data probably also helps with some of the other issues people are having with getting that executive buy-in, because data-
Well, yes
... data does is convincing, yeah.
And all I have to do is teach 32 nurse leaders how the Magnet stories work, and then I get instant empirical outcome examples because they know how to use data, they know how to use evidence, they're master's prepared nurses, and we have just a bucket full. And, you know, EO examples, we can just sort through the pile.
Right.
Works great. Can you guys tell-
All right
... do I love this?
Yeah.
Yes. I wish we had another half an hour. It would be so much fun to talk.
I know. I know. Well, thank you so much, Terry. I think we're getting close to the end of our hour here, and we've had a lot of really great questions, and think we've got most of them answered. So, I wanna just thank everybody for attending, and I also wanted to mention, because we did talk about HCAHPS a little bit and those changes, that we do have a link to our webcast that we're gonna be, that's upcoming on the Resources page. If you go there, it's gonna be called the HCAHPS Insider Live, and we're actually gonna jump into those HCAHPS changes and just give you an overall broad rundown of what that looks like.
Overall, we've got very robust plans to make sure that we've supported all of our partners through those changes so that we're all ready for that 2025 window.
Well, thank you, all, and I wanna thank NRC. We really value our partnership with them. We admire the great work that NRC's doing and their longevity in the space, and, you know, I'm pretty loyal to the state of Nebraska, and, you know, NRC's a Nebraska company. So go Huskers!
Yes. Yes. Thank you so much, Terry, and thanks everyone for joining me.
Thank you, all.
Yeah.
Please reach out if we can be of any assistance at our end, too. Bye-bye.
Great job, everybody. That went awesome.