New Plans for VA Nursing's Future
Monday March 28, 2005
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Lynda Olender, RN, MA, ANP, chief nurse executive, Bronx VA Medical Center, is passionate about improving the clinical environment.
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In January 2005, Nursing Spectrum spoke with Lynda Olender, RN, MA, ANP, chief nurse executive of the Bronx VA Medical Center, about Veterans Health Administration (VHA) nursing initiatives that have dramatically improved patient care in VA facilities around the country.
What kinds of changes and transitions has the VA undergone in the past several years to improve patient care?
The VHA has undergone a significant change over the last decade. In the mid-1990s, the undersecretary for health, Ken Kizer, came forward with a prescription for change that included plans for the VHA to make the transition to being both a provider of choice for our veterans and an employer of choice for our staff. The changes made were primarily outcome-based - related to patient and staff satisfaction and patient clinical outcome measures.
How does the "provider of choice" initiative work?
The provider of choice iniatitive uses evidence-based health care outcome measures. This initiative took years; it did not happen overnight. We considered the top morbidity and mortality data, our patient population, and the evidence that can make a difference in determining longevity for individual patients - particularly those with chronic diseases. Each medical center director - including myself and the individuals whom I manage - is accountable for making sure that these quality measures are met for our patients.
We now have quarterly reports that compare each facility to the others. All of these measures are tracked electronically. The infrastructure to track them has been a key part of the intiative's success. VA hospital patient enrollment has significantly increased over the last decade - the word is getting out.
What patient care issues do these measures address?
In addition to patient satisfaction, other measures include ensuring that wait times for appointments are less than 20 minutes, and that no more than 30 days pass between appointments. There are performance measures to see how well we manage patients with diabetes or high-blood pressure; how precisely we adhere to standards of evidence-based medicine, such as prescribing beta blockers for patients recovering from a heart attack; what percentage of our patients get the flu or pneumococcal vaccine annually; how many receive counseling on smoking cessation, etc.
Has there been any evaluation of how the VA is doing with these outcome measures?
In 2003, The New England Journal of Medicine published a study comparing VA outcome measures with the private sector, and our outcome measures were significantly better. Subsequently, the Annals of Internal Medicine published a study comparing veterans' health facilities with commercial managed health care systems in the treatment of diabetes. The VA provided better care in all seven measures of diabetes care.
This past year, the National Committee for Quality Assurance (NCQA) awarded their seal of approval,which is the gold standard in the health care industry to the VA. Now is a very exciting time for the VA.
You spoke of the VHA as an "employer of choice" for nursing. What are your goals in this area?
We have a national nursing strategic plan that delineates the goals for VA nurses and patients alike. This plan addresses key initiatives for nursing, including patient and staff safety initiatives, technology, leadership, and career development, and succession planning.
What are some of the safety and technology initiatives and how do they interrelate?
The VA is known as a leader in safety because of the technology and the integrated health information systems [we employ]. Each facility has a patient safety officer who tracks incidents and near misses. In addition, proactive teams address the 'what ifs?' by designing and implementing contingency plans for systems that may shut down, for example, in the event of a power failure.
Technology plays a huge role in safety. Physician medication orders are computerized so that handwriting is not an issue. Medications for inpatients are administered via bar code technology and charted within the computerized patient record system. The computer system allows the nurse to check lab results in seconds. Or, the nurse can check drug references instantly if he or she is unsure of the indication for a particular drug. Everything is at the nurse's fingertips. We've found that to be enormously satisfying for our nurses, aside from being a huge patient safety initiative as well.
In addition, VA nurses are working to identify and measure key nursing practice quality performance indicators to support evidence-based nursing practice. The program, called VA Nursing Outcome Data Bases, or VANOD, will provide a standardized approach to how we track nursing-sensitive measures, such as hospital-acquired decubitus ulcers, falls, and medication errors.
Remember - we have a totally integrated computerized system. Imagine the research potential for this.
Describe your telemedicine program.
A certain percentage of our patients with chronic illnesses are being enrolled into our telemedicine programs. We have a telephone triage system that provides 24-hour, 7 day a week access to nursing for health-related inquiries. Patients who are being integrated into the system will have access to their own health records and will actively participate in achieving their health goals. The program is called Health-E University, and it's part of the telehealth initiative. In some parts of the country, patients have their own computer set-ups at home so that they can record and send in their vital signs to help with their care plans. It's been very successful. We're just starting to enroll patients here in this network.
Aside from patient safety initiatives, what is the focus for nursing?
This year, our goal is to ensure that every nurse manager and nurse executive works with a long-term mentor. In the past, mentoring was informal, and leadership training was primarily on the job. Today, we have developed core curriculum (both didactic and experiential), we are training formal mentors, and matching programs for mentor and apprentice are underway. Also, formal succession planning programs will ensure that our aging leadership workforce has trained, competent leaders ready to take their places. We are also exploring a new nursing role - the clinical nurse leader - that will allow the staff nurse to stay at the point of care and still advance in her career. We're very excited about that.
How will the clinical nurse leader advance her career while remaining at the bedside?
One nurse on each shift will be designated as the clinical nurse leader for that shift. It will be his or her role to work with the inpatient team on the interdisciplinary plans, the education plans, and the evaluation and documentation for all patients. The clinical nurse leader will work alongside the staff nurses and serve as a consultant.
In the past, we have wanted to keep nurses at the bedside while letting them advance their careers, but we haven't had anywhere for them to go. I believe that, unless we fix the [problems that exist at the] bedside, we are not going to fix nursing.
What do you think it will take for the bedside to be the environment of choice for nurses?
To answer that, we have to value the role of the nurse at the bedside. Although we're just rolling it out as a pilot, the clinical nurse leader can serve as a model. We hope nurses will find that to be a satisfier. It's sort of like the nurse is a clinical case manager who has his or her own patients - an attending nurse, so to speak. We're excited about it and we hope to see it grow and create change as time goes on.
What is it about the bedside that nurses have trouble with? Why do so many nurses leave?
I served as faculty at New York University (NYU) for many years, and have asked many bright nursing students that same question. [The problem] is not unique to the VA. There is a real perception that nurses should work in a clinical inpatient area for a while to get their skills, and then move on to something else. Once, at NYU, some colleagues and I were participating in a career outreach. I remember one of my colleagues telling prospective students, "Go into nursing, work in a hospital, pay your dues, and then you can become this or that." That kind of thought hurts nursing because the concept is 'you pay your dues and you leave.'
In recognition of this, I have suggested that we develop a model of care for nurses at the bedside where there's continuity, where they have a caseload of patients, where they are like the 'attending nurse.' The model would allow nurses to manage patients from admission to discharge, because nurses are there 24/7. Physicians are visitors, when you think about it.
Creating a model that fosters this concept is challenging. We have to train our leaders and continue to work with our nurses to develop a work environment where nurses feel that they can really make a difference for patients. And so, while the technology is very nice and it's very helpful, the real touchy/feely things about developing relationships with patients is, perhaps, the most important challenge of them all.
Having said that, I'm working very hard to train units for a patient-centered care delivery model, where one nurse has a patient from admission to discharge, regardless of who he or she is assigned to. Nurses would have a caseload of patients - one or two or three - that they manage.
How does that differ from primary nursing?
In primary nursing, a nurse is assigned to a patient each shift and they get the same patient every day. Evening shift also gets the same patient and night shift gets the same patient. But, when you look at a patient's documentation, which nurse is really responsible for the whole case?
This is a modified primary care model, where you have care teams - the RN works with an LPN and two nursing assistants for a certain number of patients on a shift, but one or two of those patients will be their responsibility from admission to discharge. It's different. [Under this model], when I want to look at the care plan or the assessment or the evaluation of how well these patients are doing, I know exactly who 'owns' each patient. It's like the nurses have a private practice in addition to their assignments. So the day nurse can say to the evening nurse, "Mr. So-and-So has diabetes. He knows how to give himself insulin, but what I need you to follow up on is...." You see? Patient care is coordinated with each shift.
It's a bit of a different concept, but nurses love it. One of our units has no vacancies - a waiting list to get into a med/surg unit! This is because the RNs from the unit and the residents [from The Mount Sinai Hospital, who have privileges at our facility] admit patients together. In other words, the resident and the nurse are partners in managing the patient. It's been a delightful experience to watch this collaborative practice evolve. And, of course, the nurse manager makes rounds with the attending physicians.
Tell me about the VHA's succession planning.
My boss has allocated five bright people - all of whom have or are in the process of obtaining their master's degrees - for me to train to be the managers of our future. Fifty percent of our nurse managers could potentially retire today. So, as they leave, we will have a dynamic group of trained, confident leaders to bring these delivery systems into fruition - to really be able to do the job.
Is succession planning a new concept or has it been around a while? It sounds as if you are really planning for the future.
That's part of the VHA's employer of choice initiaive. The average age of the VA nurse in 2002 was 47.4. Only 17% of nurses were under age 40. Of course, we hired a lot of new nurses. But, it became apparent that we had to implement succession planning for our leadership, and we did. There are leaders all over the country now. It has become a performance measure for each facility director to ensure that these trained individuals are ready to fill the shoes of the retirees.
What does a chief nursing executive at the VA do? Do you go to a lot of meetings? Do a lot of paperwork involving initiatives? Are you on the floor talking to people?
Yes, all of the above. I make it a point to visit every unit once a week. If you were to make rounds with me, you would be amazed that people know me. I'm very visible. I'm part of a quadrad - the medical center director (or CEO), the associate director, the chief of staff, and I manage the entire facility.
We develop contracts collaboratively with the managers to set expectations around meeting the performance measures. And we meet in the beginning of the fiscal year, then midway, and at the end to optimize the likelihood of meeting our goals.
What is the status of the proposed closing of the Manhattan VA hospital?
There is no proposal to close the N.Y. VA hospital. Some of the VAs have a lot of property and buildings that they're not really using. A national group called the Capital Asset Realignment for Enhanced Services (CARES) wants to look at the VA's assets as a whole, including the buildings and clinics, to determine what the patients' needs really are.
People were worried that they were going to close the N.Y. VA, but that really wasn't ever on the table. There was some bad press and some veterans' service organizations became upset. That's all there is to that.
What else is on the agenda for the VHA in the coming years?
Congress was concerned about the nursing shortage and asked what we could do to attract nurses to the VA system. We formed the VA Commission on Nursing and it came up with recommendations about work hours, flex time, pay scale, promotion, and qualification standards. Congress approved everything. Now, we have a huge job ahead of us to implement all of these recommendations. (Laughing) I shudder to think about it - I am a busy woman!
Robyn DeSantis Ringler, RN, Esq., is a frequent contributor to Nursing Spectrum.
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