Dixie Regional Medical Center, part of the Intermountain Healthcare system in St. George, UT, is reporting success with a program called POKE that significantly reduces the number of invasive procedures patients must undergo while hospitalized.
The hospital also is seeing success with the use of escalation huddles to enhance communication among clinicians, administrators, and other hospital leaders.
POKE, which stands for “Prevent pain and Organisms from sKin and catheter Entry,” was created in 2008 to minimize infections and other consequences of invasive procedures in the neonatal intensive care unit (NICU), says R. Erick Ridout, MD, a neonatologist with Intermountain Healthcare in Salt Lake City. The idea was based on the reasoning that with fewer pokes of any sort, there should be fewer ill effects.
Since the program began, the hospital has eliminated 11,000 pokes, and NICU length of stay has fallen by 21%. Associated costs have dropped by 28%.
“The foundation of POKE is having the right leaders in place and nursing buy-in. Extreme humility goes a long way, subjugating ego and flattening the hierarchy at the bedside so that the only person at the bedside who outranks everyone else in the room is the patient,” Ridout says. “Everyone has a voice and all voices are valued. Leaders speak last.”
Eliminating Unneeded Patient Pokes
In addition to monitoring how often patients are poked for blood draws and other needs, and minimizing that wherever possible, POKE also factors in to how the environment is structured and how work processes are designed, Ridout notes. The goal always is to add value and not waste resources, he says.
With POKE, Intermountain wanted to identify all the care the patient was receiving and eliminate that which did not add value, Ridout explains.
“The giant hurdle we have in healthcare is that we are finding a tremendous amount of care that patients experience just doesn’t add value. Tests are being done that don’t help and may harm,” Ridout says. “But physicians are used to carrying out those tests and getting that data, and when they lose that, that’s where the pushback comes in.”
The changes have to be implemented in a way that illustrates the benefits to the patient, he says.
“The result was that we were able to decrease length of stay and hospital-acquired infections so that our babies have extraordinary outcomes and go home sooner. We’re deploying this laterally throughout our NICUs at Intermountain and also are taking it outside our system.”
Better to Pull Than Push
POKE is successful in part because Intermountain has encouraged units to “pull” the effort to them, rather than a central authority “pushing” it on them, Ridout explains. That approach is always more effective in continuous quality improvement, he notes.
“We want folks to self-determine where they want to go and then just need the tools and someone to come in and coach them. You coach them to be experts and world-class experts,” Ridout says. “You get that pull by having a compelling story and data to demonstrate it. The people that are interested will pull you in, and then eventually you get a critical mass where everyone wants to do it, and it might even be required by regulation.”
POKE also benefits from the way Intermountain erases the lines between facility, physicians, and nursing, explains Jeannette Cutner, BSN, RN, nurse manager with Dixie Regional Medical Center. Traditionally, those three groups have had different concerns and levels of influence, with the disparities getting in the way of best practice implementation, Cutner explains.
“We had physicians and nursing become one and working with the facility. Instead of physicians telling staff what to do or the physicians not even knowing what the staff were trying to accomplish, we did it in lockstep,” Cutner explains.
“Others are still struggling to adopt something two or three years later, when we have it as soon as we educate to it because everyone has a voice at the table. Everyone understands their role and everyone else’s role, too, so you don’t have physicians pushing for change without understanding the heavy lifting that will be required of the nurses to make that happen.”
Intermountain also conducts a survey of facilities to identify units that are ready for change, looking for evidence that they have the right mindset with psychological safety and a culture of accountability.
“When you identify the units that are ready in that way, you can take big ideas to them and implement them well,” Cutner says.
“The units that are struggling will have a hard time adopting something this big, so they have to work on their culture first. The culture work has to be up front, and then they can adopt whatever you present them for best practices.”
Escalation Huddles Improve Communication
Another example of best practice implementation is Intermountain’s escalation huddles, which were started four years ago. The health system’s Continuous Improvement Team oversaw 652,080 huddles in the first year, Cutner says.
Playing off the huddle concept used by many hospitals, Intermountain facilities first started with each charge nurse organizing a huddle at 6 a.m. every day with incoming and outgoing shift nurses. They discuss their goals and challenges for the day.
“It was done with little success on our unit. Charge nurses work 12-hour shifts, three or two days a week, and they don’t necessarily have the 60,000-foot view, but they do know how to run a floor for 12 hours,” Cutner explains.
“That’s what they’re really good at, but we wanted the huddle to be much broader so we could talk about elevating the culture of our unit and the principles of zero harm.”
Intermountain changed the huddle procedure so that tiered escalation huddles start with frontline caregivers — Tier 1 — huddling at 8:45 a.m., followed by five other tiers of management and leadership, up to Tier 6, the executive leadership team, at 10 a.m. The discussions occur around huddle whiteboards showing metrics and other information.
Nurses Encouraged to Speak Up
The tiered huddles provide a communication channel from the frontline staff all the way up to the C-suite and back down again, Cutner explains. Ideas, strategies, concerns, and needs are effectively communicated up and down the line, she says.
Ridout and Cutner huddle every day at 9 a.m., and that huddle is repeated at 9 p.m. by the nurse practitioner and charge nurse. “We found that it adds tremendous value for the staff. They enjoy the huddle, and it has dramatically impacted the culture of our unit,” Cutner says. “The huddles might focus on praise, gratitude, zero harm techniques — whatever is hot, we talk about it every 12 hours from a global perspective and take it to the bedside.”
Cutner recalls how the huddles helped address a common problem in healthcare: the nurse who is aware of a dangerous situation but afraid to speak up. The issue was addressed in labor and delivery huddles, with Cutner requesting that the hospitalists ask the nurses every day, “How are you going to help me keep my patients safe today?”
“The nurses were quiet and hesitant in the beginning, but then they started responding with ‘I will use SBAR [Situation, Background, Assessment, Recommendation], I will stop and resolve, I will speak up when I see a patient safety issue.’ Then the physician would reply with, ‘You promise me?’” Cutner explains.
“Just putting it out on the table made the zero-harm principles real and viable. Even if the nurse was hesitant or 23 years old and inexperienced, that nurse felt more comfortable speaking up to tell the physician in the moment because he or she had told the nurse that morning that that input was not just OK but desired and expected.”
- Jeannette Cutner, BSN, RN, Nurse Manager, Dixie Regional Medical Center, St. George, UT. Phone: (435) 251-1000.
- R. Erick Ridout, MD, Neonatologist, Intermountain Healthcare, Salt Lake City. Phone: (435) 251-5200.