Pushing the envelope in lines of service
Advanced accreditation: a way to tout expertise
If you had to guess what department Sara Bohling, MSN, RN, APRN-CCNS, Certified Neonatal Clinical Nurse Specialist, worked in at Saint Elizabeth Regional Medical Center in Lincoln, NE, it would probably be pretty easy. She has a soothing voice meant for calming infants, singing songs, and telling stories.
But behind the soft voice is a nurse devoted to evidence-based care and ensuring that her charges get the most advanced treatment available. That is the reason that about four years ago, the hospital sought advanced certification in both high-risk obstetrics and premature infant care through The Joint Commission. Those are two of dozens of line of service and disease-specific advanced certifications offered by the organization to hospitals that can demonstrate that there are evidence-based care practices associated with the service line or care for a particular disease process, and then can show that they are able to gather and report data, create performance improvement plans related to metrics associated with the evidence-based care related to the service or disease, and show continued improvement in those metrics.
Hundreds of hospitals and other healthcare organizations have pursued the option in the last dozen years, says Jean Range, the commission's executive director of certification. The program is based on 28 standards of care from the chronic care model (described in Health Affairs in 2001 — http://content.healthaffairs.org/content/20/6/64) that can be applied to just about any chronic illness, condition, or line of service.
While eight of the certifications — those related to stroke and cardiac care, for instance — are overseen by third parties such as the American Heart Association, these line of care and other chronic illness advance certifications are evaluated by the commission. The models are the same, and the processes for certification are the same, she says.
Hospitals gather data for several months on four metrics related to the evidence-based care of the condition or service line, Range says. There is a site visit during which the commission uses the same tracer methodology it does with a regular hospital accreditation survey. If the data collected do not meet benchmarks, then the program may have to create a remediation plan that the commission will have to approve. Only after improvement and achieving a certain level of excellence will the commission grant the advanced certification. The certification lasts for two years, with a long conference call in the off year to gauge progress and trouble-shoot any problem areas.
"This is for facilities that have programs that are over and above standard clinical treatment," says Range. "It is a way to make sure you limit variations in practice and as a means to evaluate your performance.
Indeed, Bohling says one of the main points of having the accreditation is to keep pushing the envelope, which allows her patients to continue to get the most cutting-edge care there is.
Only six hospitals in the country have advanced certifications of preterm labor and high-risk OB, and only nine have it for premature infant care. They are the hospitals that are constantly looking to see what is new and where they can excel, Bohling says. "This is a way for us to maintain the highest quality care according to what the very latest research says."
The program and its staff do not rest on their laurels. Every recertification, they have to submit data on four standards. So they choose four that have the highest impact on patient care. If there are metrics that are sitting pretty at 100% or 0% (depending on the metric), Bohling and her team will choose something else that needs attention, rather than continue to focus their efforts on something they have already mastered.
Bohling's initial four metrics included admission hypothermia, central line-associated blood stream infections (CLABSI), breast milk at discharge, and growth at discharge. CLABSI was retired. Admission hypothermia is still measured, but there have been changes in care process that make continued measurement important. There was also a change in the way nurses measured infant growth. Now they take into account issues such as growth restriction in utero.
Breast-feeding at discharge is another continued metric. It remains difficult, in part because the babies are often so young and ill and hospitalized for so long that it is hard for a mother to continue to pump breast milk for months and months. So they keep working on it, Bohling says. They added appropriately timed extubation for the next certification to replace the CLABSI measure.
"In a regular survey situation, you keep measuring things, even if you are getting good numbers," Bohling explains. "Here, we change our focus because this certification is about growth, rather than maintaining focus. The role of this program is to push us, to advance us."
The survey itself is similar — the site visit feels the same, Bohling says, with a collaborative approach, but an attention to every detail that looks far beyond the data and other paperwork submitted. "It is the same combination of pride and nerves, of showing off all our hard work, but worrying about whether you did not present something in your documentation in as convincing a manner as you could have."
The recognition in the marketplace for the certification is all well and good. The marketing department is thrilled. But for Bohling, the reason behind doing this is patient care. "It is about learning from every patient, about providing teamwork, and about providing the best patient care. And that is what this certification process does for us. It is an extra level of accountability. We are submitting this additional data and proving ourselves at another level."
It also helps them get better at patient care. The reason the admission hypothermia procedures changed came directly out of the advanced certification process, Bohling says. "When we started, we figured we'd be fine on that metric. We were admitting the babies from the C-section room right across the hall. We'd scoop them right up and into a warm room. Their admissions temps were good. But then a year ago we started doing initial stabilization in the C-section room as part of new evidence-based standards of care. That totally changed things."
Surgeons like to keep OR suites cool — for their comfort and to keep germs from multiplying in a warm environment. "How can we keep a one-pound baby warm in a cold OR?" Bohling wondered. It took a lot of collaboration, compromise, and teamwork to come up with a solution. The doctors gave on the temperature a little and there were some tech solutions related to beds and blankets. "We had some dips in those temperature data when we changed the process initially, but we worked together to improve that, and they are back up again."
The advanced certification also spawned regular conversations between team members. "Before, we had monthly multidisciplinary meetings," Bohling says. "We weren't in the groove of talking much more than that, but it improves the care of our babies if we do. That has changed over time, too."
She believes that anyone who thinks they have a line of service where they are providing the best level of evidence-based care should pursue this. "It is not for the faint of heart, but it is an honor, and it pushes us forward."
Keeping staff to a higher standard
Susan San Marco, RN, WCC, the ostomy and wound care service line director at Goleta Valley Cottage Hospital in Santa Barbara, CA, agrees that certification is an impetus to stretch staff. Her wound care center is one of only four in the state to have advanced care certification, and the only one in her area.
She spent a year getting ready for certification, identifying areas that needed a quality improvement focus. She was lucky to find a mentor in a hospital that had pursued certification before her — John Muir Medical Center in Walnut Creek, CA. The people there were very willing to talk to San Marco about their experience and offer advice to her.
She decided to focus on patient satisfaction because while they strove to stay at 100% all the time; in wound care, that can be a hard thing to do. People with wounds that aren't healing well are usually less than compliant. They may not be happy people to begin with. San Marco wanted to make sure she and her team were doing all they could every day to ensure the highest patient satisfaction.
She also looked at metrics like the heal rate, median days to heal, and outliers who aren't healing in an appropriate amount of time — more often than not consisting mainly of those non-compliant patients.
San Marco started collecting data on those four areas and began work on her presentation, featuring performance improvement goals and plans, and an overview of the wound care program. She made sure to talk about what set Cottage Hospital apart from other clinics in the area, and how the care people received impacted the community. "When you have a regular survey, the commission will look at your EMR and your environment of care. But with this, they are doing that in much finer detail in a single line of service."
The education the patients get, whether it is received in a useful manner, and how San Marco knows that they are understanding it were all key elements of her presentation. "It can be really hard in wound care to do this in a wound care clinic, because we do not usually have these patients all day every day," she says. "Most are in the outpatient clinic and we get them for an hour. We have to assess how they are doing overall, assess the wound, identify barriers to healing, identify educational opportunities, and ensure they understand those. We have to give them multiple resources — verbal and written. We have to review those resources, and teach the caregiver or family. And all that time, we need to be preparing them for discharge, telling them what has to happen for them to get better and figure out what issues there are in the home that might be barriers to that."
They managed to impress The Joint Commission, gaining certification last summer. "In leading my staff through this, we have raised the bar and the professional expectation of the care we give," San Marco says. "Our commitment to excellence is a team sport. We have seen increased collaboration, better communication, and a real sense of pride."
Her nurses are very self-driven, but they also hold each other accountable, she continues. They are also sure that what they are doing "is not just the ordinary, but the extraordinary," San Marco says. "The program we have in place has a goal of exceeding what is expected. We have an enthusiasm for what we do, and our patients — who are already happy with our performance — see that in our work. They know we are always striving to improve. They see we constantly look to improve."
She says anyone with a stellar program should consider advanced certification. Be open with your progress toward goals and share data with everyone. Look for outliers and study them, because you can learn the best lessons from the cases where things did not go as planned or turn out as you thought they should.
"We learn so much so quickly now because of the data we collect," San Marco says. "We do not have to wait until something is catastrophic to see it or do something about it."
The certification process also helped San Marco become more organized with her data, and more open in sharing it. "We talk about it regularly and share it with everyone," she says. "We round on every patient and have outlier meetings every month. We are not as mature as some wound centers, and there are probably tools that they use we do not know about yet. But this has moved us into a different realm. We know things now we did not know before, and if you do not know, you can't improve."
Do not be intimidated, San Marco says. "This process will strengthen your team and your program. It will show you where you are weak and where you need to get stronger. It may seem like this is a lot of work, but embrace the challenge."
More information on The Joint Commission's advanced certification program is available at the website at http://www.jointcommission.org/certification/advanced_certification_diseasespecific_care.aspx.
Editor's Note: For more information on this topic, contact:
- Sara Bohling MSN, RN, APRN-CCNS, Certified Neonatal Clinical Nurse Specialist, Saint Elizabeth Regional Medical Center, Lincoln, NE. Telephone: (402) 219-7383.
- Susan C. San Marco RN, WCC, Center for Wound Management and Skin Wound, Ostomy Service Line Director, Goleta Valley Cottage Hospital, Santa Barbara, CA. Email: firstname.lastname@example.org.
- Jean Range, Executive Director, Certification, Joint Commission, Oakbrook Terrace, IL. Email: email@example.com.