National Nurses United

C A L I F O R N I A N U R S E J U N E 2 0 0 5 17 Services (DHS). The DHS issued a State- ment of Deficiency stating that "based on observation, interview, and record review, the facility failed to follow their policy and procedure for staffing in the intensive care units. The policy does not define criteria for 2:1 or 1:1 nurse to patient ratio." The hospital first claimed that the community standard was to relieve each other for breaks and trips off the unit. The DHS responded that this was an unac- ceptable Plan of Correction. They then wrote they used a 5 per- cent flex bed, that some of the patients were really medical-surgical patients. The DHS responded that they (DHS) had not been contacted regarding a need to keep med-surg patients in ICU, so this was not acceptable either. The hospital filed many other unacceptable plans. Finally, the hospital submitted an acceptable Plan of Correction, stating "An additional unassigned Senior RN position will be added to the ICU, for a total of two Senior RNs. The ICU patients will be staffed at a ratio of 1:2." This became a precedent-setting Statement of Deficiency, soon there- after issued by the DHS for similar vio- lations. Remember, it all started with education and the will and courage to stand up for patients and be an effective patient advocate. S E C T I O N I I . Quality is Everybody's Business: Collective Advocacy Through the RN Quality Liaison Program The voice of the registered nurse (RN) as patient advocate has become crucial in shaping an environment that protects the health and well-being of patients. The combination of assessment skills, scien- tific knowledge, and frequent, direct con- tact with patients gives RNs a unique ability to create a safe, healing environ- ment at the bedside. The California Nurses Association (CNA) recognizes the value of the RN direct care perspective in keeping patient safety central to a quali- ty-focused agenda. In order to formalize and structure the concept of RN collective advocacy within healthcare organizations, the "Quality Liaison" program was born. HISTORY In 1998, after difficult and lengthy nego- tiations between CNA and Kaiser Permanente (KP), the Quality Liaison pro- gram was developed as an innovative pro- gram linking the direct patient care expe- rience of RNs to established quality struc- tures within the organization. At the inception of the program, the RNs/NPs were charged with the task of creating relationships with colleagues, managers, physicians, quality department personnel, union representatives, and regional administration. To function as a Quality Liaison, they developed communication pathways and escalation tools to establish program recognition and credibility. In 2002, the program title was changed to the "Registered Nurse Quality Liaison Program" (RNQL) to more appropriately identify the importance of the RN in pro- moting quality patient care. MISSION The goals of the RNQL program are to improve quality patient care and out- comes, and to increase staff RN/NP par- ticipation in the quality assurance and/or performance improvement process with- in the organization. During their three- year term, the RNQLs participate in the Quality Process/Structure Committees, GRASP (acuity staffing system), Professional Performance Committees (PPC), Nurse Practitioner Regional Committee (NPRC), and Home Health Committees to achieve the program's goal: to create a safer patient care environment. The RNQL supports patient safety by par- ticipating in monthly Nursing Quality forums that focus on creating a culture toward promoting responsible reporting of errors and near misses, and promoting system changes leading to a safer patient care environment. TOOLS To prepare themselves for this demand- ing role, the RNQLs receive education in a variety of areas. Problem solving starts with an introduction to the current tools adapted by JCAHO to analyze systems. These tools include "Root Cause Analysis," "Failure Modes Effects Analysis," and the "Plan, Do, Check, Act" process. Each RNQL learns how to appro- priately escalate concerns that cannot be resolved with lower level interventions, starting with the manager and moving up the chain of command until problem res- olution occurs. Sentinel Events are occur- rences that JCAHO has deemed worthy of extensive review and modification of cur- rent practices. A knowledge of these estab- lished mechanisms to evaluate problems, create alternative practices, and motivate the employer to change faulty systems to maintain accreditation are valuable tools for the QL to use in effecting change. NURSING ACTIVISM PPCs have existed within the organization since 1974 and the seeds were sown for collective patient advocacy with the work of these committees. However, because of a lack of formal communication between these committees, their effectiveness was limited. The RNQL program provided a mechanism to bridge this isolation and these groups. The liaison/leadership role of the RNQL provided the impetus need- ed to move knowledge into action. As a result of this increased activism among RNs/NPs, numerous problem areas were identified in local facilities, creating a necessity for additional PPCs in satellite clinics, call centers, and an increased need for NP involvement and, ultimately, the creation of Nursing Quality Forums. RNQL ACCOMPLISHMENTS Despite the many challenges of this role, the RNQLs have been successful in accomplishing many of their goals which have lead to system improvements in patient care across the continuum. The following are examples of the many accomplishments of the RNQL program. Call Center: The RNQLs found that there were no common condition treat- ment protocols for pregnant women seek- ing advice from the call center or in after-hours clinics. These women were instructed to either see their primary provider the next day or were sent to the emergency department. The RNQLs, working with the appropriate call center committees, created effective solutions for these problems, providing improved access and care to these members. Home Health: The RNQLs found that patients were not getting oxygen delivered to their home upon discharge. This delay in care resulted from an inefficient com- munication system between discharge planners and the vendor. The RNQLs requested that the home health RNs doc- ument each incident. When the frequen- cy and seriousness of the problem was revealed, the vendor changed its national policy to ensure efficient communication of orders and prompt delivery of essential equipment to patients' homes. In the South Bay area, patients were being sent home from the hospital with

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