Essentials of Advanced Nursing Practice

Running head: ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD Essentials of Advanced Nursing Practice Field Experience Anitha Madhu Western Governors University 1 ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 2 Purpose and overview of consultation In current healthcare settings, changes are continuous, and it is hard to accommodate the changes even though it is inevitable to improve patient satisfaction and quality outcome. The purpose of this consultation is to identify the strength and weakness within MD Anderson hospital, a state hospital in Houston, Texas. The University of Texas MD Anderson Cancer Center is one of the world’s most respected centers devoted exclusively to cancer patient care, research, education, and prevention of cancer (MD Anderson Cancer Center, 2018).

This meeting provides an overview of the weakness and the strength within the facility and the development of a change process to improve patient outcomes. With this consultation process, I will discover any weaknesses or gaps in the organization that can impact the poor patient outcome. Data will be collected from the Clinical Nurse Leader (CNL) interview, through website review, and patient assessment. The description of the organization The organization I choose to interview is The University of Texas MD Anderson Cancer Center, is one of the world’s most valued centers devoted exclusively to cancer patient care, research, education, and prevention and located in central Houston in the Texas Medical Center. According to U.S news and world report, MD Anderson ranked in number one in cancer care. MD Anderson is well known to the world through cancer research and individual patient care. The institution has been named one of the nation’s top two hospitals for cancer care every year since 1990. The organization named after Monroe Dunaway Anderson, who was a banker born in Oklahoma and lived in Houston, formed a charitable foundation that takes his name and funded it. After the death of MD Anderson in 1939, trustee decided to invest the charity fund into health care. In 1941 hospital established and named as Texas State Cancer Hospital and the Commented [AE131]: Sentence Fluency – Extra word *Note – Similar errors exist throughout Module 5: Sentence Fluency https://lrps.wgu.edu/provision/71484224 Click the link above to be directed to the Guide to Academic Writing created by the WGU Writing Center. This link includes information on the writing trait of Sentence Fluency, more specifically, Writing Sentences.

ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 3 Division of Cancer Research. Name of the organization changed many times from then and in 1988 final change was made into The University of Texas M. D. Anderson Cancer Center (MD Commented [AE132]: Sentence Fluency – Unclear phrasing due to ineffective construction *Note – Similar errors exist throughout from 1944 for cancer care. In 2017 patient number was 137,000 and among those 44,000 were Module 5: Sentence Fluency https://lrps.wgu.edu/provision/71484224 Click the link above to be directed to the Guide to Academic Writing created by the WGU Writing Center. This link includes information on the writing trait of Sentence Fluency, more specifically, Writing Sentences. new patients. About 1,250 patients were participated in clinical trials to explore the innovative Commented [AE133]: Conventions – Missing comma *Note – Similar errors exist throughout treatments. Moreover, MD Anderson provided uninsured or underinsured Texans more than Module 7: Conventions https://lrps.wgu.edu/provision/104450487 Anderson, 2018). According to the institutional profile, MD Anderson has 1.3 million patients turn over $179.4 million in uncompensated care (Institutional Profile, 2018). This institution provides care for all kinds of cancers which include solid tumors and liquid tumors in all age. MD Anderson has international patients from different areas of the world. Cultural diversity in employees and patients is an exciting factor in MD Anderson hospital. MD Anderson hospital has more than 19,530 employees, 1,743 faculty members, and roughly 3,200 onsite and offsite volunteers (Institutional Profile, 2018). The University of Texas MD Anderson Cancer Center has a new leadership structure designed to enhance teamwork and collaborative decision-making. This structure based on advancing institutional priorities of financial sustainability, connecting the MD Anderson community to its decision-making process and improved teamwork.  Essentials of Advanced Nursing Practice

The outcome includes improved clarity in decision making, facilitation of a team-based culture and increased integration (MD Anderson announces a new leadership structure, 2017). Leadership structure in MD Anderson cancer center includes president, vice president and twelve senior vice presidents with different operational responsibilities. Senior vice presidents are focused on their areas of responsibility, allowing them to work within their teams and across the institution to do what’s best for patients and the mission. Which include People Click the link above to be directed to the Guide to Academic Writing created by the WGU Writing Center. This link includes information on the writing trait of Conventions, more specifically, Commas. ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 4 and business operations, financial operation, political relation, institutional advancement operations, strategy, and developmental business operations, regulatory affairs, chief medical officer, chief nursing officer, chief academic officer, research administration and industry relations, Discovery and Platforms, and network development. Additionally divisional heads of each department. MD Anderson is a large institution with an inpatient size of 681 beds an annual inpatient admission as 28,973 as per 2017 statistics. MD Anderson provides cancer treatment and related care to pediatric and to adults. Demography of this institution is diverse. MD Anderson situated in Houston which is country’s fourth-largest city, and third-largest county. Houston has more than 2.2 million residents with a wide verity of heritages. MD Anderson hospital is a magnet recognized, regulated by state and federal rules, and also has Joint Commission accreditation and certification.

Magnet recognition is a performance-driven recognition credential from the American Nurses Credentialing Center (ANCC) (ANA, 2010). MD Anderson has a range of services available to patient and families to make them more comfortable and convenient. This organization offers banking and cashier services, dining services, flower and gift shops, outpatient pharmacies and a mobile app. Appearances shop, information centers, language assistance, laundry services, medical records, postal services, security and safety, transportation, web, telephone, and television services are also available in MD Anderson hospital (Services and Amenities, 2018). Primary Needs of Population The University of Texas MD Anderson Cancer Center is a degree-granting academic institution and a cancer treatment and research center located at the Texas Medical Center in Houston. Texas Medical Center is the largest medical center in the world with one of the highest Commented [AE134]: Sentence Fluency – Sentence fragment *Note – Similar errors exist throughout Module 8.23: Sentence Fragments https://lrps.wgu.edu/provision/117997361 Click the link above to be directed to the Guide to Academic Writing created by the WGU Writing Center. This link includes information on Sentence Fragments. ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 5 densities of clinical facilities for patient care, translational research, and basic science. This institute has grown surprisingly within the last ten years. The complex now includes 681 inpatient beds, several research buildings and outpatient clinic buildings, two faculty office buildings, and a patient-family hotel in addition to other off-site facilities for clinical and research use. In 2017 MD Anderson cared for 137,000 patients, and 44,000 of whom were new patients. Essentials of Advanced Nursing Practice

Patients include pediatric, adult and geriatric. MD Anderson has only one race in their treatment, that patient with cancer. Patients are coming from worldwide to MD Anderson with the ultimate hope of a cure. The core value of this institution says that “By our words and actions, we create a caring environment for everyone (Quick Facts, 2017). The primary needs of the cancer patients are broad in an acute care hospital such as MD Anderson hospital. Needs include control of pain and anxiety, generalized weakness, lack of nutrition, safety, shortness of breath, infection, dysfunctional bowel movements, impaired elimination, and pressure injury. Prevention of infection always has a priority in cancer care due to low immunity level with the immunosuppressant therapy. There are many regulators and quality markers available to keep MD Anderson hospital as number one hospital in the United States. Magnet recognition is one the highest and most prestigious distinction a healthcare organization can receive for nursing excellence and highquality patient care(ANA,2010).Hospital consumer assessment of health care providers and system( HCAHPS) survey is the national, standardized, publicly reported survey of patients’ perspectives of hospital care and this survey is available to the public as well as to the regulators such as the Centers for Medicare & Medicaid Services (CMS)( Center for Medicare &Medicare Services, 2018). According to the patient survey for last year, 88%of patients responded MD Anderson is the best, and 95%patients recommended this hospital to family and others. Commented [AE135]: Parts of Speech – Noun form error (Singular/plural) ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 6 All these regulator’s requirements are met by MD Anderson hospital by keeping all the quality indicators below the national benchmark. Major quality indicators monitored by the national database of nursing quality indicators(NDNQI) are pressure injury(PI), central lineassociated bloodstream infection(CLABSI),catheter-associated urinary tract infection(CAUTI),and falls. NDNQI is the national nursing database that provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level (ANA, 2010). Quality indicator’s information is publicly available on websites. Since this information is accessible to the public, that affects the business management of the organization. Nurse Leader’s Role. I interviewed the Clinical Nurse Leader (CNL) in MD Anderson hospital. The CNL is a mastered educated nurse, prepared by American Association of College of Nursing (AACN) in collaboration with leaders from healthcare practice and education to address the critical need to improve the quality of patient care outcomes and to prepare nurses with the competencies needed to achieve in healthcare system currently and in future (AACN, 2018). Essentials of Advanced Nursing Practice

Role and scope of practice of CNL in the organization include care coordination, quality Improvement, risk assessment, outcomes measurement, transitions of care, inter-professional communication, team leadership, implementation of best practices based on evidence, mentoring to nursing staff, and to maintain a healthy working environment. CNL supports the organizational goal of patient safety as her goal. For instance, CNL’s goal is to prevent falls with injury and prevention of hospital-acquired pressure injury. Both of these goals are organizational goals. Stakeholders of CNL’s job is primarily patients and staff, physicians, and other treatment team members in her organization as internally. An external stakeholder includes NDNQI and government regulator such as CMS. CNL is responsible for delivering high-quality care, and to ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 7 assure the safety of the patient by risk assessment, outcome measurement and by implementing the evidence-based practice outcome. CNL also deliver the proper education, coaching, and mentoring to the employees in order to keep the patient safety as well as the safety of the employees. CNL role in this organization is well aligned with the role which is defined in the essential of the masters of education in nursing as essential three, which is quality improvement and safety. As in this essential three, CNL is able t to articulate in the methods, tools, performance measures, standards related to quality, and also prepared to apply quality principles within an organization(AACN,2011). CNL in this organization is well supported by the division of nursing in the institution. Characteristics of Organization According to the interview report of the CNL, the current strength of the organization is the wealth of resource which they have. Resources include, employ resource and patient resources. Patient resources include: The learning centers with books, CDs, DVDs, brochures and pamphlets, online medical journals, health magazines, journals, newsletters, and patient education videos are available in the learning center: patient family education classes regarding orientation to the hospital, central venous line care class for patient and family, bowel management classes and computer-related education to access the MD Anderson website in the remote area also. Significant resources for patients include the use of a research center, a wealth of the dedicated physicians and the support from the different interdisciplinary team such as nutrition, radiography, diagnostic and imaging, therapies, and pharmacy. Service to patients and family include banking and cashier services, dining services, beauty shop, language assistance, laundry services, medical records availability, and postal service. Electronic Health Record (HER) is another strength of the organization in order to keep the patient safety. Patient safety ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 8 intelligence (PSI) is another source which is adding patient safety by tracking the events and the root cause analysis to educate the staff and to improve the patient outcome. Employ resources includes educational opportunities, support from the management team. Employ assistance program for consults with the specialists includes work related, family, related, legal issues and mental health free screening and to receive feedback. Another program is discount to the employees in purchasing automotive, bookstore, education, child care, and Commented [AE136]: Word Choice – Inaccurate word choice *Note – Similar errors exist throughout Module 8.30: Vocabulary in Academic Writing https://lrps.wgu.edu/provision/117997269 Click the link above to be directed to the Guide to Academic Writing created by the WGU Writing Center. This link includes information on the writing trait of Vocabulary. deals for the movie, travel, lodging, and discount for wireless services such as a phone (MD Andrson employee resources, 2017) As per the CNL, weakness of the hospital is the size of the organization. According to her, communication is getting delayed or not reaching to every employee even though they have access via email, intranet services, face to face communication from management via meetings and conferences. For instance, central line-associated bloodstream infection (CLABSI) rate was high in the organization from the national benchmark. According to CNL, this is due to a lack of communication between the unit since some the medical unit has CLABSI rate below the national benchmark. According to CNL, if the communication was effective in the organization, the CLABSI rate would not be as high as this. The togetherness of employees also a hardship due to the large volume of employees. With the uniform and badge, only employees recognize each other, so the personal closeness and relation between workers lack in CNL’s opinion. Current evidence-based practices include prevention of pressure injury (PI), central lineassociated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and falls are the current evidence-based practices in the organization. In MD Anderson hospital the E.M.P.O.W.E.R(Enhancing My Practice and Outcomes with Evidence and Research) program is focused on supporting nurses across the institution to enhance the professional Commented [AE137]: Sentence Fluency – Sentence fragment ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD 9 practice and patient outcomes through assessment , integration, and evaluation of the available evidence(Nursing at MD Anderson EBP, 2012). Quality improvement (QI) goal is to deliver safe and high-quality health care to patients in all clinical settings, and it consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of the patient population(AHRQ,2013). Quality improvement projects in MD Anderson hospital is primarily on Pressure Ulcers, Ventilator-Associated Pneumonia (VAP),I Catheter-Related Infections, Urinary Catheter-Related Infections, Reducing Medication Errors, Handoff at shift change, Working Conditions and Work Environment for Nurses, and Nursing Turnover. Recommendation for Organizational Change As per the CNL’s interview report, the organization is planning to do change in the practice of Central Venous Catheter (CVC) care for prevention of CLABSI. Central lines are being used in MD Anderson increasingly in the inpatient and outpatient setting to provide longterm venous access for chemotherapy treatment and for blood work up. Central lines disrupt the integrity of the skin, making infection with bacteria particularly when the population in this organization is vulnerable to infection with immunosuppressant therapies. Essentials of Advanced Nursing Practice

CLABSI prevention is entirely patient-centered because of the participation of the patient in the care of central lines. CLABSI can make increased morbidity and prolonged hospitalization. Current practice in central venous catheters is with a bundle of care includes: The central line bundle has five key components: • Hand hygiene • Maximal barrier precautions • Chlorhexidine skin antisepsis Commented [AE138]: Parts of Speech – Missing article *Note – Similar errors exist throughout Module 8.15: Article Usage https://lrps.wgu.edu/provision/117123633 Click the link above to be directed to the Guide to Academic Writing created by the WGU Writing Center. This link includes information on Article Usage. ESSENTIALS OF ADVANCED NURSING PRACTICE FIELD • 10 Optimal catheter site selection, with avoidance of using the femoral vein for central venous access in adult patients • Daily review of line necessity, with prompt removal of unnecessary lines. Essentials of Advanced Nursing Practice

With the current practice of bundles in CVC care, CLABSI rate in the organization is 1.46, and the national benchmark is 0.89. This difference shows that there is a necessity for practice change in CVC line care for the safety of the patient as well as the organizational need. The need of the population and risk also identified now; the next step is to implement a PlanDo-Study Act-(PDSA)cycle in order to assess the performance and track improvements in practice systematically(Quality connect, 2015). In the planning stage, the goal is to achieve the CLABSI rate in MD Anderson hospital inpatient setting to below the national benchmark level of 0.89 in 6weeks and in 12 weeks CLABSI rate to be 0% in all over the institution. In the planning, stage team is developed with unit director, unit manager, CNL, charge nurse, and nurse clinician, nurse practitioner, Infectious disease consultant, and a nursing assistant. CNL is the leader of the team. Plan for meeting every week, the audit will be every day in the gynecology oncology unit. Planned changed are adding one more step to the care bundle in the prevention of CLABSI. An additional step … Essentials of Advanced Nursing Practice