Unlocking the Full Value of Accreditation: Nurse Champions Driving QI

Along the road to achieving accreditation, hospitals see many gains in process improvement and patient outcomes. That's surely been the case for Lahey Hospital and Medical Center in Burlington, MA, as it works towards Cardiac Cath Lab Accreditation and Electrophysiology (EP) Accreditation. But they've also found an unexpected outcome: nurses at all levels have become the champions driving the quality improvement, supplying the hard work and the enthusiasm for the benefits of accreditation.

"The nurses have taken ownership of the process with a sustained commitment," says Frederic S. Resnic, MD, MSc, FACC, chair, division of cardiovascular medicine at Lahey. He also serves on ACC's NCDR Management Board. Not only have they embraced the two current accreditation efforts underway, they're already looking ahead to taking on the next ones, he adds.

To Be or Not to Be ... Dry? Hydration and Renal Outcomes

Take a proactive, patient-focused team and empower them to make data-driven change and what do you get? Two team champions revamping a cath lab hydration policy to reduce the rates of contrast-induced acute kidney injury.

NCDR benchmarking data showed that Lahey is below the national standard for this measure. Jennifer Bruso, RN, and Michael P. Carney, RN, the team champions for the Cardiac Cath Lab Accreditation at Lahey, are taking on the process improvement to meet the standard. "We've learned through the data that we do a lot of things really well, like radial cases and door-to-balloon times," says Bruso. "But in this case, we learned we have work to do." This includes creating awareness, updating policies and procedures and accountability.


When the leadership at Lahey, a 335-bed hospital that serves more than 3,000 patients daily, decided to take on accreditation they knew it would require more work from an already very hard working nursing staff in the cath and EP labs. What they didn't know is that this decision would bring positive outcomes within the hospital staff, along with those for patient care.

"Accreditation has become a vehicle that's fostered stronger inter- and intra-department communication and collaboration around a common project," notes Resnic.

Nurses on the Front Line: Driving Change

Nurses are known for focusing on patient outcomes, along with patient care itself. For those working in a setting like the cath or EP labs, it's generally a short window of about a day to follow outcomes. Now with accreditation underway, that's extended to 30 days or more – and a whole new focus.

"This has brought about grassroots-driven change," says Helen Tuffee, RN, BSN, nursing director of interventional and cardiovascular services at Lahey. She describes three high-functioning teams, one each for the cath lab, EP lab and ICHU, each co-led by team two nurse champions who are using NCDR data to influence and drive change in the department and delve into processes and policies.

As the teams use the NCDR data to understand the reasons benchmarks aren't being met, they're determining how to address this from a nursing perspective. And the teams are driving the physicians, telling them what's needed from them, while taking on the actual work and research themselves.

Team Champs of Accreditation

Jennifer Bruso, RN, and Michael P. Carney, RN, are both staff nurses in the cardiac cath lab at Lahey Hospital and Medical Center. They are also co-team leads for ACC's Cardiac Cath Lab Accreditation, tapped by their nursing director, Helen Tuffee, RN, BSN.

"It's an honor and privilege to represent my peers in the cath lab in this accreditation process, as we collaborate with other departments to adapt policies and procedures," says Bruso. Carney adds, "Collectively, we have a stronger voice because of the accreditation process." This allows them to more easily communicate with other departments and bring a focus and appropriate attention to issues that arise and reach a resolution.


Often in nursing decisions and change are gut-driven, notes Tuffee, but the NCDR data and the accreditation process has given the teams a firm foundation to make decisions, adapt policies and course correct with new insights from the data.

Of course, all of this requires empowerment of the nurses and teams, and this fits with the overall ethos of empowerment and peer-to-peer accountability at Lahey. The team champions attend relevant meetings in relation to policies they're changing and are empowered to reach out as needed to all levels of staff across the hospital. "This has increased their visibility throughout the hospital and brought recognition for their work," says Tuffee.

This and more is bringing a lot of professional growth in the team members. "From a management perspective, this fits with the overall hospital vision of respect, accountability and growth," notes Tuffee. If they see a practice that doesn't seem right or well executed, they hold their team member accountable. Further, they help each other when needed, even if it's outside their usual work area.

The team cohesiveness, positivity, respect, accountability, increased focus and improved work flow processes that have been gained through the accreditation process "have been icing on the cake," adds Tuffee. It's also built better bonds between nurses and their physician groups – allowing the honest and transparent conversations needed to drive change. Finally, there's also been improvements in the nursing satisfaction surveys and remarkable improvements in morale and their approach to work.

Ultimately, the result is a streamlined patient journey and experience because of seamless transition of care from unit to unit in the service line. The accreditation process has reinforced improved communication, greater awareness by all of outcomes data and greater understanding of the reasons behind procedures and policies, further enhancing Lahey's work to optimize its service line.

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Keywords: ACC Publications, Cardiology Magazine, Benchmarking, Leadership, Quality Improvement, Morale, Ownership, Personal Satisfaction, Workflow, Patient Transfer, Accreditation, Nursing Staff, Learning, Hospitals, Acute Kidney Injury, Social Responsibility, Electrophysiology, National Cardiovascular Data Registries

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