Establishing a Shared Governance, Unit Based Council for the Hematology/Hematopoietic Cell Transplantation (Hem/HCT) Nurse Coordinator (NC) and Clinical Trial Nurse (CTN)
Biology of Blood and Marrow Transplantation
Purpose: To describe strategies for successful implementation and positive outcomes of a comprehensive outpatient Adult Blood and Marrow Transplant (ABMT) Apheresis Program Bone Marrow Transplant (BMT) nurses are trained experts in the care of patients along the continuum including pre-transplant, peri-transplant and post-transplant periods. Leukapheresis for the collection of peripheral blood progenitor cells (PBPC), donor lymphocytes, granulocytes, and Extracorporeal Photopheresis (ECP) can
... successfully incorporated into the scope of practice of the BMT outpatient nurse. With the opening of the Duke Adult Blood and Marrow Transplant (ABMT) Clinic in 1992, all nurses were trained in apheresis and were required to perform leukapheresis for the collection of PBPC. This consisted of a staff of 5 registered nurses. The initial model allowed for flexibility in staffing to accommodate a changing patient census and acuity in the clinic and apheresis. Our apheresis program has experienced a 50 % growth in the past 10 years. With this growth we have added two new apheresis devices which added another level of complexity to the scope of practice. As our program and staff grew, and as regulations regarding safe practice have evolved, we found it increasingly challenging to maintain apheresis competency for our larger staff, and still provide high quality care in the outpatient setting. Therefore, in 2010, we implemented an optional Core Apheresis Team model, to which nurses may voluntarily commit to being a member. To maintain apheresis competency of a core group of nurses, a regular rotation assignment was implemented and an apheresis coordinator was designated. Advantages of this model include: 1) improved competency validation 2) decrease in procedural errors 75% and associated costs in the first month 3) consistency in apheresis practice 4) increased nursing satisfaction by allowing nurses to opt whether they become a member of the core team. Apheresis has long been an outpatient procedure. As we move more care into the outpatient setting, our coordination of apheresis practice provides a model to follow for implementation of other services we provide to our ABMT patients. Background: Transplant nurse coordinators at City of Hope work daily to manage patient schedules, collaborate care coordination, provide patient education and achieve patient expectations through complexities of daily challenges. Employees create "work-arounds" instead of solving problems. As any work place, problems in the daily work are opportunities for improvement. At COH, there has not been a standard problem solving methodology. In many cases, improvements are implemented but are not consistently sustained. Not all staff members participate in project improvement projects. Solved problems, or "work-arounds," are not documented and tracked. COH recognized the need to create a culture of continuous improvement. COH needed to advance to daily problem solving and information sharing activities in the HEM/HCT department and as well as throughout COH Medical Center. Purpose: To create a process of daily problem solving and information sharing activities. The staff is fully engaged with; finding, prioritizing, assigning, and solving problems in progress until completion. To develop a place for staff to share information and to promote diversity & inclusion by encouraging all team members to share ideas with each other. Intervention: A pilot of Managing Daily Improvement (MDI) through daily huddles at the "huddle central" board was implemented in the department. Through the Accelerating City of Hope Excellence (ACE) team, management and key personnel were given education on an MDI tool: "huddle central." Standard work on conducting the huddle was created. Management and key personnel then educated staff on standard work which includes filling out "Improvement Opportunity" cards to identify challenges the staff have. Discussion: Through the ACE initiative, several key areas were selected to pilot MDI. HEM/HCT Nurse Coordinator area was one of first 4 areas selected. The focus is on practical problem solving to improve communication and promote a culture of continuous improvement. It establishes a daily discipline of finding, prioritizing, assigning, and solving problems until completion. Staff are encouraged and empowered to solve problems in teams. It is a place for staff to share key information about their daily work with each other. The huddle metric targets were: 1) solved 4 problems per month; 2) are held 90% of the time; and 3) 75% of staff attends daily. Since May, the problems solved per month averaged 6.75; huddles held per month averaged 95%; and staff daily attendance averaged 68%. Some examples of solutions were: improvement of pre-transplant class patient attendance; improvement of communication and disseminating information to other department; and improving timely turnaround of physician orders for signature. We will continue to monitor the metrics established, improve the daily huddle attendance and number of problems solved.