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ABSTRACTS
Year : 2023 | Volume
: 9
| Issue : 2 | Page : 73-115
Selected long abstracts from the st. luke's university health network quality awards program (2021–2022)
Diana M Tarone1, Anna Ng-Pellegrino2, Vanessa Reese2, Allincia Michaud2, Maria Martinez-Baladejo2, Michael Salibi2, Aaron Mack2, Christian Schill2
1 Department of Quality Administration, St. Luke's University Health Network, Bethlehem, PA, USA
2 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
Correspondence Address:
Dr. Anna Ng-Pellegrino
Department of Research and Innovation, 801, Ostrum Street, Bethlehem 18015, PA
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijam.ijam_33_23
The Annual St. Luke's University Health Network (SLUHN) Quality Awards Program (QAP) was created in 2008 to celebrate quality improvement throughout the Network. The program recognizes the contributions made by staff every day to provide quality health care to our patients and community. This venture has been very successful in encouraging our staff to become involved and to embrace performance improvement (PI) projects. The QAP is open to all twelve SLUHN campuses and other entities, including inpatient and outpatient areas, and both clinical and nonclinical staff.
The PI Project Manager is responsible for planning, organizing, and managing the timeline for the event with the assistance of other Quality Resources Department (QRD) members. The QRD also coordinates the organization's PI activities. These activities include network-wide planning, project development, team facilitation, statistical analysis, information retrieval, and the preparation of project data for audio-visual presentations. This team also identifies benchmark data sources, monitors PI requirements of regulatory and accrediting agencies, and educates staff on the appropriate use of PI tools and terminology.
A quality resources member is assigned to each project and serves in consultative/advisory capacity, providing mentorship to participating teams and supporting the application process. Blinded applications are sent to competition judges for review using pre-defined, objective criteria. Scoring evaluates PI methodology, relevance of the project to SLUHN institutional mission and alignment with The Five Points of the Star Leadership Model (quality, service, people, finance, and growth) which defines focus for our organization.
The Annual St. Luke's University Health Network (SLUHN) Quality Awards Program (QAP) was held on Oct 20, 2022 in Bethlehem, Pennsylvania. This special event marked the QAPs 14th year of recognizing network-wide contributions to improve the quality of care provided to our patients and community. Members from the Board of Trustees and Network Administrators participated in the ceremony, along with numerous care providers and other institutional contributors/supporters. There are six first-place winners, six second-place winners, and 12 honorable mentions. The submissions are grouped according to the above-defined areas of quality, people, service, finance, and growth. From among the first-place winners, The President's Award for Quality is chosen. In 2022, The President's Award for Quality was awarded to a project titled “SLUHN Travel Nurse Program” by members of the Human Resources, Education, and Patient Care Service Department: Elizabeth Kopp, Anil Pai, Rachael Kelly, Elizabeth Serratore, and Lenny Merchant.
Traditionally, our QAP has served as a springboard to external awards, other programs, as well as publications. We also take the opportunity to use this venue to acknowledge other achievements from around SLUHN. St. Luke's employees deeply value the QAP and embrace the recognition and pride it brings to the Network. In addition, the QAP creates a sense of healthy competition within the organization. It is an excellent way to recognize teams that proactively engage in, and demonstrate, performance excellence. In that capacity, the QAP plays a critical role in our journey toward performance excellence as an organization.
In this issue of the International Journal of Academic Medicine, we will present selected long abstracts from the award years 2021-2022, focusing on the highest quality submissions and QAP winners. Each abstract listing features primary authors while also fully recognizing all scientific contributors and participating quality project team members. As in previous years, each long abstract is uniformly structured and consists of an introductory section, project aim/objective, methods, results, sourced/referenced discussion, and conclusions.
The following core competencies are addressed in this article: Interpersonal and communication skills, Medical knowledge, Patient care, Practice-based learning and improvement, Professionalism, Systems-based practice.
Keywords: Hospital and Health System Association of Pennsylvania, performance improvement, quality awards, quality improvement, St. Luke's University Health Network
Abstract Number 1SLUHN Travel Nurse Program
Elizabeth Kopp1, Allinica Michaud2, Anil Pai3, Rachael Kelly3, Elizabeth Serratore1, Lenny Merchant4
Departments of 1Educational Services, 2Research and Innovation, 3Human Resources Management Systems and People Services and 4Patient Care Services, St. Luke's University Health Network, Bethlehem, PA, USA
Core competencies addressed in this abstract: Practice-based learning and improvement, Systems-based practice.
Year of submission: 2022
Introduction: The number of healthcare professionals in the workforce has been steadily declining, and this has had significant implications, leading to delayed or inadequate healthcare services, increased healthcare costs, health disparities and more patients presenting with debilitating conditions.[1],[2],[3],[4],[5] Thus, with the growing number of inpatient visits and the increasing shortage of nursing professionals nationwide, there has been a deficit of hospital nurses (departmental/inpatient) to provide care.[1] Shortages vary by type of nurse, level of care, and geographic location, with rural and underserved areas being the most affected. The U.S. Bureau of Labor Statistics estimates that more than 275,000 additional nurses are needed from 2020 to 2030.[2],[3] Although the scarcity of clinicians/physicians can exceedingly negatively affect healthcare systems, because of the magnitude of nurse shortage and because nurses deliver the highest percentage of patient care, the nursing shortage is said to be most perilous for healthcare systems.[1],[2],[3] According to the 2022 Nursing Solutions Inc (NSI) National Health Care Retention & RN Staffing Report, there is a 2.47% reduction in the hospital registered nurse (RN) workforce, resulting in an RN vacancy rate of 17% nationwide.[4] This is a significant increase from 2021 (7.1 points) and “has a direct impact on quality outcomes, the patient experience, and leads to excess labor costs such as overtime, travel/agency usage.“[4] With COVID-19 further highlighting the effects of the nurse shortage on the hospital workforce, hospital systems nationwide are finding it extremely challenging to retain their staff and to develop recruitment strategies that could keep up with the pace of this vacancy rate. Thus, managers turned to travel or staff agencies to temporarily provide qualified RNs through various incentives and methods. However, there are some challenges that come with hiring Agency Nurses, most notably the associated expenditure. The average cost of an agency nurse is $154.00/hour which converts to $320,320.00 annually per 1.0 full-time equivalent (FTE), which is considerably higher than a hospital-budgeted nurse.[4] In addition to the financial burden, agency nurses lack an understanding of the network's mission, vision, and core values. During their strategic analysis, the St. Luke's Nursing Leadership Team identified a surge in the use of agency nurses throughout the network to fill nursing vacancies. To compete with the competitive hiring market and to decrease the amount of agency nurses, we developed an internal St. Luke's University Health Network Travel Nurse Alternate Route Program (SLUHN-TNARP). By integrating, creating, and implementing our internal Program, we can instill the standards of St. Luke's mission, vision, and core values while having a positive budgetary impact on the network.
Aim and Objectives: The primary aim of this project was to reduce the number of agency nursing staff utilized across the network in-patient setting by 50% within six months through the development and implementation of a standardized internal SLUHN Travel Nurse Alternate Route Program.
Methods: Development and integration of the quality improvement project program into the network's system occurred over a three-month period, from September 2021-December 2022. To effectively implement a network-wide bridging institution-specific program, a multidisciplinary team was established to collaborate and develop the SLUHN TNARP. The key stakeholders were comprised of the Information Technology and Processes team, Nursing Director, Educational Specialist, Credential Trainer, and others. In developing and streamlining our innovative onboarding and orientation process for prospective nurses, the team initially conducted a comprehensive evaluation and review of the SLUHN Nursing Policy and Procedure Orientation as well as the Administrative Policy and Procedure Manual: Non-Employed Personnel policy manuals, to gain insights into the current process for onboarding and orientation of both SLUHN budgeted nurses and external agency nurses. This analysis was then used to establish the Travel Nurse Alternate Route program framework. Based on preliminary data, each aspect of the Program would need to meet all accreditation standards while decreasing the amount of time spent in orientation. Subsequently, this accelerated program would require applicants to have 1-2 years of experience within the specialty they were applying to. Once the framework was established, the Travel Nurse Alternate Route End-to-End process was developed, which set the responsibilities of the various stakeholders in the project [Figure 1]. Using the End-to-End process, stakeholders (Information Technology and Processes team, Nursing Director, Educational Specialist, Credential Trainer, etc.) were assigned job-specific tasks, these include:
Figure 1: Travel and agency nurse alternate route orientation end-to-end.[5],[6] HR = Human resources, MEL = My E Learning, LMS = Learning management systemDevelopment of system integrations in the Workday platform (financial and human capital management system) to create the role of an Internal Travel NurseCollaboration of specialty-specific clinical educators in the development of various technical skills checklists and skills self-assessmentsDevelopment of Medication Administration and Dysrhythmia Assessments that would determine a nurse's competency in these areas with remediation/retest plans for varying resultsReviewed and revised current New Hire My E-Learning programs (SLUHN-specific learning platform) to streamline what was assignedDevelopment of standardized teaching contentDevelopment of an online phlebotomy program that would reduce the amount of in-person trainingDevelopment of various specialty-specific “playlists” that would deploy the appropriate required online learning modulesIdentification of physical training location, supplies, and instructors needed for trainingDevelopment of a fit testing plan to provide Personal Protective Equipment (PPE) masks that could be utilized in all SLUHN Hospitals.Educators for the theoretical aspect of the program were then recruited, and campus leads were identified to guarantee that the program was implemented and followed according to the outline. The campus leads were brief on the new process for “the alternate route' orientation process, and they provided necessary feedback. During this time, it was identified that additional resources were required to provide better support for the different facets of the program. As such, prior to the implementation of the program, the following resources were created and provided:
Patient Care Manager (PCM) Overview: Travel & Agency Nurse Position Request & Onboarding GuideExpress Class Tip Sheet for uploading checklistsMEL (My E Learning) Test Engine Review Tip SheetAlternate Nurse Route Program Overview for Educators Supporting Classroom Day 1 OrientationFit testing training for Educators supporting Classroom Day 1 Orientation.Due to the immediate and urgent staffing needs, the Human Resources department underwent restructuring and reorganizing to ensure efficient onboarding and orientation while still setting the agency/travel nurse up for success in providing safe and quality patient care. Consequentially, with the assistance of the Workday team, a 3-day onboarding and orientation process was implemented. The Workday team also created a “new hire weekly report/schedule” crucial in identifying the workforce needed during orientation. A post-orientation survey to assess participants' attitudes on whether the program prepared and supported their need to care for patients in the health system was also instituted. Additionally, the Workday team took innovative steps to facilitate the program's new hire orientation. They applied a self-assessment via Workday to optimize and streamline initial competency documentation. After the Nurse Travel Program framework was established and integrated, potential travel nurse applicant began their application by completing a skills self-assessment, interviewing with appropriate patient care areas, and, if offered, completing the appropriate assessment materials [Figure 2].
The piloted program was implemented in the 2022 calendar year, from January 2022 to July 2022. Post-orientation survey results were collected and tabulated for nurses enrolled in our travel program. Additionally, data on the number of nurses associated with external agencies and their cumulative institutional expenditure were collected, analyzed, and subsequently compared to the novel program. This cost analysis was based on the average per hour rate of $160-$175 for agency nurses versus the average hourly SLUHN nurse rate of $115 at the time of the study and was adapted as the agency pricing diminished.
Results: At the launch of the program in January 2022, 181 external agency nurses were working at SLUHN, with the inaugural class consisting of 9 nurses, for a total of 190 travel nurses. The post-orientation survey, which focuses on questions that gauge participants' feelings about being prepared and supported to care for patients in our health system, notes that approximately 85% of nurses found the orientation sufficient and relevant and provided the necessary information to perform their job function successfully. While 14% thought the orientation length was inadequate, less than 10% found the materials to be inept or redundant [Figure 3]. Six months (January-July) after implementing the program, the team had reduced the volume of external agency staff utilized by the network and increased the number of SLUHN travel nurses. The number of external agency nurses peaked in March 2022 at 260, and by July 1st, 2022, there were 169 internal SLUHN travel nurses and only 99 external agency nurses within the network [Figure 4]. Thus, we saw a 62% decrease in external agency nurses and a 95% increase in SLUHN travel nurse recruitment. The SLUHN-TNARP also led to the conversion of 93 agency nurses to internal SLUHN travel staff. At the same time, 68 (40%) of the SLUHN travel nurses extended their stay within the network after their initial contracts were completed. Furthermore, at the end of our initial study period, four nurses from the travel agency converted into SLUHN budgeted employee positions.
Figure 3: Agency post-orientation survey results. PCRAFT = Pride Caring Respect Accountability Flexibility Teamwork
Figure 4: Total expenditure and number of nurses associated with External Agency vs. Internal SLUHN Travel Nurses (January 2022–July 2022). SLUHN = St. Luke's University Health NetworkDiscussion: A declining nursing workforce is not a new problem; however, this deficit has become worse with the COVID-19 pandemic, further broadening this deficiency. Numerous policies and strategies over the last decade have been proposed to address this, from federal to state policies to hospital and institutional programs.[5]. For employers and institutions, strategies include increasing recruitment and retention efforts, expanding education and training programs, and providing financial incentives. We believe an in-house Alternate Travel Nurse program is one of the best strategies to address this constantly changing environment. To our knowledge, six (6) other Health Systems - Mercy Health System, Advent Health, UC Health Colorado, and OSF HealthCare, have instituted similar internal traveling nurse programs throughout the country, with the University of Pittsburgh Medical Center (UPMC) and WellSpan Health being the newest addition. Of the health system mentioned above, only UPMC and WellSpan offered such programs in the Mid-Atlantic US area. We are the first to launch the internal traveling nurse programs within our institution's service area and within Lehigh Valley [6],[7]
This initiative has substantially reduced the number of agency travel nurses employed by, and within our institution. Financially, the SLUHN-TNARP has resulted in an estimated $820,330.00 in savings on classroom orientation costs and $972,952.00 on preceptor clinical orientation costs. Clinically the network saved an estimated $2,594,598.95 over the six-month period by using SLUHN travel nurses. At the end of the piloted period, the SLUHN TNARP saved the network an estimated $4,387,880.95. Based on these preliminary results, the network's budgetary savings are projected to double after 1 year. At the end of our pilot phase, Geisinger Medical Center, a health system in the northeastern area, announced the establishment of its internal travel nurse program [8].
Limitations: Even though the initiative effectively achieved the primary goal, throughout the first weeks of the program operation, several barriers were encountered and a few areas that needed strengthening that prevented the execution of the program from running smoothly. As an example, there were unexpected delays with IT services in allowing travel nurses access to the hospital EMR (EPIC) and automatic dispensing cabinets for medications. In addition, it took time to have all travel nurses complete their assigned online education. Feedback from the educators organizing the training, HR staff assisting with the onboarding, onboarding managers, and the new hires surveys were considered when making program changes. These include NIH Stroke certifications, badge readiness, new hire orientation documentation completion, and PCM onboarding access for MEL/Epic. As appropriate, subcommittees/task forces were developed to create solutions. Implementation improvements were seen in the onboarding and orientation with each solution. Other limitations of this study include a lack of cost data for the first month of the program, which could lead to an incomplete picture of the overall costs.
Conclusion: Implementation of the SLUHN Alternate Travel Nurse program was successful in reducing the reliance and cost of agency staff while providing a potential long-term solution for shortages and future growth/recruiting of staff that embody the values of the network. This initiative is ongoing, and as the institution enrolls more applicants and expands the program into other disciplines, the new SLUHN-TNARP is anticipated to invariably reduce the network's future reliance on agency staff and its expenditure while retaining staff.
ReferencesAmerican Association of Colleges of Nursing. Nursing Fact Sheet. American Association of Colleges of Nursing: The Voice of Academic Nursing; 2022. Available from: https://www.aacnnursing.org/news-Information/fact-sheets/nursing-fact sheet#:~:text=Nurses%20comprise%20the%20largest%20component,the%20nation' s%20long%2Dterm%20care. [Last accessed on 2023 Apr 10].US Department of Labor. Employment and Training Administration. US Department of Labor Announces $80M Funding Opportunity to Help Train, Expand, Diversify Nursing Workforce; Address Shortage of Nurses. U.S Department of Labor; 2022. Available from: https://www.dol.gov/newsroom/releases/eta/eta20221003. [Last accessed on 2023 Mar 27].Haddad, Lisa M., Pavan Annamaraju, and Tammy J. Toney-Butler. “Nursing shortage.” In StatPearls [Internet]. StatPearls Publishing, Treasure Island, FL, 2022. [Last accessed on 2023 Apr 10].NSI National Health Care Retention and RN Staffing Report. NSI Nursing Solutions Inc; 2022. Availabe from: https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf. [Last accessed on 2023 Jan 20].Costa, D. K., & Friese, C. R. (2022). Policy strategies for addressing current threats to the US nursing workforce. The New England journal of medicine, 386(26), 2454-2456.UPMC Media Relations. (2021). UPMC launches Travel Staffing Agency to address nursing shortage. UPMC. https://www.upmc.com/media/news/121721-upmc-travel-staffing. [Last accessed on 2023 May 14].Brusie, C. (n.d.). These hospitals offer internal, direct-hire, travel nurse programs (list). Nurse.org. https://nurse.org/articles/hospitals-internal-travel-nurse-programs/. [Last accessed on 2023 May 14].Geisinger News Releases. (2022). Geisinger Launches Travel Nurse Program. Geisinger. https://www.geisinger.org/about-geisinger/news-and-media/news-releases/2022/06/10/18/02/geisinger-launches-travel-nurse-program. [Last accessed on 2023 May 14]. Abstract Number 2 Automating Testing in IT to Reduce Project Costs and Manual Testing Efforts
Joe Borda1, Maria Martinez-Baladejo2, Matt Rumpf1
Departments of 1Information Technology and 2Research and Innovation, St. Luke's Health Network, Bethlehem, PA, USA
Introduction: Automatic testing, also known as automated testing or test automation, refers to using software tools and scripts to execute tests on a software application automatically.[1] Automatic testing can speed up testing, allowing for faster software application deployment and release. Automated testing can detect defects and errors that may not be found during manual testing. Improving the software quality enhances medical records, improving the overall patient care quality. While automated testing requires an initial investment in software and tools, it reduces the need for manual testing, freeing up resources for other tasks and reducing associated costs. Finally, automated testing can cover more test cases and scenarios than manual testing, leading to a more inclusive testing process. Automatic testing tests the application based on a script created by humans. These scripts can be re-executed multiple times continuously, which helps to save time over manual testing.[1] Automated testing aims to eliminate repetitive efforts and decrease the turnaround time of reported issues in production.[2] One of the limitations of automated testing is that initially, the scripts have to be created; this can occur manually by human effort or by using artificial intelligence (AI).[1] Epic[3] integrated test scripts are a list of steps analysts use to test a workflow from start to finish, ranging from 50 to 600 steps per script. Eggplant, an automated testing tool, uses image-based testing and machine learning, eliminating the need for traditional scripting or code-based approaches. This enables users to create tests quickly and easily without programming. Machine learning improves test automation by learning from past results, identifying potential issues, and suggesting areas for improvement.[2],[4] This, in turn, decreases the false positives and negatives. Overall, automated testing is a valuable tool in information technology (IT) for reducing project costs and manual testing efforts while improving the quality of software applications.
Aim and Objectives: The testing automation initiative aims to reduce the hours IT analysts spend performing manual testing by 79% within the first year of implementation on those workflows added to the automated software.
Methods: Due to an increase in manual testing in the network, in the summer of 2019, the IT Testing Team, now named Readiness & Delivery (R&D) team, started exploring options to automate the Epic testing efforts performed by IT analysts [Figure 1]. To perform this manual testing, 16 IT analysts were assigned 16 weeks of testing. During these testing efforts, 100 individual integrated test scripts were run, 37 of which overlapped between campuses. The goal of performing testing automation was to make the process faster and reduce repetitive tasks. These were key performing indicators that we used to evaluate our testing automation output, focusing initially on project resource hours and cost by reducing the manual testing performed by IT analysts. As part of a review using Epic recommendations as well as reviewing the Gartner Magic Quadrant for testing automation solutions, the product Eggplant Testing Automation was selected as our software solution and production licenses were obtained in March of 2020.[4] Using a return on investment (ROI) tool provided by Eggplant, it was estimated that we could reduce our manual testing efforts for automated workflows by 79%. When deciding which workflows would be first automated, the R&D team reviewed the most repetitive workflows being performed by Epic analysts during testing initiatives for the three new hospitals built in 2019. Based on this review as well as input from Epic teams via a survey [Figure 2], it was decided that test patient creation and registration would be the first major effort to be fully automated. For data analysis, the R&D team maintained a document in a password secured Excel program highlighting the workflows and efforts replaced by automated scripts to track ROI. Estimated manual hours saved when replaced by the automated testing efforts and the time spent in developing automated solutions can be seen in [Figure 3] and [Figure 4]. To create and confirm script success, we developed a workflow seen in [Figure 5], which allowed us to match the automation of the work IT analysts would normally perform manually. Once the automation script was written and approved by the team owning the workflow, the script was then updated to track issues better and provide documentation within the programming code. If the workflow reviewed with the R&D team were incorrect, the team would correct the computer program code to correct the script. Descriptive statistics were performed for the data analysis.
Figure 1: Proof of concept and production timelines. FTE = Full-time equivalent, POC = Proof of concept
Figure 3: Estimated cost savings of manual testing labor versus time to develop automated solution. RPA/Decom = Robotic Process Automation/DecommissionResults: Prior to the implementation, the team spent 10 hours of their work time in training, and the initial cost of the software license was $105,000. In 2019 it was estimated that the IT analysts' most repetitive workflows, creating a test patient and registration, took five to ten minutes to complete per patient. It was also estimated that automating these scripts would save 8-17 hours of work [Figure 4]. In addition to these scripts, 12 other processes were automated [Figure 6]. Based on automated workflows built and executed from March 2021 through May 2022, a reduction of 94% of manual testing hours was saved. This equates to 1,525.5 FTE hours and $91,530 full-time equivalent (FTE) resource dollars being saved amongst the IT Projects where testing automation was used instead of manual resource time [Figure 6]. Time saved from automation by reducing the testing window can be seen in [Figure 7].
Figure 4: Manual testing effort work versus automated examples. ADT = Admission, discharge, and transfer, CRM = Customer relationship management
Figure 7: Automated script time to test versus manual time to test. RPA = Robotic process automation, Decom = Decommission, CRM = Customer relationship managementDiscussion: The primary goal of reducing manual testing hours by more than 79% for a total of 94% for the scripts that have been automated in the system was achieved. This equated to 1525 FTE hours that the IT analysts were able to use to assist other projects and also saved the network $91,530. Currently, there is no consensus in the literature on the cost-effectiveness of automated testing. Ramler and Wolfmaier [5] describe this as the break-even point, which refers to the manual vs. automated cost of testing. Once the break-even point is surpassed, the execution cost is reduced. We demonstrated that the initial cost was high but after surpassing the break-even point we were able to reduce the cost in the network. While automated testing reduces expenditure, manual testing can also be expensive as there may be tasks that are tedious are lengthy. [6] With this project, it has been shown that as automated scripts perform more workflows, the time it takes to complete comparable work when using manual resources decreases. This will allow project timelines to shorten to account for the more efficient and faster testing efforts being performed by the automation work being developed by the R&D team [Figure 6].
Two internal major initiatives using automated scripts demonstrated promising results. The first used an automated script to compare 8,000 patient records between the Microsoft Customer Relationship Management (CRM) and Epic databases, which saved 667 manual testing hours and $40,020 towards that project. The second used Eggplant as a robotic process automation (RPA) tool. This effort saved 775 manual hours and $46,500 by creating an automated script to export each of the 31,000 patient records on the Quakertown AllScripts Pro server to a file. An outside vendor was also quoted to perform this work at $51,250, which was saved by the work being completed by internal employees and the Eggplant tool. Both projects are referenced in [Figure 3], [Figure 6], and [Figure 7].
During the studies calendar year, the implementation cost totaled $102,000, and the savings for that year equaled $142,780. In total, the network saved $37,780 using script automated testing. Our automated testing results are comparable to previous results in the literature. For example, Fewster and Graham [7] explain a study that found that it cost more to manually find and resolve computer software bugs, which translates in the company losing revenues and customers. Another example is the use of Infosys by Honda which was able to achieve a 90 percent cost reduction of their manual testing through automation.[8] During the project's first phase, the analyst assigned to developing automated testing scripts was not entirely dedicated to these efforts. One of the limitations of automated testing is the maintenance overhead. Automated test scripts require manual maintenance, as changes in the software application can require updates to the test scripts. However, these changes within the network take approximately 30 minutes to one hour to complete and only occur once or twice per year. Two fully dedicated analysts were assigned to this automated testing in order to overcome these limitations, increase the number of scripts, and subsequently increase the savings to the network. Another limitation of the implementation of automated testing was network security measures involving the use of remote computers. This was overcome by discussing the solution and lack of data sharing with the Information Security Officer, Eggplant, and CORL (a vendor that the IT Security team uses to review the cyber security of a third-party before it can be used inside the network). Once it was understood that no data sharing would occur with the script coding program, the security team approved the project.
Conclusions: The team will continue to build out more Epic workflows to automate for testing. The more workflows become automated, the more coverage the solution will have on the validation of Epic changes. Also in development is a Digital Artificial Intelligence (DAI) solution to allow testing scripts to be scheduled nightly. This will allow testing to become proactive and continuous, reporting out daily on Epic and building changes that are now causing issues from the prior day. Work is also underway to build a library of automated testing for the in-house developed St. Luke's mobile application. The application is currently manually tested by a group of 2-3 analysts. Building out a library of automated testing for this work is high on the priority list to not only free up those analysts, but to supply better coverage of testing for the mobile development team on both their Android and Apple iOS builds. Work for the upcoming National Leapfrog awards in 2023 will also be considered for work that can be automated. This work is currently done by several IT analysts over 3-4 weeks. Moving this prep and information-gathering work into an automated solution will save time and free up those 2-3 analysts that would typically be dedicated to that work. The team is looking forward to the future and producing more automated testing and RPA solutions to improve workflow within the network. Outside of testing, work to replicate tasks using automation is increasing as well. Currently, nine other servers require patient records to be exported before they can be decommissioned. Using the automated scripts, a savings of approximately $50,000 per server to automate these exports can be expected.
ReferencesSamad, Abdus, Md Tabrez Nafis, Shibli Rahmani, and Shahab Saquib Sohail. “A Cognitive Approach in Software Automation Testing.” In Proceedings of the International Conference on Innovative Computing & Communication (ICICC). 2021.Matson SG. “How to leverage intelligent automation for differentiation in application testing services.” Gartner Research. April 1, 2019. P. 1-10. https://www.gartner.com/en/documents/3906267. Last accessed: 20 May 2023.Johnson III R. “A comprehensive review of an electronic health record system soon to assume market ascendancy: EPIC.” Journal of Helathcare Communications. Vol 1, no. 4:36, 8 August 8 2018, pp 1-16. iMedPub Journals. Doi:10.4172/2472-1654.100036.Herschmann J, et al. “Magic quadrant for software test automation.” Gartner Research. 27 November 2018. https://www.gartner.com/en/documents/3975493. Last accessed 19 May 2023Ramler R. & Wolfmaier K. Economic Perspectives in Test Automation: Balancing Automated and Manual Testing with Opportunity Cost. Proceedings of the 2006 International Workshop on Automation of Software Test. 2006. DOI: 10.1145/1138929.1138946.Murazvu, GV. Software testing: an analysis of the impacts of test automation on software's cost, quality and time. 2020. University of Huddersfield. PhD dissertation. https://www.academia.edu/78864424/Software_Testing_An_Analysis_of_the_Impacts_of_Test_Automation_on_Software_s_Cost_Quality_and_TimeFewster, M., and Graham, D. Software test automation: effective use of test execution tools. ACM Press/Addison-Wesley Publishing Co. 1999Honda saves 90 percent on manual test operations through automation. Infosys. 2023. https://www.infosys.com/services/validation-solutions/features-opinions/honda-save-through-automation.html Abstract Number 3 A Multidisciplinary Approach to Reduce Employee Injuries Associated with Workplace Violence
Kelsey Hochheimer1, Maria Martinez-Baladejo2, Linda Machado3, Christina Zelko-Bennick4, Andrew Benner3
Departments of 1Patient Care Services, 2Research and Innovation and 3Quality Resources, and 4Network Patient Care Services and Inpatient Behavioral Health, St. Luke's Health Network, Bethlehem, PA, USA
Introduction: Workplace violence (WPV) is a significant issue in various industries, including healthcare. Hospitals are high-risk environments due to the nature of the work. Healthcare professionals face multiple risks and threats from patients, visitors, and sometimes co-workers. Studies have shown that WPV in psychiatric units is of significant concern.[1],[2] Hesketh et al. found that 20% of psychiatric nurses were physically assaulted, and 43% were threatened with physical assault.[3] WPV can result in injuries ranging from minor to severe, temporary and permanent disability, psychological trauma, increased job stress, low morale, a hostile working environment, and even loss of life.[4] A meta-analysis found that 7.5% to 33% of nurses that experience WPV often develop post-aggression symptoms such as anxiety, depression, and avoidance behavior.[1] Moreover, post-traumatic stress syndrome is also common and can occur regardless of the severity of physical damage.[5] Finally, WPV decreases employee engagement and job satisfaction and severely affects the quality of care of healthcare workers, which is detrimental to the overall functioning of the healthcare system.[4],[6],[7],[8] The Occupational Safety and Health Administration (OSHA) states that a well-written WPV Program or incorporating WPV prevention into a preexisting Safety and Health Program, combined with engineering controls, administrative controls, and training, can reduce WPV.[9] To create an effective intervention, OSHA states that there are five necessary building blocks: management commitment and employee participation, worksite analysis, hazard prevention control, safety and health training, record keeping and program evaluation.[9] Lakatos et al. implemented these recommendations in the SAFE (Spot a threat, Assess the risk, Formulate a safe response, and Evaluate the outcome) quality improvement project, which decreased WPV by 40% after implementing an interprofessional committee that evaluated the cases and educated the personnel.[10] It is crucial to understand the causes and effects of workplace violence in hospitals and to develop strategies to prevent and address such incidents. This quality improvement study explores potential solutions for the issue of workplace violence in behavioral health units.
Aims and Objectives: The study's primary objective was to reduce employee injuries associated with workplace violence in all St. Luke's Sacred Heart Behavioral Health Units (BHU) by 10% by June 2022.
Methods: A multidisciplinary team at the Sacred Heart Campus was developed in April of 2021 to discuss WPV within the Sacred Heart Campus of the hospital network, due to an increase in WPV events and associated injuries across the campus, specifically in the BHU. The development of the multidisciplinary team falls in line with Standard LD.03.01.01 from the Joint Commission R[3] Report released in June 2021.[11] This multidisciplinary team consisted of senior leadership, nursing management, human resources, security, quality and clinical risk management, behavioral health education, and frontline staff. The primary target population was healthcare personnel from behavioral care units. Personnel were included into the study only if they had been hurt or injured by a patient. Personnel were excluded if the injury was not caused by a violent or threatening act by the patient (i.e.: an employee hurts his back lifting a patient in behavioral health would not contribute/require the WPV follow up form). The committee met monthly and established a charter that outlined the committee's purpose and reporting structure through the campus's Physical Environment & Emergency Management Committee. The initial interventions were implemented in May 2021. Interventions included the development of a WPV injury follow-up form that garnered valuable information and was subsequently utilized to trend WPV injuries while assessing gaps and/or barriers in current processes. To brainstorm contributing factors to WPV injuries/events, the WPV Prevention Committee created a Fishbone Diagram [Figure 1]. These factors were based on notable trends within the department and feedback from frontline staff. Utilizing a rapid Plan-Do-Check-Act (PDCA) cycle, small tests of change were implemented throughout the next year and a half while evaluating the efforts impacting on the overall rates. Best practice interventions were identified and implemented over time. Furthermore, the committee expanded its membership to include representation from all behavioral health units across the network. With support from leadership, personal panic buttons were reinforced and provided to staff to wear on their person to alert the unit if there was a concern. Training was provided to staff by demonstration when the new panic buttons were rolled out. We also reinforced the use of restraints during training. For data collection, Workday (a Human Resources platform) was used, in addition to the implemented Work-Related Employee Injury Follow-Up Form. The form consisted of interviewing the employee to share their experience, feedback, and learning opportunities to prevent future WPV encounters [Figure 2]. All employees who were victims of WPV were also required to have a follow-up meeting with their manager to discuss from their perspective what had occurred, concerns moving forward, and suggestions/feedback for improvement. With senior leadership approval, the campus transitioned in October 2021 from Crisis Prevention Intervention (CPI®) to Management of Aggressive Behaviors (MOAB®). This training was provided twice a month as an additional layer to help staff learn de-escalation techniques and hands-on training. Behavioral Health Education Specialists created a bi-monthly newsletter with up-to-date information on spatial awareness, de-escalation techniques, and pharmacological management of aggressive patients. The committee co-chairs also facilitated three pieces of training, launched as mandatory training across the Network, including behavioral health staff. Statistical analysis was performed using descriptive statistics in Excel. An improvement in outcome was defined as a decrease of 10% WPV-related injuries from the fiscal year 2021 (FY21) to the fiscal year 2022 (FY22).
Figure 1: Fishbone diagram of contributing factors to workplace violence. R/T = Related toResults: This study included 5 behavioral health units with a total of 109 patient beds. After the initiation of the WPV Follow-up form for an entire fiscal year (FY22) there were 19 reported instances of WPV associated injuries within these departments, compared to the fiscal year prior (FY21) where there were 27 instances of WPV. This represents a 29.6% reduction in incidents. The severity of WPV injuries was also monitored using the following criteria: mild – no assessment by a health care provider, no missed work time, moderate – assessment by a health care provider but no missed work time, and severe – assessment by a health care provider and the employee missed work time. Using the previously mentioned criteria, in FY21 there were 6 severe WPV injuries, compared to FY22 where there were 4 injuries classified as severe, 33% reduction in severe WPV associated injuries. This quality improvement study focused on reducing WPV-related injuries by 10% from FY21 to FY22 in the behavioral care unit of St. Luke's Sacred Heart. In FY21, the overall employee injury rate due to WPV in behavioral care units was 0.87%, resulting in 517 missed workdays. As of June 2022, the injury rate for FY22 is 0.67 [Graph 1], resulting in 226 missed workdays. This totals a 23% decrease in the overall employee injury rate, and a 56% reduction in missed workdays.
Discussion: Despite having established education and training programs for frontline staff that were specifically focused on crisis intervention, de-escalation, management of agitation, and personal protection; we realized that an increasing proportion of the patient population was presenting with more violent and psychotic behaviors. There were also variations in the education provided to staff as it pertained to Control Teams, PRN medication administration, and Workplace Violence as a whole. There were also variations in how WPV events/injuries were managed across all units. After the implementation of this quality project, we achieved our aim of reducing employee injuries across all Sacred Heart Behavioral Health Units as a result of workplace violence by 10% by June 2022. Prior to the implementation of this project, the overall employee injury rate due to WPV was 0.87% compared to 0.67% after the implementation [Graph 1]. We also observed a 23% decrease in WPV at the St. Luke's Sacred Heart Campus within the Behavioral Health Units year after the implementation. These results are comparable to those found in the literature. For example, Lanza et al. found that having biweekly 30-minute community meetings in the inpatient behavioral unit to discuss topics related to WPV reduced incidences of violence by 85% [10]. Moreover, an Ohio hospital found that implementing WPV training techniques and protective personal equipment reduced staff injuries by 65% [11]. Moreover, research has shown a correlation between WPV, absenteeism, and attrition rates [12],[13],[14],[15],[16]. In this quality improvement program, we observed a 56% reduction in missed days among healthcare workers in the behavioral units.
We achieved these results by formalizing a prevention program and overseeing WPV events with a multidisciplinary team. This team implemented a form to report incidents in the internal human resources platform, analyzed incident trends, standardized follow-ups, and supported victims and witnesses affected by workplace violence. The standardization of the follow-ups allowed the employee to be referred to an employee assistance program if necessary. When the follow-up interviews occurred, witnesses were involved in them. The committee then discussed areas for development after reviewing the case in a monthly meeting.
At the beginning of this project, there were no consistent means of alerting the floor when there was an escalating patient. Thus, as panic buttons are associated with lower physical violent rates,[17] we implemented personal panic buttons that could be used in escalating aggressive situations. We also found that nurses often have an ethical dilemma when applying restraints.[18] As a consequence, restraints can be underused, and not used at all even when the aggressive situation demands it. Thus, we encourage nurses to use restraints when appropriate, and w
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