With a record volume of patients being seen across all emergency departments (EDs), UW Health is continuously looking for ways to ensure patients receive safe and timely care. At University Hospital, a cross-functional group of ED team members partnered with Organizational Improvement to conduct a three-day rapid improvement event (RIE) focusing on the safe, timely assessment and rapid treatment (CareSTART) area of the ED. 

With CareSTART, a nurse, physician, advance practice provider and ED tech rapidly assess patients to initiate care even before they can be placed in an ED treatment room. 

The goal of the rapid improvement event was to gain efficiency, decrease time from patient arrival to initiation of care and create a more sustainable process for staff. The team gathered data before the event to have a good understanding of current challenges and allow them to quickly begin generating ideas for change on the first day of the event.

Ray Kline, BSN, RN, is one of the emergency department nurses who participated.

“As part of the preparation weeks ahead of the event, observers tracked my movements and then again studied my processes during the event,” Ray said.

Staff were timed performing tasks by observers with stop watches. “One of the biggest things we found was how much energy and time was wasted looking for medications and supplies,” said April Wilson, RN, nurse manager.

On the second day of the event the team began implementing tests of change and deciding whether to adopt, adapt or abandon each change. They brainstormed 30 improvement ideas — 20 were tested and eight ideas were implemented.

Day 3 of the event was used for final testing of changes and development of a sustainment plan.

Some changes implemented include reassigning tasks to a different team member, performing tasks in a different order, relocating frequently used supplies and equipment and updating the stocked medications in the CareSTART Omnicell (automated dispensing). These changes addressed different types of waste in the process, including extra time members spent searching for supplies as well as unnecessary waiting and transport of materials from one place to another. 

Eliminating the unnecessary activities saved a significant amount of time — 2 minutes per patient by standardizing supplies and three minutes per patient by standardizing available medications. A total of six hours per day of non-value-added activity was eliminated. 

“One of the greatest benefits of this rapid improvement event is how it empowers frontline staff, who are most familiar with the work, how to identify and implement changes. They choose the things to try,” said Jen Hankwitz, Director of Emergency Services. 

Ray said the impact of the event goes beyond fixing the initial problem. “We’re familiar with the process now which will hopefully more easily help us solve problems down the road,” he said.

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Check out more stories featuring the great work of our nurses in the Nursing Year in Review 2023 (pdf).

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To better meet the needs of our newest nurses in a post-pandemic world, nursing leadership made important changes to the UW Health Nurse Residency Program and Nurse Externship Program.

Nurse Residency Program

UW Health implemented the Vizient/American Association of Colleges of Nursing Nurse Residency Program for inpatient care in 2004 and added a nurse residency for ambulatory care in 2021. Through the residency program, newly hired nurses train for 12 months alongside experienced colleagues following graduation from an accredited nursing program.

This intensive training has become even more important in recent years.

“At the time COVID-19 was happening, we thought it was an intense in-the-moment experience,” said Kim McPhee, MS, RN, NPD-BC, who has coordinated the program for 17 years. “We thought we’d return to normal, but what was considered ‘normal’ has changed.”

Graduating nurses are much less confident about their skills and much more anxious. “It’s normal to feel anxious transitioning from student to professional nurse, but we were finding ourselves triaging acute distress situations we had never experienced before,” said Molly Daniels, MSN, RN, CMSRN, nursing education specialist, who supports the inpatient residency and externship programs.

UW Health is one of a handful of organizations in the country to offer a nurse residency for ambulatory care. A special focus on telephone triage training helps build assessment skills and a strong foundation for new nurses who may not always see patients in person. Terri White, RN, MSN, NPD-BC, nurse education specialist, supports the Ambulatory Nurse Residency Program. With feedback from their UW–Madison School of Nursing colleagues and recent graduate nurses, Kim and Molly made changes to the inpatient program to help nurse residents build stronger skills and a community of support. New resident orientation includes more skills-building training and is now offered in longer days, and monthly classes were moved so everyone could meet as one large group. Additionally, the well-being series was expanded and is now included in monthly classes.

Responding to a survey is usually not at the top of anyone’s to-do list, especially for health care professionals who are already busy prioritizing patient care and supporting their teams. But while the task of taking surveys might be inconvenient, the results are essential to the development of well-informed, data-driven decisions and action plans.

RN satisfaction: Why we survey

UW Health Employee Voice Strategy, managed by Human Resources, provides employees with multiple opportunities to give feedback or offer ideas on how to improve the workplace through participation in different surveys (e.g., annual engagement survey, annual diversity, equity and inclusion survey, biannual culture of safety survey).

The RN satisfaction survey provides an opportunity beyond the annual all-employee engagement survey to hear from nurses regarding elements specific to their nursing practice experience, with the goal of identifying opportunities for improving the practice environment for all UW Health nurses. Additionally, data from this survey is required to participate in national benchmarking opportunities and to meet external reporting requirements (e.g., regulatory and Magnet).

Survey vendor comparison

Historically, UW Health nursing in Wisconsin and northern Illinois has used the National Database of Nursing Quality Indicators (NDNQI) as our RN Satisfaction Survey vendor. The survey market, however, has evolved and there are new vendors available that provide comparable, if not more robust, survey tools and support. Perceptyx is one such vendor that also serves as the preferred vendor for the organization’s employee voice strategy.

In 2023, nursing was presented with an opportunity to pilot the Perceptyx RN Satisfaction Survey in combination with the employee engagement survey from human resources. To ensure the integrity of our RN satisfaction data and compare survey vendors, UW Health nurses in Wisconsin participated in both the Perceptyx and NDNQI RN Satisfaction Surveys in August and October 2023, respectively.

Going forward, we want to ensure UW Health nurses are participating in the surveys that accurately capture their work experiences, provide secure platforms to share their feedback and deliver meaningful results that lead to advancements and improvements in the nurse practice environment. 

High-scoring units

While results from NDNQI and the preferred RN Satisfaction Survey vendor decision are pending (as of December 2023), the August 2023 Perceptyx engagement and RN Satisfaction Survey results highlighted several areas in nursing with outstanding performance.  East Madison Hospital 3rd and 4th floor inpatient units scored higher than average in all nine engagement categories and seven nurse satisfaction domains. Nurses on both units attribute their scores to the hard work their teams have put in over the past few years to build and sustain a culture of teamwork and respect on their units. They’ve created spaces where care team members support each other and feel empowered to do their best work on every shift, every day.

East Madison Hospital 4th floor: A unit transformed

Against the odds, a multidisciplinary team in the emergency department used lifesaving measures to revive a woman who wasn’t breathing when her frantic husband pulled up to the front door of the University Hospital Emergency Department.

“The patient woke up at home that morning with chest pain and shortness of breath, so she and her husband headed to the hospital, but she stopped breathing on the drive here,” said Jenna Meier Payne, BSN, RN, CCRN, clinical nurse specialist.

The team used Extracorporeal Cardiopulmonary Resuscitation (ECPR). ECPR is a combination of CPR and Extracorporeal Membrane Oxygenation (ECMO). ECMO is lifesaving therapy that pulls the patient’s blood out of their body, circulates it though an artificial lung and pushes the oxygenated blood back into the patient.

The case was the most powerful example of the ECPR program since its inception in March 2019, and the impact it had for that patient and her family is what Jenna said is most gratifying for staff. “Clinicians don’t always realize the impact they have, but this is one example of the difference our work can make,” she said.

The use of ECPR at UW Health is getting attention. In 2023, UW Health received the Extracorporeal Life Support Organization (ELSO) Award for Excellence in Life Support. The award recognizes ECLS programs worldwide that distinguish themselves by having processes, procedures and systems in place that promote excellence and exceptional care in extracorporeal membrane oxygenation.

UW Health nurses also shared their work using ECPR at the Wisconsin Emergency Nurses Association conference, further boosting awareness of their efforts using this life-sustaining method.

“Providing education and awareness about ECPR helps make the program successful, because it’s not used every day,” said Jacinda Krueger, RN, Emergency Department Supervisor. “We’re optimistic ECPR will be used to make a difference for many more patients,” she said.

When influenza destroyed Kyleigh Willams’ lungs, Med Flight, extracorporeal membrane oxygenation (ECMO) and a lung transplant helped keep her alive.

But when you ask her mom, Nikki Williams, what truly saved her daughter, who everyone calls Ky, she credits the American Family Children’s Hospital nurses and other staff who walked with Ky every step of her nearly seven-month journey to get back home.

“Lauren Batcher is amazing,’’ Nikki said of her daughter’s main nurse. “She went above and beyond with Ky. She never took a break when she was there.”

In December 2022, Ky was a 15-year-old student athlete at Clinton High School, who played travel basketball, softball, and was, in the words of her mom, “never sick.” Then Ky came down with influenza A and was soon having so much trouble breathing that her mom drove her to Beloit Memorial Hospital.

“They took a pulse ox on her, and from then, it’s a blur,” Nikki said.

The Beloit team called UW Health Med Flight to take Ky to American Family Children’s Hospital. Nikki and her husband, Jeremy, jumped in the car and beat the helicopter to Madison. After an exam, doctors in the Pediatric Intensive Care Unit (PICU) decided to put Ky on an ECMO machine, which does the work of the heart and lungs so the body can heal.

Except Ky got worse, as the inflammation led to necrotizing pneumonia, and then a bacterial infection and kidney failure. By Christmas, she was on dialysis and a ventilator.

“The hardest part was Christmas. She was just coming to and realizing what was going on, and that things were not getting better,’’ said Lauren Batcher, BSN, RN. She was with the Williams family when they got the somber news that a lung transplant was the best hope.

Nikki reflected on the devastating time. “All I remember is sitting in the room, and the doctor sat and cried with us and mourned,” she said.

Amanda Minnig, RN, BSN, CCRN, pre-transplant coordinator could sympathize.

“This was completely unexpected and not something they ever imagined,” she said. “It’s so rare (to need a transplant) without underlying conditions.”

The team focused on preparing Ky for transplant surgery. Normally, a transplant patient is up and walking, but it took six people just to get Ky to the edge of the bed and onto a “stander” to put weight on her legs.

“She was one of the most deconditioned patients we’ve ever done transplant on,’’ Lauren said. “You have to work your lungs and work your body. We had to really push to get her ready. She got mad at me every day, but she had trust in me.”

To try to lighten the mood, Lauren and Brittani Butler, RRT, ECMO specialist, worked out a TikTok dance to “Wannabe,” by the Spice Girls.

“Ky looked horrified,’’ Lauren said with a laugh.

Following the transplant, the team planned fun distractions: A purple theme for Valentine’s Day, bunny ears at Easter and a “beach day” that involved hauling buckets of sand and water to Ky’s hospital room and batting around beach balls.

The big event was a talent show judged by Ky and won by Kelsey Konz, physical therapist, who played a Morgan Wallen tune on the piano in the hospital lobby.

Night nurse Hanna Kremsreiter, BSN, RN, would bring Ky to the nurse’s station for company as she did charting, and style her hair and do art projects with her. And as winter turned to spring and Ky got stronger, Lauren took Ky on wheelchair outings to the Healing Garden and the University Hospital Gift Shop. Meanwhile, Ky started to work with Mary Witte, BSN, RN, transplant coordinator, on her transition back to home and school.

“I told her, ‘Ky, I’m your new best friend,’ and Lauren was like “What?!,’’ Mary said.

Kidding aside, Mary said, “I credit a lot of Kyleigh’s success to Lauren. She really went above and beyond on the hard days to cheer Kyleigh up and motivate her.”

Ky is now getting back to high school activities, going to the homecoming dance and earning her driver’s license. “For us she was a celebrity patient,’’ Mary said. “But for her, she just wants to get back to being a normal teenager.”

UW Health ambulatory RNs continue to raise the bar across outpatient settings. They represent the essence of where science meets art — applying their exceptional clinical acumen and innovative approaches to care delivery — while forming meaningful relationships with patients throughout the continuum of care. It’s no wonder their pivotal roles place them among national leaders in the ambulatory practice arena.

Helping shape the future of ambulatory nursing practice

Nurses impact many aspects of health care beyond the act of providing nursing care. The American Academy of Ambulatory Care Nursing (AAACN) charges ambulatory RNs to work to ensure that their expertise is recognized and incorporated into practice, education, research and leadership.

To keep pace with this charge, the AAACN asked a member task force to revise its position statement titled “The Role of the Ambulatory Care RN in Nursing (pdf),” updating it with the latest evidence in those four areas. Terri White, MSN, RN, NPD-BC, UW Health ambulatory nurse educator, was part of that group and the work that went into finalizing the position statement, which now serves as a foundational document to shape the purpose, direction and future state of ambulatory nursing practice in the U.S.

Excellence in urgent care redesign

In late 2021, UW Health West Towne Clinic Urgent Care began making changes to its care model using UW Health improvement tools, Kotter’s eight-step change model and a collaborative, interdisciplinary approach. The goal: Create a positive impact for team members while improving the patient experience.

Since that time, the quality improvement strategies helped enculturate the changes into the urgent care daily practice model. This has resulted in several positive changes, including decreased wait times, higher patient experience satisfaction scores and continuity of care for patients due to better communication between patients and their care teams. Additionally, the care team has experienced improvements in communication, equalized workload distribution, earlier end times for closing shifts and a decreased turnover rate.

This work was so impactful that the West Towne Urgent Care team received a 2023 UW Health Nursing Quality Excellence Award. Rebecca Pollard, BSN, RN, clinic supervisor, presented the redesign project at the American Academy of Ambulatory Care Nursing (AAACN) Conference in April 2023 in Orlando, Fla., further demonstrating that UW Health ambulatory nurses are helping shape nursing practice on a national level.

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Check out more stories featuring the great work of our nurses in the Nursing Year in Review 2023 (pdf).

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UW Health nurses are our unsung heroes, not only tending to the medical needs of our patients, but also actively building an environment of safety and comfort for those in need.

The UW Health Shared Governance Professional Development Council in northern Illinois participates in a variety of fundraising drives in the community. One program very close to their hearts for several years now is Rock House Kids.

An evening shelter for youth, located in downtown Rockford, Rock House Kids began in 1999 with a 9-year-old boy who was running away from a dangerous home situation. The founder of Rock House assisted him with food, clothing, school support and other items, and soon after, his friends joined him. Over the years, Rock House Kids has grown to become a safe haven for children in Rockford, providing a safe space for them to get off the streets, have an evening meal and be mentored by loving staff and volunteers.

Several of our UW Health nurses frequently volunteer as mentors, provide food and decorate the building. In November 2023, the council held a stocking stuffer drive that resulted in more than 100 items donated for the kids at Rock House.

“Having a safe space for children in our community to go is so important, and as caregivers, we recognize how Rock House not only addresses immediate health concerns but also contributes to the long-term well-being and happiness of these children,” said Ashley Ponder, MSN, RN, NPD-BC, manager, nursing professional development.

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Check out more stories featuring the great work of our nurses in the Nursing Year in Review 2023 (pdf).

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The concept of birth equity in health care includes advocating for fair treatment during pregnancy and childbirth for all individuals, no matter their socioeconomic status, race, ethnicity or gender identification. UW Health is proud to stand at the forefront of this movement, and recent partnerships in the northern Illinois area work to further ensure every individual a safe and respectful childbirth experience.

“Every patient who comes in our doors should be able to say they were honored and cared for,” said Jennifer Callison, director, Women and Children’s Services, UW Health in northern Illinois. “We do our work here every day, but for some, this is a once-in-a-lifetime experience. It’s their birth story, and they are deserving of a safe and equitable delivery.”

In Fall 2021, the UW Health SwedishAmerican Women and Children’s Hospital joined forces with the Illinois Perinatal Quality Collaborative (ILPQC) to address maternal disparities and promote birth equity. This statewide quality improvement initiative offered key opportunities for our team to explore and implement, including:

• Ensuring a universal Social Determinants of Health (SDOH) screening is taking place both prenatally and during hospital admission to connect patients with needed resources and services. Courtney Fisk, RN, and Michelle Strand, LSW, led the implementation at SwedishAmerican Hospital, working diligently to create a five-county resource mapping tool that allows staff the capability to easily assist patients. This tool has been a crucial piece in ensuring patients are receiving the assistance they need prior to discharge.
• Reviewing hospital-level maternal health quality data by race, ethnicity and Medicaid status to identify disparities and opportunities for improvement. Each month, maternal quality data is reviewed to identify disparities and address opportunities for improvement.
• Engaging patients and community members to provide input on quality improvement efforts. SwedishAmerican Hospital has a long-standing community presence. By working with key community members and building partnerships, we continue to engage with patients outside the hospital and clinical settings to bring birthing education out into the community.
• Implementing a strategy for sharing care practices with patients and labor support persons. It is our goal that each patient receives standardized discharge education, is ensured communication access to their providers and are taught general postpartum safety.
• Standardizing training for staff and providers to address implicit bias and promote active listening and respect in patient care. This includes watching mandatory documentaries that illustrate how some patients slip through the cracks.
• Surveying patients before discharge to get feedback on their care. UW Health proudly excels in this area. In 2023, we led all hospitals in Illinois with the highest number of returned surveys.

The initiative led to many highlights in 2023, including the start of a community-wide Respectful Care Breakfast hosted by SwedishAmerican Hospital, as well as being recognized by the ILPQC with the 2023 Birth Equity Quality Improvement Excellence Award. The award signifies that UW Health SwedishAmerican Women and Children’s Hospital has submitted all required data, implemented all elements of the initiative, and met all the goals and objectives.

“We were very honored to receive the award, as it recognizes the commitment of many, including our nurses, physicians, social workers, leadership and community members,” Callison said. “Hopefully this is just the start, because we continue to set and reach new goals. We take this very seriously, because this is about honoring every patient and their individual journey.”

Float pool nurse Abigail Callaway, RN, had been at University Hospital for about a year when she got the chance to “up train” to care for patients in the hospital’s growing number of Intermediate Care Units (IMCs) throughout the system.

“I joined because I wanted to see what other types of nursing are out there,” Abigail said. “In my previous job, I saw IMC patients and I wanted to keep up on those skills. A lot of our patients are very complex, and I like the challenge of being able to care for more complex patients and to learn more.”

Abigail was one of the first float nurses to go through a three-month training program that had her rotate through the hospital’s four main IMCs, as well as some of the specialty care IMCs. In each unit, she was assigned to a preceptor nurse who supervised her training. All new hires into the float pool are automatically being uptrained during their orientation period and the chance for uptraining is offered to current float pool nurses.

The new program was the brainchild of a group that included Amy Marver, MSN, RN, nurse manager, nursing operations support; Tracy Moriarty, MSN, RN, clinical nurse specialist; and Nikki Elson, MSN, RN, nursing education specialist.

The program was created to solve a dilemma: the hospital had a growing population of sicker patients who needed the intermediate level of care. But because the general medical surgical float pool nurses didn’t have the training to care for those patients, critical care nurses trained for the Intensive Care Unit (ICU) had to be assigned to the openings.

“As an organization, we were finding that ICU nurses were getting assigned to intermediate care, and when that happens, it can cause dissatisfaction,’’ Marver said.

Moriarty agreed, adding, “This has been a concern for critical care nurses, that they were spending too much time in IMCs. It was nice to finally have a solution.”

Marver had the idea of developing a program in orientation that could elevate the training of general medical surgical nurses, and the chance to “up train” was offered right away in orientation.

The program began in October 2022. Elson said the nursing education staff came up with a template that can be individualized to the nurse’s situation. For example, if a nurse had a background in cardiac care, the training might give them more experience with trauma and other specialty care.

 “I think it’s really important to offer an opportunity to our experienced nurses to grow,’’ Elson said. “I’m thrilled to contribute to a training program that can get experienced nurses re-energized in their practice by giving them a new challenge to tackle.”

Over the past few years, the ongoing challenge of capacity constraints has impacted general care units at University Hospital, requiring adjustments in nurse-to-patient staffing ratios to accommodate the increase in patient acuities and specialty patient populations. Although the goal has always been to staff to meet the needs of all patients, the adjusted models lacked consistency across units.

Early in 2023, inpatient RNs within the medical/surgical nursing division expressed dissatisfaction with disparities in the adjusted staffing ratios, conveying an increase in workloads due to their challenging patient populations.

Pivotal feedback from RNs

To assess the situation, nursing leaders included staffing ratios as a consistent topic of conversation with direct care RNs during regular rounding — especially those working night shifts — who were experiencing the highest level of dissatisfaction due to their nurse-to-patient ratios changing from 1:4 to 1:5 based on demands.

“Some units decrease RN staffing for night shift,” said Alysia Hanson, DNP, RN, director of medical/surgical nursing. “Nurses provided important feedback that it had become more challenging to decrease staffing on night shift given the increasing acuity of the patient population at University Hospital.”

In addition to the feedback obtained during rounding, direct care nurses on general care units performed data collection for one week to determine if 1:3 RN-to-patient ratios might be needed based on a specified rationale that involved a list of 13 patient scenarios and care needs.   

“Unlike intensive care units where they have criteria to determine when a 1:1 ratio is required, there isn’t a consistent mechanism to account for increases in staffing needs based on acuity on general care units,” Alysia said. “When the nurses performed the data collection, it revealed that staff felt 35.8 patients per day (across general care units), required a 1:3 ratio.”

RNs shape the change

Based on the feedback, the assessment (which included benchmarking data) and other data collected by staff, a baseline acute care matrix was developed and implemented on four medical/surgical units that had been consistently staffed with ratios of 1:4-5 on night shift. The result was an addition of 6.4 RN FTE across night shift teams on the four units. In addition, there was continued support for leveraging acuity-based staffing logic within Health Link, the electronic medical record.  

The General Internal Medicine Unit was one area that experienced the staffing improvement. Courtney Harvey, BSN, RN, care team leader, comments on the positive effect it had on nurse satisfaction and night shift morale.

“Having another RN added to our night shift has been a huge benefit to all. Our nurses have had more time to spend at the bedside and are able to address the needs of our patients in a timely manner,” Courtney said. “As a care team leader, this change also allows me to spend more time supporting our newer staff and serving as a resource to all, especially during unpredictable situations or events that may occur throughout a shift. Overall, this has been an incredibly welcomed staffing reform for our nurses. I am so thankful our voices were heard and that our staff have felt such a positive impact from this exciting change.”

What comes next

The vision for this work spans into fiscal year (FY) 2026, with the goal of leveraging the Health Link workload scoring tool in 2024. Additionally, there will be ongoing efforts to reassess the level of care criteria as we look forward to the opening of the D2 tower and increased capacity.