#53 - Patient Manager Charge Nurse Impact

Jeff Terry:  

Hello and welcome. I'm Jeff Terry. Delighted to be joined today by Vicky Martin, who's the charge nurse on 8.2 at Halifax Infirmary. Hello Vicky. Thanks for joining us. Good morning.  

Vicky Martin:  

Hi Jeff. Good morning. 

Jeff Terry:  

Awesome. So happy that you're here. Maybe to start, describe your background, you know, why did you get into nursing and how did you end up on 8.2?  

Vicky Martin:  

Well, a long time ago, in 1979, I graduated from a little hospital in Cape Breton. I started there on a surgery floor, basically very busy. Worked there for a year and a half and decided to move to Halifax. When I got there, I switched over to medicine and medicine has been my love for the last 35, 40 years. I've been there at the HI, we were in a teaching hospital, something I had never done before and I loved working with the residents, those kind of, it was compared to what I worked in Cape Breton, it was very much a hierarchy whereas here in Halifax it was much more of an equal playing field. Everybody seemed to work together, it was much more of a team. So I worked there for about nine years and moved to Ontario. I did some more medicine there and then I came back to Halifax because I really missed Nova Scotia. So when I got back here, it was in the process of, they were amalgamating all the hospitals. They were amalgamating the old Camp Hill, which is a really, it's gone now, but the old Camp Hill, switching over to the HI and then they joined from the HI to the VG. So it was kind of like skipping stones. You just kept going from one place to the other. And finally I ended up on 8.2. And 8.2 at one point was orthopedics, but now it's switched over to medicine and I took the job of charge nurse and I've been here 22 years. 

Jeff Terry:  

That's amazing. And that amalgamation process, was that sort of the formation of Nova Scotia Health Authority? Is that what was driving that?  

Vicky Martin:  

It was the beginning of that. Yes. It was, basically, we just kept getting bigger and bigger and it all became one. Yeah. 

Jeff Terry:  

And then I'm curious, 8.2, does that mean that it's the eighth floor and it's one of two units on the eighth floor? Is that how that works or?  

Vicky Martin:  

One of four. It's one of four units on the eighth floor and there was surgery, orthopedics would've been on another wing and it was medicine and family medicine type patients. Yeah. Yeah. 

Jeff Terry:  

And I mean, that's amazing that you've been playing, but, in like, I think all of our audience, but have such massive respect and appreciation for charge nurses and for that leadership role and the caregiving role of that. You must have developed a lot of young nurses over the years and seen people, I mean, do you mind commenting on that, the sort of the leadership development aspect of it or the nursing development?  

Vicky Martin:  

Yes, I have to say, when I was a nursing graduated in 1979, this is a different nurse today. The nurse today is so much better in the sense that they are much more involved with the patient. Their assessment skills are so much better than when we first graduated. We were kind of the handmaidens of the lord kind of thing in the sense that, you know, the doctors were here and we were at a much lower level. We didn't seem to have the same amount of respect or teamwork. And now it seems that the nurses today are bright, they're goal oriented, they want to keep on gaining new skills. And so they come to this unit particularly because it is probably one of the fastest-paced, highest-acuity medicine units on the floor. And all of the internal medicine doctors come through here for the rotation. So they want the most interesting cases. They want, you know, the complexity of a medicine patient. So yeah, I've seen a lot of nurses come through here and they've gone on to so many other things, but I think it's a great starting point for a new nurse. 

Jeff Terry:  

And do you think that that shift in the teamwork that I hear described is sort of the elevation of the role of a nurse and with that, a different way of a care team working? Do you think that's common or that's representative of sort of an overall trend elsewhere?  

Vicky Martin:  

I think it has changed, yes. I think that now the nurse is recognized for what she brings to the table. Like, I mean, she contributes a lot. She's the person that spends the most time with the patient so she gets to know the patient really well. But you can only do this job with good teamwork. I mean, you have to have respect on all sides. It doesn't matter what level you are when you come into the program, you still need like excellent communication skills. You need mutual respect, you need lots of compassion and you need to be able to handle the stress load. 

Jeff Terry:  

Absolutely. You know, one thing that I've always enjoyed, by the way, about just the clinical context and the clinical environment on, you know, on nursing units and in different parts of the hospital is what I have found to be tremendous professionalism and respect among the different caregivers and disciplines of caregiving. You know, even in sort of the chaos of it all, the way that people engage with each other is so, I find, focused, professional. To be honest, I sometimes I wish more people would see it, 'cause sometimes healthcare is an easy thing to pick on. It's expensive, you know, and everybody dies in the end. So, you know, it can't be perfect and what does it all mean? But I think if more people saw inside those activities, I find it, just, to me, it's like watching Navy Seals teams on an operation 24 hours a day that are calmly delivering these really quite remarkable services to people 24 hours a day forever.  

Vicky Martin:  

Yes, and I do believe that, you know, when a nurse is in the right place for her, I mean, she does do an excellent job, but it's the reward factor as well. I mean, we do this job for the reward of actually doing it. And in a lot of cases, at the end of the day, it's, you know, you've gained skills. You're, you know, very important, but it's more important to have the sense of satisfaction at the end of the day that you've contributed something to somebody that somebody is better off because you were there. 

Jeff Terry:  

Hmm. And that's clearly why you got in into nursing and have stayed with it. And do you find that that remains the thing that draws most people into the profession?  

Vicky Martin:  

I think that it draws a lot of people into the profession. I also think that nursing now has become so diversified that there is so many avenues for people to go, that it doesn't necessarily mean that you have to be, you know, necessarily a people person. You could be someone that likes to be behind the scenes. There's just so much work that any nurse, that a lot of nurses can do that we didn't have open to us when I first started. So we branched out to a lot of different places. And I think that, you know, depending on your skillset, it depends on where you end up. 

Jeff Terry:  

Hmm. And out of curiosity, is that the typical new nurse to join your team, is she an like an early-career nurse, a mid-career nurse? Is it a mix? Is it people coming from other part? Yeah.  

Vicky Martin:  

I think it's early career. I think that I'd say it would be highly recommended that most people would say, if you can do medicine, you can do anything. So what that means is- 

Jeff Terry:  

Absolutely.  

Vicky Martin:  

That it's not just one thing over and over again. It's a wide variety of illnesses and so therefore, a new nurse needs to gather as much skill as she can in assessing that and treating. So she needs that background. I think that then they'll branch off sometimes to something more focused. But I mean, there's also the group out there that love the complexity of, you know, it's basically a balancing act between, you know, your kidneys and your heart and your this and your that. And it's kind of like that's what they like to do. It's a bit more of a puzzle. That's why I think I chose medicine. But I do believe that from a basic nurse starting the profession, I would absolutely recommend that she start in medicine. Yeah. 

Jeff Terry:  

You can do medicine, you can do anything. And you've got enough of a sense to probably know what you want and be useful everywhere.  

Vicky Martin:  

Yes, yes. 

Jeff Terry:  

That's great. Well, one thing I should mention for our audience is that Halifax Infirmary and some of the other hospitals in Nova Scotia have recently started using our Command Center software, particularly the Patient Manager. And we wanted to get your take on that, obviously, as a super knowledgeable voice on how, you know, what really works and what really doesn't. So would you mind commenting on how you use Patient Manager and how it's changed your daily workflow in unit bullet rounds and shift handover and things like that?  

Vicky Martin:  

Sure. So when that came on, I mean basically we were involved in the beginning setup of it. So basically we were the pilot project, which was good for us because we got in on the ground floor and we could see things as they were forming and we had input into the whole process. When I first looked at it, I thought, oh, this, I was mesmerized by it all and I mean, I'm the older one in the group, so technology isn't necessarily something that I gravitate towards. So to get rid of my whiteboard, which is what I used to do, and, it basically, we did bullet rounds on the floor, which is a daily meeting that we have with all of the team. And it's quite a large team. All of your clinicians, all of your interdisciplinary staff, your PT/OT, pharmacy, all of those people, and the nurses and the docs as well. So we would meet at 2:30 and we would basically go over, and using my whiteboard, all of the patients, it's a 30 minute for 38 patients and you have to be quick and you have to keep moving. And it's mostly about why the person is still here, what do they need to have happen, how quickly can we get them out and in a safe manner. So that was replaced by the Patient Manager Tile, which after using it, I am a big fan and it took a little bit, but I mean like in the sense of, initially I didn't necessarily know if we would have all of the information, but it became clear that actually we have more information because now we're not erasing as people leave in our discharge. We used to erase out the name of the person that started over, or we move them around due to infection control concerns. And now it's all kept up to date on the computer and we just basically have to go through our patient load, but it's much more accurate and it's also, it's got a good history. So you can look at that history and know what's happened to your patient. And each day is a very different day sometimes for some of these people. And they may have been stable one day, they're not stable the next day and this is all captured on the computer much easier than actually trying to follow it on a whiteboard. So it took, I'm the dinosaur in the group, I'm kind of like the one that hasn't, you know, I've moved forward, but basically they've taken me, you know, with me. So some of these people, especially the younger nurses are very, you know, they're used to computers. That's what they grew up with. But I really like the fact that it's a simple, easy-to-use, accurate, very accurate, piece of information that is constantly changing as the information is being inputted into it. So it's a lot less work for us than it used to be. 

Jeff Terry:  

Well, that's what I was going to ask. So was it you personally who maintained the whiteboard or others in the team? Or how did that work?  

Vicky Martin:  

It was my role to run the bullet rounds, which means that I'm the one that basically is sort of at the whiteboard, changing it up as they're going through and giving me the information. It's very much a team approach and like, you know, what's physio's findings are and what OTs findings are and all that stuff. And the barriers of discharge are being identified as we do the bullet rounds. But if now the interdisciplinary team are involved as well, they are probably inputting the data. They take turns so everybody gets to use the system and to basically get, you know, familiar with it. And it's also more buy-in. Like, I mean, I think that I'm the one that runs it, but at the same time, there's a lot more buy-in from the fact that everybody's using this system. It's not only the people at the bullet rounds, it's a unit clerk that's at the helm every day facing the public. I mean if I know that something's changed during night shift and now the patient is ready to go where they weren't ready the day before, then we tell the unit clerk, "Well, input that into your system." And then the information is, you know, as time happens, it's accurate. It's basically, we're not doing a lot of phone calls saying, "Well, I think this person's going to go, that person's going to go, or no, something else has changed." It's on the computer, everybody's seeing it. So the Command Center downstairs has the information that they need and we are using the information at the bullet rounds to update it so that each day they're kept up to date. 

Jeff Terry:  

And has the whiteboard officially been retired? Is that...  

Vicky Martin:  

We have basically thrown it out. 

Jeff Terry:  

Which is amazing and I have a sense of how big a deal that is and I say, I think, sometimes it's fashionable to say, "Well, you know, these clinicians are resistant to change." But I always say, "Well, there's probably a good reason for that." You know, you have to actually, you know, provide something that solves the need that is useful in the real clinical context and that can be very difficult to do. So that's tremendous that it's actually provided that value for you. And does it reduce the time of the bullet round, for example?  

Vicky Martin:  

Yes, it does. I think it does in the sense that I'm not trying to keep up with, you know, my lovely little marker. Basically, you know, somebody's inputting the data as we speak and we're being very clear about what our goal is, which is basically, "Okay, this is happening. Is our EDD, our estimated date of discharge, is it accurate? Does it need to change? How much time do you think you need?" So we're constantly updating the EDD, which means that we're hoping for more accuracy when it comes to predicting who's going and, you know, how fast can we get them out the door. 

Jeff Terry:  

And do you, I'm curious if you agree with that, I find like the magic, a well-groomed EDD is magic, right? Because the others can prioritize off it, but it yeah, the best groomed EDD is one where yeah, the people closest to the patient are making an informed consideration on an ongoing basis 'cause the situation does change. And, I believe, and I've found that if we can make that easy then people are more likely to engage and therefore it's a higher-value problem solving process, and therefore, a more accurate and a more current EDD which then can be used by others. And that's, I think, the same wavelength you're on.  

Vicky Martin:  

Yes. Yeah. I think that it's accuracy that we're looking for and I mean, we don't have it down pat yet. Like, I mean we are working on it, but I mean, and people are changing all the time. You can't say with a hundred percent certainty that someone's going to go out the door because something can happen overnight and it's changed. But I mean, as we get better and better at it, I think that we are going to get closer and closer to, you know, more accuracy as far as predictions go. 

Jeff Terry:  

So, and as you know, the medicine units obviously can have some of the toughest to predict because of the mix of the patients and the change, the nature of the, yeah, it's not a total needs right, which you can really dial in with a higher degree of accuracy in many cases.  

Vicky Martin:  

Yes, I mean it's not a surgical procedure where they're given four days after and then they're going to go home. This is complex medical patients, they're the hardest ones to predict and they also have some of the biggest social issues as well. So I mean there's big barriers in the system with this. The social problems that we have and identifying barriers that we can actually do something about is huge because then we will save, you know, like what's keeping the patient in, what can we do about it? And then, you know, the escalation Tile or the escalation piece of the Tile where they're basically looking at, how can we solve the problem so that we can actually, you know, get the person to where they need to go. 

Jeff Terry:  

So you guys in Patient Manager, you're escalating from time to time up to the Command Center that we have and they're responding and barrierbusting for you, is that?  

Vicky Martin:  

Yes, exactly. And that is so good to see because, you know, for years we've talked about all the problems and we know that there's lots of barriers, but you know, everybody actually having a spotlight on those barriers is helping. And to know that somebody out there is basically, not just us but everybody, you know, every floor is on this, so we all know that everybody's doing the same thing. So that those things are what's going to change things. Like, I mean, and to do things just for the sake of doing it, I mean, we're all tired of that. And the workload on every floor, I'm sure everywhere is so much more difficult. There's less personnel to work with, there's all kinds of stresses in the system, but when you see something change for the better and you actually think that the energy and time that you put into it is actually making a difference, that's a good thing. That's a really good. 

Jeff Terry:  

Hmm. That's wonderful. And would you mind commenting briefly on shift handover? Do you use it the same way in shift handover?  

Vicky Martin:  

So we're not completely there yet because we would like to bring the nurses on board. Like there's a few people that would replace me or my counterpart and they would do charge and so they'll be brought on board. But because of the lack of staff right now and the number of vacancies on the unit, we haven't had time yet to actually bring all of the nurses on board. And those are the gals that would be, or guys, that would be on at nighttime that might be able to access and basically change some of the data. I think we'll get there eventually, but until we get the staffing issues rectified, we're still working on that. But when I come on in the morning, I get shift handover and then basically the first thing that we do in the morning before we do anything else is check our Tile. So we check what the predictions are and then we also check, you know, what has changed so that maybe those predictions aren't actually right. And then we would have the unit clerk actually go in, change those numbers before our bed meeting, which is at 8:30 in the morning. 

Jeff Terry:  

And do all the charge, that's the campus bed meeting, is that right? And do all the charges join that? Is that how that works?  

Vicky Martin:  

Yeah, all the charges and I think a lot of the unit managers and directors, I'm sure there's a large group. Yeah. Yeah. 

Jeff Terry:  

Yeah, that's awesome. And you've been at on 8.2 for a long time and seen a lot, I'm sure, seen a lot of initiatives come and go on EDD and throughput and access and all these topics and they're going to, you know, these topics will go on forever, right? It's the nature of it. But there's also the tools that are used to make things easier. And I'm sure you've seen specific tools come and go. I guess what, I don't want to put words in your mouth, but from your comments, it seems like you're having a good experience with Patient Manager. So, I guess, what gives you confidence in Patient Manager or how do you think it's different than some other things that have come and gone perhaps?  

Vicky Martin:  

I think it is more central. I think that everybody's involved. I think before it was always, we were doing things separately. In other words, we'd try something, someone else would try something. It didn't seem to be like a very well-coordinated process. So basically at this point, the information that we're all seeing is basically to try and solve the problem. I think everybody understands the problem. I just think that now with the technology that we have, it's going to make it easier. I think it was much more difficult before and I think we had a lot of meetings that we had to attend to and there was, you know, it seemed like we lost our energy and this seems to be something that, you know, it is a good system. It's actually been tried elsewhere and we are just seeing the benefits start now. I'm sure that there's lots more that's going to come from it and all of the information that we have inputted into it, I'm sure that there will be things that they can actually, you know, pull from it that basically is going to change how we look at how patients come through our system. I don't know for sure all of the benefits, but I do know that it's not just B and it's not just 8.2, it's the entire system. So we're hoping. 

Jeff Terry:  

Heck yes. And can I ask, my sense, I guess I'm thinking of, you know, obviously 38-patient unit, you have a lot of nurses and there's, you know, turnover and new nurses and as you mentioned, and my hope and belief is that something like Patient Manager can be particularly useful for the novice nurse because it scaffolds some of the activity. It almost gives a playbook, you know, sort of work left to right to get through the round. And I think that's important 'cause the last thing we want to do to a novice nurse is make her life more difficult. So is it your sense that it's helpful even for the novice nurses, if you will?  

Vicky Martin:  

I think it will be. I think that number one, they also need to, by attending bullet rounds, by seeing how the team works and how important their information is. I mean, they're doing the basic assessments every day of the patients. They see them the most, the interdisciplinary team. Like it just shows how a well-run team would work. And the C3 is kind of a representative of that. It's just at a much bigger level. I mean we are the floor unit, but when you actually take the entire thing and put it together, it's basically everybody's energy is on the same thing. Better patient outcomes I'm sure will come out of it. 

Jeff Terry:  

Totally, and you mentioned that before, but it's one, yeah, you can't have a, well this is, we're working on throughput in this way on 8.2 in a different way in another unit. And the the set, you know, the bed control's got a different approach and... By working in a joined-up way, clearly we perform better. So another thought, so Halifax Infirmary, no surprise, is on the leading edge of the use of this tool in Nova Scotia. Some other hospitals are adopting it now and others will begin adopting it in a few months. What would your words of wisdom be to that charge nurse, you know, in the next hospital in line?  

Vicky Martin:  

I think I'd say, "Don't panic, don't panic." It's not something, I mean, for someone that's not used to working with this program, it looks like a lot when you first look at it, but it actually makes a lot of sense. And I think that very quickly when we were working with it, we incorporated it into a daily routine. I just think that anybody that's trying it for the first time, initially it looks like it's, you know, a little bit more complex, but it's actually quite user-friendly. And the other thing is the benefits that you gain from it, you don't realize, but they are there and we've seen quite a few positive results and that's in the short time that we've been using it. So I wouldn't be here to spread the news about C3 if I didn't believe that. I really believe that it's a good program, but it's also something that for all of us that are using it, that it's not complex. The information is accurate, we're transparent. We're not working separately. Like each unit is not in this, we're all in the same boat. And I think that most people don't understand, like, I'm not against, you know, like we're not against each other. We're working together. And I really believe that people sometimes used to think, "Well, you know, 8.2 is so busy they get..." you know, whatever. I think now it's like everybody's busy. Everybody has barriers. What can we do about it? 

Jeff Terry:  

That's such a great, I love that we're all in the same boat. Helping people understand that and operationalize, which can mean for people who maybe haven't been around that environment can sound crazy. Well of course we're in the same boat. How hard can that be? But it's actually quite tremendously difficult to give the frontline a sense of the enterprise situation and the folks at the enterprise level, a sense of the frontline situation. And it's really, really hard.  

Vicky Martin:  

Yeah. 

Jeff Terry:  

That's tremendous. And if we can give a little bit of time back to you with all of the knowledge and skill that you have and obviously your peers, that's immensely valuable in the way that you can reinvest that, I think.  

Vicky Martin:  

Yeah, and I think that the patients, they don't want to be in hospital. They would like to get out as soon as they can. And sometimes, I mean, we're stuck waiting for a diagnostic test. I mean, if C3 can expedite that test so that person doesn't have to be in hospital away from their family, they're going to do better at home and they need to have this test done if it's one of the blocking, you know, like one of the barriers of getting this person out, thank God somebody's doing something about it. You know, let's get them out. 

Jeff Terry:  

Heck yes. And I should mention for our audience, by the way, C3 is the Care Coordination Center, which is a physical center at Halifax Infirmary that's supporting the, well, more and more of Nova Scotia Health Authority over time. And it's also the name of sort of this program that's using this software to work in a more joined up way for throughput and access and more and more down the road. Brilliant. Well, Vicky, with that, well, I'm so happy that you joined us. I could talk about it all day. I appreciate your insights very much and I guess I just had such a admiration and appreciation for the work that you do and have done for such a long time. So your feedback and perspective is super. Yeah, it's not just valuable, but it's so credible. So thank you very, very much.  

Vicky Martin:  

Well, thank you very much for having me. 

Jeff Terry:  

Awesome. We'll leave it there. Thank you for joining the podcast, everyone.