A strong spirit of innovation and action is contagious among employees at BJC Healthcare. In December, leaders planted the seeds for a virtual nursing program and, just five weeks later, the pilot was up and running.
The St. Louis-based system piloted the program at O'Fallon, Mo.-based Progress West Hospital and Barnes-Jewish St. Peters (Mo.) Hospital in the first quarter of this year. The program has since expanded to four hospitals across the system and is used to support admissions and discharges, patient education, registered nurse mentoring, quality and safety auditing, second-RN sign-offs, care coordination, sepsis monitoring, and interdisciplinary rounds, when appropriate.
Thomas Maddox, MD, MSc, BJC's vice president of digital products and innovation, credits the smooth rollout to three main components: strong initial buy-in and engagement from nursing leaders, a comprehensive understanding of nurses' workflows thanks to previous research conducted by the system's human-centered design team, and the use of Agile delivery techniques that allowed leaders to rapidly develop, iterate and test virtual nursing capabilities while simultaneously collecting staff feedback.
Tommye Austin, PhD, MSN, RN, senior vice president and chief nurse executive at BJC, also played an instrumental role in championing the effort and maintaining momentum.
"Having an innovation lab sets us apart from other organizations in that we can fail fast or succeed fast, but it gives us the opportunity to try new things," she told Becker's. "And to me, that was the biggest secret sauce."
Lighting a spark
Dr. Austin joined BJC as chief nurse and senior vice president of patient care systems in October. Soon after, she raised the idea of virtual nursing, which was well received by other leaders.
"People [at BJC] were open-minded about an opportunity to do virtual," she said. "To me, that was half the battle."
One of the main objectives for launching a virtual nursing program was to ensure the health system could retain existing staff while also creating an environment that would attract more medical-surgical nurses. At the time, BJC had about 1,100 traveling nurses on its payroll and its two hospitals in Charles County, Mo. — Progress West and Barnes-Jewish St. Peters — were having trouble attracting med-surg nurses.
Virtual nursing emerged as a way to concurrently improve nursing workflows for the health system's current staff members while also attracting new graduates, especially licensed practical nurses and those with associate's degrees.
"With 31,000 associate degree nurses graduating in Missouri and about 19,000 LPNs, that was an untapped source for us," she said.
Nurses working in spaces such as the intensive care unit are surrounded by technology and innovation, but the same is not always the case for med-surg nurses. Dr. Austin said she realized virtual nursing would be a prime opportunity to create a similar type of work environment for these subsectors of the nursing workforce.
"Because everybody was aligned with what we wanted to accomplish — a better work environment for med-surg nurses — it was not that hard of a lift," she said of the rollout. "Because BJC creates a culture of belonging, it makes it easy to work together. It's an environment where you can really be creative if you go about it the right way."
Sprints, not a marathon
Leaders planned to test virtual nursing capabilities for discharge and admissions processes at Progress West and Barnes-Jewish St. Peters. However, leaders first had to gain buy-in from nurses.
"At first, a lot of nurses thought we would replace them with robots," Dr. Austin said. "They were very hesitant. [Hospital leaders] had to really work with that nursing team and prepare them for change."
BJC's design team had previously conducted interviews with nurses, as well as ethnographic research and other granular mapping of a bedside nurse's workflow, which helped leaders understand nurses' top pain points and where virtual capabilities could help most.
From there, BJC organized cross-functional teams of technology, innovation and nursing leaders to design and run two-week "sprints" within the pilot period. This structure allowed teams to quickly collect experience and data about what worked and what did not. From there, the teams could make adjustments, reset and run another sprint, building on those lessons.
The first sprint involved using virtual nursing for patient admissions. The original admission process was time intensive and disjointed, Dr. Maddox said. Nurses often spent 30 to 45 minutes interviewing new patients admitted to the floor and often would get called away to aid in other tasks, such as lifting a patient. What's more, most nurses would write down admission notes on paper before eventually entering them into the EHR, so teams had delayed visibility into the data.
During the pilot, virtual nurses — placed in an isolated part of the hospital — would interview patients via video call while simultaneously typing patient notes into the EHR. Not only did documentation rates improve, but patients appreciated having uninterrupted attention with a nurse who could answer their questions, Dr. Maddox said.
Nurses have also responded positively to the program. Earlier this summer, Dr. Austin attended a workplace outing where she connected with virtual nurses and managers involved in the pilot.
"There is a sense of pride about the virtual nursing project. … They told me they feel hopeful. They feel that there is change coming," she said, adding that the system has hired more LPNs so registered nurses can expand their footprint and work at the top of their license.
Innovation continues
The same day the virtual nursing pilot went live, BJC also launched a nurse scheduling application, called BJC Flex, to promote visibility into open shifts that internal employed nurses could take.
"The problem we were solving was the fact that information about open nursing shifts was squirreled away on spreadsheets or in someone's head," Dr. Maddox said. "There was no visibility into open and available shifts."
To remedy the issue, developers built a custom digital interface on top of the system's enterprise resource platforms that nurses could access on their cellphones. Similar to the virtual nursing initiative, BJC used user-centered design and rapid, iterative sprints to pilot the technology at Christian Hospital in St. Louis. This strategy allowed the developer team to take nurses' feedback and come back the next day with their suggested changes implemented.
"It's been really fun to see that bidirectional partnership between tech and the nurses," Dr. Maddox said.
BJC Flex has since expanded systemwide and now includes patient care technicians, ultrasound technicians, patient services assistants and monitor technicians. In total, these healthcare workers are using the app to pick up an average of 78,000 hours per week.
Strong team alignment, a bias toward action and continual feedback from front-line employees are just several of the factors that help explain BJC's speed of innovation. Another is widespread support from senior leadership.
"It is very hip to say, 'We fail fast.' But a lot of leaders when they hear about a failure raise an eyebrow and say, 'Don't do that again.' That is not how you fail fast," Dr. Maddox said. "What [our leaders] have done is say, 'Oh, that didn't work? Why not? What do you think we should do now?' That is the culture and psychological safety you need to get the true benefit of failing fast, which is you learn faster. That's the ultimate goal."