The last 4 years have prepared our ambulatory care service line for the changes needed for our team to move and pivot as we tackle the challenges and demands of COVID-19. We began our journey in 2016 with Ms. Ferlie Villacorte when she arrived at Harbor-UCLA Medical Center, an acute care, Level I trauma hospital that's part of the Los Angeles County safety net system—a public teaching environment that serves the underserved and resource-poor population. Ferlie arrived with extensive operational experiences in other county facilities, from public health to juvenile correction services.
The ambulatory care service line at Harbor-UCLA had limited structure and resources, with two nurse managers (one of whom was retiring), 110 clinics on campus, and two clinics off campus. Clinics ran from 0800 until the last patient left, which was unpredictable. The philosophy was to do the best for the patients we serviced and survive the day. The goal was to prepare ambulatory care to respond to new challenges, such as Affordable Care Act MediCal patients converting to a managed care environment with capitation rates and loss of waivers for caring for the indigent patient population. The focus was on preventive care rather than disease treatment/management. Also coming into view was Public Hospital Redesign and Incentives (PRIME).
Ferlie began by getting to know the leadership team, going to the “Gemba”—a Japanese term we learned from the Toyota Production System (TPS) that means going to “the actual place.” At Harbor-UCLA, this meant speaking with clinical nurses and healthcare providers. It meant breaking down silos and developing relationships. We reviewed policies and operating procedures, looking at current standards and expectations. Ferlie was also able to work with the medical leadership team to develop a solid organizational chart and reporting structure. Using words like “psychological safety,” we had critical conversations about where we were headed as a department, and these discussions with medical and nursing leadership led to a common mission and vision.
With the help of the TPS, the ambulatory care team developed standard work for intake, patient visits, scheduling, and discharge. Throughout the Department of Health Services (DHS), standard protocols/standard procedures (SP/SP) were developed, which allowed staff members to practice at the top of their certification or license. This required staff education and empowerment. Once the SP/SP were implemented, nursing staff members no longer needed a physician or NP order to perform certain assessments. Ferlie took the need for education and moved the group to the development of continuing-education modules. She has also home grown our clinical education department from one to five employees. This allowed staff members to put the pieces together to improve the quality of patient care, from certified medical assistants to RNs.
Ferlie knew that staff members needed to understand the “whys” to buy in to the new expectations and workflows. Our annual town hall meeting was restructured to ensure that all line staff received the same message at one time. The town hall not only provided education, but also the introduction of our STAR and perfect attendance awards. Much to the surprise of the line staff, the town hall included a full dance production from the leadership team! Yes, we were all moved out of our comfort zone. What we didn't realize is that as we moved together, our team was growing stronger and more resilient. Ferlie was laying the foundation of a strong team with each activity—whether it was a healthy competition during an escape room exercise or a weekend retreat to discuss the goals for the next year.
Being a transformational leader is difficult. There's increased criticism from nurse traditionalists who have difficulty with changing the status quo. Just like Florence Nightingale, Mary Eliza Mahoney, and Clara Barton before her, Ferlie is transforming the way we think about nursing today. Due to COVID-19, where there were hints of healthcare gaps, fissures have opened. Supply, demand, and expectations are changing daily and some days hourly, from new CDC guidelines to changes in how patients are accessing care.
The DHS was years away from telehealth but under Ferlie's leadership, within 1 week we were converting face-to-face visits to telephone visits. Workflows were turned upside down. Ambulatory care nursing staff members were moved to the inpatient arena to support patient care activities. Nursing staff members were now handling triage calls from patients wanting more information regarding COVID-19. There was also an urgent need to develop a plan for drive-through COVID-19 testing. And as healthcare providers began to telework, new communication challenges became a reality.
In the midst of new demands and changes, we've watched our ambulatory care team pivot and move to meet these needs. With great effort and energy, Ferlie has not only kept us grounded in the mission and vision of our work, but she's also creating the future vision by setting clear goals with high expectations. She motivates and encourages others to think outside the box. She's the lead RN for drive-through COVID-19 community testing, she convenes stand-up huddles to problem solve on the spot, and she helps the team develop short- and long-term goals. Always transparent, she's able to reflect on what's working and which areas need improvement.
Although on a smaller scale, the celebration and recognition of nursing staff during Nurses Week in May wasn't lost during the pandemic. As ambulatory care nursing staff members return from their temporary inpatient deployment, we continue to celebrate each one. Under Ferlie's leadership, we're staying one step ahead by planning for surge activities based on our resources and capabilities. She understands that during this time, more than ever, there's a need to build relationships and show our colleagues they're valued. Ferlie gives and receives regular feedback from leadership, which assists with daily decision-making. She uses her management style to motivate the team to take ownership and perform beyond expectations. This is reflected in the quality care our patients receive, the abilities of our line staff, and the resiliency of the leadership team.
Our data reflect these positive trajectories. Based on PRIME data, our DHS system secured $153 million in revenue. Per our last report, compliance data remain at 94% to 96% for nursing documentation standards, even with the number of face-to-face visits down by 20%. We're learning a whole new approach in managing telephone and video visits from intake to discharge. We've changed how patient education is done and how communication is managed. The work has just begun as we move down an uncertain path.
Charting a new path
If COVID-19 has taught us nothing else so far, we know we must change how care is provided and embrace our new roles and expectations as nurses. If our organizations are to survive, we must chart a new path. Transformational leaders like Ferlie are ready, willing, and able to use their talents and skills to grow and produce high functioning, resilient teams who'll improve the quality of care across the continuum. It's a pleasure to be part of Ferlie's team and we've thrived in her E4 philosophy: EDUCATE, ELEVATE, EMPOWER, and ENJOY.