Utilizing Change Management for Successful Implementation of Blue light cystoscopy (BLC™) - Rebecca Roe

December 4, 2019

Rebecca Roe speaks to an interdisciplinary approach to implementation of Blue Light Cystoscopy (BLC™) in her community hospital center, giving a Clinical Education Program Coordinator's perspective. Her team engaged in the five management practices looking at ongoing communication and clinical training and measured things along the way, seeking feedback from every discipline that was utilized, whether it be pharmacy, medical staff, nursing staff, communication, or leadership within the Surgical Services Departments.


Rebecca B. Roe, MSN-Ed., RN, CNOR, Clinical Education Program Coordinator Surgical Services, Northside Hospital, Cumming, GA

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Rebecca Roe: Hello everybody, my name is Rebecca Roe. I am a Clinical Education Program Coordinator for Surgical Services, which is a big long name for someone who directs and implements and coordinates all the educational activities for Surgical Services Departments within this community hospital. We're one of three large hospitals now and we've just purchased three more. So we're becoming a very large presence in the Atlanta Metropolitan Area and outside of Atlanta as well.

One of the things that we implemented this year, which is really great, was the Blue Light Cystoscopy procedure, which was for our bladder cancer patients. And what we found that we needed to do was to have an interdisciplinary approach to making this implementation successful for everyone. And when I was looking at this process, it was really important to me to figure out how nursing can drive this program and how we can fill a large seat at the table when we're trying to provide good patient care and the latest technology for our community.

So I looked into change management theories and we looked at modifying some of the different processes. And so this slide presentation is going to be "Utilizing Change Management for Successful Implementation of Blue Light Cystoscopy". So I'll just keep flipping through and you can kind of share along with me what we've done here at this hospital.

So what we found was that we had to use about five management practices to make this successful. For some reason, this concept seems to be a natural thing when you think about it, but when you're trying to implement it or introduce it, it's very complicated for some reason. But it takes a lot of effort to do it and make the change and to make it stick, so to speak. So this community hospital engaged in the five management practices and what we did was looked at ongoing communication, clinical training, we measured things along the way to see if things were going to be useful or not. We begged for feedback from every single discipline that was utilized, whether it be pharmacy, medical staff, nursing staff, communication, leadership within the Surgical Services Departments. We designed and redesigned some of our patient flow and we also got feedback from our patients as well to find out if our workflow was optimal.

We had the sustained attention throughout every segment of our process and we had total work involvement, and I think that had to do with our preliminary salesmanship of this program and how it would advance health of our community, especially for bladder cancer patients. So we introduced some evidence supporting the benefits of this Blue Light Cystoscopy procedure compared to the standard White Light. We had some skeptical physicians that weren't quite sold on the idea, but we also had some very staunch physician champions who really wanted to use this technique and were there to also help their colleagues along the way, so it was a very interesting process. This also offered nursing staff one of those rare moments in time where we have the ability to lead a project and help determine whether this thing is going to be adopted and whether the hospital should actually invest in this technology because it is an expensive process.

This is kind of a review of what the five change management processes were, which I talked about. I can't emphasize enough the worker involvement was really important because we had to make sure that everybody was buying into the fact that this procedure is actually going to help the patient. It's actually going to be something that will prevent them from having to have so many traumatic procedures to their body over time, over and over and over again and it gives them a better quality of life.

We did research in this process. We looked at the materials and the budgeting. Of course, money is always a factor and if this was not going to have any reimbursement or insurance was going to be a problem for that, then that was going to be some of that, the financial segment of the corporate side of hospital politics and things that nurses are not always involved in. But it is important because if we don't have the money to budget for this technology, it's going to be hard to drive it and make it successful. We also did a lot of multidisciplinary planning, training. We had people from the Photocure® Department come, we had people from the KARL STORZ company come to help them with training for the physicians and the nursing staff and then we had to make sure that our instruments and our equipment was allocated to the right places and all that was a logistical thing.

Our surgery scheduling had to be worked with. We had to get the right nomenclature down. We had to talk to them who are centrally located in our hospital system. And then we also had to add comments to that surgery schedule so we make sure that we had the right equipment and the right labeling on our equipment so that we had the right equipment available for the surgery itself, and that the physician's office who provided that information actually got the right information to the scheduling department. That is crucial because we can't have these cases the first case of the day. So the schedule and order of the cases was something that we had to really emphasize and that took just a lot of communication with the physicians to help them understand that it is a pre-op heavy procedure, not so much a post-op heavy procedure.

The case calendars were really important because we had to make sure that during the trial that we were running to decide whether we were going to accept this technology in our hospital or not had to do with how many of these cases we were going to use in our trial. And then we used electronic and direct messaging in between departments, which was somewhat of a first for us because our hospital policy does not allow for electronic devices, personal electronic devices, smartphones, tablets, that kind of thing. So for this particular situation, we utilized everything that we had at our disposal to make sure that that communication between the pre-operative department and the pharmacy and the intra-op area, that that communication was timely and we didn't miss any phone calls.

The clinical training part is pretty much what we do for any kind of new procedure that we bring in, but this one was most difficult on the pre-op side. You're not just getting somebody ready for surgery, there's a huge amount of skills that nurses have to have in the pre-op area. They have to be comfortable with catheterizing an awake patient, which at surgery we do most all of our catheterizations, urinary catheterizations, when the patient is asleep and relaxed. So there's a lot of talking through with the patient, a lot of patient teaching, a lot of that kind of personal care and attention to that procedure to allay any discomfort or nerves. And what we found in this situation was that most nurses, they kind of balked at it at first, but we had a few nurse champions that really wanted to make sure that this was successful and so they eased a lot of people in that department's fears and we were able to demonstrate how to do that properly.

There was also a nursing skill set for the OR that had to be attained and that came from just using the equipment and being able to troubleshoot equipment and making sure that we had the right trays and the right materials for the procedure itself. So that worked out really well with using Photocure® and also using STORZ to make sure that our cystoscopy room was set up and we were able to effectively monitor all of the procedures really well for the doctor, that we didn't have any glitches in the electronics. The skillset from the PACU was not as much as I would say for pre-op. They basically just needed to know what we were doing and they were very interested in the process. Their skillset did not change much post-operatively for taking care of any cystoscopy patients, so their skillset was mainly in teaching and discharging and making sure that the patients knew what to do once they got home.

Sterile processing was a little bit of a challenge for us and I can explain that a little bit further, but there are specific things for sterile processing that we came across that we had to address right away. There is fluid light cable, it has to have a certain sterilization process and we did not have that so we had to work out alternatives to making sure that our fluid light cables, which are crucial for Blue Light system, were sent to their proper processing areas and we had to use couriers and things for that process and so in the future now we have dedicated money to get the right sterilization that's validated for the Cystoscopy Blue Light procedure.

The anesthesia assessment, and this was really huge too, because the medications are expensive, the timing is crucial, if these patients, if they're in a certain age bracket where they have a lot of comorbidities, if they had problems with cardiology or blood pressure control or they were on blood thinners, then we had to cancel their surgery. So the anesthesia assessment prior to surgery, we've developed, that that was a really important thing, if we get that assessment and the consult done as soon as possible, as soon as the patient gets to the pre-op area, then we can go ahead and start pharmacy mixing the meds and all of that and in this hospital the nurses are not allowed to mix the meds. The pharmacy does all of that under a hood device, which makes sure that the process is sterile. And that is one of the unique processes that we came across in this particular situation because most places allow the nurses and even Photocure® allow the nurses to admix the medication prior to instillation, but the pharmacy at this particular hospital would not allow that to happen. So, we had to factor all that timing into our process to make this work.

Measuring the feedback. This was about delays in of that malfunction or any repairs that had to be done. The logistical challenges that I was addressing about sterile processing and sending the fluid light cable over to another facility to have it sterilized. We had to have all of these pieces in order to make sure that it would function and we would have turnover if we had multiple cases in one day. All of those things had to be worked out.

A schedule order. If somebody mistakenly put this patient at the first of the day that it made some of our physicians a little bit upset because they didn't get to start when they wanted to because our medication needed to stay in the patient's bladder for a certain period of time if we were going to get a good outcome for the Blue Light and for that medication to actually take effect the way it's meant to do.

And then our workflow ... How pre-op and inter-op departments communicated was a really amazing process to watch because the nurses in the operating room would always be checking with pre-op on when the instillation occurred so they would know how to communicate that to the doctor when the case was going to be able to be brought back to the OR.

Some of the situations there. The doctor would allow us to wait as short as 30 minutes and some would allow us to go into the full 45 minutes to an hour for instillation, which was optimal. So we worked that nursing workflow out as far as communicating and getting all those glitches taken care of, and we ended up with a very seamless process. The nurses that were helping us with that information debriefed every single case that we did in this trial. And we looked at all the things that went right. We looked at the things that could have been done better, and we looked at things that were not good outcomes and we needed to fix these things. And so we looked at the whole thing from stem to stern and made sure that people were rewarded for some outstanding performance.

Our sustained attention absolved in followup meetings and case analysis and looking at the nomenclature for the scheduling, we found that over time, different doctors' offices would schedule cases with different terminology instead of the ones that we wanted, really, so we found that we just had to concentrate on education to the doctor's offices and making sure that those few variations on the theme actually had Blue light in there or they had Photocure® in there or they had Cysview® in there. So one of those three words had to be in the scheduling nomenclature. And then the vendor cooperation and support was phenomenal and we still have vendor support today through Photocure®. The physicians appreciate having that, that cooperation there. They need that support when they're doing the procedure just to make sure that all of the STORZ equipment is working and functioning properly and to make sure that they have guidelines and that they are checking after they do the switching back from Blue Light to White Light, that they're actually reforming the procedure well. So that vendor support and cooperation has been great helping us train all the nurses, pharmacy and everyone else that was involved in these cases.

We developed a nursing competency, which was really important to us. We looked at all the videos, we looked at the patient interviews, we looked at the process of the procedure itself, and we developed competencies based on the phase of care that they were working in, whether it's pre-op or intra-op or post-op. And so we looked at those and started using those on all of our new hires as they come into the system as we have successfully implemented this program.

Our debriefs are pretty short and sweet. We look at things that, like I said, that went well, what could have gone better. We also worked with the anesthesia to make sure that if there's any issues with them not seeing those patients immediately, what is the hold-up and what do we need to do to support making sure that those anesthesia consults are done in a timely manner.

So the worker involvement. This was really crucial because of our product evaluation. This was a lot of products, our straight cath sets that we had, we decided we wanted to go with latex-free options so we didn't have to deal with any problems with latex allergies in any way. So the different catheters kits that we had right about that time, I think we had the hurricane and we found out that most of our catheter kits were produced in Puerto Rico, and so all of those areas where they were under production kind of stopped and stalled, so we were on backorder for some of these things for a little while until Puerto Rico was back up and running.

That was an interesting little part of this whole trial is that we had some acts of nature that actually intervened here and then we found out that we had to use other products. So it all worked out. It just took a lot of feedback from the staff to let us know that we don't have this infirm anymore and we need to look at something else. And that's exactly what we did and we found our suitable substitution until we could get back to our normal kit that everyone seemed to like. We did ask for product evaluations on these things and just to get, you know, ease of use, was it quality, did it cause pain in the patient, were they able to drain the bladder effectively if the patient couldn't get up and go to the restroom. So these things were really important to us and getting that information.

The communication improvement, like I said, between the departments became really a historical event because most people, if you've ever worked in surgery before, most areas don't communicate very well with each other. And this whole episode demonstrated how you can communicate between departments and how that communication really drives a better efficient outcome for the workflow and also for enlightening everyone to where the patient is in the process. And so that whole part worked out really, really well for us as well.

Also, the workers, at this point, from the very beginning knew that their evaluation in this product, this evaluation of the process, the evaluation of the technology was going to determine the sustainability. If we couldn't get workers involved in this and engaged in this, it was going to be an unsuccessful event. And it would be a struggle for weeks to come if we could not get that engagement that we needed upfront.

So this kind of gives you an overview of all the different documents. Some of these things, and this is kind of a crazy slide, but the yellow pads, we had things in every color known to mankind, trying to make sure that we got every bit of feedback. We did all kinds of studies. This is the picture of the calendar that we use to plan the cases, our staff education, the catheter kit itself, the competency format, which is demo in the blue and the green at the bottom of the page, and then some instructions on how to actually perform the instillation of the medication or the dye. So when I say medication, some of you may not consider the Photocure® dye as a medication, but in this particular situation, the pharmacy does call it a medication. So that's what we're having to refer to it.

We also had to write a physician's order set to get Uro-Jet® for the lidocaine jelly. And to make sure that the instructions for the Cysview®, that hexaminolevulinate were actually written in the pharmacy order. So that was really important to get that done from the pharmacy perspective and that had to all go through a committee to approve that. So it was a fairly long process but we got that down and we had to kind of make one ourselves, print it out, and then make sure that we had the timing in there as well. So all that had to go with pharmacy policy. At the top of the page there was a flow chart kind of gives you every phase of care that we had from the pharmacy to pre-op to the OR to sterile processing or SPD to the PACU. So, and the warning label was down there as well as what, you know, who cannot have this procedure done.

So basically we had 17 patients in our trial. We covered the trial from July to August in '17. The average time of all of this was 61 minutes instillation time. For each of these cases we had six restagings, six recurrent bladder cancer patients, two with negative-positive cytology, one with visible margins unseen with a White Light, which showed up, one patient did not have luminescence, and then two were used concomitantly with the mitomycin or chemotherapy instillation in the bladder.

So, to finish up with what we did in this program, we found out that this algorithm worked really well afore between phases. We did develop that initial competency for nurses, which really helped out a lot. We did select, based on just to try and eliminate any complications or problems with the patient's care, eliminated latex when we did our intermittent catheter kit. And then we developed a logical plan for our sterile processing of the Blue Light cable and we developed the need for the STERRAD® Sterilizer as a result of implementation because in the STORZ documentation, there's not a validation for anything outside of STERRAD®. So we had what we call a V-PRO maX, which is a similar technology but not exactly the same. And since STORZ has not validated on every PRO-maX, we had to find that STERRAD®. So now we're going to budget for the STERRAD® that will be in-house. We will not eventually have to transport our fluid light cables via courier to another processing area.

We developed an order set for the physicians and at the same time we went into a new computer, a system called Cerner. This order set was developed for all surgeons to use and they all collaborated together, they all approved on, and they all got together and decided that they liked using that same order set. So that has been developed with this process.

We have both written and electronic orders in case of downtime, of course, no computer stays up forever and then we also developed a change with the anesthesia assessment suggesting to them that to prevent case cancellation, which actually turned out to be one of their big quality improvement markers that we want to, we bought into that and tried to tap into that quality improvement process to try to prevent case cancellations on the day of surgery. This is a big patient dissatisfier. It reflects on our scores. It also reflects on our ability to prioritize anesthesia consults and so it hit home to them that they really needed to re-evaluate what cases they prioritize and have. Those are the first cases of the day.

Proper timing for the medication mixing and labeling by the pharmacy, that was really important also, to make sure that we don't have these scheduled at the earliest cases of the day. Our pre-op does not open until 5-5:30, so in order for them to get the patient settled in and do their procedure, the earliest they could possibly get the patient back to surgery in our area without opening pre-op earlier would be 8:00. So those cases will be always a second case of the day.

The trial results were very positive. A lot of doctors that were very skeptical, like I said in the beginning, didn't think that this technology would really benefit, but they have really seen things that they have missed and because of the Blue Light they were able to get as much of the tumor and the bladder cancer out as possible and that's a big satisfier for the patient. They don't have to come back every six weeks or whatever the schedule is. They don't have to return to have another procedure done. It's extremely important and these patients have been extremely pleased. So doctors, even the most skeptical, have seen the benefit of the Blue Light Cystoscopy procedure. And so the hospital, based on our results, have adopted and purchased the product and we're using it today. In fact, we've had several cases today and some of our doctors that are using it today are some of our most skeptical. So they do see the benefits as well.

So these are the people that helped us out during this trial. You can see that there's quite a few here. We've had our doctor champion, which is Dr. Adam Mellis, and then we've had their vendor support, which there's KARL STORZ and the Photocure® folks, Mara Schubert and Travis Hiscutt. And then all of our Northside nurses who made this successful, listed here. As far as our administrators, we have to have them. Our leadership team, Amy Fisher, and our Manager of Perioperative Services helped us with pre-op and PACU workflows. Our OR Manager and our Clinical Supervisor for Urology and our Charge Preceptor were very helpful in making sure that those communication paths were structured and solidified during our trial and after. Our PharmD's, helping us with medications and making sure that timing was done and the labeling was done. There is a formal process now for that which has developed out of our trial and how we've edited and tweaked the trial to make it more efficient as we've gone along. And then Susie Kittle, who is no longer with our department. She retired, but this was one of her last contributions to our Nursing Urology Department, was to obtain this procedure and she was very passionate about it, so we were very glad that we could bring this to fruition even as she retired before it actually was implemented.

And then Cynthia Newell, who was our overall Surgical Services Quality and Education Manager. She helped us quite a bit in structuring some of our education. The Forsyth campus was the first one and since has been the only one that has been able to successfully implement this process. Other campuses have tried and it has been less successful. Some of the doctors have not felt the ability to easily get these cases on, they wanted them to be the first cases of the day and because this case can't be the first one of the day, they just really just didn't, they abandoned it.

So Forsyth is the one that is working it and we continue to do so and I think they're going to implement it at another campus very soon. And they've recently purchased the equipment for our new hospital that we purchased and brought into the family system. So we should have three hospitals in the very near future that will offer this kind of a triangular geographical area in the Atlanta Metro area. So, that's what we did and I hope that this can help everyone use those five change processes to implement this program because it is so helpful for the patient and we want the best for our patients. And I thank you for having me this afternoon.