How to be a Disruptive Innovation Agent

Texas Health Resources: Presbyterian Dallas's chief nursing officer helps drive transformative change through the innovative Clinical Nurse Leader Program

Healthcare needs a major transformation, according to Dr. Cole Edmonson, chief nursing officer for Texas Health Resources: Presbyterian Dallas. He believes that steady evolution isn’t enough. What US healthcare needs, Edmonson says, is no less than sweeping disruptive innovation, and he intends to be a change agent to further that end.

“We all know that the healthcare system is plagued with waste,” Edmonson says. “We are getting poorer outcomes than other developed countries and spending more. I see it as a leader’s obligation to help cultivate disruptive innovation.”

Edmonson points to three recent programs as examples of disruptive innovation within Texas Health Resources, which operates hospitals in sixteen counties in North Central Texas. All three have radically changed entrenched operations and furthered efforts to advance the triple aim of cost savings, improved patient outcomes, and better patient experience—and Edmonson has had a hand in all of them.

Dr. Cole Edmonson, chief nursing officer for Texas Health Resources: Presbyterian Dallas

Of the three initiatives, the one impacting patients most directly is the Clinical Nurse Leader (CNL) Program, which trains and empowers nurses to coordinate patient care and educate patients on preventive measures. The two-year, master’s-level CNL program at Texas Health Resources is a partnership with Texas Christian University in Fort Worth. Participants work at a Texas Health Resources hospital as patient-care facilitators—a precursor role of certified CNLs—while taking classes at TCU. Once assigned a CNL mentor, each participant receives in-depth, on-the-job education at patients’ bedsides along with classroom courses that bolster their knowledge.

 

Most nurses in the program have at least three years of work experience before they enroll in the CNL program. They focus on matters related to coordinating care as advanced pathology and radiology and how to apply the latest research concerning patient recovery. When they become full-fledged CNLs, they step into a role that Edmonson says is the basis for Texas Health Resources’ radical new approach to patient care.

“They are the quarterback of the care team—the one clinician that understands the patient’s entire case history and shepherds the patient through the healthcare system,” Edmonson says. “CNLs are advanced generalists that look to make sure that tests, medications, and treatment plans make sense. They are experts in closing gaps and finding opportunities to improve care.”

CNLs serve between twelve and sixteen patients at a time and participate in daily meetings with caregivers to gather updates on each patient’s case. If a specialist is unable to attend the meeting, the CNL can request that they check in when they are available. These daily checkpoints assure that each patient has an advocate that keeps up to date on their progress. CNLs also function as backstops that can avert oversights. They might find delayed test results and identify medication gaps. If, for example, a patient is taking medications before admission, they can ensure that the patient continues to receive those drugs while in the hospital. If there is an instance of poor communication among caregivers, CNLs are well-poised to step in and correct misunderstandings.

“If you take a class and don’t revisit the training for a full year, your skills degrade.”

As patient advocates, CNLs can translate medical jargon for the patient to layman’s terms. Their duties include ensuring that discharge planning is underway from the beginning of the patient’s stay. They also coordinate among caregivers to make sure the discharge happens in a timely manner, and they help patients clearly understand postdischarge medication and recovery plans. These efforts help to prevent readmissions and have paid measurable dividends.

“We have been able to improve all-cause readmissions to well below the national benchmark and make significant improvement in patient satisfaction scores,” Edmonson says. There has also been a reduction of length of stay where there are CNLs, he adds. The program has been so successful that Texas Health Resources has rolled it out across all of its hospitals.

Another initiative with a transformative impact is the triad model of organizational leadership. In 2013, Texas Health Resources elevated the status of the chief medical officer and chief nursing officer to the same level as the president. The trio now has equal levels of decision-making responsibility and accountability. They work as a team on strategic planning, business planning, quality of care, and employee engagement, Edmonson says.

The president, as is the case with most hospital groups, brings a business background and perspective to the table. The two clinicians offer an MD and nursing perspective. Formally looping in the two clinicians to the highest level of decision making has had significant benefits. “This allows for more emphasis on clinical input,” Edmonson says. “It puts quality patient experience and safety on equal par with finance.” The result, Edmonson says, has been continued improvement in quality metrics and employee engagement scores.

Adopting a drastically new approach to CPR training—the American Heart Association’s Resuscitation Quality Improvement (RQI) methodology—is an additional disruptive change that has borne fruit. First piloted on a small scale in 2012, RQI raises the quality of CPR training and cuts costs. Instead of taking off-site, classroom-based courses every year to certify their skills, clinicians use a hospital-based lab equipped with high-tech mannequins that measure compression and frequency. Clinicians refresh their skills at least every six months, using this technology that acts like a coach and provides real-time feedback. The results are better-trained clinicians that do not need to take a half-day or more away from the hospital to take a class.

“If you take a class and don’t revisit training for a full year, your skills degrade,” Edmonson says. More frequent training is better. Since the organization adopted the RQI program in 2013, there has been a measurable jump in quality of care across the organization. “We’ve essentially doubled the survival rates of patients on postresuscitation events,” he says.

Edmonson will continue to seek ways to beneficially disrupt old hidebound operations that no longer serve healthcare institutions well. It’s a mission he relishes, and as someone with a nursing background, he brings valuable insight to the effort.


Research has shown that psychomotor skills decay rapidly over time, and the current two-year certification model does not lend itself to the maintenance of high-quality CPR skills that can lead to improved patient outcomes. The American Heart Association’s Resuscitation Quality Improvement Program (AHA RQI Program) offers an innovative approach for sustaining high-quality CPR skills. Students complete cognitive components online, then perform CPR at mobile RQI Simulation Stations equipped with adult and infant manikins. Through ongoing participation in the RQI Program, students achieve a perpetually valid CPR card, and the focus is shifted from course completion to mastery of CPR skills.