When the emergency and neurosciences division first heard of Nursing Management's Visionary Leader 2007, we immediately thought of our leader Marilyn Margolis. She has led the emergency departments (EDs) at both Emory University Hospital and Emory Crawford Long Hospital for the last several years and more recently acquired the neuroscience service line at Emory University. Margolis has an extensive history within the Emory Healthcare System as a staff nurse, department director, director of nursing, and most recently as director of operations for Emory University. Her ability to work her way from staff nurse to a nursing leadership position that shapes the functioning of a large academic institution is indicative of her many talents and creativity. Margolis is an inspirational leader and truly motivates those around her to achieve new heights in their own careers. As a division, we consider ourselves fortunate to work in her presence. Our division has outlined a few of Margolis's extraordinary contributions to improving nurses' work environments and clinical practice.
LEAN methodology
In October 2005, the ED began utilizing LEAN technology to identify waste in processes and determine how to dedicate more value-added time to the patient during ED visits. LEAN is a process used by Toyota's manufacturing plants to minimize variation from their processes and improve performance. It has recently begun expanding into the healthcare realm. Margolis was instrumental in leading our first several projects as a team leader and has recently become a certified instructor in LEAN. Our projects, always centered on processes that would be valued by the patient, have ranged from decreasing the time from arrival to triage completion, decreasing the time from arrival to antibiotic infusion for our pneumonia patients, and decreasing the time from arrival to our cardiac catheterization lab intervention. Her enthusiastic leadership style has led the staff nurses to partner with physicians, administration, and leadership from ancillary departments to create innovative ways to increase efficiency through collaboration.
Our LEAN project that led to decreasing our time from arrival to cath lab intervention, nicknamed Heart Attack Rescue Team (HART), blossomed into another project entirely. The HART program uses the assistance of local emergency medical system (EMS) responders to send 12-lead electrocardiograms (ECGs) highly suspect of acute myocardial infarctions (MI) through a phone to a printer in the ED at Emory Crawford Long or Emory University Hospital. An attending ED physician can then interpret the ECG to determine whether or not it's appropriate to mobilize the cath lab team. The hope was that this process would shave off precious minutes from the amount of time it takes to begin a patient's cath lab intervention.
Margolis then worked to take this idea a step further. Along with many other dedicated nurses and physicians, the Timely Intervention to Myocardial Emergencies (TIME) group was born. There are now five different hospitals in the metro Atlanta area equipped with a cath lab, encompassing four different healthcare systems, participating in the TIME program. If the EMS team responding to a call believes its patient is having an acute MI, the ECG is transferred to one central printer. If the patient is having an MI, he or she is then transferred to the closest participating facility to have the quickest possible intervention. As we've all heard, time is muscle. Margolis was an integral part of this collaborative team and went on to win a Quality and Patient Safety Award in 2006 from The Partnership for Health and Accountability for her participation in making this a successful program. This program has led to meeting the door-to-intervention time of less than 90 minutes more than 85% of the time, a massive improvement in patient care.
Stroke Center certification
Margolis has led many system-wide improvements. One of the most exciting developments is the attainment of Emory University Hospital's Primary Stroke Center certification by The Joint Commission. Margolis led and coordinated education and changes to make our certification a reality. Her administrative support enabled emergency services, neurology, neurosurgery, radiology, lab, pharmacy, research, and other areas to collaborate to make improvements in our stroke care. She brought together patients, nurses, and physicians to evaluate and improve services. She also supported community outreach, like Stop Stroke Saturday, and EMS partnerships and training. Her unique people skills brought diverse groups together to achieve our goal of stroke certification.
Bariatric Center of Excellence application
Margolis is now bringing these same people skills together to apply for Bariatric Center of Excellence for Emory Crawford Long Hospital. Margolis is a great support person for education. Piloting of specialized bariatric equipment, full time equivalent support, and working toward obtainment of a director for this initiative are other ways that Margolis has contributed to achieving designation as a bariatric center. Through collaboration with another large academic center with bariatric certification, Margolis has gleaned insights to improve and develop our bariatric center. The American College of Surgeons certifies bariatric centers, and Margolis is providing administrative support for resources that would make this happen.
Electronic charting/CPOE
Margolis takes a keen interest in improving the hand-off of care between nurses. Through her ability to relate well with frontline staff, she has greatly improved ease of electronic charting. She truly believes in making electronic charting work for the nurses. She has initiated several projects between ED and inpatient nurses to share ideas to improve the electronic fax report sent to inpatient areas for admitted patients. Her working relationship with consultants has resulted in innovative ideas to simplify the ED's fax report, and also yielding the content necessary to provide safe inpatient care.
Emory's ED has gone through many positive changes in recent years, and Margolis has been the driving force. The projects she has taken on are deeply grounded in research and are on the cutting edge of technical advancement, such as electronic charting and computerized physician order entry (CPOE). Margolis replaced the ED's outdated system with a new updated version of computerized charting, the Emory Electronic Medical Record. She was responsible for bringing the electronic charting system to the Emory Healthcare organization, a system that integrated Emory Crawford Long Hospital, Emory University Hospital, Wesley Woods Geriatric Hospital, and The Emory Clinic. Emory University Hospital's ED was one of the first to "go live" with this new system. The support and encouragement Margolis gave to the nurses, nurse technicians, unit clerks, and physicians made this a smooth transition. The new electronic charting system allows for standardized care throughout the entire organization and also decreases expenses related to dictation (approximately $60,000 a month). Under Margolis's guidance we've seen staff motivated to strive for and achieve exceptionally high standards as the ED moves forward with the latest technology. Margolis creates an environment that facilitates input from frontline staff to constantly improve our methods of charting.
Neurosurgical ICU
Margolis was given the responsibility of opening a 20-bed neurosurgical intensive care unit (ICU), which spans over 23,000 square feet. The time frame from the first organizational meeting to opening the ICU was 18 months. During this time, Margolis had several system-wide projects. She used her talents to find and assign key responsibilities to individuals who are capable of developing and implementing projects. She also collaborated with a team she led to mutual decision making, as well as creatively helped increase individuals' performance. This is an example of the "FIT" factor, "Fully Igniting Team." In times where change meets resistance and departments isolate themselves, Margolis is able to stir imagination, create energy, and break down walls of inefficiency throughout the health system.
From the very beginning, she was able to organize large groups so that the greatest input in the unit design would be one of community; all would be involved. One of these opportunities dealt with setting up a life-size replica of the nurse's station, patient room, and family studio. She supported the process and in the end had over 40 personnel involved. Healthcare design consultants, the local university engineering department, administrators, multiple vendors, nurse practitioners, physicians, nurses, nursing assistants, and other specialists were involved in redesigning the unit. Multiple patient care scenarios were enacted and were photographed and videotaped to develop the unit's workflow. At the end of each scenario, the group met and workflow changes would be made. This process gave voice, input, and involvement to all parties.
Two of Margolis's challenges were to make the unit fully operational while implementing patient-centered care (PCC) and incorporate open visitation and family presence during resuscitation. This was no easy task, but our innovative leader took her expertise in the Toyota LEAN Process and used these principles to achieve unit goals. This project dealt with the need to transition into a new unit while taking into consideration patients, families, and staff members. She helped formulate two LEAN groups that addressed patient/family flow and unit operations. Margolis scheduled 10 nursing staff members to work alongside nurse practitioners and medical staff to create these two teams. The entire process, which defined the actions that needed to be taken, took 4 full days. The team leaders were senior clinical nurses who helped define how the unit operations and patient and family process would take place on February 1, 2007.
Patient-centered care
PCC was an overarching concept that our leader wanted to integrate in the department. The literature on PCC states that it involves doing what's best for the patient and his or her family. Margolis proposed that a family coordinator was needed to care for the patient's family needs. The LEAN team put together by Margolis developed the job description for the family coordinator along with specific training requirements. Margolis's ED experience led to implementation of family presence during resuscitation in the ICU. Less than 5% of hospitals currently involve families during resuscitation efforts. The LEAN working group not only set the basic guidelines for family presence, but also had it approved for pilot use in the unit.
The next step in implementation of PCC was developing the "code support person," a nurse who'd respond to the resuscitation effort and support the family. Chaplains provided training for this nurse to assist them in their efforts in providing positive support for patients and families. An 8-hour communication class was also provided to 80% of the staff prior to opening the unit. The team also developed numerous guidelines that dealt with open visitation, communication, patient and family education, use of the unit's amenities, and many other projects. Margolis invited family members who had loved ones in the unit for over 60 days to participate in our LEAN group. Their voices were heard and ideas accepted on how we could support families during times of great stress. We knew with Margolis's guidance that PCC would be a success with nurses, patients, and families.
The operations LEAN group had project timelines that dealt with supplies, equipment, arrangement of required medical forms, placement and use of a patient census electronic board, and location of all the required electronic documentation systems. The first draft list had 69 items that needed to be accomplished prior to the unit opening. With Margolis's support, the group was able to schedule at least 20 ancillary service department representatives to engage in the process and assist them in determining best practice. This process defined timelines for all involved to assist in the transition into the new unit. It was an extreme team effort, which influenced the direct care of patients and staff support. The unit was ready, and we were prepared to open due to the work that many provided.
In summary, Margolis is a magnificent example of visionary leadership. She continuously strives to improve patient safety by removing barriers to patient care for frontline nursing staff. Her creativity and personal touch make each person at Emory-the janitorial staff, ancillary staff, nursing technicians, physicians, and nursing staff-feel heard and understood. She's approachable and trustworthy, and works to make each topic as transparent as possible to enable collaborative teams to make the best possible decisions. The emergency services and the neuroscience division at Emory Healthcare enthusiastically recommend Marilyn Margolis as your Visionary Leader 2007.