Transformation through Teamwork

June 2017

​Reorganization Transforms Bone Marrow Transplant Program at University of Colorado Hospital

Each year, nearly 50,000 bone marrow transplants are carried out across the globe. The treatment is often the last resort for patients battling blood diseases such as leukemia, lymphoma, Hodgkin’s disease and multiple myeloma. 

Though transplants have boosted survival rates for some blood cancers to almost 85%, a positive outcome is by no means certain. Bone marrow transplants carry a significant risk of serious complications like graft versus host disease, infections and side effects from chemotherapy.

Yet this is what makes the bone marrow transplant (BMT) program at University of Colorado Hospital all the more remarkable. As Jeffrey Glasheen​, MD, professor, medicine-internal medicine and chief quality officer at UCHealth, explains, their outcomes are better than 90+% of programs in the United States when actual outcomes are compared to expected outcomes.

“When you examine their outcomes you quickly realize how truly impressive this program has become,” he said. “If you look at their one-year survival rates versus predicted outcomes over the past four years, they are better than 98% of programs in the country. That didn’t happen by chance. It happened because of vision, expert leadership and dedicated work. Ultimately, it is our patients who reap the benefits of those efforts.”

These statistics come from the Center for International Blood and Marrow Transplant Research (CIBMTR) data on the 179 transplant centers across the US. Since each center has different patient demographics, the CIBMTR measures success by comparing expected outcomes to actual outcomes.

University of Colorado Hospital is one of just 17 centers whose actual outcomes exceeded their expected outcomes. Significantly, it is also one of only five to have achieved this for the last four reporting years in a row.

Driven by expert leadership

Clay Smith​, MD, SOM professor, medicine-hematology, leads the program as director of general hematology, blood cancers and bone marrow transplant programs at University of Colorado Cancer Center​. He states that organizational change and renewed teamwork lie behind this achievement. (pictured at right, Clay Smith, MD)

“We’re very proud of this result; particularly because it was achieved during a period when our patient numbers doubled. It’s a real testament to our team approach and the effort we have all put in to create more structure around the care we provide.”

In recent years, the team has developed structured guidelines for almost every process, from who should get what type of transplant to how they should receive care. The team also collects data on these processes so they can analyze how they are performing and make incremental improvements.

“This is the best way we can achieve our mission: to provide the best possible care and always strive to advance the care we provide,” Dr. Smith said. “But we couldn’t have achieved this without the support of the wider organization. The School of Medicine and our leaders in quality and patient experience have been phenomenal. They have taught us that there’s a real rigor and science to improving quality. They also send a great message that patients come first, and that filters through the whole organization.”

Karley Trautman​, DNP, ANP-BC, AGACNP-BC, is the clinical director of advanced practice provider services for the BMT program at UCH. She explains that Dr. Smith has led the team through a considerable transition in recent years.

“Advancements in immune and cellular therapy have changed the landscape and added a new dimension to our work,” she said. “As we improve our skills we also manage to keep our patients alive for longer, which again changes many aspects of our work.

“Dr. Smith helped us reorganize and realign our program to better meet the needs of this changing patient population. He helped us absorb our patient growth while still maintaining—and improving—our excellent standards of care.”

Similarly, Trautman believes Jonathan Gutman​, MD, also brought considerable positive change when he took over as director of allogeneic stem cell transplantation in 2009.

“His knowledge and expertise brought new ways of selecting patients for transplant and new ways to think about donor sources,” she said. “We’re now one of the leading institutions in the country for cord blood donation and he has played a large role in our excellent outcomes overall.”

United by a passionate and committed team

Yet for organizational change to be a success, everyone must strive toward the same goal as part of a cohesive team. 

At UCH, the BMT team comprises a range of providers, including physicians, advanced practice providers, nurse practitioners, social workers, psychologists and dieticians, who all work in concert to achieve the best possible patient outcomes.

“Our team works incredibly well together,” Dr. Smith said. “Our advanced practice providers (APPs) in particular are an amazing group of providers, and we have been one of the leaders in getting this sort of team in place.”

The rise of the advanced practice provider

Previously, the BMT program was staffed largely by residents who did not necessarily have specialist knowledge of bone marrow transplant care. Since 2013, APPs have been providing 24/7 specialized medical care for the inpatient unit and seven-day-a-week coverage for outpatients. 

APPs are typically physician assistants or nurse practitioners who have gone on to achieve a three-year master’s degree.

“Our large group of advanced practice providers are the backbone of the bone marrow transplant program,” Trautman said. “They take care of our patients day in, day out, and allow us to provide specialized care across both inpatient and outpatient settings. They often bring expertise on side effects and the early recognition of complications, and so may prevent many problems.”

Helping to build the expertise of APPs is a specially designed 12-week training program created by Glen Peterson​, NP, RN. Here, providers are trained specifically in the care of hematologic malignancy and BMT patients. 

“This program is essential in helping our team learn the intricacies of managing this seriously ill population,” Trautman said. “As a result of their training and experience, our APPs are working at the very top of the scope of their practice.”

Creating a stronger infrastructure for BMT nurses

The nurses on the BMT program—who Dr. Smith notes are probably the best nurses he’s ever worked with—are also one of the cornerstones of the program’s success.

Jamie Nordhagen, RN, BSN, OCN, is nurse manager of the bone marrow transplant and oncology inpatient unit at UCH. She explains that the rapid growth in patient numbers several years ago made it difficult for nurses to maintain high levels of competency with BMT patients. 

“We found ourselves taking care of a huge spectrum of patients—medicine, surgical, oncology and transplant. This meant there was always someone different taking care of our BMT patients. We needed to find a way to get back to owning our practice as BMT specialist nurses.”

To turn things around, Nordhagen took several measures. She wrote a business plan to improve the patient:nurse ratio of the BMT program from 4:1 during the day and 5:1 at night to 3:1 at all times. She also helped to create the pathways program, where nurses can shadow an APP, learn specialist knowledge and discover how best to communicate with APPs and the rest of the team.

“We’ve worked hard to create some continuity for our nurses,” she said. “Teamwork and trust improves when there’s more consistency.”

Getting results through collaborative leadership

To bring the program together, the entire leadership team (including Dr. Smith, Trautman, Peterson, Nordhagen and Lindsay McMenimen, RN, BSN, BMTCN, practice manager) meet regularly and have developed new avenues for communication within the team.

They attend each other’s meetings as a way to improve collaboration and ensure everyone involved in the program feels able to raise ideas or concerns. Since September 2016 they have also established multidisciplinary patient rounds, which has correlated with an increase in patient experience scores. 

“Our nurses and APPs now report feeling more able to have crucial conversations with each other,” Nordhagen said. “We’ve taken measures to improve the way we communicate emotional topics and developed a process for what to do if there’s conflict. This is important because without strong relationships this really would impact patient care. It’s been extremely gratifying to see comradery, trust and respect flourish as a result of our efforts.”

Such a united front is no doubt why the BMT program sailed through their most recent inspection from FACT, the Foundation for the Accreditation of Cellular Therapy. 

“FACT reviews BMT programs every three years,” Dr. Smith said. “Our most recent one in December 2016 was the best I’ve ever experienced and our quality assurance manager, Leigh Gates, deserves a lot of credit for that. Our performance in that inspection is a real testament to her leadership and the whole team’s approach to quality.”

Continuing to push boundaries

Yet despite their great results, the BMT team is not resting on their laurels. Trautman says that although the recent FACT accreditation process felt more like a showcase of their achievements than an inspection, the team will never be happy with the status quo.

“There are always new treatments, more ways to specialize nursing care, new developments in infection control management. We’re always going to be pushing the boundaries to find what’s best for our patients, because they are what’s most important.”

For Dr. Smith, the bonds he and his team develop with patients are what drives the program forward.

“There’s something incredibly enriching about getting to know your patients and their families, and that emotional attachment creates a strong drive to always seek to do better,” he said. “I believe we’ve managed to achieve such good outcomes because every single person involved in this program has that same attachment and is truly dedicated to caring for our patients.”

Trautman agrees, and says that at the heart of the BMT program is the fact that they treat their patients like family.

“As oncology providers we are meeting the patient at a critical time that has sent their whole life into a tailspin,” she said. “They can be with us in the hospital for a long time and it’s our job to provide some stability, reassure them that they can trust us and that we have their best interests at heart. We can tuck them under our wing and help them through it.

“As we continue to grow, it’s important to all of us that we don’t lose that personal connection, as I believe that’s what sets us apart from every other program in the country.”