Hiyam Nadel, MBA, BSN, RN: Nurses Are Natural Innovators

Nurses are natural innovators. What they often term workarounds are really innovations in action. Nurses have a unique outlook on patient care and often build an intimate connection with patients and their families. Because of this, they're perfectly suited to change patient care.

For Hiyam Nadel, who serves as the nursing director for outpatient obstetrics and gynecology at Mass General, innovation has been built in to her career from the very beginning. Hiyam came to Mass General in the 1990s and was charged with helping to relaunch the obstetrics program after four– after a four-decade hiatus. She jumped at the opportunity to build a new unit from scratch and devised a new model of care that centered nurses at the point of continuity for patients rather than relegating them to triage roles.

In 2013, Hiyam received her MBA from Babson University, which she sought out for its emphasis on innovation. She's now actively supporting other nurses to become innovators themselves as the newly appointed director for the Center for Innovation in Patient Care, Care Delivery.

Welcome, Hiyam.

A: Thank you, Amy. Happy to be here.

Q: Can we start out by talking about what drew you to nursing initially?

A: Sure. Initially, I actually didn't know what I wanted to do. I knew something in healthcare, however. And then my parents said, "Why don't you volunteer at the hospital?" We did. And then, and as I shadowed physicians and I shadowed other healthcare workers, nursing really resonated with me. And it was the very high touch point with patients and the relationship that they developed.

Q: Was there a particular point that you knew that's what you wanted to do?

A: Um, I think in particular there was in the intensive care units, and that relationship that a nurse can help a patient in critical condition, then get them through. And even if it becomes a bad outcome and then to help the family. So also the relationship with families is what really drew that.

Q: Yeah, absolutely. And I know you've talked about the fact that innovation has kind of always been a part of your practice. So how did you get into that space?

A: So first of all, I think Mass General is very innovative. And when we were asked to launch the OB program, I walked in, I first just wanted to consult because I didn't know if I wanted to leave my current institution. And then, they said, "Here, here are the architects; build it. Here are the computer programs; go ahead and design the the electronic medical record."

And so, first, the confidence that they instilled with you, I was absolutely petrified. But I said, you know what, I can do this. I can walk through this as a patient. I can walk through this as a clinician. And so, we did. We built it the way we work. And I think that was so exciting.

Q: And was that something you'd done before? Had you built something? Had you come up with new ideas and put them into practice before?

A: So I think people that, if you talk to a lot of innovators, I think they will tell you that they're different. They think differently. The see things differently. Regardless of where we are, what we're doing, we're always thinking of how we can improve things.

I recognized that in myself very early on when I was a student. And so, I worked on a respiratory floor, and of course those patients, it's important to ambulate them. And they all had Foley catheters, and they would wince from the pain. And so, I devised this taping measure on their legs to sort of secure the catheter. And I'm sure a gazillion nurses have done that as well.

And then, several years later I saw that it was on the market and it was commercialized. And realized, oh, darn, that was my idea, why didn't I do that?

And so, that's when my passion came around, as to really try to instill in other nurses that in fact you can innovate. Your modification, your workaround is, in fact, an invention.

Q: It's so interesting to me that reframing a workaround, it's just a thing that you do. But an innovation has this sort of spark behind it. Do you find, when you talk to other nurses about innovation, is that something that resonates with them?

A: They get so excited. And even sometimes when I lecture, I'll, I just get a roll of tape and I'll say, "How many of you have done things with this tape?" And all the hands go up because just using tape to modify a lot of the equipment that doesn't work quite right. And so, it does resonate. Because just like myself, I didn't have a mentor or somebody say, "Hey, wait, this is great. Let's develop this further."

And that's what we're trying to do now.

A: What excites me, just working with the current nurses now, is that they are solving real problems. And the most excitement for me, I'll always say, "So, you're going to become famous. What do you think you're going to do? Will you be leaving?" And they said, "Oh, my god, no, I need to stay at the bedside, Because if I can continue to innovate, I can only do it because I'm at the bedside. So I understand what is going on and get my ideas from there.”

And to me, because there's a big concern that there's a high turnover rate of 17% of nurses leaving the bedside, coupled with 8% that we're not filling at all. So if we can excite them through this creative process and keep them at the bedside, I think everyone wins.

Q: So going back, you mentioned coming to Mass General, reopening this program. What gave you that idea? Why did you want to build a program that was so different?

A: So I think when I was attending the meetings, people were very excited and I think babies make people happy. And so, it was the birth of a new way of practicing. We had the opportunity to build our own electronic medical record. So everything was new. We as current clinicians know what does work and doesn't work, so let's build it. This was an opportunity to just build it the way we functioned.

So the flow helps the efficiency, and keeping the team together when they see patients. And the way we created it was a one-stop shop. So when you come to your prenatal care, you have your– you see your prenatal provider, which could be a high-risk doctor or a generalist or a midwife. And then if you needed to see a nutritionist or social worker, we bring them to our unit so that they see the patients. If you need an ultrasound, genetics appointment.

So literally, it's very efficient. The patients can be there one day and get all that care taken care of, rather than having to go to a different building to see the midwife, or a different building to get their ultrasound.

Additionally, before I left my other institution, I sat and just did time studies. I observed everyone working and realized that, at the end of the day, there was an hour-and-a-half, on average, wasted for clinicians to come out of the room and look for someone to come in and help them. And so, what can we do to help with that efficiency and get that out of the system for the day?

Also, these providers would be on the main campus one day, and they have to go to a health center the next, and on call the following day. So who was going to be the continuity for the patients? And that's when I proposed to my boss, "Look, I want to try a different nursing model." And he said, "What? That's crazy!" So he thought about, came back and said, "Look, I'll give you two years to prove yourself. If it doesn't work, then we'll part ways."

And of course, we went from an average of 12 patients a session to 20. Now we're a little bit too busy [laughter], but the nurses actually paid for themselves by being part of the team and doing a lot of pre-work, seeing patients, and then the post-work after the session.

Q: So you went from 12 to 20. So the efficiency almost doubled.

A: Correct. So if you think about having everyone practice to the, highest level of their license, and there's more and more things to do for one pregnant patient, all the different mandates. So who should really be doing all of that?

And so, we, you know, we also have a medical assistant who rooms the patients, but the nurses go in, they answer all the questions they can. They do all the education, so everything is done. So by the time the clinician goes in, they can really focus on answering the more complicated questions, et cetera. So I think it makes us all efficient. But more than that, I think everyone enjoys their job more.

Q: And everyone can sort of specialize in their piece of the process.

A: Exactly.

Q: And really own that patient experience in that moment. You mentioned this was totally new, it was daunting to set about doing it. When you were building this program, and it was so different, what gave you the confidence to move forward?

A: So I think two things. First of all, the providers I came here with, I have known them for a very long time, and over time we've built a lot of respect and trust. We could push back on each other respectfully, and we all get smarter and better. So I felt totally confident to do that.

But again, when I walked into Mass General, it just was different. you were treated as one of the members of the team. And you know, my physician colleague, he would work on one pathway and I would work on another pathway. And then we'd come together.

And so, you know, it just gave you the confidence. You just felt it when you came here.

Q: Were there roadblocks or bumps along the way that you had to overcome?

A: I think there's always roadblocks and barriers. So normally, in most practices, or any ambulatory practices, what the nurses do is generally triage calls. So if you just say "let me prove it to you," or, "give a timeline," or, "let's pilot," that's all you can ask for because you might be wrong, too. So I think if everyone stays open in trying new things, then everybody wins.

Q: Yeah.

A: And you can't hold on to the idea you have. You have to be able to implement it quickly, change quickly.

Q: Were there points when you had to pivot and change course?

A: Always. We're still pivoting and changing course. But that's– I keep telling my staff that's how you stay young. [laughter]

Q: And so, you have this great experience of building this new model of care. How are you imparting that to the people under you?

A: Right. So I think what's important is– first of all, nurses are problem solvers. But when you become a leader, there are situations where you actually have to make decisions quickly. But most of the time now, as a leader, you really need to sit and watch the entire process. And I firmly believe in process maps, because you sit and you talk to everyone involved. You write it down. And then you can actually see where you can improve or what needs to change.

I don't like patient complaints, but I think we can always learn from patient complaints. Luckily, we don't get many. But I love talking to patients because you're learning from their perspective. I can think it's a wonderful idea, but it may not work for the patient.

So that constant interaction with patients really gives you insight into what they feel is important to them.

Q: Yeah. Are there any examples you can give of a time where you maybe had one of these interactions with a patient that led to an improvement?

A: So we had a patient that was really escalating– it was actually the patient's husband. And they had a fairly bad experience before. Not with us, but with another institution. And he felt nobody was listening. And so, from that, what we gained was, do we actually listen to partners that come in to the clinic?

They're equally as important, equally as nervous. And so, we're really looking at their needs, too, because we have to treat not just the patient, but the entire family. It's a high anxiety time for many, especially because we see high-risk patients.

And then, I did get back to him and say, "This is what we've done. You've made us realize, although the staff was very welcoming to partners, they weren't really focused on their needs.” Because that's what we're taught – this is the patient in front of us. But not, not so much in obstetrics. We need to really think through that.

Q: Yeah, I think– it seems like medicine in general we're starting to realize things are connected in a way–

A: Right.

Q: –that maybe we didn't always think of it.

A: Well, we always screen for depression, which is a big deal in pregnancy and beyond. So if you think about depression and you're asking the patient to let you know when they're depressed, that's sort of doesn't really make sense. You know, so we should involve their partner.

We want them to recognize what the symptoms of depression so they're– and in fact, when we do have a, you know, very depressed mom, it's usually the significant other that's calling us. So of course it makes sense. But sometimes you're in your own world, and you don't realize that.

Q: Yeah, and you get so busy and focused on what's right–

A: Exactly.

Q: –in front of you. I'm wondering, when you're working with nurses and talking about innovation, do you think their outlook is different from other types of innovators?

A: I think that's yet to be determined. However, I think what's unique about nursing is, first of all, there's four million nurses in the country. They're the largest workforce. And they touch every aspect of healthcare throughout the entire continuum – hospitals, ambulatory, school nursing, home care, rehab.

And so, why not get them all together and I think they can really transform healthcare. Because just the sheer volume and also because they hit every continuum. But also, I think it's a deeper relationship with the patient. They're at the bedside, or they're taking care of these patients all the time.

I think you'll see patients say, "Can I ask you? I was afraid to, you know, ask that question." And sometimes we translate medicine for the patients. [laughter] And then watching the dynamics of the family – is it helpful, is it not, and what we can do.

So yeah, I think in some ways it's very unique and can give a different aspect. And I'll give you an example: So you know, you have the car. That's a great invention. And I think what, the nurses are going yet a deeper level – "Well, that's a great invention, but guess what? We can't drive that car without windshield wipers." And they're sort of coming up with the windshield wipers.

Q: How do you engage with other nurses to really get them invested and excited about doing this work?

A: So there's a couple of things. I've been at Northeastern for the last three years, and what we started there was the Nurse Hackathons, so it would be partly educational. And Mass General sent a bunch of the nurses there. So we'd start Friday. People would just sort of pitch their idea. Then we'd formulate groups. And people can self-select to those groups. And then, people like myself, we can mentor them over the weekend to develop that idea. And then, on Sunday they usually pitch to the judges. And there's voting that takes place.

So we're teaching them, we're generating ideas. And we're hoping to do the same here at Mass General. And our chief nurse, who's very innovative, has not only created a culture of innovation, but is awarding two $5000 awards to staff in the Patient Care Services to come up with ideas and help develop them.

Q: So exciting–

A: Yeah.

Q: –to think about putting it– you know, not just talking about it, but actually putting it into practice.

A: Exactly. And hopefully, as these nurses go through the process, then they can teach others on their unit.

Q: Sort of the trickle down effect.

A: Exactly.

Q: Are people surprised when they meet you and find out that you're a nurse, but you're also this innovator?

A: Yes, I think so. [laughter] And I think there's what I call the awakening around nursing innovation is starting to happen. So Johnson and Johnson, we have their attention. They had started their own QuickFire Challenge; they're giving $100,000 for a nurse to come up with an idea. So we're judging for that. So I think we're getting industry attention around that.

So we'll see. We'll see where it goes.

Q: Have there been any ideas that came out of the Northeastern hackathon that have been pursued further?

A: I think there was a nurse team that developed sort of how the IV goes into, especially babies where they cause little sores underneath. And they invented the, it's called the Luer Lock, to just look differently and lay differently on the skin. So I think they've already formed their own company.

Q: Wow.

A: [laughter] Yeah. It's very exciting

Q: It's always interesting to me, too, with innovation, oftentimes how it can be such a small change, can have such a big impact.

A: Um hmm.

A: Yeah, well, I think if you ask people what's the definition of innovation, I think you'll get many definitions. But for me, it's all about problem solving, right? So we can become creative and do it in a completely different way. But it does have to meet some criteria, which is, can it be widely adopted? Does it increase efficiency? Help with cost? Increase quality and safety?

And so, therefore, it could be a product, it could be a strategy, it could be a process, a device, or a technology solution. But I think right now, we're all focused on technology. And we shouldn't forget about the different ways we can solve problems.

Q: Yeah. There's all these hot tech companies–

A: Oh, yes.

Q: –and I think people think innovation equals tech.

A: Exactly. Exactly. But it's much more than that.

Q: Thinking about how we can build more innovation into nursing, what do you see as the steps that we need to take to marry those two?

A: So first of all, I think what's important – and this is what we're doing with the Center of Innovation – is to build the infrastructure. We can generate a gazillion ideas, but we also need to be able to take a few of those to the finish line. So I think if we're just asking for ideas and we're not going anywhere with them, I think that probably would be a disadvantage. So we don't want to elicit lots of ideas just yet until we can accommodate that.

Once we build the infrastructure, we need funding. So it will take funding to go to that next level.

And then, once we have those two in place, my hope is then I will be able to travel throughout the hospital, work with people – What are your pain points? Tell me about them? What can we do about them? And just keep creating.

The other thought, you know, eventually what I would love to do is what we call reverse pitches. So we can identify a problem that the hospital has and we'll say, Okay, here's the problem. All right, everybody, give us your solution. So everybody's working on the same thing. And hopefully we can pick the best solution.

Q: Yeah. Is there one of those particular questions that you're dying to go after?

A: Oh, god, there's so many problems. [laughter] Um, I really, hmm, didn't think about that. Probably burden, administrative burdens, I think.

Q: Yeah.

A: I think that's, we're feeling that everywhere.

Q: Yeah, I've been thinking about that a lot, I keep hearing things about the electronic medical record.

A: Yes.

Q: And there's so much power in it, you know, all this data and it's allowing all this research that's amazing, but there's two sides to it.

A: It is. I think I agree with you, the electronic medical record is great. I think we don't also understand the full potential. But I also think there's a whole layer, which is, come work with us and really understand the flow and how it should supplement our flow, and not be a burden, or yet another thing to do.

Q: You mentioned earlier these grants for nurses here at Mass General. Can you talk a little bit more about what those are–

A: Sure.

Q: –and how the process works?

A: The IDEA program is, it stands for Innovation Design Excellence Awards. We designed this program to award two $5000 award winners so that we can understand some of the ideas that are generated from the front patient-facing staff.

So we send out applications every year around April. We tell them that this is an innovation award. We don't put limits on the ideas, except that they have to meet patient care or– they have to meet something – a problem, work, you know, a process or an invention. And so, because we like to see what type of ideas people have.

So then we have an executive committee, which is also includes some of the previous award winners, so that they get to judge. And then we talk about all the different applications. And lots of them can be researched, so we'll give them to the research arm. And then we choose.

And then I become their mentor. And essentially what I do is accelerate their idea. And so, I act like a clinician, but I also act like Shark Tank. And then I also act like [laughter] an incubator. And so, is the idea good? Is there something out there already? You know, if not, great. If there is,is it different enough that we can move forward?

And then we teach them all that. So you're– so I'm going between a clinician and an investor for them because I want them to be able to scale it. It's not just for our institution.

Q: So the goal is really to create something that can be rolled out as a product.

A: Exactly. And so, I walk them through that steps so they can learn. Um, and then we have several prototypes already.

Q: Are there any success stories that you can share?

A: They're all success stories. They're just in different stages. But I can speak to the medical intensive care unit team who borrowed a systems engineering that Toyota in fact uses on their plants. So they would all gather around this flip chart and each week that they didn't have an accident on the plant, they would flip the chart. So it became very competitive, and they looked at anything that could cause issues and really worked on it.

So we borrowed that and put it into the intensive care unit around central line infections, which can be very, very serious and deadly. And so, the same thing – they would round every morning, talk about every patient that has a central line – can it come ou? why not? you know, et cetera. And then, each week they would flip the chart. And so, already they've achieved 27 weeks CLABSI-free. That's amazing.

And then, the NICU, which is the neonatal intensive care, borrowed some of that work and did their own modifications, and they've gone a year.

Q: Wow!

A: Yeah.

Q: A year is incredible.

A: Exactly.

Q: Especially for babies.

A: Yes! Yeah.

Q: The tiniest patients.

A: Exactly. Well, the central line goes right in, very close and into your heart. So it's a pretty serious infection. The other, the other success idea is the, um, hospital falls are a big issue. There's 700,000 to a million falls in the hospital throughout the country. They cost the hospital systems billions of dollars. And more than half of them are around toileting.

And so, we've done a lot to help decrease hospital falls, but this particular idea was, well, why can't we affect the hospital falls around the bathroom? And the current way is to have a patient that needs to use the bathroom, and the nurse has to stand at arm's length of the patient. And therefore, they're not calling.

So the theory for this nurse is that there's an overwhelming desire to have privacy and that's why they still continue to get up, they still try to go to the bathroom on their own. And then, they're weak and they fall. So he developed a harness that can keep them safe in the bathroom, close the door.

We're just in the final stages of the prototyping. We're going to meet with all the nurses, let them test it, feel it, try it on, is it easy.

Q: How does the harness work?

A: Yeah, so you, the idea would be to place it on the patient before you walk the patient to the bathroom, but you can at least communicate to the patient, "Hey, look, I'm going to give you your privacy, but you need to call me and then we'll walk you there." And once they're in the bathroom, they will get tethered to the wall, and and keep them safe and give them their privacy.

So we have a provisional patent for that already. And so, we'll be testing and doing more modifications, and then hopefully put in an IRB to see how it works with patients.

Q: That's so exciting.

A: It's very exciting. Because I really think he's on to something. Whenever you say that, they're like, "Oh, my god, of course I want my privacy in the bathroom." [laughter]

Q: Yeah, I mean, it's only natural, we all want that privacy.

A: Right, exactly. I was at the tailor and he was cutting up my daughter's backpack, so we were just putting something together to mimic the harness. And everyone that walked in, his customers were, "What are you two working on?"

Q: [laughter]

A: And then we would tell them and, "Oh, my god, I wish I had that at home. My father's weak." And you know, so it really resonates just with everyone.

Q: It's interesting, too. We hear a lot about the aging population and where will people age and how will we care for them. So these small solutions.

A: Exactly. that's what I teach. The nurse, his name is Jared, you know, initially he had this device that would just encompass the patient in the bathroom, but it doesn't fit in every bathroom. So I teach them scale – How can you scale it? Don't we want this in people's home? Nursing homes? Rehabs? We want to be able to put this in every bathroom.

And so, I teach them to think a little bit differently from their idea. And so, those are things that we walk through. And it takes about a good year to come up with to come up with a prototype. And I've already engaged a design company who works with us on all these. And that's been a lot of fun.

So I try to do most of the work because we only have $5000. And then we engage the design company who is so excited about these projects. It's giving them something more meaningful to work with.

Q: And as you've been building the program and, you know, building these innovation challenges and structures, what are the biggest challenges you've faced?

A: So the biggest challenge for me is the funding – where do we go next? I think we have a lot of potential to unleash. It's we need to worry about the timing and we need to make sure that we have the funding and infrastructure just to get these few, winners, to get to the finish line and maybe commercialize some of them, license some of them.

But we didn't know. We didn't know what the ideas would be. It could have been a process improvement. But these are really products. [laughter]

Q: If you look five or ten years down the line, what do you, what's your dream for this program?

A: I want the dream that every venture capitalist will be like, "Can I work with you? We will invest in every healthcare." And really modifying it around patient care services. It's, I think physicians and PhD researchers have lots of avenues for funding and things like that. And I would love to see the same for nurses and people in patient care services. So, occupational therapists, physical therapists.

Q: One last question. When you think about all this innovation, how does it feed back in to patient care?

A: So I think we're directly helping patient care. So I think if we can prevent infection rates, hospital-acquired infections, if we can prevent– even if we decrease hospital falls by 10%, we're really doing a great service. So just think about that. All of them are impacting patient care.

Q: Absolutely. All right, thank you, Hiyam.

A: Thank you.

Q: Before I let you go, I have my final five questions.

A: Okay.

Q: What's the best advice you've ever gotten?

A: The best advice. From my father – go where you need to go, but don't hurt anybody along the way. Bring people with you. [laughter]

Q: It's good advice.

A: And go for it. [laughter]

Q: What rituals help you have a successful day?

A: So I'm still working on that. It's always a work in progress. But I like to be in touch with all the staff, at least round on my units. And just trying to understand their work and their work life. So I can make better decisions. I don't think you sit in an office and figure that out; you really need to be with your troops, right in the trenches, as they say.

Q: How do you recharge?

A: So [laughter] I'm still working on this one, too, is how to leave work at a reasonable hour. Because I come in very early and try to stay late. Well, I'd like to try not to stay late, actually.

Recharging, I do a lot of outdoor activities. And rock climbing is one of my favorite things to do.

Q: Yeah. Where do you climb?

A: In the nice weather we rock climb anywhere from New Hampshire, and we go to New York, and we've been out West.

Q: Oh, wow.

Q: If you weren't a nurse, what would you be?

A: I think I would be a venture capitalist, investing in nurses. [laughter]

Q: What advice would you give your younger self?

A: I think, you know, I think it took a long time to build confidence. And so, I think I'd just trust in my thought process and the way I think. Because sometimes I feel, you know, my ideas come to fruition in about two or three years. [laughter] Not everyone can do that. And then, looking towards the future to really– and have that confidence to pursue it.