Strategies for Nurse Managers May 2010
See the discharge process through the patient’s eyes
After reading this article, you will be able to:
- Integrate providing positive patient experience with creating a discharge plan
The most important people in a hospital are not the physicians, the nurses, or the executives; they are the patients. Taking the time to see the hospital through their eyes can do wonders for the facility, according to Greg Nelson, president of Baptist Leadership Group in Pensacola, FL.
“The overall focus here is moving from provider to patient centeredness,” Nelson says.
Basic challenges at any facility include overcoming barriers to discharge, promoting physician buy-in, and increasing patient flow and throughput. In order to address these issues, you also must address the discharge process, says Nelson.
Shorter length of stay means harder discharge planning
The advent of the diagnosis-related group system gave hospitals an incentive to decrease the length of stay.
The average length of stay is two days shorter than it was 15 years, Nelson says. “We are trying now to get our patients home as soon as we can. I understand the financial reason for that, but we must understand the clinical implications,” he says.
Stefani Daniels, RN, MSNA, ACM, CMAC, managing partner at Phoenix Medical Management, Inc., in Pompano Beach, FL, says financial implications are not the only reason to reduce length of stay. The acute care setting is a high-risk environment, and patients are safer in a lower level of care or at home. Regardless, the reduction in length of stay has made the discharge process critical. Patients and their families now change wound dressings, administer medications, and monitor progress.
“We expect patients to serve as their own little case managers,” Daniels says. “And in most cases, it is unrealistic.”
Staff members in every facility must reinforce the discharge plan, make sure that patients clearly understand the discharge instructions, and follow up with patients so they remember what their instructions are.
“Patients remember 10%–15% of the content of discharge instructions even when they are given a brochure and formal instruction,” Nelson says.
Having dedicated staff members who contact patients within 48 hours of discharge to remind them of discharge instructions is a great way to ensure compliance with the discharge plan, say Daniels and Nelson.
Because patients are more responsible for their own care than ever before, it makes sense that hospitals should become more patient centered.
“Patients need to know we aren’t kicking them out before they are ready to go,” Daniels says. “We want to make sure they are in the safest environment.”
Multiple patient encounters require teamwork
In the average three-and-half-day stay, a patient will interact with 50 to 55 staff members, according to Nelson. That includes nurses, physicians, housekeepers, food service staff, and maintenance staff. In order to ensure that every patient has a positive experience, all these caregivers must be on the same page.
Making eye contact, showing patience, and taking time to listen and address patients’ concerns will make patient feel like they are safe and being taken care of.
“[Hospitals] should demonstrate with every person that touches the patient, that [they] care,” Nelson says.
Nelson plans to expand on how the patient-centered approach can improve patient care at the 2010 NICM/ACMA National Conference in San Antonio.
The presentation, “Patient/Family Centered Discharge Planning: Moving from Provider to Patient Centeredness,” will discuss practical tactics such as service mapping and rounding with patients.
The session will also talk about the benefits of requiring clinical representatives to call patients at home within 24 to 48 hours of discharge.
Adapted from Case Management Monthly, April 2010, HCPro, Inc.
Ohio hospital keeps TABS on patients
Riverside Methodist Hospital develops a bedside tool to help with patient reports
After reading this article, you will be able to:
- Describe the new bedside reporting method used at Riverside Methodist Hospital
- Identify why Riverside Methodist Hospital’s old patient reporting process was unsuccessful
In October 2008, staff members at Riverside Methodist Hospital (RMH) in Columbus, OH, approached Sheryl Tripp, MSN, RN-BC, nurse manager for the gynecology/gynecology-oncology (gyn/gyn-onc) surgical unit, in hopes of changing the way nurses were issuing patient reports.
Tripp reviewed the current process on the gyn/gyn-onc surgical unit for patient reports, along with the unit’s Press Ganey patient satisfaction scores, and decided it was time to implement a new process for patient reports and end-of-shift reports.
Tripp led an effort to implement a new reporting process, Transferring Accountability at the Bed Side (TABS), that includes an interaction between the nurse whose shift is ending and the nurse whose shift is beginning. Under the new process, both nurses visit the patient’s bedside together, as opposed to each nurse reporting separately.
The new process has improved the unit’s Press Ganey scores dramatically, Tripp says.
Time for a change
For as long as Tripp could remember, nurses on her unit used tape recorders to create patient reports. At the end of each shift, the nurse would go into the designated recording room to record patient reports. The nurse coming in for the next shift would listen to that report and attend to patients and daily tasks.
“This process is all right, but most of the time nurses would end up doing verbal reports because the tape recorder would fail, or they had problems understanding what the nurse was saying on the recording,” explains Tripp.
The unit’s Press Ganey scores were hovering around 50% for nurse-to-patient communication and safety during the patient’s stay. Tripp knew it was time to honor her nursing staff members’ requests to help improve patient safety and nurse communication.
Research and trial and error
To start, Tripp ran a series of two-week trial methods on her unit that involved preparing a few types of reports: tape-recorded, written, verbal, and a bedside report. “We told the staff members each week the style of reporting we would do, and then asked them to report back to us with any feedback,” says Tripp.
During the trial period, Tripp would visit patients’ rooms and talk with them about each of the reports, specifically the bedside reporting.
On RMH’s gyn/gyn-onc surgical unit, semiprivate and private rooms are available, and there are patients who share rooms. Tripp wanted to make sure patients did not have any problems concerning their privacy during bedside reporting.
“During this trial period, a majority of the patients I talked with liked the bedside process, so I decided this was the right process,” Tripp says.
Education and implementation
Tripp, her clinical nurse manager, the women’s health clinical nurse specialist, and a research nurse at RMH formed an evidence-based practice team to research information on bedside reporting.
While researching, the team chose three articles that highlighted the pros and cons of bedside reporting. Nursing staff members received these articles for education in preparation for the upcoming change in reporting process.
As part of the TABS process, when the two nurses enter a patient’s room, the nurse coming off shift introduces the nurse coming on shift to the patient. Then, the new nurse checks the patient’s armband and asks the patient’s name and date of birth.
The nurse coming on shift then writes his or her own name, along with the patient’s name on the whiteboard located in each patient room.
In addition to having the two nurses work together and converse with the patient more, a report sheet is kept outside the patient’s room.
“The report sheet is used as a guideline for the nurses to communicate with one another, especially if a float nurse comes to the unit,” says Tripp. (See the “Nurse-to-nurse report sheet” on p. 5.)
After using the new TABS process for a month, Tripp and her team sent out surveys to the nursing staff members. Overall, the new process of reporting was well received, and many nurses liked the process better than they had expected.
“Nurses reported that they were now clocking out on time, as opposed to leaving a half an hour after their shift has ended,” says Tripp.
In addition to receiving great reviews from the nursing staff members and the patients on the gyn/gyn-onc surgical unit, the TABS process vastly improved the Press Ganey scores. The three areas on which RMH focuses are:
- How well nurses keep patients informed
- How well staff worked together to care for patients
- Whether staff members include patients in the decision-making process
Prior to implementation, Tripp’s unit scores were hovering around 26%, 50%, and 60% satisfaction for each of the three foci respectively. Just three weeks after implementing reporting at the bedside, each focus area reached 99% satisfaction.
“It is great to know that even now, a year after implementation, that our Press Ganey score has not dropped,” says Tripp.
Adapted from Patient Safety Monitor (Briefings on Patient Safety), February 2010, HCPro, Inc.
Transferring Accountability at the Bed Side: An evidence-based practice project
Purpose: To improve patient safety and nurse-to-nurse communication by using an evidence-based practice (EBP) model to implement Transferring Accountability at the Bed Side (TABS) in a shift-to-shift report.
Clinical issue: The current method of shift-to-shift reporting was not standardized or consistent. Patients were not actively involved in their daily plan of care. Reports did not follow SBAR format and had the potential to omit essential patient care information.
- Team assembled
- Literature reviewed
- Staff and patients surveyed
- Pilot designed
- SBAR worksheet created
- Staff and patient education provided
- Outcomes measured
1. Customer Service: Press Ganey data
- “How well the nurses kept you informed”: Prior to improvement project, 26%; post, 99%
- “How well staff worked together to care for you”: Prior to improvement project, 51%; post, 99%
- “Staff effort to include you in decisions about your treatment”: Prior to improvement project, 64%; post, 99%
2. Quality of care/safety: This process enhances numerous bedside safety checks:
- ID bands
- IV and dressing change dates
3. Quality of work life:
- Monitor Nursing Database of Nursing Quality Indicator scores
- Efficient transfer of information
- Increased awareness of patients’ needs
- Decreased overtime at shift change
Conclusion: The 2009 National Patient Safety Goals support a culture of safety for developing a process for effective handoffs. The EBP TABS improves patient safety and enhances RN and patient satisfaction.
Knowledge and innovation
EBP and nursing research: Avoiding confusion
After reading this article, you will be able to:
- Understand the differences between evidence-based practice and nursing research
- Identify examples of evidence-based practice
The ANCC Magnet Recognition Program® requires hospitals to have evidence-based practice embedded in the culture of the organization. In the documentation, hospitals must demonstrate that nurses evaluate and use published research in all aspects of clinical and operational processes.
The ANCC also expects nurses to conduct research projects and that knowledge from these projects will be shared with nurses within and outside the organization. Although the two requirements have the potential for overlapping concepts in the minds of many nurses, evidence-based practice and research projects are distinctly different—and, if the differences are not recognized, it is possible for an organization’s documentation to fail to adequately explain how it meets both requirements.
In the most basic terms, evidence-based practice looks at research findings, quality improvement data and other forms of evaluation data, and expert opinion to identify methods of improvement. It’s identifying what exactly differentiates evidence-based practice from research that can be challenging for staff members.
“Evidence-based practice is used to close the gap between the research being conducted and the practice—the ‘research/practice gap,’ ” says Marquetta Flaugher, ARNP-BC, DSN, an advanced practice nurse at Bay Pines (FL) VA Hospital.
Evidence-based practice challenges nurses to look at the “why” behind existing methods and processes in the search for improvement. “So much is based on opinion and tradition, and we can’t do that anymore,” says Flaugher. “We need to use evidence and speak that language.”
Best practices in nursing are always evolving. The example Flaugher likes to use is treatment for acute muscle strain. In school, nurses were taught to use ice for the first 24 hours and then heat to increase blood flow to the muscle after that point.
“We didn’t really question our faculty,” says Flaugher. “Now if you look at the evidence, research says that we just use heat. We’ve validated our outcomes.”
The language of research
Why do we struggle to understand the difference between evidence-based practice and nursing research? It is often a matter of education and experience—and learning a foreign language.
“A lot of nurses know research but haven’t done research,” says Flaugher. “If you don’t understand the concepts and rules of research, there’s potential for confusion.”
Not all staff members have the background to immediately differentiate between the two. It’s a matter of education. “If you don’t understand research, then levels of study won’t make sense. … If you don’t have the foundation on research, it’s hard to use it in evidence-based practice,” says Flaugher.
Research is generating new knowledge about a phenomenon or validating existing knowledge, she explains. Although evidence-based practice may have opinion—expert opinion, but opinion still—woven in, research is built in such a way to avoid bias.
“Research is pretty cut-and-dry,” says Flaugher. “You take so many safeguards against bias.”
In many ways, research is a foreign language. You must be able to speak and understand it to truly do it.
“We start talking about variables and phenomena and statistical analysis, things we don’t use in everyday language,” says Flaugher.
But there is hope: Every hospital has people who do speak the language of research.
“You have a lot of people in the hospital who have had experience with research and can become mentors to others,” says Flaugher. “They should be seen as leaders in the facility and active in councils and committees” where their experience is needed.
Look at who the people are in your facility currently doing research; in smaller facilities, these names will already be well known. In addition, look also at who is sitting on the institutional review board. Take note of what questions are being asked—what they are looking at when examining proposals. These experts do not have to be nurses; look for help across other disciplines as well.
Once you have established the difference between evidence-based practice and nursing research, the next trick is obtaining buy-in from the nursing staff for both requirements.
“You somehow need to show the staff how this is directly going to benefit not only themselves, but also the patient,” says Flaugher. “A lot of what we do can be changed, and it will save time and energy.”
For example, if the research shows that taking vital signs every hour instead of every 30 minutes for a given population is beneficial, you could potentially save a lot of time and documentation, and in the end also give the best care to patients as supported by the research.
Flaugher points to the benefits of ownership as a way of promoting buy-in for evidence-based practice and nursing research among staff members. If they are part of a major change that is supported by leadership, implemented, and demonstrated to be successful, this can lead to greater buy-in for future improvements.
“If nurses can start asking, ‘Do we need to do [this particular process]?’ they can start doing a literature review and find evidence for support,” says Flaugher.
This is the key thing with MRP and looking at evidence-based practice, she says.
“Nurses want to be recognized as a professional discipline in control of our own practice,” she says. “Evidence-based practice can help all nurses regardless of where they are to help them improve.”
Adapted from HCPro’s Advisor to the ANCC Magnet Recognition Program®, February 2010, HCPro, Inc.
Examples of evidence-based practice projects
- Developing a rapid response team to decrease incidents of code blue outside the ICU
- Evaluating appropriate clinical parameters for placement and removal of urinary catheters
- Instituting a hand hygiene educational video for visitors in the neonatal ICU
- Discussing how to determine whether chlorhexidine is a more effective skin antiseptic than other cleansing agents in preventing probable peripheral IV catheter-related infection
- Developing an orientation on hospitalization for patients and families and monitoring its effect on patient satisfaction
- Evaluating an inservice intervention aimed at increasing the use of alternatives to restraints
- Assessing adequacy of pain treatment in the first 24 hours postoperatively
- Determining how you can promote smoking cessation
Staffing effectiveness in 2010: The interim standards
After reading this article, you will be able to:
- Identify the changes made to the staffing effectiveness standard
Originally introduced by The Joint Commission to the standards in July 2002, staffing effectiveness is the appropriate level of nurse staffing that will provide for the best possible outcome of individual patients throughout a particular facility.
When first introduced, hospitals were required to track two human resource indicators and two patient outcome indicators, track data, and determine whether the variation in performance caused by the number, skill mix, or competency of staff.
“Hospitals collected the data, nurse leaders looked for correlations, and no correlations have been found,” says Susan W. Hendrickson, MHRD/OD, RN, CPHQ, FACHE, director of clinical quality and patient safety at Via Christi Wichita (KS) Health Network.
Hendrickson says even if hospitals did find what they believed to be a correlation between staffing and a patient outcome, when the information was examined more closely, it was not statistically valid.
Fast-forward to June 2009: The Joint Commission suspended these standards due to the debate of the results from across the country.
However, this suspension proved to be short-lived. In December 2009, The Joint Commission announced the approval of its interim staffing effectiveness standards for 2010.
The new standards will become effective July 1, and will remain in effect as The Joint Commission continues to research the issues of staffing effectiveness.
Interim standards at a glance
The first requirement affects LD.04.04.05, element of performance (EP) 13, and states that at least once per year, the hospital/organization must provide written reports on all system or process failures, the number and types of sentinel events, information provided to families/patients about the events, and actions taken to improve patient safety.
“In a broader sense, EP 13 ties staffing to outcomes and puts accountability at the leadership’s feet,” says Hendrickson. She suggests hospitals submit the reports to the board quarterly or monthly, rather than annually.
“Think about this: Every time a medical error occurs and you have to document it, this may be a long report for the board to get a grip on,” says Hendrickson.
Rather than compile an itemized list of failures, hospitals should instead classify the events and report on them statistically.
“Sentinel events, you will want to try to discuss the events as soon as possible, and disclose general information to the board,” says Hendrickson. “And if a sentinel event did occur, then disclose information on any action taken to prevent similar events.”
In addition to EP 13, the new interim requirements affect PI.02.01.01, EPs 12–14.
EP 12 states that any time the organization has an undesirable event, it must evaluate its staff and their effectiveness. EP 13 states that if a negative trend in the staff is noted, a report must be provided to the leadership.
In EP 14, a written report of the identified issues must be provided at least once per year to the leadership in charge of the patient safety program.
“The organization needs to have a process or policy that speaks to this so the surveyor can review the information,” says Hendrickson. “The Joint Commission believes that if you are not in compliance, this is an immediate risk to patient safety because there are few processes to intervene.”
Now if an organization is cited for any staffing effectiveness, a short-term resolution is given, and the organization is required to come up with a solution within 45 days.
Turning to patient-staff ratio
In addition to the new interim standards, a more intricate part of staffing effectiveness under examination is the patient-to-staff ratio. However, California is no stranger to this because a staffing ratio has been imposed on all organizations in the state since 2004.