Indiana hospital involves patients and families in shift change bedside report

After reading this article, you will be able to:

• Identify how Riley Hospital involves patients in the shift change bedside report
• Describe the education staff members at Riley Hospital receive to learn more about bedside reporting 

Until 2007, nurses at Riley Hospital for Children in Indianapolis relied on traditional shift change reporting methods to communicate patient care information from caregiver to caregiver. But when challenged by Riley’s leadership team to find ways to improve hospital documentation, the Clinical Practice Council began looking at a standardized approach to hospitalwide shift change reporting.

After a six-month pilot program, an educational video and PowerPoint^® presentation, and another six-month training process, Riley implemented its hospitalwide nurse-to-nurse shift change report at the bedside with families.

Not only did leadership, the nursing staff, and physicians accept the process, but patients and families also became more involved and felt safer as a result.

Riley was recently recognized for its efforts by the National Patient Safety Foundation with the 2010 Socius Award, which symbolizes the relationship between healthcare providers and the patients and families they serve.  

Developing a hospitalwide process

Melanie Cline, RN, MSN, clinical director at Riley, teamed up with a 30-person group of staff nurses, educators, the clinical nurse specialist, clinical managers, and the family-centered care coordinator to review current literature and best practices for shift report processes.

“Our highest priority was to include parents in the process as their involvement and input is critical to achieving the best outcomes for each child,” says Cline.

The old process consisted of the charge nurse gathering information from the nurses going off shift about 30 minutes before the change of shift. Another 30 minutes would pass while the charge nurse documented the information.

In addition to making sure the parents were included in the shift report, Cline also had to keep the staff’s best interests in mind. Nurses commonly complained that the handoff information they received could be 60–90 minutes old with the previous process. The staff nurses coming on shift would often find that their patient’s condition had changed by the time they got to the patient. 

“When dealing with pediatrics, a child’s condition can change within a matter of minutes,” says Cline. “Getting to the patient sooner is better so potentially avoidable problems are picked up right away.”

Another factor that was vital to determining the components of the shift report was making sure the nurse going off shift and the nurse coming on shift could visualize the patient together, says Cline. This helped develop an understanding of how the patient was assessed on the previous shift.

Finally, Cline and her team developed five standards that are always included in the shift change report:

• Head-to-toe assessment
• Nurse-to-nurse involvement in viewing
• Medication check
• Orders verification
• Care plan

The five standards of a shift report

The head-to-toe assessment, the first of the five standards, involves the nurses coming on and off shift as well as the patient’s parents. This assessment enhances patient safety—in fact, it has helped identify a few near misses.

“In one case, nurses were discussing pain in a 3-year-old’s left knee, and the mother spoke up and corrected their information, saying it was actually the right knee that was bothering the patient,” says Cline.

The second shift report standard ensures that nurses examine their patient together and discuss how each patient was assessed and monitored. Cline offers the example of a patient’s breathing: Nurses can establish how the patient is breathing and how each patient’s “normal” breathing looks.

The third standard, medication check, is a safety measure that also saves time. During the old process, nurses coming on shift would often have to call the previous nurse at home to double-check medication information.

“By conducting the medication check in real time, it helps save time and eliminates oversights or omissions on the chart,” says Cline.

The orders verification, the fourth standard, involves reviewing all current physician orders and communicating the implementation status of all new orders. 

Finally, nurses discuss the care plan with the patient and the family at the patient’s bedside. This is where the next 12 hours of care are planned.

Cline says the entire process takes 30 minutes to complete, and even though the new process takes the same amount of time as the old one, in the grand scheme of things, it saves the staff time.

For instance, nurses no longer need to call nurses off shift to clarify a medication question because the two nurses review this information together during the shift report. Also, with parents now involved in the process, nurses can get questions answered up front as opposed to trying to find the parents later on during the shift.

Education and training

Before these standards and the bedside shift report could be implemented hospitalwide, Cline and her team developed a PowerPoint presentation and video to help educate staff members on the new process. The video reviewed the process step by step—using staff nurses as actors—and reminded staff of the importance of consistency.

Patients and their families also were involved in making the video. At the end of the video, parents described in their own words how the old process was sometimes scary but the new one helped them feel safer. 

“It was very powerful for the staff to hear a parent’s testimony about how the old shift report left them out of the process, which can be frightening,” says Cline.

After viewing the video and PowerPoint presentation, those team members responsible for developing the new process coached and observed nursing staff on three occasions prior to rolling out the new bedside shift reporting.

“The 30 staff members who were part of the developmental process came in days, nights, and weekends to coach and mentor their colleagues,” says Cline.

The process took another six months for all units at Riley to successfully implement, making the total time for implementation one year, Cline says. 

Finally, in January 2008, all nurses at Riley were involved in the nurse-to-nurse shift change bedside reporting involving parents.

Buy-in from all levels

Some nurses were skeptical of the new process, thinking it would take more time than before because the addition of family involvement would slow them down, says Cline.

As time passed, however, the skeptics began to appreciate the new bedside reporting for the communication it improves and the questions it eliminates—both of which save time in the end.

“The process kind of sold itself to a lot of the staff because of the situations they avoided, like the near misses,” says Cline. The new process ensures that nurses coming on shift visualize patients before the nurse going off shift leaves the unit.   

Words of advice

As family-centered care is the focus at Riley, Cline suggests getting the parents or family members involved early on and keeping them engaged throughout the process.

“Having the patient and their family involved is critical,” says Cline. “It helps with any clarification or mix-up in communication that might occur during handoffs and offers comfort to the patient and family during this critical time.”

Source 

Briefings on Patient Safety, August 2010, HCPro, Inc. 

Core measures

Hospital uses pocket-sized handout to improve core measures compliance

After reading this article, you will be able to: 

• Identify which staff are most in need of core measures education
• Discuss how physicians use the core measures brochure daily
• Describe methods for using data to increase buy-in

Editor’s note: Regional Medical Center of San Jose is one of this year’s winners for a free registration to the 2010 Association for Healthcare Accreditation Professionals Conference. For more on the contest, the association, or the conference, visit www.accreditationprofessional.org. 

Core measures are a part of the fabric of hospital life, particularly given their connection to CMS reimbursement numbers. All staff have encountered core measures at some point and have a basic understanding of them. But how do you ensure that their knowledge level is up to date and sufficient to keep your hospital’s reimbursements optimized? 

At Regional Medical Center (RMC) of San Jose (CA), the quality department created the Core Measures 101 brochure, an educational tool designed to improve new hires’ understanding of core measures.  

“We give this out in every new employee orientation and to the nursing and medical staff who need core measure education,” says RMC quality coordinator Odette Carreon. “It contains all the basic information one has to know about core measure guidelines, including helpful links, resources, and contact numbers of the quality department.” 

The brochure is printed in full color and distributed to staff. Rather than try to teach employees core measures guidelines from scratch, the brochure is intended as a go-to reference on the fly as well as a reminder or update for experienced staff. 

“Most of the staff are very familiar with core measures,” says Nancy Fore, chief quality officer at RMC. New hires will have heard about core measures through their previous jobs, but the tool acts as a key reminder for them. “You can’t not know something about core measures in the U.S.,” says Fore. “It’s every hospital’s focus because of the reimbursement factors.”

The information contained in the brochure (see p. 6) is a collection of facts from The Joint Commission and CMS, with a focus on publicly reported measures. Although the hospital is educating its staff on all of the core measures guidelines, the brochure sticks with the publicly reported indicators as a way to keep things streamlined. “We had very limited space,” Carreon says. 

The tool has been well received by the staff. “The colorful presentation helped in delivering the message,” says Carreon. 

The brochure’s minimal size has helped keep it useful for staff as well. “The size of it is convenient—the trifold slips into a lab coat pocket,” Fore says. “It’s informational as well as convenient.” 

So convenient, in fact, that certain members of the staff carry it at all times. “Our hospitalists keep it in their pockets and use it during discharge and admissions,” says Cindy Stewart, director of quality at RMC. 

RMC hospitalists and intensivists use the brochure to verify that they are following the appropriate steps at pivotal times in patient care. 

“I equate it to a clinical pathway,” says Fore. “They’re making sure they’ve done every step along the way.” 

The quality department is hoping to expand this go-to style of use to the nursing staff as well. 

“Our goal is for every nurse to refer to it also,” says Fore. “They don’t have the same level of control, in that they’re not writing the orders, but they are following up on orders. 

“What RMC hopes to achieve, ultimately,” she explains, “is that nurses are jarring the memory of physicians: Did they remember to write the order in this instance? The intent is to create a check and balance between caregivers to improve patient outcomes.” 

The bigger picture

The brochure is only one part of a larger core measures plan. RMC has taken multiple steps to make core measures part of the hospital’s culture. 

“We’ve created a core measures binder that contains our forms, checklist, documentation, that’s used as a reference binder,” explains Stewart. “We also have a core measures team that meets daily. We do ongoing education every step of the way.”

The goal of the meeting is to always be looking at RMC’s processes, says Fore. 

“We want to modify our processes in a concurrent way so we’re on top of it and make sure we don’t have any fallout for the day where one of the steps wasn’t  actually instituted,” she says. “It’s always morphing into something else. The people who sit at the team meeting every day are responsible for taking back the changes and education to their staff. I’d say it’s one of the most vibrant performance projects in our hospital.” 

There’s a large amount of energy and resources put toward this project because the impact is so great, Fore explains. 

“Adherence to core measure guidelines by everyone in our organization is essential. [The hospital system] is trying to adapt something like this in all its hospitals,” she says. “We talk with other facilities in our region about demonstrated best practices. This is a big focus area with our healthcare system.” 

The biggest challenge thus far has been physician endorsement, which is always an obstacle at the start of any change. 

“The way we work through that is to educate every day,” says Fore. “We’re sometimes successful, sometimes not, but the more momentum we’ve built with our outcome scores, the more [physicians] become involved—just from the competitive nature of healthcare, everyone wants to be successful.” 

RMC publishes its outcomes all over the hospital, which taps into the competitive spirit of the providers and improves outcomes across the board. 

Providing data also helps with physician involvement because physicians respond well when presented with data supporting the change.

“You’ve got to allocate the resources for this. It’s not something you can do with a limited number of resources,” says Fore. “Not every quality department has the resources to do this; therefore, everyone in the hospital has to be engaged in core measures.” 

It also helps to have leadership on your side, firmly behind the tracking and improvement of core measures. 

“Leadership definitely supports this,” says Fore. “It is coming from the top down. Our CEO is very involved. Every single member of the executive team is familiar with core measure outcomes. It’s very much a focus for RMC and [Hospital Corporation of America].”

Door-to-balloon time

One core measure indicator that provided additional challenges during RMC’s improvement efforts was door-to-balloon time. Door-to-balloon is an emergency cardiac care measurement of time for treatment of ST-segment elevation myocardial infarction (STEMI) and is a core quality measure of The Joint Commission. 

The interval starts with the patient’s arrival in the ED and ends when a balloon catheter crosses the culprit lesion in the cardiac cath lab. Delays in treating a myocardial infarction increase the likelihood and amount of cardiac muscle damage due to localized hypoxia. Guidelines recommend a door-to-balloon interval of no more than 90 minutes. 

“Our door-to-balloon time was a challenge,” Stewart says. “We’ve got a multidisciplinary team together to look at our STEMI patients.”

“This was a multidiscipline improvement project, working with staff from EKG, cath lab, admissions, laboratory, and more,” Fore says. “RMC dropped its door-to-balloon time from 120 minutes to 90 minutes, with more improvements on the way. 

“Very soon it will be 60 minutes,” she predicts. “We’ve been under 90 minutes for the better part of a year. The way we will be able to meet that 60-minute target in our geographic area is to have a countywide STEMI program.” 

The ambulances and paramedics in the region, once they recognize symptoms of chest pain, are able to run an EKG and determine with good certainty what they are dealing with.

This information is transmitted to the closest facility, and the paramedics can start medications in the field. 

“We know exactly what our goal is when the patient arrives—we’re taking them right to the cath lab,” says Fore.  

There are eight STEMI-designated emergency rooms in the county, which had to prove they could provide patients with a door-to-balloon intervention in a window of under 90 minutes. RMC’s emergency room is one of the eight. 

“Our next challenge will be to add more diagnoses to core measures,” says Fore. 

RMC’s next target will be in perinatal initiatives.

Source 

Briefings on The Joint Commission, May 2010, HCPro, Inc.

Joint Commission readiness

Improve the focus of your PPR

After reading this article, you will be able to:

• Identify strategies for conducting a focused PPR

The Periodic Performance Review (PPR) is an annual self-assessment process designed to enhance Joint Commission readiness. However, organizations often make the mistake of scoring their electronic surveys so harshly that they end up with numerous noncompliant standards. This leads to the initiation of cumbersome, complex action plans that are difficult to fulfill. 

It is more helpful to focus on standards that put your organization at the highest risk of failure to achieve/maintain accreditation. Here are some suggestions that will help you conduct a more efficient, helpful PPR:

• Don’t go through the entire electronic PPR every year. Use your previous year’s PPR as a baseline and incorporate assessment of new or changed standards.
• Determine priority standards on which to focus and develop a realistic, attainable measure of success (MOS). 
• Remember that surveyors will use the information from your MOS to assess whether your organization is realistically working toward compliance.
• When reviewing new or changed standards, evaluate the processes already in place. Decide whether each process is in compliance, needs revision, or should be replaced with a new process. Do not automatically establish new processes if current ones are adequate.
• Focus on keeping things simple. Reduce rather than increase the number of steps needed to maintain or achieve compliance. 
• If your organization uses an on-site PPR instead of an electronic submission, be sure to ask the surveyor about ways to achieve and maintain compliance. Use the surveyor’s presence as an opportunity to learn.

Reference

Bielanski, G. (2010). “Issues surrounding the PPR.” Briefings on The Joint Commission.

Infection control

New technology could replace the traditional pencil and paper method

iPhone app attempts to streamline hand hygiene tracking

After reading this article, you will be able to: 

• Explain how the iScrub™ makes hand hygiene compliance tracking easier  
• List the WHO’s “5 Moments for Hand Hygiene”
• Describe how the next version of iScrub™ could improve data collection

If you have an iPhone^® or an iPod touch^®,you’ve probably already downloaded a number of applications that make everyday tasks—such as opening the trunk of your car or turning off your lights—as simple as touching a screen. 

But for those of you with an iPhonein the medical setting, a newly released app will streamline hand hygiene compliance tracking.

The appropriately named “iScrub” app, developed at the University of Iowa (UI), aims to replace the traditional method of pencil and paper tracking, providing more accurate data and a less time-consuming collection process. 

The iScrub app was released May 5 in collaboration with the Centers on Disease Control and Prevention (CDC) and coinciding with the World Health Organization’s (WHO) “5 Moments for Hand Hygiene” campaign.

“The long-term goal of our research is to understand hand hygiene behavior and use the feedback to help improve rates. This app can help standardize and streamline how observations are recorded,” Philip Polgreen, MD, one of the application’s developers and an assistant professor of internal medicine at the UI Roy J. and Lucille A. Carver College of Medicine, said in a press release.

The CDC Guideline for Hand Hygiene in Healthcare Settings recommends that medical facilities periodically monitor hand hygiene adherence among staff members. Additionally, one of The Joint Commission’s National Patient Safety Goals (NPSG.07.01.01) specifically requires medical facilities to comply with guidelines from the CDC and the WHO. 

Therefore, most facilities are already collecting hand hygiene compliance data, but this new app could translate to less time collecting data and more time actually improving compliance rates. 

How it works

The idea originated when medical professors at the UI Roy J. and Lucille A. Carver College of Medicine teamed with developers in the Computational Epidemiology group in the UI Department of Computer Science. Chris Hlady, a doctoral student in computer science, built the first version of iScrub (iScrub Lite) and has gained traction with the product as two more doctoral students, Donald Curtis and Jason Fries, have expanded the platform to iScrub Pro, currently in pilot deployment. 

“I think hospitals have been tracking this compliance for a while,” Curtis says. “I think it was the idea that we have been given this device and we have a way for replacing clipboards and pencils and transcription, so why not do it?”

The plus side is that medical facilities won’t need to purchase hundreds of mobile devices to effectively use the app. “The idea is you have a couple of these devices in the hospital and they are used to track the hand hygiene,” Curtis says. “It’s designed so you don’t have to buy one for everyone.”

Staff members assigned to track hand hygiene can input data according to the WHO’s “5 Moments for Hand Hygiene”:

• Before touching a patient
• Before clean/aseptic procedures
• After body fluid exposure/risk
• After touching a patient
• After touching patient surroundings

Observers can also separate data into job titles of their choosing to track compliance among specific subsets of staff members such as nurses, physicians, or physical therapists. Additionally, there is room to indicate whether a patient was on contact, droplet, or airborne precautions and whether the healthcare worker used gloves, a mask, and a gown. 

Data and observations are then sent to an e-mail address and can be transferred onto a spreadsheet for documentation. 

“I think everybody that has used it is really excited, not just about what’s been done, but about the future of using devices like this,” Curtis says. “I guess the most positive feedback is how quickly using a device like this allows the data to get fed back into the system.”

A streamlined approach

In addition to making the cumbersome process of hand hygiene data collection more efficient, the iScrub app also allows a streamlined approach to hand hygiene compliance.

Although most hospitals constantly track compliance, the methods used to monitor adherence can vary significantly from facility to facility. The iScrub app ensures that each hospital uses the same measures and definitions. 

Grants from the CDC and the National Institutes of Health went toward the development of this project, which gave developers access to a standardized process.

“One aspect we are trying to take with iScrub is how do we help standardize hand hygiene monitoring,” says Curtis. “We’ve worked closely with the CDC and the WHO to design iScrub to encapsulate everything that hospitals need to record when they are doing hand hygiene observations.”

The next steps

Currently, iScrub Lite 1.5 is available to download for free at the iTunes^® App Store, but the team and UI are already working on the upgraded iScrub Pro model. 

The Pro model allows users to send data to a website rather than an e-mail address. The website puts the information in a database and generates charts based on the data. “It’s kind of a next step,” Curtis says. “Here we have the whole input device, which is iScrub Lite, and then there is what do you do with that data. That’s part of what we are working on in the Pro version.” 

Currently, iScrub Pro is undergoing a pilot study on units at the University of Iowa Hospitals and Clinics. Interested facilities can also apply to be a part of the pilot program at the iScrub website.

“I guess the next step for us is to start expanding from there,” Curtis says. “It’s about evolving the product and getting people to use it and getting feedback.”

Source

Briefings on Infection Control, July 2010, HCPro, Inc.

Two versions of the iScrub app

Currently, there are two versions of iScrub, but only one is available to the public; the other is still undergoing pilot testing. 

iScrub Lite 1.5

• Currently available in the Apple iTunes App Store for free
• Compatible with iPhone^® and iPod touch^®
• Ability to track and input specific hand hygiene measures
• Raw data can be sent via e-mail

iScrub™ Pro

• Currently being pilot-tested at the University of Iowa
• Same data input features as iScrub™ Lite 1.5
• Compatible with iPhone^® and iPod touch^®
• Data can be sent to an interactive website, which stores information and creates charts and graphs for staff consumption

Teaching strategies

The verdict is in: Mock trials are guilty of teaching learners

After reading this article, you will be able to:

• Describe the concept of a mock trial as a teaching strategy 
• Explain strategies for implementing a mock trial

Mock trials are similar to debates since learners must review literature, gather evidence, and build a case for a particular viewpoint. They allow learners to become more engaged than in a typical debate, and they provide some fun and entertainment as part of the learning process.  

Beth A. Staffileno, PhD, FAHA, assistant professor at Rush University Medical Center in Chicago, helped design and implement a mock trial at the Rush North Shore Medical Center, a member of Illinois-based North Shore University Health System. The 200-bed community hospital had recently implemented shared governance, and its nursing leaders identified a need for education regarding evidence-based practice (EBP) and research. 

Serving as a research consultant, Staffileno worked with the EBP and research councils and with the staff development department at the hospital to design the mock trial. 

Preparing for the trial

Following council member input, the group decided to try the question, “Should family members be present  during procedures?”

Members of the councils worked together to prepare pro and con arguments. They started by reviewing the literature, which presented a challenge to some nurses who were unfamiliar with how to critically analyze articles. 

This necessitated a series of education offerings to teach nurses how to conduct literature reviews, critique articles, synthesize findings from data analysis, and rate evidence. 

One of the goals of implementing the mock trial was to get the nurses “out of their comfort zones,” says Staffileno. 

”We wanted them to learn to expand their knowledge base and apply new knowledge to promote EBP and improve patient outcomes.”

The councils worked for three months to prepare. At first, the council members were overly concerned with acting out their roles as clinical experts and attorneys; they wanted to give polished performances during the trial. 

“I had to help them realize that the most important part of the mock trial was to provide evidence and persuasive arguments for their respective positions,” says Staffileno. 

“They were not going to be evaluated on their acting abilities.”

The trial begins

The mock trial was held in a large conference room set up to simulate a courtroom. About 150 people attended the event, including staff nurses, physicians, the CEO, and vice presidents of the hospital. It was videotaped for those unable to attend.

Prior to the event, juror instructions were taped underneath 12 seats. The people sitting in those seats became the jury. 

The hospital attorney served as the judge, and a hospital security guard was the bailiff who called the court to order. 

Council members acted as prosecuting and defense attorneys, delivered opening and closing remarks, and called witnesses to provide testimony. Council members also functioned as clinical experts, content experts, research experts, and family members. 

After listening to the information, the jury deliberated and reached its ruling: They decided to allow family presence during p