Optimizing your nursing staff's time at the bedside is the key to better patient safety
As the primary caregivers in hospitals, nurses are best positioned to improve quality and patient safety. However, they are often pulled away from the bedside to conduct tasks that have nothing to do with actually taking care of patients—such as filling out paperwork and other administrative duties.
“Nurses spend between 20 percent to 30 percent of their time in direct patient care,” says Pat Rutherford, R.N., vice president for the Institute for Healthcare Improvement in Cambridge, Mass. “There’s a great deal of waste in nursing activities. By removing waste, nurses can participate more meaningfully in the care of their patients.”
Improving nursing efficiency is even more important as the nursing shortage intensifies. The Department of Health & Human Services predicts that the United States will need 2.8 million nurses by 2020—1 million more than the projected supply.
One of the best ways to improve efficiency is to ask nurses directly about the problems they confront in their work environments. “Nurses know what needs to happen in their practice,” says Beverly Nelson, R.N., director of nursing programs at the University of Texas M.D. Anderson Cancer Center in Houston. “They are the most informed.”
To give nurses more time to spend at the bedside, hospitals need to develop supportive work environments that foster communication and teamwork and eliminate wasteful work. That will reduce staff turnover, increase patient satisfaction and improve clinical outcomes. This gatefold examines the role of the nurse in patient safety and presents best practices to support the nurse as a patient safety advocate.
Building a Culture of Patient-Centered Care
The nurse-patient relationship is a pivotal component of any patient safety program. “It’s all about communication,” says Kay Beauregard, R.N., vice president of medical services at Beaumont Hospital, Royal Oak (Mich). “The No. 1 driver of patient safety is communication.” Patients at Beaumont are given a brochure on admission, “You and Your Caregivers: Partners in Safety,” that instructs them to ask questions and to be a part of all treatment decisions. Beauregard describes the organization’s efforts to engage patients in their care as a back-to-basics approach. “We designate a time of day for the nurse to come in and sit down with the patient,” she says. It’s important for nurses to make eye contact. “Stepping into a room and asking a patient how they are doing is not personal enough.” Nurses also work with patients to develop a list of daily goals that are then written on a whiteboard in the room. The process of working together and developing a care plan enhances safety and improves patient satisfaction. And the beauty of it, Beauregard says, is that “it’s so simple.”:
Tips for Creating a Culture of Patient-Centered Care
The National Patient Safety Foundation calls on hospitals to build a culture of patient-centered care. According to the NPSF, “To improve safety is to improve the partnership between patients and providers at every level.”
To create a culture of patient-centered care, hospitals should:
Source: National Agenda for Action: Patients and Families in Patient Safety, NPSF, www.npsf.org, 2008
Challenges to Nurses
The level of your staff’s involvement in quality and patient safety activities is influenced by several factors, ranging from simply not having enough of them to insufficient training in traditional education models.
Source: The Role of Nurses in Hospital Quality Improvement: Research Brief No. 3, The Center for Studying Health System Change, March 2008
TCAB Transforming Care at the Bedside
Transforming Care at the Bedside, an Institute for Healthcare Improvement initiative funded by the Robert Wood Johnson Foundation, seeks to improve the quality and safety of patient care on medical and surgical units. According to IHI, between 35 percent and 40 percent of unexpected hospital deaths occur on these units.
TCAB began in 2003 as a pilot program in three hospitals. Today, more than 60 hospitals participate in the initiative that empowers front-line staff to make significant changes in the care process. This includes changes in care delivery, nursing care models, the physical environment and culture. The goal is to achieve improvements in patient safety and service delivery, develop more effective care teams, involve patients and families in the care process, improve staff satisfaction and retention, and enhance efficiency.
|How It Works||TCAB is a unit-based initiative that encourages front-line caregivers to develop solutions to challenges they face in their work environment. Once ideas are vetted, they are tested on a small scale and quickly assessed. Depending on the outcome, they are either abandoned, altered or adopted and spread to other areas. This rapid-cycle improvement process allows for continuous improvement and encourages front-line staff to share ideas and work together to improve the quality of care delivery.|
|The TCAB Framework
TCAB projects are built around four themes, which serve as a framework for organizing and focusing various transformational efforts. The IHI suggests that by simultaneously working on these areas, organizations will be able to truly transform care.
Safe and Reliable Care
Vitality and Teamwork
|• Care for moderately sick patients is safe, reliable, effective and equitable.
• The adoption and adaptation of best practices, such as patient safety leadership rounds and rapid response teams, can improve reliability and prevent system failures.'
|• Effective care teams continually strive for excellence, especially within a joyful, supportive environment that nurtures professional formation and career development.
• Effective teams positively impact patient outcomes.
|• Truly patient-centered care honors the whole person and family, respects individual values and choices, and ensures continuity of care.
• Redesigning work to be more patient-centered can create better patient outcomes and reduce costs.
|• All care processes are free of waste and promote continuous flow.
• The elimination of inefficiencies through work redesign and placement of supplies at the bedside increases staff satisfaction and morale.
Because TCAB is essentially a grassroots initiative, projects will vary from hospital to hospital and from unit to unit. IHI has developed a list of goals for participating organ izations. These include:
|• Adverse events are reduced to 1 (or less) per 1,000 patient days.
• 25% reduction in deaths on TCAB units.
• 95% compliance with all key clinical process measures for the three top clinical conditions on the TCAB unit.
• 95% of clinicians, students and staff would agree with the statement, “I work within a supportive environment that nurtures my professional formation and development.”
• 95% of clinicians, students and staff would agree with the statement, “I am part of an effective team that continuously strives for excellence even when conditions are less than optimal.”
• 95% of patients are willing to recommend and are satisfied with the facilities physical comfort, emotional support and respect for their values and preferences.
• Clinicians spend 70% of their time in direct patient care.
• Clinicians spend 90% of their time in value-added activities.
TCAB Case Studies
The University of Texas M.D. Anderson Cancer Center, Houston
M.D. Anderson Cancer Center joined the TCAB project in 2004, participating in the second and third phases of the project (which ended in May 2008). The project was piloted on two units but is now practiced on nearly all inpatient units. “The beauty of TCAB is that it relies on front-line staff to generate and test ideas for change,” says Beverly Nelson, R.N., director of nursing programs. “It gives nurses more control.” The rapid-cycle tests encourage staff engagement. The tests do not need to be extensive. “It can consist of one nurse, with one patient on one shift,” Nelson says. If the process works, the nurse can share the idea with others and test it on a broader scale. Hundreds of ideas have been generated and several TCAB initiatives have spread hospitalwide. That includes a process to streamline patient handoffs during shift changes. Nurses complained that they often spent up to an hour at the end of a shift updating the new shift on their patients’ conditions. A standardized, online shift-to-shift report was developed, and the process now takes under 20 minutes. The reduction in time saves one unit nearly $80,000 per year in overtime. And the nurses feel confident that they are providing all of the necessary information the next shift will need to care for the patients. Another change that’s been implemented hospitalwide is the placement of whiteboards in the patients’ rooms. The whiteboard includes the name of the caregivers, along with a photo, so patients and family members can recognize members of the care team.
The University of Kansas Hospital, Kansas City, Kan.
TCAB was launched in a single unit at the University of Kansas Hospital in 2005. In three years, the program has spread to almost all of the organization’s medical and surgical units and the heart center. “The spread has occurred as a result of the good work that happened on that one unit,” says Tammy Peterman, R.N., chief operating officer and chief nursing officer. “We haven’t experienced any ‘Oh my gosh’ moments,” she says. “The small changes add up and really make an impact on the patients.” One small change that’s been spread hospitalwide addressed the loss of patients’ eyeglasses. Patients’ glasses often got mixed up in the linens or otherwise misplaced. Now all patients who wear glasses are given a bright green case when they arrive. When glasses are removed, they are placed in the case. No glasses have been lost since the change was implemented. “The ideas the nurses come up with are absolutely from the patient’s perspective,” Peterman says. Another TCAB project focused on noise, a common complaint among patients. Several units now have designated quiet times during which lights are turned down and the staff limits interruptions. The time provides patients needed rest and allows staff to catch up on paperwork.
Voluntary Consensus Standards for Nursing Sensitive Care
The National Quality Forum has endorsed 15 voluntary consensus standards to help measure the extent to which acute care nurses contribute to patient safety, quality and the overall work environment. The standards reflect processes and outcomes directly impacted by nursing care. They can help consumers determine the quality of nursing care in hospitals and assist providers in identifying opportunities for improvement in both critical outcomes and processes of care.
Patient-centered outcome measures include:
Nurse-centered intervention measures include:
9. Smoking cessation counseling for acute myocardial infarction
10. Smoking cessation counseling for heart failure
11. Smoking cessation counseling for pneumonia
System-centered measures include:
12. Skill mix (registered nurse, licensed vocational/licensed practical nurse, unlicensed assistive personnel and contract)
13. Nursing care hours per patient day (RN, LPN, UAP)
14. Practice Environment Scale of the Nursing Work Index*
15. Voluntary turnover
*The PES-NWI measures how the environment supports professional practice in five areas: nurse participation in hospital affairs, nurse manager support, positive nurse-physician relations, adequate staffing and resources, and nurse foundations for quality of care.
Source: Natinal Quality Forum, 2008
How We Did It: This gatefold was produced by researching published studies and articles and conducting interviews with hospital and industry executives.
Research: Lee Ann Runy | email@example.com
Design: Chuck Lazar | firstname.lastname@example.org
This article first appeared in the November 2008 issue of H&HN magazine.
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