Nurse Practitioner-Led Care Pods: A Team Communication Enhancement Model

Background: Communication has become a key performance measure in the shift to value-based healthcare. Given the impact of communication failures on patient harm, length of stay, and dissatisfaction with care, new models of care with better communication through structured teamwork and interdisciplinary collaboration are needed. Problem: In a 16-bed geriatric medical/surgical unit of a New York City multispecialty community hospital, the workflow structure unintentionally created inconsistent handoff communication, gaps in continuity of care, missed care events, and inattention to the patient’s priorities in the care plan. A gap analysis identified communication deficiencies that impacted team effectiveness and patient care outcomes. Methods: Patient perceptions of care and staff perceptions of teamwork were assessed pre-and post-intervention for the effects of implementing structured team communication in a nurse practitioner (NP) medical management model. Responses were collected with the NRC Health Patient Experience Survey and the AHRQ TeamSTEPPS® Teamwork Perceptions Questionnaire (T-TPQ). Patient experience scores for the NP-led unit, a resident-led unit, and a physician-assistant led unit were compared. Interventions: Implementation of an NP-Led Care Pod model was evaluated over three months. An education session on structured communication tools prepared NP-Led Care Pod teams in role-based purposeful rounds, bedside shift reports, structured bedside interdisciplinary team rounds, and TeamSTEPPScommunication strategies. Results: Teamwork perception scores post-education and post-implementation fell short of the aim for a 10% increase from baseline. Patient experience survey scores increased 71.6% from baseline at two months for care team explanations, 128% for listening carefully, and 71.6% for perceived staff communication. Although not sustained, all scores were 14% higher than baseline. Team members reported increased team support, inclusion, and role satisfaction. Patients asked fewer questions about their care plans. Conclusion: The NP-Led Care Pods contributed to evidence on the effectiveness of NP-led, team-based care, with implications for nursing leadership and team communication. The NP-Led Care Pod environment improved workflow, team dynamics, and staff communication. Further studies may benefit from using measures to capture improvement in patient safety and patient experience domains that were not addressed in this project. Keywords: acute care nursing, bedside handoff, collaboration, communication, interprofessional, patient-centered care, purposeful rounding, team perceptions, TeamSTEPPS

A Team-Based Approach to Studying Complex Healthcare Processes

Communication is a critical aspect of clinical work. In 2010, the Joint Commission (JC) found that gaps in communication were among leading factors contributing to medical errors. Healthcare processes, such as patient discharge, depend on interdisciplinary communication to be successful. Electronic health records (EHRs) have the potential to facilitate communication and information sharing between interdisciplinary care team members; however, challenges remain in designing tools for team-based care and questions remain in understanding how EHRs impact interdisciplinary team communication. This dissertation focuses on understanding how EHRs can be designed to support communication and information sharing within interdisciplinary patient care teams. The first aim of the dissertation investigated how EHRs impact interdisciplinary clinical teams’ communication, shared mental models, and information sharing activities. The results showed that implementing new EHR tools appeared to have little impact on communication and shared mental models, but new information sharing activities mediated by EHR developed. These changes and lack thereof suggest that new EHR tools will be specifically needed to facilitate interdisciplinary team information sharing activities. The second aim of the dissertation investigates the information sharing activities and information needs of interdisciplinary team members during patient discharge. The results showed that the information clinicians sought out during discharge depended on the roles that person played as well as the progress of the discharge process. Future EHR tools should be aware of how patient care teams are progressing through the patient discharge process in order to provide information contextualized to their current tasks. In conclusion, interdisciplinary team communication and information sharing remain poorly supported by current EHRs and new tools designed specifically for interdisciplinary teams should provide information based on the completion of team activities

Program Evaluation of a Bundled Educational Intervention to Enhance Implementation of Professional Exchange Report

Communication handover is a source of potential error and risk to patient safety. Electronic-based tools may reduce errors and mitigate risks to patient safety. Electronic tools have been successfully implemented using multiple methods of education and training. Electronic tools vary in functionality and integration with the electronic health record (EHR). A large West Michigan Regional Health System (RHS) implemented a new EHR containing an embedded tool for communication handover called Professional Exchange Report (PER). There was inconsistency in the practice of bedside report by nurses. The RHS planned to use a bundled approach of educational interventions to implement the new tool and report structure including communications, video demonstration, in-seat training and at the elbow support during the go-live. This project systematically evaluated the interventions to implement PER using evidence based methodology. Evaluation was based on collection of data and evidence through interviews, pre- and post-implementation surveys, observations of the report process, and review of documents related to planning, implementing and evaluating the program. Organizational leaders engaged in robust planning. Educational interventions were evidence-based. Implementation was carried out effectively. The organization did not have a detailed, specific plan for evaluation of educational interventions or PER outcomes. Change in length of report could not be attributed to the process change, and nurse perceptions of the process and consistency of practice at bedside did not change. Observed opening of the EHR during report increased by 68%. There were statistically significant increases in yes responses to awareness of, understanding why, knowledge of specific, and ability to make practice changes

Taking Note: A Design Solution for Physician Documentation to Balance the Benefits of Handwritten Notes and Electronic Health Records

Master of Design in Integrative DesignUniversity of Michiganhttps://deepblue.lib.umich.edu/bitstream/2027.42/136865/1/THo_2017_MDes-Thesis.pd

The Design, implementation and Evaluation of a Technology Solution to Improve Discharge Planning Communication in a Complex Patient Population

Unnecessary delays in discharge planning can extend the length of stay (LOS) and add non-reimbursable days for socially and medically complex patients thereby increasing the financial burden to healthcare organizations. The literature supports enhanced discharge communication strategies and the use of checklists to facilitate safe and timely discharges. Following root cause analyses of significant discharge delays, one hospital identified gaps in communication as key precursors associated with discharge planning breakdown when discharging patients to skilled nursing facilities. Review of these events demonstrated the need for concurrent communication strategies between multidisciplinary care team members in planning for complex discharges. Following a complete assessment of the current discharge planning process, a web-based interactive discharge checklist was designed, implemented and evaluated in the attempt to provide guided communications to the essential partners of the patient’s team in an effort to reduce LOS and readmissions. After a six-month rollout of the new technology and concomitant procedures, the analyses revealed improvement in both the patient’s perception of discharge planning and the ability to discharge patients by noon. Results for LOS and readmission demonstrated inconsistent improvement. The use of an electronic checklist as a communication tool did reduce variability in discharge procedures and provided for continuity in handoff communication between team members. Staff agreed it promoted continuity and improved efficiency

Improving Multidisciplinary Adherence to a Daily Goals Checklist in the ICU: A Quality Improvement Initiative

Abstract Background: In November 2019, the University of Louisville Hospital merged and assumed operations of all KentuckyOne facilities. During the transition, a spike in hospital acquired infection rates ensued at Jewish Hospital, notably amongst the critical care units. In January 2020, a daily checklist was introduced to the critical care department. A Daily Checklist is a tailored communication tool designed to reduce communication error and improve adherence to patient safety measures. There continues to be a gap in adherence to the U of L daily checklist from both nurses and providers. Purpose: The purpose of this project was to improve multidisciplinary adherence to a daily review of a quality and safety checklist to ultimately reduce the incidence of hospital-acquired infections. Methods: This was a quality improvement project that included a retrospective review and prospective cohort design. The project was conducted on a 10-bed neurological and a 10-bed surgical-transplant critical care unit in a Level II Urban Hospital. The NICU/SICU departments’ nursing handoff document was modified to incorporate the U of L approved daily checklist which has been endorsed by the Agency of Health Care Research and Society of Critical Care Medicine. This tailored, reusable document (Daily Goals Document) was used for nurse-to-nurse handoff and multidisciplinary rounds. The project incorporated two Plan, Do, Study, Act (PDSA) cycles. The first cycle consisted of brief point of care training sessions for both nursing staff and providers, and the Daily Goals Document was modified to meet unit needs. The second PDSA cycle monitored multidisciplinary adherence to quality review during daily rounds. Descriptive and Inferential Data was collected for both study samples for PDSA Cycle 1 and 2. Results: There was a significant reduction of adherence to checklist review following the first PDSA cycle (NICU p p p.05), and a marginal reduction of Infection-related Ventilator Associated Conditions in the Neuro ICU. All pairwise comparisons are significant except Audit Form 2 versus the Daily Goals Document Audit (p \u3c .001) for both foley and central line rationale documentation. Conclusion: Despite nurse acceptance of the Daily Goals Document, there was a reduction in verbal checklist adherence during multidisciplinary rounds and there was a marginal reduction in hospital-acquired infection rates. The Daily Goals Document is comparable to the Quality Audit Form as a tool for monitoring infection control data. Keywords: Daily Checklist, Quality Improvement, Multidisciplinary, Quality and Safety, Hospital-acquired infection

Investigating the need for clinicians to use tablet computers with a newly envisioned electronic health record

Objective: The Veterans Health Administration (VHA) has deployed a large number of tablet computers in the last several years. However, little is known about how clinicians may use these devices with a newly planned Web-based electronic health record (EHR), as well as other clinical tools. The objective of this study was to understand the types of use that can be expected of tablet computers versus desktops. Methods: Semi-structured interviews were conducted with 24 clinicians at a Veterans Health Administration (VHA) Medical Center. Results: An inductive qualitative analysis resulted in findings organized around recurrent themes of: (1) Barriers, (2) Facilitators, (3) Current Use, (4) Anticipated Use, (5) Patient Interaction, and (6) Connection. Conclusions: Our study generated several recommendations for the use of tablet computers with new health information technology tools being developed. Continuous connectivity for the mobile device is essential to avoid interruptions and clinician frustration. Also, making a physical keyboard available as an option for the tablet was a clear desire from the clinicians. Larger tablets (e.g., regular size iPad as compared to an iPad mini) were preferred. Being able to use secure messaging tools with the tablet computer was another consistent finding. Finally, more simplicity is needed for accessing patient data on mobile devices, while balancing the important need for adequate security

Intraprofessional Nursing Communication and Collaboration: APN-RN-Patient Bedside Rounding

Executive Summary Leading advisory agencies have long advocated that health care must be safe and effective (Institute of Medicine [IOM], 2001). In order for health care to be safe and effective, good communication and collaboration are essential. Research has found that in health care, poor communication and teamwork failures are the major contributors to adverse events (Cornell, Townsend-Gervis, Vardaman, & Yates, 2014; The Joint Commission, 2011; O’Leary, 2012). Such communication-related adverse events can cause avoidable injury, loss of life, and financial devastation. In light of advanced practice nurses’ (APN) increasing contribution in care management, and in order to ensure delivery of high-quality patient care, hospital administrators and nurse executives in particular, must foster improved communication and collaboration between APNs and RNs. The potential benefits of improving APN–RN teamwork are multiple. For example, Naylor et al. (2013) have reported that, in their study, nurse-led interdisciplinary interventions resulted in quality improvement and cost savings. One solution for improving communication within the health care team pertains to bedside rounding. Daily bedside rounding presents an opportunity for care team members to cooperatively develop and communicate care strategies. Staff nurses are typically not included in physician led patient rounds. This exclusion is unfortunate because, during rounds, nurses could provide essential nursing expertise and knowledge about patients’ health status; furthermore, nurses are uniquely positioned to encourage patients’ proactive participation in their own health care team. The primary objective of the DNP project described in this doctoral project paper was to develop a structured learning module to improve collaboration and communication between APNs and RNs through the implementation of APN–RN patient bedside rounding. To establish a basis for creating the learning module, the DNP project began with an in-depth literature review of research on (a) APN–clinical nurse communication and collaboration and (b) the contributions of APNs and clinical nurses to the quality of patient care. Evidence-based best practice recommendations guided the development of the learning module to instruct APN and clinical nursing staff on proper communication and collaboration in conjunction with the use of a daily goals sheet to facilitate structured APN–RN–patient beside rounding. (For example, the use of bedside rounding with daily goal reminder sheets has demonstrated improved communication in patient-centered care.) King goal attainment theory provided the underpinning for this project with Knowles’ conceptual framework of andragogy provided a methodology, framework, and mechanism that informed the learning module’s design. After an initial draft of the module was completed, it was sent to three of the hospital’s APNs for their review; all of these APNs had had prior experience with APN–RN rounding at other hospitals. Following the APN’s review, the main modifications of the learning module included expanding the explanations of (a) breakdown of communication (specifically, nonverbal communication), (b) roadblocks to collaboration, and (c) inclusion of the patient’s family in rounding discussions, when possible discussion, when possible. Bedside rounding presents a daily opportunity for health care team members to cooperatively strategize and to communicate the plan and goals of care to the patient and family; this cooperative activity reflects a concerted team effort to achieve the patient’s goals. Effective communication and collaboration are requisite for building a patient centered care partnership. The learning module developed in this DNP project can assist APNs and RNs in improving their communication and collaboration

Improving Communication and Collaboration Between Disciplines: Utilization of aDaily Goals Sheet During Daily Multidisciplinary Rounds in the Critical Care Setting

Communication problems have been cited as the “top safety incident” causing patient harm in intensive care units (Halm, 2008). Many concerns related to interdisciplinary communication and collaboration were found in a small, satellite critical care unit of a major teaching facility. This led to missed patient care goals and opportunities for improved patient outcomes, as well as increased length of stay. The researcher used a convenience sample of 40 nurses and advanced care providers and a mixed methods quasi-experimental pre/post survey design to explore whether multidisciplinary rounds utilizing a rounding tool would improve communication and collaboration between advanced care providers and nursing staff, as well as improve understanding of the daily goals of patient care. Quantitative and qualitative data were analyzed yielding mixed results with both positive and negative attributes to interdisciplinary communication and collaboration. Overall, the study supported the use of daily multidisciplinary rounds in the critical care setting utilizing the Daily Goals Sheet to increase interdisciplinary communication and collaboration and improve understanding of the daily goals of patient care, when compared with rounds not using the Daily Goals Sheet. Major limitations of the study were the small sample size and increased workload and staff resistance in using the Daily Goals Sheet and completing the surveys. The most significant implication of this study is that the researcher plans to continue integration of the Daily Goals Sheet into the research study site’s new computer system, as well as to continue future research in this quality improvement area