Doing More Under Laborious Limits
Hospitals explore innovative models of care that address the nation’s patient and workforce challenges.
By Laura Ramos | Print the pdf of this story
Trying to improve quality and increase patient and employee satisfaction in the middle of a recession and a staffing shortage seems akin to trying to do a lot more with less. However, leading-edge providers are experimenting with ways to make the most of their workforces, particularly nurses. Their stories suggest creative ways to restructure roles and responsibilities and redesign workflow to attain promising results without adding significant dollars.
Nurses as Care Coordinators
The nursing shortage has forced many hospitals to reconsider how they can make the best use of their experienced registered nurses (RNs)—while ensuring that patients receive adequate nursing care. A common answer is to give highly skilled RNs responsibility for overseeing and coordinating the care of a group of patients. In this elevated role, RNs are given increased authority and accountability for achieving successful patient quality, safety, and satisfaction outcomes. They may also take on a larger role in directing and mentoring the novice nurses and allied health workers who help provide bedside care.
For example, at Sherman Hospital in Elgin, Ill., leaders wanted to help nurses collaborate and learn from each other. So nurses piloted a new care delivery model on Sherman’s telemetry unit. They flattened the nursing management structure and retired the traditional charge nurse model—in which unit nurses care for five or six patients while a charge nurse rounds with physicians and completes other managerial duties. Instead, charge nurses were replaced with patient care coordinators (PCCs), who are RNs who serve as clinical leaders. Each experienced PCC works with a less experienced nurse who assists in the care of a group of patients.
“This partnering approach means additional nursing resources at the bedside for our patients,” says Judy Balcitis, RN, MSN, vice president and chief nursing officer, Sherman Hospital. “Our nurses are supported as they continue to gain valuable clinical experience.”
Partnering also improves communication, she says. “More than one person is informed about the patient’s treatment plan, preferences, and progress. As clinical leaders, the PCCs also promote best practices, coordinate care, and think beyond the shift.”
The results have been promising: Patient satisfaction has increased from the 50th to the 70th percentile, length of stay has decreased from 4.3 days to 3.7 days, heart failure discharge instruction compliance improved from 60 percent to 100 percent, and nursing turnover has declined from 14 percent to 10 percent over two years. In the coming year, Sherman plans to roll out the model to other units.
Same Bed; Same Nurses
In its new 20-bed cardiac unit, Allegiance Health in Jackson, Mich., rolled out a universal care model that allows cardiac patients to avoid being transferred to another patient room and to receive many clinical interventions without leaving their hospital rooms. Unit staff now bring care to the patient—rather than the patient to the care.
“Transferring patients requires a lot of nonvalue-added work for staff, and it’s disruptive to patients,” says Jacalyn Liebowitz, CNE, MBA, NEA-BC, vice president of the patient care continuum. In February 2008, Allegiance opened a new cardiac unit featuring a universal bed model, in which patients stay in the same room and bed for their whole visit. It allows heart patients to receive all of their pre- and postoperative treatment from one bed, eliminating transports to the ICU, the step-down unit, and the medical-surgical units.
Besides eliminating transfers, the universal bed model keeps the same nurses with the same patients.
“Nurses who are familiar with a patient may be better able to detect subtle changes in the patient’s condition,” she says. “Having continuity in nursing care is good for the entire team. It’s easier for staff to come together and plan care, rather than moving patients in and out of the unit.”
Communication is also improved between the care team and patients’ families.
The model does require staff to work differently. For example, ICU nurses assigned to the unit must care for a combination of ICU and medical-surgical patients. Staffing was a challenge in the beginning. “ICU techs tend to work differently than med-surg certified nursing assistants, so we had to find the best way we could work together on the same unit,” she says.
The results have been favorable. Patient satisfaction in the new unit is in the 99th percentile, and the hospital has avoided $50 per patient in transfer and housekeeping costs. Based on the success of the unit, Allegiance plans to roll out the new model throughout the hospital’s med-surg units in late April 2009, designating each unit around a particular type of patient, such as orthopedic and cancer patients.
“You really need to involve every discipline when you make a change like this,” Liebowitz says.
For example, pharmacy had to regroup its staffing to ensure there were enough clinical pharmacists who had a combined knowledge of caring for ICU cardiac patients and less acute cardiac patients. Liebowitz says involving other disciplines early on in a new care model’s design can help a hospital identify—and avoid—potential problems.
Partnering with Patients
Many hospitals have embraced the belief that engaging patients and families in care delivery will help improve quality and patient satisfaction. “Hospitals should strive to see patients as partners in care from the time of admission,” says Heidi Crooks, RN, MA, senior associate director of operations and patient care services, UCLA Health System.
Key to building this provider-patient partnership is creating opportunities for communication. “It is essential to have a forum where care can be coordinated and discussed with the team,” she says.
That’s what the Ronald Reagan UCLA Medical Center has achieved in its neurotrauma ICU. There, a family member of each patient is invited to attend daily rounds. During that time, the unit’s dedicated neurointensivist, pulmonologist, social workers, nurses, respiratory therapists, and other team members are available to answer questions about nutrition, ventilator management, glucose management, and so forth.
Involving families in the care model is not easy, particularly when loved ones are facing end-of-life issues. This challenge may be especially difficult in a specialty pediatrics environment, such as at Mattel Children’s Hospital at UCLA.
In 2007, hospital leaders at Mattel developed a palliative care service to help patients and families cope with the stress of serious and life-threatening illness. The multidisciplinary effort includes a physician, chaplain, child-life specialists, psychologist, social workers, and other staff members.
To help guide and direct the program’s focus, pediatric leaders invited five families to serve on an advisory committee. It’s a delicate partnership, as these are parents who lost a child who had received care at the children’s hospital. By collaborating with families, however, the grant-funded program has educated new graduate nurses and pediatric house staff on how to deliver bad news to families as well as other issues.
Patient- and family-centered care also requires providers to partner with their customers, rather than simply providing a service. When Scottsdale Healthcare in Arizona decided to embrace this philosophy, it realized that its staffing model needed to change, says Peggy Reiley, RN, PhD, senior vice president and chief clinical officer. “We needed RNs in the role of managing the relationship between patients and families,” Reiley says. The organization gradually phased out its licensed practical nurses. RNs are now supported by certified nursing assistants (CNAs) and patient care technicians. Patient care technicians are able to perform more than one job, such as being a CNA or unit secretary, depending on the day or need for the shift.
Support from Support Services
Scottsdale Healthcare also rolled out a new support services role, that of a multi-skilled associate (MSA). The MSA’s role at Scottsdale is to ensure patients’ physical comfort by providing nonclinical services. Unit-based MSAs spend about half of their time with housekeeping duties, and half delivering meals, adjusting TVs and thermostats, and other tasks.
“MSAs are very available to patients and families, and because they are unit-based, they are seen as part of the care team—not just by families, but by staff as well,” Reiley says. “In the previous model, we had housekeeping and dietary staff who rotated through the hospital and didn’t get to build a relationship with the clinical staff.”
Nurses at Scottsdale are pleased with the MSA role, and since implementing the new model, nursing turnover has dropped from 16 percent in 2006 to 8 percent in 2008.
The hospital has seen several impressive outcomes, thanks to the new model and improved communication. “If you have nurses who are engaged in the care, you will have outcomes improve and reduced costs through fewer complications,” Reiley says. For example, patients’ pressure ulcer rates dropped from 5.5 percent in 2007 to 1.2 percent in late 2008.
The MSA role is one example of the type of collaboration between nursing and support services that is being advocated by the American Organization of Nurse Executives (AONE). In partnership with ARAMARK Healthcare, AONE has developed a set of guiding principles for relationships among nursing and support services. The guidelines encourage collaboration through principles such as effective nursing leadership, shared governance, and a clear scope of practice. (Visit www.aone.org to access these guiding principles.)
Driven by Results
Many hospitals that successfully launch new models of care focus first and foremost on improving patient outcomes and patient satisfaction. This is a theme carried out at Scottsdale Healthcare, where the hospital hosts monthly, cross-discipline meetings to discuss patient satisfaction scores. Such collaboration has led to patient- and family-centered improvements, such as “at your service” dining, which allows patients and families to order from a menu and have their meals arrive at their convenience.
In addition, each hospital hosts monthly “lunches with the administrator,” Reiley says. “We talk about patient satisfaction, outcomes, and financial performance. It’s a wonderful opportunity for people to get to know each other and create an open dialogue with hospital leaders. It helps us build collaboration as an organization.”
Common Themes in New Care Delivery Models
A January 2008 white paper, Innovative Care Delivery Models: Identifying New
Models that Effectively Leverage Nurses, from the Robert Wood Johnson Foundation and Health Workforce Solutions outlines several strategies being tested across the country. For the project, researchers selected 24 care delivery models to showcase the innovation under way at healthcare organizations.
To read about each of these care models visit www.innovativecaremodels.com
In studying these 24 sites, researchers identified eight themes of innovative models.
Elevated Roles for Nurses: Nurses as Care Integrators. Most organizations created at least one new role for nurses. In most of these cases, the organization elevated the registered nurse (RN) role to a more autonomous position as a “care integrator.” In this role, RNs manage and coordinate the care of their patients across disciplines and settings. In addition, RNs act as mentors to novice nurses and allied health workers.
Migration to Interdisciplinary Care: Team Approach. Many of the organizations implemented interdisciplinary care teams, including physical therapists, social workers, and pharmacists. In many cases, RNs lead these teams.
Bridging the Continuum of Care. Under this model, hospitals bridge the continuum of healthcare settings, extending care from hospitals to the patient’s home, outpatient clinics, and long-term care facilities.
Pushing the Boundaries: Home as Setting of Care. In many of the models, organizations extended the healthcare setting to the patient’s home, helping patients make the transition. In other cases, hospitals used the home as an alternative setting of care for individuals who otherwise would be admitted to a hospital or a long-term care facility.
Targeting High Users of Health Care: Elderly Plus. Building healthcare services around the needs of older adults with multiple or frequent medical conditions, some organizations sought to address the significant healthcare resources these patients consume and reduce the inefficiencies inherent in caring for these patients in a fragmented healthcare system.
Sharpened Focus on the Patient. Using this model, organizations created programs that actively engaged patients and their families in care planning and delivery, with the aim to provide greater responsiveness to patient wants and needs.
Leveraging Technology in Care Delivery. Many organizations incorporated new technology into their new care delivery models, and in some cases, developed a new model around new technology. In other cases, organizations leveraged new technology to help them manage patients in remote locations, and to manage complex outpatient care plans.
Driven by Results: Improving Satisfaction, Quality, and Cost. Many of the models developed processes to continually track results. Using these data, they made corrections, mid-course if necessary, to ensure that the model improved defined goals, such as patient satisfaction, nurse retention, and hospital readmissions.