7 Model for Patient–Family-Centered Care

7 Model for Patient–Family-Centered Care

Creating a 24/7 Model for Patient–Family-Centered Care P. Sue Fitzsimons, RN, PhD, CENP,Tahiry Sanchez, RN, MS, Paula Crombie, MSW, LCSW, and Francine...

3MB Sizes 2 Downloads 136 Views

Creating a 24/7 Model for Patient–Family-Centered Care P. Sue Fitzsimons, RN, PhD, CENP,Tahiry Sanchez, RN, MS, Paula Crombie, MSW, LCSW, and Francine LoRusso, RN, MHA, CCRN, CENP

A

major challenge for hospitals is ensuring

formance standards. Although care delivery was multi-

consistent and standardized patient care

disciplinary and provided a full range of services and

across all shifts. In particular, evenings and nights are

coverage from 7 a.m. to 3 p.m., after those prime

of concern because most patients are admitted to hos-

hours, many departments, nursing included, scaled

pitals during those hours. In 2009, Yale-New Haven

back resources. Thus, full clinical and managerial cov-

Hospital (Y-NHH), a 948-licensed-bed university teach-

erage was in fact only available one-third of the time,

ing organization, embarked on a journey to establish a

whereas two-thirds of the time, patients and staff were

24/7 leadership model to enhance the culture of safety,

working with fewer resources while caring for the same

provide seamless care delivery, and comply with per-

volume and acuity of patient populations.

56

Nurse Leader

August 2015

R

ecognizing the urgency and complexity of this problem, the Y-NHH chief nursing officer (CNO) and senior vice president for patient services, P. Sue Fitzsimons, and the president, Richard D’Aquila, sponsored the work to drive a patient–family-centered model of care and establish a leadership structure operational 24/7. The intent was to support the work of the bedside nurse with resources to augment problem solving, address education and practice issues, and increase collaboration and teamwork among all departments and practitioners.

ENGAGING STAFF Effective change is based on building trust and understanding the work of staff at the bedside, as well as exhibiting a genuine interest in their opinions and the challenges faced on a daily basis. On the basis of that premise, an expert in performance improvement met with multiple staff focus groups that incorporated over 300 frontline nurses. The purpose of the focus group was to hear the voices of the nurses as related to the importance of a new model and to review the evidence indicating that extended periods with reduced staffing levels and resources indicated the need for enhanced and focused leadership engagement. This will ultimately drive improvements in healthcare quality and safety, and reduce patient harm.1 This process allowed for participation and recommendations that led to the evolution from the off-shift administrator (OSA) to a new model with an off-shift executive (OSE) and off-shift nurse leader (OSNL), designed to influence the patient–family-centered care model. The key components of this model consisted of redesign of leadership roles, as well as the initiation of a culture of 24/7accountability. In conjunction with multidisciplinary hospital leadership, staff participated in workout sessions focused on role redesign. The plan was to ensure that new leadership roles would address the critical issues faced by off-shift staff, as well as provide practice support. A goal was to provide consistent operations support for both administrative and clinical concerns, as well as full accountability to patients, their families, and staff. The emphasis was to provide high-quality, competent leadership on all shifts. This was followed by direct work observations of the existing OSA leadership role. The observations were conducted around the clock and concentrated on workflow rather than on individual performance. It was clear from these observations that the majority of OSA time was spent in “fix-it” mode rather than defect reduction and process improvement. In fact, 80% of the OSA time was consumed with staff scheduling and bed placement for patients. Recommendations from the observers: 1. Decrease non–value-added time • Reduce time spent staffing the inpatient units on the off shifts • Reduce time spent placing patients • Reduce time spent searching for equipment • Reduce office time through improved automation/technology www.nurseleader.com

• Eliminate redundancy and variation in processes (ie, workarounds) 2. Increase value-added time • Promote institutional shared goals • Focus on patients and their families • Focus on teamwork 3. Increase training for staff • Perform needs assessment • Enhance off-shift employee training • Influence patient safety and quality outcomes 4. Increase active management time • Create productive huddles and visibility • Create a platform to provide data/reports for decisions • Provide consistent follow up to issues/barriers • Improve communication regarding closure to issues/barriers Leadership engagement with frontline staff provided the opportunity to think through new approaches, redefine successes, and effectively mobilize staff and leaders to adapt to the continually changing healthcare environment and promote innovation. If Y-NHH was to “compete on value,” then there was a need to improve outcomes, patient safety, and service, with attention to elimination of waste and redundancy. A compelling case for off-shift leadership redesign was made, with a redistribution of existing resources to create a new model that transitioned to a value-based system. Finally, it became clear that the budget assigned to the OSA role could be better utilized to introduce roles that would be more effective in supporting the bedside nurse. Division of accountabilities would ensure that the bedside nurse could renew focus on the patient–family-centered care model. The timeline and 4 new separate and distinct roles consisted of the following: 1. A clinical bed manager with 24/7 accountability was introduced from September 2009 through June 2010. 2. 24/7 centralized staffing and scheduling department leaders were identified in a continuous transition. 3. OSE was positioned July 3, 2010. 4. OSNL was positioned July 3, 2010. The clinical bed manager was to be accountable for placing the right patient in the right bed the first time.2 The centralized staffing and scheduling department managed staffing issues and decisions. This article focuses primarily on the institutional core values and the implementation and charge given to the global administrative role of the OSE and the clinical role of the OSNL as transformational leaders supporting the work of the bedside nurse.Yale-New Haven Hospital believes that high-reliability organizations exhibit certain tenets in their core values, as described in the YaleNew Haven Health System institutional vision, mission, and values (Figure 1).

RECRUITMENT STRATEGY “Successful organizations understand that employee experience drives patient experience and compassionate care; believe that supporting caregivers is essential to preserving their compassion; and incorporate compassionate care prac-

Nurse Leader

57

Figure 1. YNHHS Vision, Mission and Values

tices into their patient experience initiatives.”3 In addition, “Successful organizations have a culture of experimentation, hiring and training for compassion are critically important…compassion is why we chose to do what we do, employee experience drives patient experience and compassion of care.”3 Yale-New Haven Hospital’s CNO and chief operations officer (COO) were driven by the unwavering belief that YNHH could attain destination hospital status, which characterizes hospitals respected as medical centers of excellence that focus on attaining excellent patient outcomes while achieving cost efficiency. Senior leaders reflected on actualizing a focused and sustained, 24/7, positive patient and employee experience that would begin with the creation of the OSE role and OSNL role. The CNO and COO understood the need to influence the culture that was evident on the off shift and expected that the new roles would ensure that practices and behaviors consistently centered on evidence-based practices and established best practices. These new transformational leaders would positively influence key components of organizational strategies, throughput and efficiency, and acquisition and retaining of high-quality staff, as well as positively affecting the patient’s choice to return to the hospital as a result of their outstanding experience. The defined new structure and processes would serve as the crosswalk from living the hospitals’ core values Monday through Friday to creating an invisible, strengthening fiber as employees lived the core values 24/7. The new roles would be expected to practice rounding with influence4 in order to effectively engage our employees,

58

Nurse Leader

patients, and the patients’ families. Through rounding with influence the new executive team fosters a connection with the end user of our services on the off shift. This connection allows the executive to gain frontline insight and knowledge that would influence the development of possible patient safety improvement strategies. This partnership draws on the voice of the consumer to positively influence the hospital’s journey. The candidates would be required to possess and exhibit the personal capacity for exquisite judgment, diplomacy, communication, trust, influence, and the ability to rely on a solid frame of reference. Their multifaceted conversations with patients, families, and staff necessitated effective command of these attributes. New Off-Shift Model Hiring and Training The off-shift structure and process was redesigned and launched on July 3, 2010, with an intentional decision by the CNO and COO to defer hiring employees for the role of OSE. This meant hospital administrators would serve in this new role to define what would it would involve and require. During the first 4 months, key senior administrative stakeholders were expected to serve in the OSE role on the off shifts, affording them the opportunity to experience the “other hospital” at work. In addition, senior vice presidents and vice presidents performed intentional rounds with the hospital administrators for a portion of the off shift. In October 2010, the first 3 OSE staff members were hired. The hiring and developmental strategy was based on Goleman’s theory 5 that stipulates that individuals who exhibit emotional quotient/emotional intelligence (EQ/EI) rather

August 2015

Figure 2. Y-NHH Investment

than the intelligence quotient (IQ) have the ability to empathize and connect with the people around them. This theory maintains that EI goes beyond the limits of IQ and is a better predictor of success in the workplace. The author indicates that IQ determines academic abilities, but EQ can be used to identify successful future leaders, upright team players, and people who best work autonomously. In our ongoing evaluation of the OSE and OSNL roles, it is clear that these defined attributes have led our off-shift team to motivate others to live the institutional core values, allowing them to bring about a focused and sustained effort in the delivery of excellent care. Kolb’s 4 stages of the learning cycle6 were utilized to instruct the actual OSE staff members. Figure 2 represents the Y-NHH investment in the journey to create this solid future leader. Accordingly, strategic emphasis and investments were made, concentrating on opportunities for evolution of the future OSE and OSNL roles. It was recognized that we needed to prepare a team without direct authority that was able to rely on engagement in its purest form. The future leaders would influence staff to live the institutional values, eliciting behaviors consistent with our institutional strategies inclusive of the “I am Yale-New Haven” pledge (Figure 3). It also became evident to the precepting and mentoring team (Figure 2) that new OSE staff members required confidence and preparation to align their personal values with the organizations’ core values (Figure 1). Consistent focus and alignment would better prepare the offshift team to “walk the walk” and “talk the talk” as 24/7 leaders within the hospital and to respect diverse cultures and www.nurseleader.com

traditions as they look into the faces of those we serve. The execution of these elements could only occur in a deliberate 1:1 precepting model and eventual handoff between the hospital administrators and the new OSE staff. After a period of orientation was defined, training focused on a global institutional perspective 24/7 to ensure positive influence on the experiences and challenges of the off shift. The traditional leader training would be ineffective in grounding values because executive oversight for the hospital necessitated a multidimensional approach to learning. The hospital chose to invest in multiple learning modalities to communicate essential information, each with its own price tag. We created diverse opportunities for OSE and OSNL development (Figure 2) and were convinced that the return on investment (ROI) would be worth the added cost. The global source of positive influence would be the obvious ROI. The OSE and the OSNL journey over the global terrain of the hospital provided a unique perspective. This navigation allowed them to create roads that united us as an institution. These new roles provided a quick and accurate assessment of a moment in time, creating opportunities for the OSE and OSNL to share observations and best practices among the various environments and service lines. Presently, the OSE and the OSNL staff communicate consistently in identifying familiar patterns and, subsequently, sharing success stories.

COMMUNICATION STRATEGY Another critical component of the off-shift model was the daily commitment and responsibility to effectively hand off issues requiring immediate resolution via e-mail to key stake-

Nurse Leader

59

Figure 3. Y-NHH Service Excellence Pledge

deliver bloods or collect pharmaceuticals. This was identified as a potential patient safety concern because caregiving staff numbers are limited on the off shift. Multiple layers of solutions were implemented to address this concern: the first was a reallocation and retraining of resources to address tube system failures 24/7; another solution was to identify and deploy a team from non–direct caregiving departments to immediately respond to the inpatient areas 24/7 to ensure operations would continue and to support the work of the nurse delivering care to the patient. These preidentified non–direct care departments would deliver nonurgent lab samples and bring pharmaceuticals to the nurse at the bedside. Solutions to these chronic issues are continually addressed by teams charged to develop decision-ready recommendations.

RETURN ON INVESTMENT

holders in multiple departments. In an effort to streamline this communication, the hospital executive administrative report (HEAR) was created with a database for communicating all activities. This report, categorized by issues and subissues, consists of OSE and OSNL sharing safety stories and encounters as they go about their work on the off shift. Senior administration inclusive of the chief executive officer, COO, and CNO provided a hands-on level of support and commitment for change management. Weekly actionable data were reported by the OSE, identifying and trending issues from the HEAR and recommending potential solutions. The data were further broken down as follows: 1. Broken processes with solutions that could be executed within a minimal time frame by a process owner. An example of this would be the expectation that people in new off-shift roles would spend their time locating and delivering food, equipment, and supplies as the old OSAs did.The database report identified temporary interventions that had been in place and problems that continued to arise. Process owners were contacted and issues were addressed. For example, par levels for missing equipment or supplies were increased and re-evaluated as populations and needs changed.The HEAR reporting allowed managers to see that their current processes were not working. 2. Chronic, recurring operational systems issues affecting multiple departments that in turn affected patient care and regulatory compliance. An example of this was the tradition that when the tube system failed, precious direct caregivers left the patient bedside to

60

Nurse Leader

“To motivate people, a leader needs to understand their needs…once motivation is understood, leaders help remove constraints or inhibitions that impede the play of motivation.”9 As leaders, this team has emerged as a motivating force for hospital management and administration, sharing the needs of patients, their families, and staff 24/7. This was the ultimate goal of the 24/7 model in support of patient–family-centered care. This model allows us to close the gaps in performance and service on the off shifts, improving staff satisfaction and the patient–family experience. The off-shift program has created a framework for solving system issues and problems, as well as raised organizational initiatives to the level of a 24/7 hospital.

LESSONS LEARNED Much of the literature for this project comes out of creating leadership models to drive improvements in healthcare quality and safety and reduce patient harm. Our model examined traditional healthcare operational management oversight, best practices for executive rounding, and leadership engagement. Continuous evaluation of the model sharpens both the program and the role of the OSE and the OSNL. Here are some early identified lessons learned: 1. Technology and reports are key mechanisms for accurate communication, tracking of issues, and resolutions, both short- and long-term. 2. Lack of availability of an administrative leader on off shifts hindered facilitation of processes, immediate conflict resolution, and problem solving from department to department (ie, what may work on day shifts does not work on off shifts). 3. Training and educational opportunities were missing from off shifts. 4. Full endorsement of the off-shift leader’s role is essential, in addition to having the ability to escalate to the vice president administrator on call in the event of significant emergency situations, such as flooding, Continued on page 73

August 2015

Creating a 24/7 Model Continued from page 60

serious weather conditions, or situations posing significant risk to the institution.

IN CONCLUSION The result of creating a 24/7 model for patient–family-centered care has established structural and process improvements in line with hospital goals that both foster inspirational leadership and staff engagement. The off-shift program has successfully extended 24/7 support and needs awareness to all departments and off-shift staff. As effective communicators and operational consultants, the OSE and the OSNL teams have garnered the confidence of the hospital staff and administrators in communicating and modeling our vision, mission, and values. NL References 1. Swensen S, Pugh M, McMullan C, Kabcenell A. High Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2013. 2. Rathlev NK, Bryson C, Samra P, et al. Reducing patient placement errors in emergency department admissions: right patient, right bed. West J Emerg Med. 2014;15:687-692. 3. The Schwartz Center for Compassionate Healthcare. Building Compassion Into the Bottom Line: The Role of Compassionate Care and Patient Experience in 35 U.S. Hospitals and Health Systems. A Schwartz Center for Compassionate Healthcare White Paper. Boston, MA: The Schwartz Center; 2015. 4. Reinertsen JL, Johnson KM. Rounding to influence: leadership method helps executives answer the “hows” in patient safety initiatives. Healthcare Exec. 2010;25:72-75. 5. Goleman D. Leadership: The Power of Emotional Intelligence (Selected Writings). Northampton, MA: More Than Sound LLC; 2011. 6. Kolb D. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice Hall; 1983. 7. Nurse Manager Leadership Partnership. Nurse Manager Skills Inventory. http://www.aone.org/resources/leadership%20tools/PDFs/NMSL_Brochure FINAL.pdf. Accessed August 30, 2010. 8. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development 2nd ed. Englewood Cliffs, NJ: Prentice Hall; 2014. 9. Khalil Al-Haddad M. Leadership in healthcare management. Bahrain Med Bull. Available at: www.bahrainmedicalbulletin.com/march_2003/ Leadership.pdf. Accessed August 30, 2010.

P. Sue Fitzsimons, RN, PhD, CENP, is senior vice president of Patient Services and chief nursing officer at Yale-New Haven Hospital in New Haven, Connecticut. She can be reached at [email protected]. Tahiry Sanchez, RN, MS, is director of Off-Shift Executive Administration at Yale New-Haven Hospital. She can be reached at [email protected]. Paula Crombie, MSW, LCSW, is director of Social Work at Yale-New Haven Hospital. She can be reached at [email protected]. Francine LoRusso, RN, MHA, CCRN, CENP, is executive director of Heart & Vascular Center Services and Transplantation Center Services at Yale-New Haven Hospital. 1541-4612/2014/ $ See front matter Copyright 2015 by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2015.05.008

www.nurseleader.com

Nurse Leader

73