Integrating Evidence, Innovation, and Outcomes: The Oncology Acuity-Adaptable Unit

Integrating Evidence, Innovation, and Outcomes: The Oncology Acuity-Adaptable Unit Diane Drexler, RN, BSN, MBA, FACHE, Sandra Davidson, RN, MSN, PhD, Wendy Cimini, HRIT and Mark Kharoufeh, RN

I

n order to remain successful in today’s chal-

medical centers in an attempt to improve patient

lenging healthcare environment, medical cen-

care. It has been suggested by many healthcare

ters are examining the business case for the

leaders that the AAU model represents the future of

adoption of an acuity-adaptable unit (AAU) in oncol-

the industry.1–5 However, it is important for health-

ogy and the impact the unit has on patients, care-

care facilities to consider both benefits and chal-

givers, staff, and other support members of the care

lenges of the acuity-adaptable nursing model when

delivery team. The AAU design has been adapted by

introducing it into their facilities’ growth plans.

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A

dditionally, it is critical for the clinical leadership to fully understand the patient population this model will serve. Porter-O’Grady, a well-known healthcare futurist, has stated that “past success may be our greatest barrier to future success.”6(p.266) This sentiment indeed suits the situation of transitioning to a new model of care such as the AAU design. The commonly used conventions for staffing and workflow on traditional units can be an impediment to developing effective staffing and flow on the AAU. Applying traditional staffing and workflow to an innovative new design is like trying to put a square peg into a round hole; it simply does not fit. This article provides an overview of one medical center’s experiences and lessons learned in implementing the acuity-adaptable model on the inpatient nursing unit of an oncology specialty medical center. This article describes how the nursing AAU was planned, implemented, measured, and analyzed. The analysis on the nursing unit explains what we have learned, solutions we have put into place, and our recommendations for the future growth for nursing AAUs. It is our hope that in sharing our journey and learning with others, the design can be adopted successfully in other hospitals and medical centers.

LITERATURE REVIEW Early in our implementation process, we searched the literature for existing evidence and guidance about implementing an AAU. There are only a handful of studies that focused on the AAU or universal bed concept. Most of the studies were written from a hospital planning and architectural design perspective, with fewer studies that discussed the outcomes and implications of operationalizing this type of model.1 Research has revealed that the acuity-adaptable model can lead to higher patient and care provider satisfaction,2,3 noteworthy quality improvements such as decreased falls, sentinel events, and medication error rates,4 and operational cost savings such as decreased average length of stay and a reduction in patient transfers.2,5 The AAU model is not without challenges and is not a good fit for all environments. The research seems to indicate that the AAU model appears to work best with specialties, such as cardiac surgery, with predictable schedules and wellknown recovery pathways.2,4,5 Two similar, but different, concepts are seen in the literature related to this type of design. Acuity-adaptable and universal room concepts reveal comparable features and design, as well as a similar goal of providing flexibility for changing patient acuity; however, the primary difference is related to purpose.2 The AAU concept is primarily focused on eliminating patient transfers by providing a comprehensive care–combined staffing model where the flexibility is utilized in real time, patient to patient.2 The universal room concept focuses on providing an adaptable room design that can accommodate changing acuity or clinical needs over a period of years, and does not alter the current clinical care practice and transfer of patients.2 As noted in this section, most of the units that have implemented the AAU have been cardiac/coronary units2,4 or other critical care settings.5 To our knowledge, the AAU at Cancer Treatment Centers of America® www.nurseleader.com

(CTCA) is the first attempt at using this model in oncology care, and we are optimistic that this model will yield positive outcomes with the oncology patient population.

ORGANIZATIONAL CONTEXT Founded in 1988, CTCA provides a comprehensive, patientcentered treatment model that fully integrates state-of-the-art medical treatments with scientifically supported complementary therapies such as nutrition, naturopathic medicine, psychosocial counseling, physical therapy, and spiritual support to meet the special, whole-person needs of cancer patients living with complex and advanced-stage disease. With a network of cancer treatment hospitals and community oncology programs in Illinois, Oklahoma, Pennsylvania, Washington, and Arizona, CTCA encourages patients and their families to actively participate in treatment decisions with its Patient Empowered CareSM model. At the heart of our organization’s philosophy is the Mother Standard® of care. Simply stated, every patient who visits a CTCA facility is treated with the same care and compassion that we would wish for our own family. Western Regional Medical Center (WRMC) is the newest facility within the CTCA network. WRMC opened its doors on December 29th, 2008, in Goodyear, Arizona. As the newest facility to CTCA, the leadership and clinicians at WRMC have embraced many innovative strategies and treatment options to provide our patients with an experience of healing in an environment that promotes hope and wellbeing. One of these strategies is the adoption of the acuityadaptable model of care on the inpatient unit. This model seemed to be a good fit with CTCA’s care philosophy because it fosters high patient/caregiver satisfaction and increased continuity of care. This acuity-adaptable model works synergistically with our Mother Standard® of care philosophy and Patient Empowered CareSM model.

PURPOSE OR SPECIFIC GOALS TO ACHIEVE As the world pushes for new and innovative approaches to oncology care, CTCA has tested a model that has delivered promising results. WRMC’s AAU is the first patient care unit of its kind in Arizona. This model of care enables our nursing team to provide care to patients across multiple levels of acuity (critical care, intermediate care, and medical/surgical). With this type of unit, the patient is able to stay in one room and be cared for by the same nursing team throughout their hospital stay. The objectives of the unit are to increase patient satisfaction and decrease nurse movement away from the patient, decrease medication errors, and increase staff satisfaction. The AAU has now been operational since January 2009, and we have overcome many challenges and learned many valuable lessons. To understand how the unit has affected nursing, CTCA focused on three components of the AAU design: universal bed design, decentralized nursing stations, and nursing education. Table 1 presents a summary of the acuity-adaptable design components and the key adaptations and considerations taken into account in the design of the unit. We recognize

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Table 1. Summary of AAU Design Components

Universal bed design

• • • • •

Safely accommodates the critical care needs of the intensive care unit patient Efficient room layout decreases wasted staff motion Meets the needs of a recovering critical care and/or telemetry patient Provides space for patient ambulation and family visitation Focuses on comfort and privacy

Decentralized nursing station

• • • •

Nursing education

• A 6-week customized acuity-adaptable orientation is completed by all nurses • Specifically created shadowing and preceptor programs allow for real-time observations and in-depth questions and mentoring • Documentation of cross-training competencies assists in quickly adapting staffing levels to meet changing acuity levels • Cross-training increases operational effectiveness, keeps costs down, and maintains unit functionality • Patient simulations utilize real patient care scenarios for continued education and development

Better meets the patient needs Reduces nurse travel time and increases efficiency Added patient surveillance has been shown to reduce patient falls Alcoves located between each patient room allow for immediate patient and caregiver needs • All-digital system using electronic medical records eliminates paper • Enhances efficiency and quality of care

there are many pieces involved in the implementation of the AAU; however, we found these three areas provided a comprehensive view of the unit. We focused on these three components to organize our thinking and create a structure that would allow us to brainstorm opportunities in specific areas. CTCA arrived at the use of these three components in various ways. The universal bed was a necessary piece of technology for the unit. With this technology, it was important to create the best room design for our patients. Furthermore, the patient room design played a role in the decision to have decentralized nursing stations. CTCA is an entirely paperless hospital and successfully utilizes the electronic health record systems. This allowed for nursing stations to be placed directly next to the universal bed rooms for more personalized care. Finally, the nursing education component is a topic that continues to evolve over time. The importance of this piece became clear as we began to delve into the universal bed and nursing station areas.

focus of this 4- to 6-week engagement will be aimed at providing our team with a strategic thought partnership in identifying comparable models, and in-depth understanding of the realities of implementing the AAU. This investigation’s aim is to enumerate and describe the practices and processes that have proven most effective and why. The results of this study will allow us to learn from our experiences at WRMC and to focus on practices that show the greatest promise for possible implementation at other CTCA facilities. Pending the outcome of this inquiry, it is anticipated that the next step will be to arrange for site visits, possibly with members of the HWS research team, to observe these models first hand. HWS has accumulated significant and pertinent data and analytical methods examining and profiling innovative care delivery models. Table 3 summarizes and defines the key measurement areas and preliminary results that will continue to be monitored.

LESSONS LEARNED AND BEST PRACTICES EVALUATIONS AND OUTCOMES Tracking and measurement in the areas of patient satisfaction, nurse satisfaction/retention, and adverse events take place to provide the oncology nurses with better insight into the successes and challenges of the AAU. The key findings related to these outcome measures are summarized in Table 2. To better understand the results and deepen our analysis of the AAU, we have partnered with Health Workforce Solutions LLC (HWS) to conduct a preliminary investigation of AAU delivery models and best practices. The primary

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As with any implementation of an innovative care model or a change in clinical practice, the importance of continuing education and professional development cannot be overstated. Matching continuing education opportunities with patient needs and demographic data is a best practice to ensure that nursing staff are developing skill and knowledge in areas that directly relate to patient needs, yielding improved patient outcomes and increased nurse satisfaction. One example of ongoing education and development that has had a positive effect on patient outcomes is the use of a

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Table 2. Summary of Key Outcomes for the AAU

Patient satisfaction

• Patient and Companion Satisfaction survey results (Jan 2009 to Jan 2010): overall satisfaction ⫽ 96.9%; Feb 2010–Sept 2010 overall satisfaction ⫽ 99%; Oct 2010–Mar 2012 ⫽ 99% • All new and return patients surveyed (survey data ⬃400 patients)

Nurse satisfaction and retention

• Surveys administered to nursing staff to measure satisfaction with the model • Turnover from Jan 2009 to Jan 2010 reported at 32.7%; turnover from Feb 2010 to Sep 2010 reported at 2%; FY 2011, 20.24%; FY 2012, 5%.

Adverse events

• Medication error rate on the AAU from Jan 2009 to Jan 2010 was 1.4%; from Feb 2010 to Sep 2010 was 1.35%; FY 2011 4th Q 0.03%; FY 2012 3rd Q 0.33% compared to the national average of 5%.7

FY ⫽ fiscal year; Q ⫽ quarter

full-time wound care nurse who rounds on every inpatient daily. The wound care nurse not only ensures that patients’ skin integrity is monitored and managed effectively, she also coaches and expands the inpatient nurses knowledge of evidence-based practice for wound care and prevention for oncology patients. Similarly, having a facility-based chemotherapy instructor has shown great results in quality of care provided to inpatients receiving chemotherapy treatment. In addition to the in-classroom teaching, the facility-based instructor also provides elbow-to-elbow support for nurses newly certified in chemotherapy. Access to this in-house resource has helped nurses attain competence and confidence in the management of inpatient chemotherapy more quickly and effectively. Additionally, the in-house chemotherapy instructor can work with the AAU nurses to keep them abreast of new and emerging chemotherapy treatments to ensure the nurses are up to date with current and emerging best practices and standards of care. Another area of continuing education that has been critical for the success of the AAU nurses is the development of knowledge, skill, and expertise in hospice care. As the AAU model of care implies, nurses must be skilled and ready to adapt to the changing levels of care and needs of their patients. This includes the transition to palliative care. CTCA has partnered with external agencies, such as Hospice of the Valley, to ensure that AAU nurses have the support and training to develop their skill in providing end-of-life care to our patients. As you can imagine, this had proven to be one of the most challenging transitions to prepare our AAU nurses to manage. Most of our AAU nurses joined us with a critical care background, and indeed, this background is necessary to manage the complexities of late-stage cancer care and the myriad innovative treatment options that we can provide at CTCA. However, the ability to switch the focus of nursing care from aggressive treatment to supportive end-of-life care requires support, training, and personal commitment to the Mother Standard of care. Being able to adapt to the changing www.nurseleader.com

spectrum of patient needs is the focal point of the AAU care model. Organizationally, it is important to support nurses to develop the wide spectrum of knowledge, skills, and attitudes that enables them to function effectively in this patient-centric care delivery model. In the development and maturation of this care delivery model, nurse retention has increased. In essence, as an organization, we became more skilled at identifying and recruiting nurses with the personal and professional values and attributes that would result in a good fit. Over time, we began to see that hiring nurses with a strong critical care background and then training those nurses to be able to develop oncology and hospice skills proved to be the most successful approach. With the increased retention of the nursing staff who had successfully adapted to the AAU model of care, we were able to implement a formal mentoring program that continues to provide formalized guidance and coaching for new hires by seasoned oncology AAU nurses. Finally, the orientation and ongoing professional development of nurses at CTCA includes cross-training to other departments. In order to meet the changing needs of our patients’ levels of care while still maintaining a viable and effective staffing ratio, it has been necessary for the AAU inpatient unit, infusion clinic, and internal medicine clinic to participate in cross-departmental training. Having staff nurses in all of these settings that have been cross-trained to the other departments allows for effective adaptation and added support for any one area that may experience a higher acuity or census than other areas at any one time.

DISCUSSION Barriers There is a need to cross-train nurses in different areas to have experience for diverse situations on the AAU. With the small size of the unit (14 beds) and the complexity of the patient population, it has become evident that the majority of the nursing staff throughout the facility had to be cross-trained

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Table 3. Summary of AAU Measurements

Measurement

FY Jan 09 to FY Jan 10

FY Feb 10 to FY Sept 10

FY 2011 4th Quarter

FY 2012 1st Quarter

Patient satisfaction

96.90%

99%

99%

100%

A measurement that obtains reports from patients about services and experiences from CTCA

Staff satisfaction (RN turnover)

32.70%

2.00%

20.24%

0.05%

A measurement to describe whether employees are happy and contented and fulfilling their desires and needs at work

Measurement

Definition

FY Jan 09 to FY Jan 10

FY Feb 10 to FY Sept 10

FY 2011 4th Quarter

FY 2012 1st Quarter

FY 2012 2nd Quarter

FY 2012 3rd Quarter

1.40

1.35

0.03

0.07

0.48

0.33

Medication errorsa per 1000 patient days a

An incorrect or wrongful administration of a medication. This may include a mistake in dosage or route of administration. CTCA benchmark is 3.82 per 1000 patient days. Estimated nationwide error rate is 5.66 per 1000 patient days for adult inpatient care units.8 FY ⫽ fiscal year

for all levels of care. Additionally, all nursing staff on the unit must be able to administer chemotherapy. The cross-training allows for flexibility, convenient staffing and increased patient safety. This service does require added expenses such as time away from the unit for nurses to be trained. The recruitment process of finding the desired nurse skill set involves specific interviewing and collaboration between nursing leadership, clinical education, and the nurse recruiter. Up-front investments in the recruiting process can minimize downstream problems with staff satisfaction and retention. During the interview process, the candidate shadows a nurse on the unit for a half day to experience the reality of the unit. Additionally, we have incorporated a peer interview process to allow the candidates to have interaction with their potential peers. The thorough recruitment processes helps to identify the candidates that are the best fit for the unit. However, the in-depth recruitment process results in increased advertising and recruitment costs and effort, and the available pool of qualified candidates is smaller than the candidate pool for traditional nursing units. Facilitators of Success It is necessary to prepare and train nurses for the amount of emotional energy required in providing nursing care on an AAU. Because the patient remains in one room, the nurse may experience all aspects of the patient journey. When patients are with us for an extended period of time, nurses become very

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close to the patients and their families. When we lose a patient, the amount of emotional energy to work through the circumstance is significant. We have developed programs for staff to express their feelings and cope with their emotions. Table 4 highlights key features of several of the programs. Ongoing training and education programs are often an expensive, but effective, way to maintain high staff satisfaction and engagement while ensuring that all staff maintain the skills and competencies for critical care and acute oncology patient population. Buy-in from nursing leadership, from the chief nursing officer (CNO) to unit managers and directors, is critical to the success of the acuity-adaptable model. In the work completed by HWS, the CNOs of successful care models cited the unit leaders’ commitment to the model as instrumental in overcoming staffing problems. Managers and directors can paint the vision for the unit and ensure that all staff and candidates understand and accept the AAU model. Finally, an essential facilitator for success is team building. The unique unit necessitates a team approach and requires a balanced blend of nurses with a wide range of skill sets. With the broad range of oncology patients we see and the complexity of their care, staff with a variety of experience lend themselves best to sharing of expertise and teaching and mentoring opportunities. We strive to develop facilitator tools for the acuity-adaptable model so it can continue to grow and evolve to best serve our patients.

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Table 4. Summary of Programs to Promote Emotional Well-Being of Staff

Tea for the Soul

• • • •

Program for staff who cared for recently deceased patient Facilitated by counselor and chaplain Vehicle for staff to express emotions and remembrances Creation of memory book for the family that includes sentiments from the staff

Caring Connections

• Helps staff deal with the death of a patient both personally and professionally and how to mindfully respond to the death • Resources available include: cards that are available in the chapel for staff to send to the family; sensitivity training on ways to approach patients and families; quarterly memorial celebration to celebrate our patients and remember the improved quality of life they had at CTCA; and a chaplain available to staff for questions, support, or encouragement

Implications for Oncology Nurses Partnering with other healthcare providers and educational institutions is recommended. We will be partnering with Arizona State University (ASU) on two programs: First is a pilot of a new clinical preceptorship program. The education department has developed and begun plans to implement a new model of unit-specific on-boarding for nurses on the AAU. This new preceptorship program is based on stakeholder feedback, a needs assessment, and best evidence. The second partner program is for advanced educational programs —registered nurse to bachelor of science in nursing, graduate programs, doctor of nursing practice, and undergraduate nursing programs. Partnering with ASU and Hospice of the Valley on the educational components of this project has been and continues to be a win–win for all institutions involved in the collaboration. The partnerships have enabled us to use the latest and greatest in technology (high-fidelity simulation) and teaching methods (the use of learning management systems, established critical care and oncology courses, and advanced nursing certifications) that might not have been realized without the partnership.

CONCLUSION The implementation of an AAU at WRMC has required thoughtful planning and collaboration among our oncology nurses. The nursing unit is able to deliver better quality of care to our cancer patients and reduces some of the challenges that patients face while staying in a hospital. The unit has enhanced nursing leadership, education, and measurements. It has required us to embark on new ways of thinking and operating. It is a new world for organizations. No longer can the past institutional models of work and workplace govern how and what people do. We now have a better understanding of the processes and necessary steps for providing the best care to our patients using this unique model. Because of the innovative nature of the acuity-adaptable model of care, the project continues to evolve in exciting ways that continually present us with opportunities for growth and learning. NL www.nurseleader.com

References 1. Berry LL, Parker D, Coile PR, Hamilton KD, O’Neill DD, Sadler BL. The business case for better buildings. Front Health Serv Manage. 2004;20(1):4-24. 2. Brown KK, Gallant D. Impacting patient outcomes through design. Crit Care Nurs Q. 2006;29:326-341. 3. Lipschutz LN. Acuity adaptable rooms. Healthc Constr Oper News. 2008;7(1):10-11. 4. Hendrich AL, Fay J, Sorrells AK. Effects of acuity-adaptable rooms on flow of patients and delivery of care. Am J Crit Care. 2004;13:35-45. 5. Gallant D, Lanning C. Streamlining patient care process through flexible room and equipment design. Crit Care Nurs Q. 2001;24:59-76. 6. Porter-O’Grady T. Of hubris and hope: transforming nursing for a new age. Dermatol Nurs. 2003;15:255-267. 7. Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients. Am J Health Syst Pharm. 2008;65:1254-1260. 8. Stratton KM, Blegen MA, Pepper G, Vaughn T. Reporting of medication errors by pediatric nurses. J Pediatr Nurs. 2004;19:385-392.

Diane Drexler, RN, BSN, MBA, FACHE, is the chief nursing officer for Yavapai Regional Medical Center in Prescott, Arizona, and can be reached at [email protected]. Sandra Davidson, RN, MSN, PhD, is the senior director of academic affairs at Carrington College in Phoenix, Arizona. Wendy Cimini is the director of quality and risk management, and Mark Kharoufeh, RN, is the director of inpatient, infusion, and quality of life clinic for the Cancer Treatment Centers of America in Goodyear, Arizona. Acknowledgment Diane Drexler would like to express her sincere appreciation and gratitude to the Robert Wood Johnson Foundation Nurse Executive Fellowship Program for their unwavering support for this project. 1541-4612/2013/ $ See front matter Copyright 2013 by Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.mnl.2012.12.009

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