Culture, Change, & Standardization

of Key Care Information

Gail Keenan, PhD, RN

HANDS

Does anyone disagree with:

There is a critical need to standardize the format and content of key care information across EHRs to decrease errors and increase continuity.

About the HANDS Project

Research team dedicated to producing

an electronic “short/story/synopsis”

of a patient’s care that is always in the

same format (STANDARDIZED) and

accessible quickly (since 1997) whenever

and wherever the patient presents.

What is the HANDS Mission?

To prevent/minimize the MILLIONS of communication misunderstandings among members of the health care team that result in patient care errors each year by standardizing key aspects of documentation and communication (the patient’s short story)

Goals of HANDS Project

Standardize a method for collecting and communicating plan of care information that:

1. Is useful to clinicians

2. Promotes continuity of care at all handovers

3. Creates a national database of comparable, valid, and rich nursing data

4. Supports research to continuously improve nursing care and practice

Current AHRQ Study

HIT Support for Safe Nursing Care

Multi-site study (8 unit – 4 organizations) and refinement of the Hands-on Automated Nursing Data System (HANDS) Method.

1 R01 HS015054-01- HHS PHS National Institutes of

Health 2004-07, Agency of Health Research and Quality

Study Aims

To demonstrate that HANDS – plan of care method (built on pilot)

1. can be successfully implemented and standardization maintained across diverse units and organizations supporting Mindfulness Heedful interrelating Collective mind

2. increases the safety culture of diverse nursing units

Study Intervention: HANDS Method

All RNs on all study units were required to:– Complete HANDS training protocol (7-8 hours) – Demonstrate competency in use of HANDS before

go-live– Enter an admission or update plan of care on each

of ones patients into HANDS (electronic tool ) at every handoff

– Use the plan to structure “report/handoff” communication (SHARE)

Sample

Selected 8 units / 4 diverse organizations / 700 RNs– Stable staff, motivated to be part of study, no other

major changes occurring, willingness to mandate use of HANDS by all personnel

4 organizations – 1 university, 2 community (part of multi-hospital

systems), 1 small community

8 units - 4 Y1 (24 mo) and 4 Y2 (12 months)– Med-surg (2), neuro, thoracic, medical ICU, progressive

care, older adult/stroke, acute care elderly

Sample (cont.)

Unit Yr Beds RNs Consent %

A 1 32/48 60/71 70-80%

B 1 42 48 70-80%

C 1 22 32 70-80%

D 1 22 26 70-80%

A2 2 60/44 120/93 70-80%

B2 2 42 79 70-80%

B3 2 10 36 70-80%

C2 2 23 22 70-80%

At Baseline

Enormous variation in documentation and communication practices within units & organizations, and across individuals and organizations

RNs focus on the details can’t see big picture

Training and support

Trained champions (opinion leaders) - nurse managers required to be part of champion training

Held regular champion calls by category of champion (educator, clinical specialist, staff nurses, managers) to address problems relative to role – problem solve together

Used Socio technical approach – involved users with designing identifying problems and designing solutions

Most of solutions came from RNs – we had resources in place to address most solutions /or told why couldn’t

Multiple Methods Used

Surveys (R)– skills, trust, culture, knowledge, satisfaction with care planning method

Observations documentation and communication (R)

Interviews, Meetings, Focus Groups (R) Inter-rater reliability checks of outcome ratings (R) Term meaning reliability checks (R) Think-alouds Analysis of transaction logs (R)

(R) = Repeated

Safety Culture Tool (Vogus, 2004)

21 Items (1-5 scale) strongly disagree to strongly agree

3 Factors – Mindfulness - 5 items

respect individual colleagues contributions and take actions that help members build on each others care

– Heedful interrelating – 10 items communicate honestly with the team, talk about and learn

from mistakes, share strengths and weaknesses – Collective mind – 6 items

Understand how all team members contribute to care, align actions to support team goals

Trust Survey (Mishra, 1992)

16 items (1-5 scale) strongly disagree to strongly agree

4 Factors (4 items each)– Concern for organization and vice versa – Openness in communication – Competence of colleagues– Reliability of colleagues

Safety Survey (Anonymous)

5 items (1 X per shift )Response applies to time since last completed

survey Can select 1 or 2 or any combo of 3,4, & 5:1. Do not wish to respond 2. No Awareness of Error3. Awareness-error Made by self4. Awareness-Avoided and Error5. Awareness-Observed an Error

3.5

3.6

3.7

3.8

3.9

4

4.1

4.2

4.3

4.4

4.5

A B3 B2 A2 C B D C2

Overall Culture at Baseline

3.5

3.6

3.7

3.8

3.9

4

4.1

4.2

4.3

4.4

A B2 A2 D B3 B C C2

Overall Culture Post HANDS

2.5

2.7

2.9

3.1

3.3

3.5

3.7

3.9

4.1

4.3

A-pre A-post B-pre B-post C-pre C-post D-pre D-post A2-pre

A2-post

B2-pre

B2-post

B3-pre

B3-post

A2-pre

A2-post

Overall Culture Pre and Post HANDS

Culture remains consistently high pre (Green) and post (Red)

Trust, Safety Survey, & Other

Trust items correlated with safety culture

Safety survey not fully analyzed, note a significant increase in % of RNs selecting “willing to to respond” options

> interest in improving care planning & documentation positively correlated with > trust & > culture scores (correlation doubled at x 2)

Associated Findings

All units want to keep HANDS “post” study 90% care periods have care plans (all units) RNs more satisfied with HANDS than previous method

(p<.05) RNs more familiar & satisfied with NNN (p<.05) Significant increase in RN willingness to respond to

safety survey over time RNs very pleased with HANDS team responsivity to

requested changes

Associated Findings

RNs in orgs independently – instituted user group– integrated into multi-disciplinary rounds– lobbied to have HANDS instituted on new unit

Care planning activity remain consistent (changes e.g, add, resolve NNN etc.)

Other Considerations

Standardization across all units in org would bring many more benefits (study costs prohibitive)

HANDS generates data for describing care, progress toward outcomes, meeting goals, RN patient load, benchmarking best practices

EHRs are costly spend billions of dollars (over and above software costs) training and tailoring to foster variation in look and feel…away from standardization

Recommendations

Put strategies and resources in place to; support staff to own change enables staff to design solutions to sustain change across time (orgs tend to move

on to next change) select best units (those most likely to succeed) to

lead the change when goal is to standardize across organization

(need buy in and commitment of top levels)

Conclusions

We need big picture in standardized language and format

HANDS “can do it” and cost effectively—but s difficult to make the case with traditional measures

Multiple methods can provide the pieces that when combined will explain the impact

Revised HANDS Framework

Organization Factors

CommunicationIntervention

Clinician & Care Outcomes

Culture Readiness•High Trust •Safety Culture Focus •Expects Clinician Mindfulness, Heedful Interrelating, and Collective Mind•Infrastructure Supports Change•Engages in Continuous Learning

Commits to Change •Adopts Standardized Plan of Care Method •Provides Ongoing Education•Provides Resources to Implement•Provides Resources to Sustain

Standardized Handoff Structure Using HANDS Promotes Heedful Interrelating & Mindfulness about HANDS story and Future Care among inter and intra-disicplinary team members

Standardized Documentation in HANDS Electronic Tool Provides a Consistent , Dynamic, Up-to-date Synopsis of Care: The Clinicians’ Collective Mind

Patient:Care Continuity

Care Quality SatisfactionSafety

Nurse:Job SatisfactionVisibility of WorkEvidence Based Practice

© G.Keenan, E.Yakel, D. Tschannen, & M. Mandeville, 2007

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Definition: Organizational Culture