Standardizing the Documentation and Communication of the Nursing Plan of Care at the Handover Using HIT

Gail Keenan PhD, RNPI, University of Illinois, College of Nursing

Beth Yakel, PhDCo- PI, University of Michigan, School of Information

Dana Tschannen, PhD, RNField Research Director, University of Michigan, School of Nursing

Currently Funded by AHRQ (2004-2007)

The presentation reports on the YR 1findings of the study:

HIT Support for Safe Nursing Care

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

1 R01 HS015054-01- HHS PHS National Institutes of Health, Agency of Health Research and Quality (AHRQ)

HANDS Project Vision (1998-present)

Nurses everywhere will use the HANDS standardized technology supported plan of care Method to document and communicate about nursing care at every handover

HANDS Core Project Teams

Support Team– Annie Browning, MSPH– Elizabeth Brough, MSN, PhDc– Sally Decker, PhD, RN– Sharie Falan, MS, RN– Yvonne Ford, MS, RN– Crystal Heath, MS, RN– Mary Killeen, PhD, RN– Deanna Marriott, PhD – Rachelle Ramos, BSN, RN– Santosh Udupi, MS– Linda Scott, PhD, RN– Julia Stocker, PhD, RN– Kathleen Sutcliffe, PhD– Marcy Treder, BSN– Dana Tschannen, PhD, RN

Administrative Team– Gail Keenan, PhD, RN – PI– Beth Yakel, PhD, Co-PI– Mary Mandeville, MBA, Director

National Policy Advisory Team – Carol Bickford, PhD, RN– Connie Delaney, PhD, RN– Barbara Frink, PhD, RN– Ada Sue Hinshaw, PhD, RN– Joan Shaver, PhD, RN – Judy Storfjell, PhD, RN

Goals of HANDS Project

Standardize method for collecting and communicating plan of care information at the Handover that

1. Is useful to clinicians

2. Promotes continuity of care across nurses

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

4. Supports research to continuously improve nursing care and practice

Standardization Defined

“….the process by which the form or function of an artifact or technique becomes specified (Feng, 2003)”

To STANDARDIZE – MUST…

Gather SAME Data ELEMENTS Same TIME Intervals Same TERMINOLOGIES Same DATABASE Structure Apply SAME Rules for Selecting, Recording, and

Rating NANDA, NOC, and NIC Terms and Measures

Apply a common approach to standardize hand-off using HANDS care plans as foundation

HANDS Method Provides:

A common format and elements for entering and updating Plan of Care

A common database for storage and retrieval Common terminologies to enter dx, interventions

and outcomes– NANDA – Nursing Dx Terms = 167– NOC – Nursing Outcome Terms = 330– NIC – Nursing Intervention Terms = 514

A common structure (SHARE) for communicating about the Plan of Care at the handover

Research and HANDS Framework

1. Continuously scan literature for related evidence

2. Employ socio-technical research methods

3. Regularly update HANDS Framework to reflect latest evidence generated from 1 and 2

Use Socio-Technical Approach

To achieve desired goals with technology (Berg, 1999)

Involve the users Use multiple methods of evaluation –

qualitative Grow knowledge through continuous

interation of the design, evaluation, and refine cycle

Multiples Methods Used

Surveys – repeated (R)– Baseline skills, trust, safety culture, knowledge N3, satisfaction with POC and N3

Observations pre-go live, hand-off (R) Interviews, Meetings, Focus Groups (R) Think-alouds (R) Analysis of transaction logs

Core Safety Framework:HANDS Care Planning Method

(Keenan & Yakel, 2005)

Effective Nurse

Communication

Effective Nurse

Handover

HANDS METHOD RN Requirements

Update (or Create 1st) Plan of Care at Handover– Re-Rate all NOC Outcomes (minimum)– Enter correct Tally for each NIC Intervention – Enter Care Period to closest 4 hour increment– As needed:

• prioritize NANDA diagnoses• add new NANDA, NOC, and NIC terms • resolve or inactivate NANDA Diagnoses & NOC Outcomes• Adjust NIC Interventions

Use HANDS – (SHARE Format) at Handover Complete HANDS Discharge Note

Comparison of Baseline Measures N units = 4, N RNs = 193

Comp Skills

M (SD)

Know NOC

M (SD)

Know NIC

M (SD)

Trust

M (SD)

Culture

M (SD)

Unit A 3.6 (1.2) 1.8 ( .8) 1.8 (.8) 30.1 (6.3) 22.2 (4.7)

Unit B 3.2 (1.1) 2.6 (1.2) 2.6 (1.2) 32.8 (8.3) 23.6 (4.4)

Unit C 3.9 (1.0) 3.0 ( .8) 3.0 ( .9) 33.4 (5.9) 25.3 (3.8)

Unit D 3.6 (1.0) 2.3 (1.1) 2.3 (1.1) 36.5 (7.9) 25.8 (5.1)

p.valu .012 .000 .000 .001 .002

Comparison of Baseline Measures N units = 4, N RNs = 193

No significant differences – nurses satisfaction with current care

planning method (low satisfaction)– knowledge of NANDA

Term Meaning Reliabilites 3 months post go-live

Unit # RNs Terms/RN Av Correct

A 10 6 65%

B 11 6 60%

C - - -

D 8 6 79%

Observations of Report 3 Months Post

Ns – units = 3 ; – reports/unit = 2; – Total RNs all repots=14

Findings– 2 units had access to HANDS Plan of Care in

Handover – 1 had NONE– 9 of 14 RN discussed at least on NNN term in

handover– Format for unit report remained very close to

original report format for each of 3 units

6 month Post Go Live Interviews and Focus Group

N for Focus Group = off site ($50)– 6 RNs (2 sites represented)

N for Interviews (on site)= $10 for 10”– 39 RNs (all 4 sites)

Tell whatever you want to say about what is and is not working about the HANDS Method

Positive Results 6 month Post Interviews and Focus Group

• agreed new Method was superior to old• Some RNs reported exceptional satisfaction (- to +)• Role models for heedfully interrelating in report (3

units) • One unit used plans of care in rounds• Ensure current plans of care were in chart• Change was occurring and moving in the right

direction• Desiring revisions to original templates (language

learning taking place)

Needs Improvement 6 month Post Interviews and Focus Group (cont)

RNs desired consistent handover format using Plan of Care to structure it

Difficult to access most current plan at handover

Some nurses not familiar with functionality needed to individualize plans

Education was variable and not completed by all RNs on unit

Integration of Finding into Next Steps – Year 2 Units

Training revamped and standardized Units required to set-up means of tracking

compliance with training and baseline competency Handover structure has been standardized

(SHARE at Computer) and included as a baseline competency

HANDS tool improved-– Provides access to Plan of Care an HX from Pt. List– Other enhancements that promote ease of use added– On-line tutorials – help available within the HANDS

application

Method Meets 2 Major Mandates

American Nurses Association (Committee on Nursing Practice Information Infrastructure) GOAL to generate electronic interoperable nursing data across organizations

the Joint Commission on Accreditation of Healthcare Organization’s new Safety Goal (2006) requirement to “Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.”

SHARE Handover Structure

S – Sketch = pt. name, age, gender, medical dx, code status, allergies, &

other pertinent information H – HANDS = Review Plan of Care Hx and

Current Plan – AT COMPUTER – add only those essential details

A – Aim = discuss care focus of next shift R – Rationale = explain your thinkingE – Exchange = invite questions, debate, dialogue

Questions???