7/19/2009
Hardwiring Nursing Model Tactics
Standard Rollout Process
By October 1, 2009, Nursing Model Tactics will
be hardwired in the Emergency Department.
This includes hourly rounding, bedside report,
individualized plan of care, and leaders rounding
for outcomes.
Project initiated with
stakeholder retreat on July 10,
2009
Patients
Families
ED staff
ED leadership team
Nurse champions
ED faculty
Retreat July 10,
2009
See next
page
Perform SWOT
Analysis
Must Haves
(X) Incorporate evidence based practice
(X) Flow Chart Process
(X) Identify metrics for evaluation
(X) Identify who needs education on initiative
(X) Assign Accountability and clear timeline
(X) Develop plan for sustained success
(X) Identify Methods of Content Delivery
(Figure 1)
See
Action
Plan
Develop Action
Plan
Debrief
Communicate
Plan
Changes Need to
be Made?
(Figure 1)
MUST PICK AT LEAST 7 WAYS FOR AT
LEAST 7 DAYS
( ) Webinservice
(X) Leader-Rounding on Initiative
(X) Post metrics and measurements
(X) Spindle Report x 7 days
(X) Formal inservice to staff
( ) Electronic Communication with Read
Receipt
( ) Add to Annual Competencies
(X) Add to Initial Orientation
(X) Cover in Staff Meetings
( ) Cover in Unit Board Meeting
(X) Send out in Friday Communication
(X) Communicate to Physicians via e-mail
(X) Post flyers on initiative in unit
(X) Recruit unit champions / superusers
from staff to promote initiative
(X) Video of role playing
Implement Action
Plan
Adjust Action
Plan
©2009 Karin League & Brent Lemonds
Vanderbilt Medical Center
SWOT Analysis
STRENGTHS
Better patient outcomes
Evidence Based Practice
Staff controls workflow
Improves patient safety
and decreases liability
Current process for report
is working
WEAKNESSES
Staff variability (CSRC)
Turnover rate high in ED
Staff is already
overwhelmed with
initiatives
Lack of ownership
OPPORTUNITIES
THREATS
Increased reputation and
satisfaction scores
Provides for a standard
plan
Increased consistency- all
staff using same model.
(includes CSRC nurses)
Opportunity to gain a win
for the standard rollout
process
Promotes teamwork
Staff may not buy in to
change
Doctors may undermine
the process
Communication confusion
Potential distractions such
as Joint commission
Team Fatigue
Leaders accountability for
rounding and debriefessential to success
Team Rating of Current State
on 1-5 scale with 1 as not
occurring most of time and 5
as hardwired behavior
Individual Plan of Care – 2
Bedside Report – 4
Hourly Rounding – 2
Leaders rounding for
Outcomes - 3
7/19/2009
Hardwiring Nursing Model Tactics
Action Plan
By October 1, 2009, Nursing Model Tactics will
be hardwired in the Emergency Department.
This includes hourly rounding, bedside report,
individualized plan of care, and leaders rounding
for outcomes.
Must Haves
Incorporate evidence based practice
Barbera, M. (1994, September). Giving report: How to Sidestep Common Pitfalls.
Nursing, 24(9), 41.
Crane, N. (2009,January), Fall Prevention. MedSurg Nursing, 18(1), 58.
Groah, L. (2006, January). Hand off-A link to Improving Patient Safety. AORN Journal, 83(1),
227-230.
Meade, C., Kennedy, J., Kaplan, J. (2008). The effects of emergency department staff
Rounding on patient safety and satisfaction. The Journal of Emergency Medicine,
Corrected proof.
Meade, C. (2007, Spring2007). ROUND Bounty. Marketing Health Services, 27(1), 2327. Retrieved July 19, 2009, from Business Source Premier Database.
Meade, C. (2006). Effects of nursing rounds: on patient’s call light use, satisfaction, and
safety. The American Journal of Nursing 106(9), 58-70.
Odom-Forren, J. (2007, August). Accurate Patient Hand Offs: Imperative for Patient Safety.
Journal of Perianesthesia Nursing, 22 (4), 233-234.
Orr, N., Tranum, K., & Kupperschmidt, B. (2006, December). Hourly rounding for positive patient
and staff outcomes: fairy tale or success story?. Oklahoma Nurse, 51(4), 11-11. Retrieved
September 26, 2009, from CINAHL database.
Roberts, D. (2007, January). Clear Communication-Accept Nothing Less. Medsurg
Nursing, 16(3), 142-148.
Sandlin, D. (2007, August). Improving Patient Safety by Implementing a Standardized
Consistent Approach to Hand-Off Communication. Journal of Perianesthsia
Nursing. 22 (4), 289-292.
and
Steiner, Jeanne. (2006, March). Managing Risk: Systems Approach Versus Personal
Responsibility for Hospital Incidents. Journal of the American Academy of Psychiatry and the
Law, 34, 96-98.
Flow Chart Process
7/19/2009
Bedside Report
At each handover of care the nursing
staff will conduct report at the patient’s
bedside and include the patient in the
process.
Off going RN
requests
permission from
patient to conduct
bedside report
Patient consents
Essentials of Bedside Report
HIPAA
Be sure to request permission to
speak in front of family members if
they are present.
AIDET
Acknowledge that the patient is part
of the report process
Introduce the oncoming RN and
manage them up
Duration- provide information about
how long this staff member will care
for them for example- Nurse X will be
here for the next 12 hours or Nurse X
will care for you until you are moved
to another room
Expectations- oncoming nurse
explains that he/she will be doing
hourly rounds. If a care partner or
medic is partnering in care the plan
for this should be discussed as well.
Be sure to tell the patient how to
contact you if needed such as use of
call light
Thank the patient for allowing you to
care for them and for participating in
report.
Off going RN
introduces
oncoming RN and
conducts report at
bedside
Patient declines
Off going RN
introduces
oncoming RN and
excuses them to
conduct report
Off going and
oncoming RNs
conduct report
outside of room
7/19/2009
Individual Plan of Care
Components of Individual Plan of
Care
Documentation of names of RN,
medics, and care partners on white
boards or clip boards
Documentation of two patient goals
(Patient/family should participate in
setting goals)
Each patient in the ED
will have an
individualized plan of
care
At beginning of each shift the
oncoming RN will review the
individual plan of care with the
patient. 2 mutually agreed upon
goals will be documented on the
white board or clipboard for hall
beds
Oncoming RN will
document his/her name
and the names of other
caregivers on the
whiteboard or clipboard
7/19/2009
Hourly Rounding
Components of Hourly Rounding
Staff will utilize Elevate principles
such as key words at key times
such as “do you need anything else?
I have time for you”.
Hourly rounds must occur hourly, but
not necessarily on the hour
Attention must be paid to each of the
4 P’s every hour
Every patient in the Emergency
Department will be rounded on
hourly. Rounding includes 4 P’s –
Pain, Position, Potty, and
Precautions.
RNs and paramedics round on patients on
the odd hours and care partners round on
even hours. Care partners include vital signs
as hourly round task.
Staff member rounding checks the
laminated clock face and informs the
patient when someone will be back
7/19/2009
Leaders Rounding for Outcomes
ED leaders including Administrative
Director, Director, Manager, Educator,
Quality Nurse, and Charge Nurses will
participate in rounding for outcomes
Rounding Frequency by position
-Directors 10 patients and staff/physician per
month.
-managers and LF base managers 5 patients and
staff per week.
-Assistant managers 10 patients and staff per
week.
-Educators 10 staff per week.
-charge nurses 5 patients and staff per shift.
-Rounding will be documented on
a rounding form and shared with
the one up supervisor during oneon-one meetings for
accountability.
-Evidence of followup on items
identified during rounding should
be apparent.
-An effort will be made by
individual management teams to
coordinate rounding for specific
outcomes.
Identify metrics for evaluation: Overhead paging audit, PRC data, NDNQI
RN Satisfaction Data, nurse driven patient outcomes; falls, pressure ulcers, patient
satisfaction, nurse retention rates.
Identify who needs education on initiative:
Patients
Families
ED staff
ED leadership team
Nurse champions
ED faculty
Assign accountability and clear timeline:
Action
Create video role modeling NMTs
Communication to CSRC regarding
expectations for staff who float into unit
Assign nurse champions (2 to 3 per
shift) Qualities include positive change
agent, role model and resource,
knowledgeable about NMTs, energetic,
strong work ethic, and accountable.
Group suggested the champions
participate in filming the video.
Set up meeting with nurse champions
to educate them on the components of
NMTs.
Present information at staff meetings:
Copies of EBP
Person Assigned
Timeline
Kory Knipp,
Amanda, Liz,
Anthony, Valerie
Riebli
Janice Sisco
September 22
Kristi Bare /,Gayle
Kilts, Valerie Riebli
(Anna Mlodzik,
Carolyn Van, Sally
Dye, Christy Hart)
September 14
Valerie Riebli
Gayle Kilts, Janice
Sisco, Valerie Riebli
August 14
Status
Completed
Completed
October 1, 2009
Oct. 12th-7:15pm
14th-2:15
16th 5:15 /7:15am
Laminated clock
Details of initiative
Collect Baseline data
Valerie Riebli
NMT goes live.
Debrief daily during first week of
initiative then weekly for 1 month.
Add information about NMTs to
orientation pathway
Utilize ED website to post information
about initiative
Provide laminated clock face for hourly
rounding
Friday communication
Standardize rounding forms
Order clipboards for hall beds
Nominations from steering group
(retreat participants) due
Define leader rounding for outcomes
and set expectations
Change white marker boards in patient
rooms to add permanent marker to
prompt info: Date, Tech, RN,
paramedic, and goals
Provide signal for hall bed patients to
use in lieu of call light
Communicate initiative to Ian Jones
Bulletin board
Janice Sisco, Anna
Mlodzik, Carolyn
Van, Sally Dye,
Christy Hart,
ED educator/Janice
Sisco
Brent Lemonds
Gary
Janice Sisco
Gayle and Tonya
Janice Sisco
All team members at
retreat
Brent and leadership
team
Tonya
Gayle
Brent
Valerie Riebli
September 10th 14th
October 16th
October 23rd
October 30th
November 6th
November 13th
August 21
Completed
completed
August 21
July 31
completed
Each Friday
August 7
July 24
Due July 17, 2009
completed
completed
completed
completed
August 21
completed
July 31
completed
August 28
completed
July 20
October 5, 2009
completed
Develop plan for sustained success: sustained success will be achieved through
ongoing leader rounding for outcomes, incorporation of education into orientation pathway,
at least yearly education to staff, sharing of outcomes data with staff linking them to the
initiative, and repeat overhead paging audits.
Identify Methods of Content Delivery: See figure 1
Metrics for evaluation: Baseline data:
Overhead paging audit
PRC data
NDNQI RN satisfaction Data
Nurse driven patient outcomes: pt falls
Pressure ulcers
Patient satisfaction
PDSA
What are we trying to accomplish? Achieve 100% compliance rate of nursing model tactics.
How will we know that a change is an improvement? Is system performing as planned?
Bedside report: standardized
Individualized Plan of Care: Patient is involved with goal-#patients meeting their goals
Hourly Rounding: decrease in call lights, patient falls, pressure ulcers, increase in patient and
staff satisfaction,
Leadership Rounding: success of NMT,s, increase in staff satisfaction
What changes can we make that will result in an improvement?
Bedside report: modeling on video what bedside report look like (tool to standardize process)
Individualized Plan of Care: Put on white boards for a visual reminder in the patient’s room
Hourly Rounding: making clocks for a visual reminder, modeling what hourly rounding looks
like on video.
Leadership Rounding: set times for rounding, therefore these times can be enforced.
Change Theory: Stetler Model TheoryThis theory integrates EBP with research.
There are five phases: 1) Preparation
2) Validation
3) Comparative evaluation and decision making
4) Translation and Application
5) Evaluation
courseweb.edteched.uottawa.ca/nsg6133/.../Stetler-Marram.pdf
OR
http://74.6.239.67/search/cache?ei=UTF-8&p=Stetler+Model+Theory&fr=yfp-t152&u=courseweb.edteched.uottawa.ca/nsg6133/Course_Modules/Module_PDFs/StetlerMarram.pdf&w=stetler+model+theory+theories&d=DwzyEd29TeE2&icp=1&.intl=us&sig=gArTsgbp
YybXu1qZMKbNfw--
Knowledge Translation-provides a framework that may be helpful in considering the challenges
that clinicians are likely to face when attempting to implement evidence based practice.
Knowledge Translation- exchange, synthesis, and ethically sound application of knowledge within
a complex system of interactions among researchers and users to accelerate capture of the
benefits of research.
Rogers Diffusion of Innovations- Behavioral theory that describes the process the user goes
through in the adaptation/rejection of new ideas, practices, and technology.