hit support for safe nursing care 2004-2007 gail keenan, ph.d., r.n. elizabeth yakel, ph.d. r01...
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HIT Support for Safe HIT Support for Safe Nursing CareNursing Care
2004-20072004-2007Gail Keenan, Ph.D., R.N.Gail Keenan, Ph.D., R.N.Elizabeth Yakel, Ph.D.Elizabeth Yakel, Ph.D.
R01 HS015054-01
NIH- Agency for Health Research and Quality (AHRQ)
HANDS Core Project Team HANDS Core Project Team
Team SupportTeam Support Annie Browning, MSPHAnnie Browning, MSPH Sharie Falan, MS, RNSharie Falan, MS, RN Yvonne Ford, MS, RNYvonne Ford, MS, RN Crystal Heath, MS, RNCrystal Heath, MS, RN Deanna Marriott, PhD Deanna Marriott, PhD Rachelle Ramos, BSN, RNRachelle Ramos, BSN, RN Emily Springfield, MSEmily Springfield, MS Marcy Treder, BSNMarcy Treder, BSN Dana Tschannen, PhD, Dana Tschannen, PhD,
RNRN Santosh Udupi, MSSantosh Udupi, MS
Administrative TeamAdministrative Team Gail Keenan, PhD, RN – PIGail Keenan, PhD, RN – PI Elizabeth Yakel, PhD, Co-PIElizabeth Yakel, PhD, Co-PI Mary Mandeville, MBA, Mary Mandeville, MBA,
DirectorDirector Advisory / Consultant Advisory / Consultant
MembersMembers Connie Delaney, PhD, RNConnie Delaney, PhD, RN Ada Sue Hinshaw, PhD, RNAda Sue Hinshaw, PhD, RN Mary Killeen, PhD, RNMary Killeen, PhD, RN Sally Decker, PhD, RNSally Decker, PhD, RN Linda Scott, PhD, RNLinda Scott, PhD, RN Julia Stocker, PhD, RNJulia Stocker, PhD, RN Kathleen Sutcliffe, PhDKathleen Sutcliffe, PhD
Study AimsStudy Aims
To demonstrate that Health To demonstrate that Health Information Technology (HIT) Information Technology (HIT) (Hands-on Automated Nursing Data (Hands-on Automated Nursing Data System (HANDS)System (HANDS) Method)Method) can be can be successfully implemented to support successfully implemented to support nurses in a dynamic Care Planning nurses in a dynamic Care Planning Process (CPP) encompassing both the Process (CPP) encompassing both the planning and provision of careplanning and provision of care
To demonstrate that implementation To demonstrate that implementation of the of the HANDS MethodHANDS Method increases the increases the safety culture of diverse nursing unitssafety culture of diverse nursing units
Hypotheses Hypotheses
Our HANDS Care Planning Process Our HANDS Care Planning Process (CPP) Method (CPP) Method H1.1 satisfactorily represents the H1.1 satisfactorily represents the collective collective
mindmind of nurses across time and of nurses across time and settingssettings
H1.2 sustains H1.2 sustains mindfulnessmindfulness in the CPP across in the CPP across timetime
and settingsand settings
H1.3 supports H1.3 supports heedfulheedful interrelating about the interrelating about the
CPP across time and settingsCPP across time and settings
Lessons Learned from Lessons Learned from Earlier Projects Earlier Projects
Competency in use of NNN builds over time Competency in use of NNN builds over time USE to FRAME HAND-OVER (Report)USE to FRAME HAND-OVER (Report)
Care Plan application must be easy and Care Plan application must be easy and accessibleaccessible
Convert to WEB-BASED VersionConvert to WEB-BASED Version IT is a MAJOR CHANGEIT is a MAJOR CHANGE
Unit to OWN changeUnit to OWN change Include RNs ALL ROLES as CHAMPIONSInclude RNs ALL ROLES as CHAMPIONS Create STRATEGY to Continuously Nurture until Create STRATEGY to Continuously Nurture until
SUSTAINEDSUSTAINED Users must LOVE itUsers must LOVE it
Focus on making it VALUABLE TO RN USERS Focus on making it VALUABLE TO RN USERS
Core Framework:Core Framework:HANDS Care Planning HANDS Care Planning
MethodMethod
(Keenan & Yakel, 2005)
HANDS Care Planning HANDS Care Planning Method and Positive Method and Positive
OutcomesOutcomes
(Keenan & Yakel, 2005)
HANDS MethodHANDS Method
Mindful Care PlanningMindful Care Planning
+ Heedful Interrelating in Report+ Heedful Interrelating in Report
= Collective Mind of RNs in HANDS= Collective Mind of RNs in HANDS
Subjects & RequirementsSubjects & Requirements
8 nursing units (4 in Year 1, 4 in Year 2) 8 nursing units (4 in Year 1, 4 in Year 2) located in 4-5 health care systems in located in 4-5 health care systems in Michigan Michigan
RNs employed on the units (n = 400+)RNs employed on the units (n = 400+) Participate in orientation to HANDS Tool and Participate in orientation to HANDS Tool and
NANDA, NOC, and NIC terminologies (8 NANDA, NOC, and NIC terminologies (8 hours)hours)
At “go live” create admission or update At “go live” create admission or update HANDS CPs on all patients for each shift HANDS CPs on all patients for each shift
RNs MUST use HANDS Care Plan in ReportRNs MUST use HANDS Care Plan in Report
Strategy with Test SitesStrategy with Test Sites
Train Champions (Across Sites)Train Champions (Across Sites) Nurse ManagersNurse Managers Clinical SpecialistsClinical Specialists Nurse EducatorsNurse Educators Nurse CliniciansNurse Clinicians
Champions Train Remaining RN Champions Train Remaining RN ColleaguesColleagues
Units Collaborate with Other Test UnitsUnits Collaborate with Other Test Units Test Units Own Care Planning Method Test Units Own Care Planning Method
Competency: HANDS Care Competency: HANDS Care Planning Methodology Planning Methodology
Definition: Definition: integration of integration of mindfulmindful care care
planning using NANDA, NOC, planning using NANDA, NOC, and NIC (N3) knowledgeand NIC (N3) knowledge
technical skills in use of HANDS technical skills in use of HANDS application (application (collective mindcollective mind), ), and and
heedful interrelating during heedful interrelating during report and other handoversreport and other handovers
Competency: HANDS Care Competency: HANDS Care Planning Methodology (Pre- Planning Methodology (Pre-
GO LIVE)GO LIVE)RN Objectives:RN Objectives: Successfully creates admission and update Successfully creates admission and update
care plans with HANDS applicationcare plans with HANDS application Demonstrates appropriate use of N3 search Demonstrates appropriate use of N3 search
modes to locate termsmodes to locate terms Uses a broad range of NANDA Diagnoses, Uses a broad range of NANDA Diagnoses,
NOC Outcomes and ratings, and NIC NOC Outcomes and ratings, and NIC Interventions and tallies appropriately in Interventions and tallies appropriately in Care PlanningCare Planning
Demonstrates knowledge and behaviors Demonstrates knowledge and behaviors supportive of a strong safety culturesupportive of a strong safety culture
Routinely engages in heedful interrelating Routinely engages in heedful interrelating with colleagues during patient report and with colleagues during patient report and handovershandovers
HANDS Care Planning HANDS Care Planning Method Method
Post – GO LIVEPost – GO LIVE Create Create admissionadmission or or updateupdate Care Plan on Care Plan on
every patient q shiftevery patient q shift Add, subtract, retain, change status of N3 as Add, subtract, retain, change status of N3 as
needed q shiftneeded q shift Rate NOC outcomes q shiftRate NOC outcomes q shift Ensure NIC tallies are correct q shiftEnsure NIC tallies are correct q shift Complete anonymous error reportingComplete anonymous error reporting Enter 1) nurse shift info, 2) patient care time Enter 1) nurse shift info, 2) patient care time
Use your submitted Care Plans in report to Use your submitted Care Plans in report to structure information shared (STICC)structure information shared (STICC)
Complete short DC form when patient leaves Complete short DC form when patient leaves unitunit
Heedful Interrelating Heedful Interrelating Nurse to Nurse Communication in Nurse to Nurse Communication in
ReportReportS-ituation S-ituation What is the patient’s situation?What is the patient’s situation?
Use current care plan and care plan history Use current care plan and care plan history
T-rajectory T-rajectory What needs to be done?What needs to be done? NANDAs, NOCs, and NICs, and other NANDAs, NOCs, and NICs, and other
important details important details
I-ntent I-ntent Why?Why? Refer to historical care plans and patient Refer to historical care plans and patient
progress noted progress noted across time, explain rationale across time, explain rationale
C-oncern C-oncern What are the priority/iesWhat are the priority/ies?? Refer to most important priority/ies to be Refer to most important priority/ies to be
attended to in attended to in next shift next shift
C-allibrate C-allibrate Invite questions to clarify and enhance Invite questions to clarify and enhance plan!plan!
What’s not clear? What do you disagree with?What’s not clear? What do you disagree with?
Aim 1: Methods & Aim 1: Methods & MeasuresMeasures
H 1.1 Collective MindH 1.1 Collective Mind Usefulness survey; Usefulness survey;
Pre-Tr, 12 moPre-Tr, 12 mo Term meaning reliabilities; Term meaning reliabilities;
Post-Trng, 6mo, 12mo, 24moPost-Trng, 6mo, 12mo, 24mo NOC rating reliabilities; NOC rating reliabilities;
Post-Tr, 6mo, 12mo, 24moPost-Tr, 6mo, 12mo, 24mo Isolate patterns of accessing hx data in Isolate patterns of accessing hx data in
HANDS;HANDS; 6mo, 12 mo, 24 mo6mo, 12 mo, 24 mo
Aim 1: Methods & Aim 1: Methods & Measure (Cont)Measure (Cont)
H1.2 MindfulnessH1.2 Mindfulness Conduct think-alouds – Post-Tr, 12 moConduct think-alouds – Post-Tr, 12 mo Examine patterns in using HANDS; Examine patterns in using HANDS;
6mo, 12 mo, 24 mo6mo, 12 mo, 24 mo Adjustments nurse makes to NCPAdjustments nurse makes to NCP Nurse use of HANDS “Help” functionsNurse use of HANDS “Help” functions Temporal pattern of data entryTemporal pattern of data entry Discrepancies between actual versus Discrepancies between actual versus
expected NOC outcome ratingsexpected NOC outcome ratings
Aim 1: Methods & Aim 1: Methods & Measures (Cont.)Measures (Cont.)
Heedful Interrelating Heedful Interrelating Observations of patient hand-offs (e.g., Observations of patient hand-offs (e.g.,
report, breaks) report, breaks) 6 mo, 12 mo, 24 mo6 mo, 12 mo, 24 mo
Focus groupsFocus groups 6 mo. 12 mo, 24 mo6 mo. 12 mo, 24 mo
Aim 2 Aim 2 HANDS CPP Method HANDS CPP Method
Enhances Safety CultureEnhances Safety Culture Criterion Measures – Safety CultureCriterion Measures – Safety Culture
Trust survey, Trust survey, Pre-HANDS, 12 mo post, 24 mo postPre-HANDS, 12 mo post, 24 mo post
Culture survey, Culture survey, Pre-HANDS, 12 mo post, 24 mo postPre-HANDS, 12 mo post, 24 mo post
Nursing errors and near errors; Nursing errors and near errors; Pre-HANDS, and 3, 6, 12, 18, 24 months Pre-HANDS, and 3, 6, 12, 18, 24 months
postpost
Preliminary Findings Preliminary Findings
Observations (Baseline)Observations (Baseline) Use of computerized documentationUse of computerized documentation
3 sites rely substantially on computerized 3 sites rely substantially on computerized documentation systemsdocumentation systems
Practices of charting differ leading to Practices of charting differ leading to different levels of efficiencies of different levels of efficiencies of documentationdocumentation
Nature of report Nature of report Varies among sitesVaries among sites One site uses taped reportsOne site uses taped reports
Care planningCare planning Meets minimal requirementsMeets minimal requirements Piece of paper in the chartPiece of paper in the chart
Preliminary Findings Preliminary Findings
Quantitative measuresQuantitative measures Organizational culture (Sutcliffe)Organizational culture (Sutcliffe) Trust (Mishra and Mishra)Trust (Mishra and Mishra)
Importance of being open to Importance of being open to organizational change organizational change
HANDS ChampionsHANDS Champions
AdministratorsAdministrators Michelle Michelle
Aebersold Nurse Aebersold Nurse ManagerManager
Jean Shlafer Jean Shlafer LiaisonLiaison
Cinda Loik Cinda Loik ManagerManager
Mary Jo Kocan, Mary Jo Kocan, Clinical SpecialistClinical Specialist
Clinician ChampionsClinician Champions Sandra LivaSandra Liva Marianne ArandaMarianne Aranda Cathleen Cathleen
GuerrieroGuerriero Sue McMahonSue McMahon Meiqing WangMeiqing Wang Sandra HatchSandra Hatch Katherine WilsonKatherine Wilson
HANDS Method Framework (Keenan & Yakel, 2005)
HANDS CPPMethod
Tool (HANDS) Computerized Standard Format N3 Terms Focus on OutcomesTraining Tool CPP Rules Expected Outcomes Safety EmphasisImplementation
EFFECTIVE CPP
RNs’ Collective Mind Representation Accurate Useful RNs Heedfully Interrelating To achieve desired outcomes RN’ Mindfulness In identifying & documenting patient problems, interventions and outcomes
SAFETY CULTURE
•Improved communication•Reduced errors•Continuity of care•Positive patient outcomes
Objectives of the HANDS Objectives of the HANDS ProjectProject
To provide: To provide: Hands-on automated support for the care Hands-on automated support for the care
planning processplanning process An “external memory” of the patient’s care An “external memory” of the patient’s care
plan that allows easy monitoring and plan that allows easy monitoring and adjustment of the care of multiple clinicians adjustment of the care of multiple clinicians to achieve desired outcomes to achieve desired outcomes
To simultaneously identify and To simultaneously identify and promote:promote: Strategies that sustain ongoing Strategies that sustain ongoing
“mindfulness” of the clinician in the care “mindfulness” of the clinician in the care planning process across planning process across
AssumptionsAssumptions Use of standardized nursing languages (SNLs) is Use of standardized nursing languages (SNLs) is
desirable because it brings visibility and desirable because it brings visibility and accountability to nursing accountability to nursing Atomic level (assessments and discrete tasks)Atomic level (assessments and discrete tasks) Meta level (judgments)Meta level (judgments)
Use of SNLs in computer systems supports the Use of SNLs in computer systems supports the generation of nursing data for multiple purposes generation of nursing data for multiple purposes
The structure and content of SNLs need to be The structure and content of SNLs need to be continuously refined to improve the data quality continuously refined to improve the data quality of information captured in computersof information captured in computers
CONTINUOUS IMPROVEMENT AND CONTINUOUS IMPROVEMENT AND DIFFUSION OF THE SNLs WILL OCCUR WITH DIFFUSION OF THE SNLs WILL OCCUR WITH USE AND REFINEMENT UNDER “REAL TIME” USE AND REFINEMENT UNDER “REAL TIME” CONDITIONSCONDITIONS