Title: Standardizing the Documentation and Communication of the Nursing Plan of Care at the Handover Using HIT Gail Keenan PhD, RN PI, University of Illinois, College of Nursing Beth Yakel, PhD Co- PI, University of Michigan, School of Information Dana
1 Standardizing the Documentation and
Communication of the Nursing Plan of Care at the
Handover Using HITGail Keenan PhD, RNPI,
University of Illinois, College of NursingBeth
Yakel, PhDCo- PI, University of Michigan, School
of InformationDana Tschannen, PhD, RNField
Research Director, University of Michigan, School
of Nursing
2Currently Funded by AHRQ (2004-2007)
- The presentation reports on the YR 1
- findings of the 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, Agency of Health Research and Quality
(AHRQ)
3HANDS 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
4HANDS 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
5Goals of HANDS Project
- Standardize method for collecting and
communicating plan of care information at the
Handover that - Is useful to clinicians
- Promotes continuity of care across nurses
- Creates a national database of comparable, valid,
and rich nursing data - Supports research to continuously improve nursing
care and practice
6Standardization Defined
- .the process by which the form or function of
an artifact or technique becomes specified (Feng,
2003)
7To 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
8HANDS 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
9Research and HANDS Framework
- Continuously scan literature for related evidence
- Employ socio-technical research methods
- Regularly update HANDS Framework to reflect
latest evidence generated from 1 and 2
10Use 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
11Multiples 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
12Core Safety FrameworkHANDS Care Planning Method
Effective Nurse Communication
Effective Nurse Handover
(Keenan Yakel, 2005)
13HANDS 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
14Comparison 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
15Comparison of Baseline Measures N units 4, N
RNs 193
- No significant differences
- nurses satisfaction with current care planning
method (low satisfaction) - knowledge of NANDA
16Term 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
17Observations of Report 3 Months Post
- Ns
- units 3
- reports/unit 2
- Total RNs all repots14
- 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
186 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
19Positive 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) -
20Needs 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
21Integration 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
22 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 Organizations new Safety Goal (2006)
requirement to Implement a standardized approach
to hand off communications, including an
opportunity to ask and respond to questions.
23SHARE 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 thinking
- E Exchange invite questions, debate, dialogue
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27Questions???