If documentation is a reflection of our care, does it show that nurses make a difference?

ASSESSMENT OF “CURRENT” PLAN OF CARE DOCUMENTION Nurses reviewing other nurse’s documentation during the handover process find it hard to identify care priorities to focus on Paper Pathways are not easy to find in the pt’s chart, not part of the electronic record & nurses feel that printing is just busy work Managers & Regulators reviewing nursing documentation find it difficult to determine the most important patient problems – Recent JCAHO survey prompted us to try changes

A PILOT….8VCH and 8S VUH 8 VCH & 8S VUH piloted a new way to document in HED…. “Priority Problems” Nurses like it because it’s easier to plan & manage patient care. Terminology is standardized and simplified using CCC Saba model. Nurses find that documenting “Priority Problems” is a PRACTICE change with no new computer skills to learn

OBJECTIVES…. Verbalize understanding of the vision for Priority Problems and Clinical Care Classification* (CCC) Nursing terminology. Use CCC Nursing terminology to document planning and managing care for a practice scenario. Including Assign & save a pathway to a patient’s medical record in StarPanel Initiating 2-3 top priority problems and their expected and actual outcomes Documenting shift expected/actual goals, Nursing Summary and Plans For your area, initiate list of top 10 pathways and 5 problems for each. Define for common problems the problem category, problem, related to…., expected outcomes and short term goals

Vision Statement Priority problems will simplify and standardize how nurses: document and communicate the patient’s top priority problems identify plans and goals assess actual outcomes This will improve patient care and clearly define nursing’s contributions to patient care and the team.

What’s Changing Save Electronic copy of Pathway in StarPanel Identify 2-3 priority patient problems and outcomes and short term expected/actual goals using CCC model WHY? Nurses, and all team members, need to focus on the most urgent needs & identifying the interventions to help patients achieve their goals. Not Changing: Document the pathway name, phase, nursing summary & plan priority in HED

Priority Problems We all have different ways of describing or talking about problems. You call it pain, I call it alteration in comfort The decision was made to standardize how we talk about nursing care. The Clinical Care Classification* (CCC) Saba Model was selected.

CCC Model is Evidence Based Over 40,000 charts were reviewed to derive the 182 Clinical Care Classification problems. The Clinical Care Classification (CCC) System* is a standardized, coded nursing terminology that identifies the specific elements of nursing practice. CCC provides a unique framework and coding structure for capturing the essence of patient care in all health care settings *Developed by Virginia K. Saba, RN , PhD

You can learn more on the Sabacare.com website about the CCC.

CCC Framework 21 Categories w/82 Problems 3 Expected Outcomes Improve Stabilize Support decline 3 Actual Outcomes Improved Stabilized Decline supported Refer to glossary

21 CCC Categories Medication Physiological Psych/Behavioral Functional Cardiac Bowel/Gastric Life cycle (pregnancy) Metabolic (glucose) Physical Regulation (infection) Respiratory Skin Integrity Tissue Perfusion Urinary Medication Psych/Behavioral Cognitive Coping Health Behavior Role Relationship Self Care Self Concept Functional Activity Fluid Volume Nutrition Safety Sensory/Pain

3 CCC Outcomes For Priority Problems Expected/Actual 1. Improve/Improved Condition will change and/or recover (fracture, pneumonia) 2. Stabilize/Stabilized Underlying chronic condition will not change but requires no further nursing care to maintain (asthma, heart failure) 3. Support Decline/Decline Supported Condition will change and worsen (cancer, ESRD). Nursing action supports decline.

Putting it all together to Build an Outcome Oriented Documentation Framework

Priority Problems: What to Do & When Admission Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED) Beginning of Shift Review Pathway & Phase - change prn (HED) Document expected Short Term Goals for your shift (HED) End of Shift Start/End Priority Problems - adjust Pathway & Phase prn (HED) Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED) Transfer/ Discharge Start/End Priority Problems. Change Pathway &/or Phase prn. Document Short Term Goal & status (HED) Document Nursing Summary & Plan & Priorities in HED Document D/C Plan in HED & denote Post Discharge Plans to address unmet goals

Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED) Admission Day of go-live also Choose the pathway that most closely reflects the expected patient progression. Usually the reason for admission. EXAMPLES: Medical Pathway – Heart Failure Admission – Orders & interventions are aimed at achieving stabilization (improving pump action through diuresis, O2, hemodynamic stability, . . .) Stabilization - achieving controlled symptoms (fluid excess control, med mgmt) Discharge – Ready for self-care; or care by another caregiver. Surgical Pathway - Knee Replacement Pre-op Post-op Stabilization Discharge

USE OF GENERIC PATHWAYS MAKE IT HARDER Specific pathways will have phases, goals and interventions that are a better fit. The evidenced based pathways can better guide care. Use generic pathways only as a last resort

List of pathways display Select & Save Pathway (StarBrowser/StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED) Admission Click Action Click EDOCS Pathway List of pathways display

3. Type the name of the pathway in search. 4. Click on Pathway to add to medical record 5. Click OK to add to Starpanel

Click to display pathway Pathway Will Display in Assessment Section of the OPC with a Link for Easy Access Click to display pathway

PRACTICE SCENARIO Admission: You are working day shift and your 27 yo ,Mary Lou was admitted to the Ortho unit around 5pm after an MRI revealed a cervical cord mass. She is experiencing weakness, is ataxic and has neck and back pain. Her pain score is a 5 with morphine on board. She is scheduled for a cervical laminectomy tomorrow. She is a single mother and concerned about her 4 and 2 year old children and how she will care for them after surgery. Assign best fit Pathway in StarPanel Document Pathway and Phase in HED Create 2-3 Priority Problems (HED) Notice that the cervical surgery pathway does not have a preop phase so pick the best fit – Day of Surgery since the pt is going for surgery tomorrow.

Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED) Admission

Definitions located in “links” from HED Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED) Admission Before doing anything in HED, think about the 2 or 3 Priority Problems for Mary Lou. Review the CCC definitions as needed. Definitions located in “links” from HED Place a check mark next to them on “Standard Nursing Problem List”

Note the 21 categories of problems Document Priority Problems in Plan of Care Tab Note the 21 categories of problems Locate the 3 categories you identified for Mary Lou.

Click Start Priority problem Admission Select & Save Pathway (StarPanel ) Document Pathway Name & Phase (HED) Create 2-3 Priority Problems (HED) Click Start Priority problem Select problem Denote “ may be related to…” Select expected outcome Type “T” for today's date and time or type in another date/ time Save

Initiating a Problem Hover over icon to see detail of problem. Problem Screen works like IV Manage, Foley Catheter & Wounds.

Enter a Nursing Summary and Plan Priorities for the next shift since it is almost shift change time. Sample Nursing Summary Mother of 2 young children admitted w/ surgical mass scheduled for cervical laminectomy in am. Has weakness, ataxia and 5/10 pain. Sample Plan Priorities Control pain, prep for surgery & explain post op course, assure no falls and provide emotional support

Day and Night shift goals may differ. Review Pathway & Phase - change prn (HED) Document expected Short Term Goals for your shift (HED) Beginning of Shift In HED, type the short term goal for the shift for each problem that will be addressed that shift. Keep in Mind…. Day and Night shift goals may differ.

Start/End Priority Problems - adjust Pathway & Phase prn (HED) Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED) End of Shift Ending problems works the same as ending a PIV or Foley. Select the magnifying glass, fill in appropriate fields.

Hover over icon to see detail of goal. Start/End Priority Problems - adjust Pathway & Phase prn (HED) Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED) End of Shift Short Term Goal Status Hover over icon to see detail of goal. Document status (met, improving, unchanged, deteriorating, not met.

Start/End Priority Problems - adjust Pathway & Phase prn (HED) Document Short Term Goal Status or outcome (HED) Document Nursing Summary & Plan & Priorities for next shift (HED) End of Shift Rule of thumb between the hours of 3 -5 to allow for printing of OPC for next shift

Start/End Priority Problems. Change Pathway &/or Phase prn. Document Short Term Goal & status (HED) Document Nursing Summary & Plan & Priorities in HED Document D/C Plan in HED & denote Post Discharge Plans to address unmet goals Transfer/ Discharge

Problems, expected outcomes and the short term goals and status. Reports will be emailed to leadership every day to assist with monitoring progress of staff and patients. Problems, expected outcomes and the short term goals and status.

Common Questions Patients have many problems, what makes it a priority problem? When it is the patient’s priority (pain, SOB, anxiety) Keeps the patient from moving to the next phase (fluid volume excess) High probability for harm (infection risk, falls) Delays discharge Note that Day & Night shift may have different priorities (ambulation vs. sleep)

Common Questions How do I choose the right problem descriptor? Example : My pt has Heart Failure – which problem do I pick? Match problem closely with the interventions If you are focusing on fluid mgmt (IV diuretics, I&O, low Na diet, fluid restriction) pick Fluid Volume Excess If you are focusing on breathing treatments, choose Respiratory Alteration Neither are wrong – both may be selected

What to do What NOT to do Do NOT Repeat all the problems from the pathway. Do NOT replicate standards of care unless they are specific to a priority problem Do NOT include “Continue to Monitor” unless there are details re: what to monitor. Do NOT change problems for a slightly better descriptor. Not all problems need be addressed every shift – day and night shift will have different priorities. Keep Problem List Short & Useable Do make Plan Priorities reflect priorities for the next 12 hr shift. Use problems started on prior shift until significant progress is made or the problem has been resolved. Make goals/ plans specific and realistic. Example monitor o2 sat w/ ambulation Review pathway and document any changes to pathway or phase.

Making Priority Problems Your Own Print 1 high use pathway for your areas Use the Priority Problem Assessment tool to identify 5 common problems for this pathway. 3. Complete the Sample plan of care exercise for these 5 problems. 4. Identify a plan to complete other 9 pathways sample plan of care or your area.

Training and Implementation Plan Live Date: Tues Training Plan: 90% of Staff Trained by go live Small groups will have opportunity to practice and ask questions Everyone needs to practice before go live 3-4 terminals will need to be identified to setup with priority problems in HED train… get those terminal IDs to your SSS person ASAP. Add to the practice scenario, a scenario for your patient population.

Training and Implementation Plan Resources: Priority Problem Resource Manual Top 10 pathways for unit Example of 5 common problems Super Users/ Educator Need enough super users for each shift Implementation Support Super User 9a-5p and 9p-5a Tue- Friday SSS 9a-5p and for 2 hours between 9p-5a Tue- Friday

TO DO LIST ASK QUESTIONS Complete 10 Top use Pathway and 5 common problems exercise (suggested to involve super users) Complete Sample Plan of Care exercises Complete Training Plan ( including recruiting super users) Identify 3-4 terminals to set up for practice and get terminal IDs to your SSS rep ASK QUESTIONS