Culture, Change, & Standardization of Key Care Information Gail Keenan, PhD, RN HANDS

Does anyone disagree with: There is a critical need to standardize the format and content of key care information across EHRs to decrease errors and increase continuity.

About the HANDS Project Research team dedicated to producing an electronic “short/story/synopsis” of a patient’s care that is always in the same format (STANDARDIZED) and accessible quickly (since 1997) whenever and wherever the patient presents.

What is the HANDS Mission?  To prevent/minimize the MILLIONS of communication misunderstandings among members of the health care team that result in patient care errors each year by standardizing key aspects of documentation and communication (the patient’s short story)

Goals of HANDS Project Standardize a method for collecting and communicating plan of care information that: 1.Is useful to clinicians 2.Promotes continuity of care at all handovers 3.Creates a national database of comparable, valid, and rich nursing data 4.Supports research to continuously improve nursing care and practice

Current AHRQ 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 HS HHS PHS National Institutes of Health , Agency of Health Research and Quality

Study Aims To demonstrate that HANDS – plan of care method (built on pilot) 1.can be successfully implemented and standardization maintained across diverse units and organizations supporting  Mindfulness  Heedful interrelating  Collective mind 2.increases the safety culture of diverse nursing units

Study Intervention: HANDS Method  All RNs on all study units were required to: –Complete HANDS training protocol (7-8 hours) –Demonstrate competency in use of HANDS before go-live –Enter an admission or update plan of care on each of ones patients into HANDS (electronic tool ) at every handoff –Use the plan to structure “report/handoff” communication (SHARE)

Sample Selected 8 units / 4 diverse organizations / 700 RNs –Stable staff, motivated to be part of study, no other major changes occurring, willingness to mandate use of HANDS by all personnel  4 organizations –1 university, 2 community (part of multi-hospital systems), 1 small community  8 units - 4 Y1 (24 mo) and 4 Y2 (12 months) –Med-surg (2), neuro, thoracic, medical ICU, progressive care, older adult/stroke, acute care elderly

Sample (cont.) UnitYrBedsRNsConsent % A132/4860/ % B % C % D % A2260/44120/ % B % B % C %

At Baseline  Enormous variation in documentation and communication practices within units & organizations, and across individuals and organizations  RNs focus on the details can’t see big picture

Training and support  Trained champions (opinion leaders) - nurse managers required to be part of champion training  Held regular champion calls by category of champion (educator, clinical specialist, staff nurses, managers) to address problems relative to role – problem solve together  Used Socio technical approach – involved users with designing identifying problems and designing solutions  Most of solutions came from RNs – we had resources in place to address most solutions /or told why couldn’t

Multiple Methods Used  Surveys (R)– skills, trust, culture, knowledge, satisfaction with care planning method  Observations documentation and communication (R)  Interviews, Meetings, Focus Groups (R)  Inter-rater reliability checks of outcome ratings (R)  Term meaning reliability checks (R)  Think-alouds  Analysis of transaction logs (R) (R) = Repeated

Safety Culture Tool (Vogus, 2004)  21 Items (1-5 scale) strongly disagree to strongly agree  3 Factors –Mindfulness - 5 items respect individual colleagues contributions and take actions that help members build on each others care –Heedful interrelating – 10 items communicate honestly with the team, talk about and learn from mistakes, share strengths and weaknesses –Collective mind – 6 items Understand how all team members contribute to care, align actions to support team goals

Trust Survey (Mishra, 1992)  16 items (1-5 scale) strongly disagree to strongly agree  4 Factors (4 items each) –Concern for organization and vice versa –Openness in communication –Competence of colleagues –Reliability of colleagues

Safety Survey (Anonymous) 5 items (1 X per shift ) Response applies to time since last completed survey Can select 1 or 2 or any combo of 3,4, & 5: 1. Do not wish to respond 2. No Awareness of Error 3. Awareness-error Made by self 4. Awareness-Avoided and Error 5. Awareness-Observed an Error

Culture remains consistently high pre (Green) and post (Red)

Trust, Safety Survey, & Other  Trust items correlated with safety culture  Safety survey not fully analyzed, note a significant increase in % of RNs selecting “willing to to respond” options  > interest in improving care planning & documentation positively correlated with > trust & > culture scores (correlation doubled at x 2)

Associated Findings  All units want to keep HANDS “post” study  90% care periods have care plans (all units)  RNs more satisfied with HANDS than previous method (p<.05)  RNs more familiar & satisfied with NNN (p<.05)  Significant increase in RN willingness to respond to safety survey over time  RNs very pleased with HANDS team responsivity to requested changes

Associated Findings  RNs in orgs independently –instituted user group –integrated into multi-disciplinary rounds –lobbied to have HANDS instituted on new unit  Care planning activity remain consistent (changes e.g, add, resolve NNN etc.)

Other Considerations  Standardization across all units in org would bring many more benefits (study costs prohibitive)  HANDS generates data for describing care, progress toward outcomes, meeting goals, RN patient load, benchmarking best practices  EHRs are costly spend billions of dollars (over and above software costs) training and tailoring to foster variation in look and feel…away from standardization

Recommendations Put strategies and resources in place to;  support staff to own change  enables staff to design solutions  to sustain change across time (orgs tend to move on to next change)  select best units (those most likely to succeed) to lead the change  when goal is to standardize across organization (need buy in and commitment of top levels)

Conclusions  We need big picture in standardized language and format  HANDS “can do it” and cost effectively— but s difficult to make the case with traditional measures  Multiple methods can provide the pieces that when combined will explain the impact

Revised HANDS Framework Organization Factors Communication Intervention Clinician & Care Outcomes Culture Readiness High Trust Safety Culture Focus Expects Clinician Mindfulness, Heedful Interrelating, and Collective Mind Infrastructure Supports Change Engages in Continuous Learning Commits to Change Adopts Standardized Plan of Care Method Provides Ongoing Education Provides Resources to Implement Provides Resources to Sustain Standardized Handoff Structure Using HANDS Promotes Heedful Interrelating & Mindfulness about HANDS story and Future Care among inter and intra-disicplinary team members Standardized Documentation in HANDS Electronic Tool Provides a Consistent, Dynamic, Up-to-date Synopsis of Care: The Clinicians’ Collective Mind Patient: Care Continuity Care Quality Satisfaction Safety Nurse: Job Satisfaction Visibility of Work Evidence Based Practice © G.Keenan, E.Yakel, D. Tschannen, & M. Mandeville, 2007 df

Definition: Organizational Culture