1. HIT Support for Safe Nursing Care 2004-2007 Gail Keenan, Ph.D., R.N. Elizabeth Yakel, Ph.D. R01 HS015054-01 NIH- Agency for Health Research and Quality (AHRQ)

2. HANDS Core Project Team Team Support Team Support Annie Browning, MSPH Annie Browning, MSPH Sharie Falan, MS, RN Sharie Falan, MS, RN Yvonne Ford, MS, RN Yvonne Ford, MS, RN Crystal Heath, MS, RN Crystal Heath, MS, RN Deanna Marriott, PhD Deanna Marriott, PhD Rachelle Ramos, BSN, RN Rachelle Ramos, BSN, RN Emily Springfield, MS Emily Springfield, MS Marcy Treder, BSN Marcy Treder, BSN Dana Tschannen, PhD, RN Dana Tschannen, PhD, RN Santosh Udupi, MS Santosh Udupi, MS Administrative Team Gail Keenan, PhD, RN – PI Elizabeth Yakel, PhD, Co-PI Mary Mandeville, MBA, Director Advisory / Consultant Members Connie Delaney, PhD, RN Ada Sue Hinshaw, PhD, RN Mary Killeen, PhD, RN Sally Decker, PhD, RN Linda Scott, PhD, RN Julia Stocker, PhD, RN Kathleen Sutcliffe, PhD

3. Study Aims To demonstrate that Health Information Technology (HIT) (Hands-on Automated Nursing Data System (HANDS) Method) can be successfully implemented to support nurses in a dynamic Care Planning Process (CPP) encompassing both the planning and provision of care To demonstrate that Health Information Technology (HIT) (Hands-on Automated Nursing Data System (HANDS) Method) can be successfully implemented to support nurses in a dynamic Care Planning Process (CPP) encompassing both the planning and provision of care To demonstrate that implementation of the HANDS Method increases the safety culture of diverse nursing units To demonstrate that implementation of the HANDS Method increases the safety culture of diverse nursing units

4. Hypotheses Our HANDS Care Planning Process (CPP) Method Our HANDS Care Planning Process (CPP) Method H1.1 satisfactorily represents the collective mind of nurses across time and settings mind of nurses across time and settings H1.2 sustains mindfulness in the CPP across time and settings and settings H1.3 supports heedful interrelating about the CPP across time and settings CPP across time and settings

5. Lessons Learned from Earlier Projects  Competency in use of NNN builds over time  USE to FRAME HAND-OVER (Report)  Care Plan application must be easy and accessible  Convert to WEB-BASED Version  IT is a MAJOR CHANGE  Unit to OWN change  Include RNs ALL ROLES as CHAMPIONS  Create STRATEGY to Continuously Nurture until SUSTAINED  Users must LOVE it  Focus on making it VALUABLE TO RN USERS

6. Core Framework: HANDS Care Planning Method (Keenan & Yakel, 2005)

7. HANDS Care Planning Method and Positive Outcomes (Keenan & Yakel, 2005)

8. HANDS Method Mindful Care Planning Mindful Care Planning + Heedful Interrelating in Report + Heedful Interrelating in Report = Collective Mind of RNs in HANDS = Collective Mind of RNs in HANDS

9. Subjects & Requirements 8 nursing units (4 in Year 1, 4 in Year 2) located in 4-5 health care systems in Michigan 8 nursing units (4 in Year 1, 4 in Year 2) located in 4-5 health care systems in Michigan RNs employed on the units (n = 400+) RNs employed on the units (n = 400+) Participate in orientation to HANDS Tool and NANDA, NOC, and NIC terminologies (8 hours) Participate in orientation to HANDS Tool and NANDA, NOC, and NIC terminologies (8 hours) At “go live” create admission or update HANDS CPs on all patients for each shift At “go live” create admission or update HANDS CPs on all patients for each shift RNs MUST use HANDS Care Plan in Report RNs MUST use HANDS Care Plan in Report

10. Strategy with Test Sites Train Champions (Across Sites) Train Champions (Across Sites) Nurse Managers Nurse Managers Clinical Specialists Clinical Specialists Nurse Educators Nurse Educators Nurse Clinicians Nurse Clinicians Champions Train Remaining RN Colleagues Champions Train Remaining RN Colleagues Units Collaborate with Other Test Units Units Collaborate with Other Test Units Test Units Own Care Planning Method Test Units Own Care Planning Method

11. Competency: HANDS Care Planning Methodology Definition: integration of mindful care planning using NANDA, NOC, and NIC (N3) knowledge integration of mindful care planning using NANDA, NOC, and NIC (N3) knowledge technical skills in use of HANDS application (collective mind), and technical skills in use of HANDS application (collective mind), and heedful interrelating during report and other handovers heedful interrelating during report and other handovers

12. Competency: HANDS Care Planning Methodology (Pre- GO LIVE) RN Objectives: Successfully creates admission and update care plans with HANDS application Successfully creates admission and update care plans with HANDS application Demonstrates appropriate use of N3 search modes to locate terms Demonstrates appropriate use of N3 search modes to locate terms Uses a broad range of NANDA Diagnoses, NOC Outcomes and ratings, and NIC Interventions and tallies appropriately in Care Planning Uses a broad range of NANDA Diagnoses, NOC Outcomes and ratings, and NIC Interventions and tallies appropriately in Care Planning Demonstrates knowledge and behaviors supportive of a strong safety culture Demonstrates knowledge and behaviors supportive of a strong safety culture Routinely engages in heedful interrelating with colleagues during patient report and handovers Routinely engages in heedful interrelating with colleagues during patient report and handovers

13. HANDS Care Planning Method Post – GO LIVE HANDS Care Planning Method Post – GO LIVE Create admission or update Care Plan on every patient q shift Create admission or update Care Plan on every patient q shift Add, subtract, retain, change status of N3 as needed q shift Add, subtract, retain, change status of N3 as needed q shift Rate NOC outcomes q shift Rate NOC outcomes q shift Ensure NIC tallies are correct q shift Ensure NIC tallies are correct q shift Complete anonymous error reporting Complete 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 structure information shared (STICC) Use your submitted Care Plans in report to structure information shared (STICC) Complete short DC form when patient leaves unit Complete short DC form when patient leaves unit

14. Heedful Interrelating Nurse to Nurse Communication in Report S-ituation What is the patient’s situation? Use current care plan and care plan history Use current care plan and care plan history T-rajectory What needs to be done? NANDAs, NOCs, and NICs, and other important details NANDAs, NOCs, and NICs, and other important details I-ntent Why? I-ntent Why? Refer to historical care plans and patient progress noted across time, explain rationale Refer to historical care plans and patient progress noted across time, explain rationale C-oncern What are the priority/ies? Refer to most important priority/ies to be attended to in Refer to most important priority/ies to be attended to in next shift next shift C-allibrate Invite questions to clarify and enhance plan! What’s not clear? What do you disagree with? What’s not clear? What do you disagree with?

15. Aim 1: Methods & Measures H 1.1 Collective Mind H 1.1 Collective Mind Usefulness survey; Usefulness survey; Pre-Tr, 12 mo Pre-Tr, 12 mo Term meaning reliabilities; Term meaning reliabilities; Post-Trng, 6mo, 12mo, 24mo Post-Trng, 6mo, 12mo, 24mo NOC rating reliabilities; NOC rating reliabilities; Post-Tr, 6mo, 12mo, 24mo Post-Tr, 6mo, 12mo, 24mo Isolate patterns of accessing hx data in HANDS; Isolate patterns of accessing hx data in HANDS; 6mo, 12 mo, 24 mo 6mo, 12 mo, 24 mo

16. Aim 1: Methods & Measure (Cont) H1.2 Mindfulness H1.2 Mindfulness Conduct think-alouds – Post-Tr, 12 mo Conduct think-alouds – Post-Tr, 12 mo Examine patterns in using HANDS; 6mo, 12 mo, 24 mo Examine patterns in using HANDS; 6mo, 12 mo, 24 mo Adjustments nurse makes to NCP Adjustments nurse makes to NCP Nurse use of HANDS “Help” functions Nurse use of HANDS “Help” functions Temporal pattern of data entry Temporal pattern of data entry Discrepancies between actual versus expected NOC outcome ratings Discrepancies between actual versus expected NOC outcome ratings

17. Aim 1: Methods & Measures (Cont.) Heedful Interrelating Heedful Interrelating Observations of patient hand-offs (e.g., report, breaks) Observations of patient hand-offs (e.g., report, breaks) 6 mo, 12 mo, 24 mo 6 mo, 12 mo, 24 mo Focus groups Focus groups 6 mo. 12 mo, 24 mo 6 mo. 12 mo, 24 mo

18. Aim 2 HANDS CPP Method Enhances Safety Culture Criterion Measures – Safety Culture Criterion Measures – Safety Culture Trust survey, Trust survey, Pre-HANDS, 12 mo post, 24 mo post Pre-HANDS, 12 mo post, 24 mo post Culture survey, Culture survey, Pre-HANDS, 12 mo post, 24 mo post Pre-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 post Pre-HANDS, and 3, 6, 12, 18, 24 months post

19. Preliminary Findings Observations (Baseline) Observations (Baseline) Use of computerized documentation Use of computerized documentation 3 sites rely substantially on computerized documentation systems 3 sites rely substantially on computerized documentation systems Practices of charting differ leading to different levels of efficiencies of documentation Practices of charting differ leading to different levels of efficiencies of documentation Nature of report Nature of report Varies among sites Varies among sites One site uses taped reports One site uses taped reports Care planning Care planning Meets minimal requirements Meets minimal requirements Piece of paper in the chart Piece of paper in the chart

20. Preliminary Findings Quantitative measures Quantitative measures Organizational culture (Sutcliffe) Organizational culture (Sutcliffe) Trust (Mishra and Mishra) Trust (Mishra and Mishra) Importance of being open to organizational change Importance of being open to organizational change

29. HANDS Champions Administrators Administrators Michelle Aebersold Nurse Manager Michelle Aebersold Nurse Manager Jean Shlafer Liaison Jean Shlafer Liaison Cinda Loik Manager Cinda Loik Manager Mary Jo Kocan, Clinical Specialist Mary Jo Kocan, Clinical Specialist Clinician Champions Sandra Liva Marianne Aranda Cathleen Guerriero Sue McMahon Meiqing Wang Sandra Hatch Katherine Wilson

30. HANDS Method Framework (Keenan & Yakel, 2005) HANDS CPP Method Tool (HANDS) Computerized Standard Format N3 Terms Focus on Outcomes Training Tool CPP Rules Expected Outcomes Safety Emphasis Implementation 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

31. Copyright  2000 The Regents of The University of Michigan

32. Objectives of the HANDS Project To provide: To provide: Hands-on automated support for the care planning process Hands-on automated support for the care planning process An “external memory” of the patient’s care plan that allows easy monitoring and adjustment of the care of multiple clinicians to achieve desired outcomes An “external memory” of the patient’s care plan that allows easy monitoring and adjustment of the care of multiple clinicians to achieve desired outcomes To simultaneously identify and promote: To simultaneously identify and promote: Strategies that sustain ongoing “mindfulness” of the clinician in the care planning process across Strategies that sustain ongoing “mindfulness” of the clinician in the care planning process across

33. Assumptions Use of standardized nursing languages (SNLs) is desirable because it brings visibility and accountability to nursing Use of standardized nursing languages (SNLs) is desirable because it brings visibility and 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 generation of nursing data for multiple purposes Use of SNLs in computer systems supports the generation of nursing data for multiple purposes The structure and content of SNLs need to be continuously refined to improve the data quality of information captured in computers The structure and content of SNLs need to be continuously refined to improve the data quality of information captured in computers CONTINUOUS IMPROVEMENT AND DIFFUSION OF THE SNLs WILL OCCUR WITH USE AND REFINEMENT UNDER “REAL TIME” CONDITIONS CONTINUOUS IMPROVEMENT AND DIFFUSION OF THE SNLs WILL OCCUR WITH USE AND REFINEMENT UNDER “REAL TIME” CONDITIONS