RELATIONSHIPS AND RESULTS ORIENTED HEALTH CARE

1. RELATIONSHIPS AND RESULTS ORIENTED HEALTH CARE WSU Nursing Students Tiffani Abrams Kelly Roe

2. WHAT HAVE WE OBSERVED IN OUR SHORT TIME HERE: • We have learned a lot! • You all work hard everyday • You all want to do your job well • Your patients have many good things to say about you!

3. WHAT MAKES YOU GUYS GREAT? • In the surveys, you told us: Family-centered care really helped patients feel more at ease while their families felt incorporated in the patient’s care. • What the patients told us: staff were so helpful and friendly… they would definitely recommend this unit to their family and friends.

4. SOMETIMES IT’S HARD TO GIVE THIS STELLAR CARE FOR EVERY PATIENT… WHY? • In the surveys you told us: one barrier to providing excellent family-centered care is communication breakdowns between caregivers. • In the surveys you told us: another barrier to doing your best is time constraints.

5. YOU HAVE A COMMON GOAL TO HELP GIVE THE BEST CARE TO YOUR PATIENTS… BUT HOW DO WE GET TO THIS GOAL? • We’re so glad that you asked!!!

6. WE BEGIN WITH A RROHC STORY… During our 6 weeks onsite, we met a 6 day old patient who was transferred to the Pediatrics unit for treatment of his jaundice; single overhead phototherapy for elevated bilirubin levels (13.9 mg/dL). It didn’t take long to recognize, that it was his mother, Mrs. R., who had more pressing needs than the actual patient due to her pain in her perineal area.

7. THE RROHC STORY UNFOLDS… During shift report, it was mentioned that the first-time mother was given some treatment (Derma-blast) and was recommended for a home visit after discharge. But, the dialogue proceeded with the understanding that it was actually the newborn that remained the focus of care. What we came to learn through this experience, was how family-centered care as mentioned under the RROHC model, would actually optimize care for the newborn during this hospitalization by taking care of the patient’s family member.

8. A HAPPY ENDING TO THE STORY… Mrs. R’s “angel” arranged a doctor’s appointment and it was found that she had suffered second-degree perineal burns (from spraying area with hot water). Once her own pain issues were addressed and treated, Mrs. R. visibly reduced her own anxiety as a first-time mother and was able to focus more on care of her newborn (such as breast-feeding and pumping). Secondarily, by resolving her own issue, Mrs. R also turned out to be less disruptive with staff scheduled on that shift.

9. HOW DO WE LEARN FROM THIS EXPERIENCE? • As Nursing Students, our assignment consisted of shadowing Managers to learn about the challenges of management as well as to learn about the culture of the units. • During this time, we became aware of everyday routines, including passage of critical information between caregivers. We chose to narrow in on the communication between Nurses and Nursing Assistants and Nursing Techs. • Concurrent to our rotation, your managers have been learning about the RROHC model of care, which stands for Relationships and Results Oriented Health Care.

10. A LEARNING EXPERIENCE FOR ALL • We began by observation of the shift-change reporting in Pediatrics department and also of the “board review” process in the Labor & Delivery unit. • We concluded the following: • Currently the MCH team does not utilize interdisciplinary rounds regularly • There is no consistent use of bedside consults • Planning does not consistently address patient’s goals and current progress • Shift reporting does not consistently include a patient’s plan of care toward discharge

11. AND THE SURVEY SAYS… • We conducted a survey to increase our understanding of the current processes by which patient and family centered care is currently implemented at WBH. Here’s what the nurses had to say. • “We permit the parents to spend the night with their children in Peds.” • “Food trays and showers are provided for the overnight parent [in Peds].” • “Full team reports are used [in Peds].” • “ In SCN, we encourage the parents to participate in infant care (diapering, swaddling, baths, etc.). We also arrange feedings around [the times] when parents can be here.”

12. The patient truly is “the center of all that you do.” You already have so many great ways to incorporate the patient and his/her family in facilitating care. The MCH staff is excellent at maintaining the goals set for the patient. But…

13. What about the patient’s goals for herself? • We noticed that no one mentioned the importance of determining the patient’s own personal goals. • Of course, you are aware of the patient’s desired outcomes. • But, is that relayed in report? • Are the goals set by the patient evaluated with the same dedication as the “official” goals listed in the care plan?

14. That’s where RROHC comes in!

15. LET US TELL YOU MORE ABOUT RROHC “RROHC (Relationships and Results Oriented Health Care) is an overarching philosophy & method of delivering care that combines patient & family-centered communication with high impact team practices to create positive health outcomes.” (Hansten, 2005)

16. ARE YOU READY TO GIVE IT A TRY? • In the surveys you told us… you’re open to trying a new idea called “checkpoints” that would help with improving your patients’ care… and even better if it also makes your workday easier! • As Beaumont Nurses, your mission statement includes that “the patient is the center of all that you do.” (The Beaumont Nurse publication, 2005 & 2006)

17. THEN, HOW CAN WE GET STARTED ON RROHC? There are 4 elements behind Relationships and Results Oriented Health Care: • Purpose: Why is patient here? What are your patient’s priorities? • Picture: What results are you looking for, both short-term and long-term? • Plan: What worked and what did not work? • Part: what part does each of us play and what can I expect of myself and of others? (Hansten, 2005)

18. These principles will keep you “RROHCking” ! • Make assignments based on the patient’s 4 Ps using critical thinking • Perform shift report and handoffs using the 4 Ps • Plan with the team and give initial direction: Critical Thinking • Implement introductory rounds • Focused patient interviews at eye level: Plan • Communicate plan and the patient’s 4 Ps • Implement interdisciplinary rounds • Perform checkpoints • Feedback and celebration of successes • Use the critical thinking problem solving process to revise plans based on feedback and evaluation.

19. IS THIS EVEN POSSIBLE WITH ALL OF THE OTHER THINGS THAT YOU NEED TO DO DURING THE DAY? Quote Steven Covey: “begin with the end in mind…” • Make it part of your daily workflow: Plan in partnership with your patient by finding out what the number one goal is for the patient that day and incorporate that into your plan. Communicate that plan with all members of the healthcare team so that everyone is following the same map. • Plan on Outcomes focused hand-offs by establishing regular checkpoints to communicate about patient goals and long term plans • Update with the team during designated “checkpoints” before and after breaks or meals to keep the bedside care team on the same plan. (Hansten, 2005)

20. MORE ABOUT CHECKPOINTS • Nurses and Nurse Assistants work side-by-side as a team, but during a busy day their focus may go towards the task instead of communication about the patient and collaborative care. Checkpoints are a chance to formally touch base regarding (1) patient’s progress, (2) to give or receive feedback from team members and (3) to make any necessary changes to that patient’s plan of care. (Hansten, 2005)

21. HELPS YOU AND HELPS THE PATIENT… HERE’S HOW TO DO IT… • It starts small… start with incorporating one bedside “checkpoint” with each patient before taking break or going to lunch. • It takes everyone… everyone is on the same “team” for the patient. “Interdisciplinary communication and teamwork are vital as they promote mutual respect and role clarity.” (Koloroutis, 2004, p. 11) • There might be bumps in the road, but keep trying until you’ve got it!

22. OKAY, SOUNDS NICE… BUT DOES IT WORK? Here’s what other people are saying…

23. A LOOK INTO THE LITERATURE… In response to the national mandates for reducing medical errors by staff (To Error is Human: Building a Safer Health System), one institution in Portland, Maine incorporated “Partnership Care Rounds,” including many hospital disciplines. It was found through their study, that on average 33 minutes per shift was “lost” with coping with interdisciplinary errors or problems. This was often handled first by nurses, who utilized “first-order” problem-solving, which could only deliver short-term solutions. Therefore, their institution felt that, “nurses are in the ideal leadership role to bring about this transformational change.” (Wiggins, 2006, p. 343) “Successful collaboration consists of communication, strong interpersonal relationships, based on trust, and time.” (Wiggins, 2006, p. 344)

24. EVEN JOHNS HOPKINS IS DOING IT… An unfortunate sentinel event caused a thorough root cause analysis in the Johns Hopkins Pediatric Oncology unit. When it was determined that poor communication was a definite contributing factor to the problem, health care teams implemented patient care “rounds” by congregating around a white board containing names of all inpatients on the unit. Staff nurses presented their patients for any colleagues that were also participating in that same patient’s care. (Blough & Walrath, 2007)

25. SOME DO BEDSIDE ROUNDING In Arizona, the oncoming Nurse and Nurse Assistant received report at the patient’s bedside. This consisted of the plan of care for the patient, and any key events that were to occur for the day. Any confidential information was relayed at a different time for staff only (especially if the patient had any guests in the room at the time of report). Additionally, Nurse Assistants planned on “team huddles” with their Nurse every 3-4 hours to exchange any new or updated information on the patient’s status or needs. (Anderson & Mangino, 2006)

26. WHAT ARE THE BENEFITS FOR DOING THIS? • By focusing on a measurable outcomes or goals, it ensures movement in the correct direction from all care providers as well as reducing confusion in care. “…continuity of team relationships…(and) continuity of care reduces the likelihood of medical errors.” (Koloroutis, 2004, p. 12) • Patient safety and patient satisfaction increased at one institution as supported in their research – in fact, the patients utilized their call lights less after implementation of bedside rounding and checkpoints!

27. THE RESEARCH SUPPORTS IT A study including 14 hospitals found the following: • Patients felt more empowered and involved in their care when the Nurse conducted a “live” shift report at the bedside; additionally patients were also able to be an additional resource. • Patients utilized their call lights less frequently by approximately 20-30% since they could anticipate a staff person coming to the bedside at a designated time for the staff “checkpoints.” One hospital in Philadelphia reported call light usage cut by 65%. • A side benefit to this change, the hospitals also reported a substantially lower patient fall rate (one institution reported 60% less falls) as less patients made desperate attempts to self-toilet knowing that assistance would be available on a regular basis. (Meade et al., 2006)

28. HOW TO IMPLEMENT THIS IN YOUR AREA • You’ve already taken your first step! Just even by attending this presentation demonstrates an interest in RROHC and shows that you really want to make a difference for your patients. • Take brochures back to your area for those that were not able to attend. • Spread the word by displaying the Poster boards in various units. • Learn from each other! One unit has implemented the “board review” meeting in Labor & Delivery… see if this is something that would work in your area as well.

29. WHAT CAN YOU DO? • Talk with your units to devise a method that works for your area – assigning designated “checkpoints” or “team huddles” between the Nurse and the Nurse Assistants or Nurse Techs: one suggestion is to have these right before leaving for break, or right before lunch, whatever works best for your unit. • Work with your team to determine if a verbal collaboration will improve upon interdisciplinary care for your patients • Work with your Clinical Nurse Specialist to streamline the shift-change reporting, possibly developing a standardized shift-change reporting form.

30. CHANGE IS HARD, BUT IT’S WORTH IT LATER “When Health Care Team members understand the results that they want, they operate from a shared common purpose to create a shared picture of success, and an effective interdisciplinary care plan which clearly outlines the critical part of each member of the team.” (Hansten, 2005)

31. ANY QUESTIONS? Ask anything… because after this, we want to give you a quiz!!!

32. REFERENCES Anderson, CD and Mangino, RR (Apr-June 2006). Nurse shift report: who says you can’t talk in front of the patient? Nursing Administration Quarterly, 30(2): 112-122. Retrieved May 16, 2007 from PubMed. Blough, CA and Walrath, JM (April-June 2007). Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic. Journal of Nursing Care Quality, 22(2): 159-163. Retrieved May 29, 2007 from CINAHL. Caruso, EM (Feb 2007). The evolution of nurse-to-nurse bedside report on a medical-surgical cardiology unit. Medsurg Nursing, 16(1): 17-22. Retrieved May 16, 2007 from PubMed. Hansten, RI (Dec 2005). Relationship and results-oriented healthcare: evaluate the basics. Journal of Nursing Administration (35(12): 522-524. Retrieved May 16, 2007 from PubMed. Koloroutis, M (Ed.). (2004). Relationship-Based Care: A model for transforming practice. Minneapolis: Creative Health Care Management. Meade, CM et al. (September 2006). Effects of nursing rounds on patients’ call light use, satisfaction, and safety. American Journal of Nursing 106(9): 58-69. Retrieved May 29, 2007 from CINAHL. Wiggins, MS (Jul-August 2006). The partnership care delivery model. Journal of Nursing Administration (36(7-8): 341-345. Retrieved May 16, 2007 from PubMed. Yoder-Wise, P (2003). Leading and Management in Nursing. St. Louis: Mosby, Inc.

33. IT’S QUIZ TIME!!

34. RROHC is an acronym for: Real Results Of Health Care Relationship and Results Oriented Health Care Readiness to Really Offer Help to Clients

35. Which of the 4 Ps describes the vision for patient outcomes? Purpose Picture Plan Part

36. Which of the following is one of the 10 principles of RROHC? Relay the 4Ps during shift report and hand offs Implement interdisciplinary rounds Give feedback and celebrate successes All of the above

37. Which of the following is not considered an objective of implementing checkpoints? To touch base regarding patient’s progress, To give or receive feedback from team members To determine when the NA can go to lunch. To make any necessary changes to the plan of care.

38. True or False: In regards to RROHC, autonomy is preferred over the team approach. True False

39. A Florida study suggests that implementation of bedside shift reports and regular “checkpoints”:(choose two) Caused patients to be uneasy Increased staffing needs Decreased patient call light usage Decreased the patient fall rate