Inpatient Plan of Care: How do we talk about the process?

Inpatient Plan of Care: How do we talk about the process? April 11, 2012

Objectives • Participants will understand the problem we are trying to solve • Participants will understand and be able to explain the Plan of Care process • Participants will be prepared to lead re-education efforts with Staff RNs • Participants will understand resources available to support this re-education effort

Problem Statement During recent tracers, Mock JC surveys, and during the Stroke certification JC survey, staff were not able to explain the Plan of Care Process. There was good evidence of Care Planning activities but lack of ability to articulate how all of the components come together to provide a multidisciplinary, patient-centered plan of care. Because we are within the window for our JC survey, the decision was made to focus on enabling staff to explain our current POC process rather than on making drastic changes to that process.

The Pathway Problem • When there are diagnosis- or procedure-specific Pathways that are up-to-date and well integrated into the team’s workflow, staff were able to explain how these guide the overall plan of care. • In areas where there are not appropriate Pathways and where staff rely mostly on Generic age-based or Service-based pathways, there was much less ability to explain how these guide the overall POC and lack of ability to cite other sources of evidence. • We will therefore continue to include Pathways as one part of the POC resources but will also educate to other sources of evidence and best practice information.

What’s changing? Not changing Changing Emphasis on Pathways as sole basis for plan of care Distinction between Patient Plan of Care (which includes Plans from all members of the team) and the Nursing Plan of Care Focus on the OPC as the place we “visualize” the Plan of Care • Use of Priority Problems, Short Term Goals, Nursing Summary, and Plan Priorities documented in HED as basis of the Nursing Plan of Care

Plan of Care training guide

Available by April 16

Next Steps Meet with SSS Rep/CAPS and leadership team as soon as possible to confirm education plan which would include: • Presentation/discussion in a Staff Meeting/Unit Board • Working with nurses individually or in small groups to: • practice explaining their plan of care process for their patients (using the “script” provided on grid) • Identify & submit questions that can be answered in FAQs • Identify resources (SSS Web Site, Mosby’s, etc.) they can access for help with POC development • “Audits” every 10 days to assess effectiveness of education efforts – with fine-tuning of efforts if ineffective.

Inpatient Plan of Care: How do we talk about the process?