In April 2013, I challenged our Chief Nurse Executive with a daunting task. I asked Mary Ellen Bonczek to find a way, by working through Lean methodology and engaging direct care providers, to redefine how we deliver patient care.
Did we have the right people performing the right tasks? Did every task need to be done the way we were doing it? How could we maximize time spent at the patient’s bedside?
We knew we were already delivering excellent care, but was it the most effective way to deliver that care, and was it always done the best way every time? Without a more efficient model, would we be able to adapt to the changes in our healthcare industry, with more quality expected while being paid less? And was every task, duty or assignment that every staff member performed focused on our most important goal - the care of the patient and the family?
Mary Ellen completed research and site visits to identify what others were doing, but most importantly, she worked with our Lean team and brought together a group of interdisciplinary staff to define our current state and then begin to create the new model.
This team then came back with a model that has transformed how we take care of patients. We call it “SharedCare,” and we have been able to implement it on three patient floors, with future expansion on the schedule. The process is moving in a measured way to allow individual units to prepare for the change in staffing mix, leadership roles and daily duties.
Not only have we had demonstrable results in terms of quality care and staff satisfaction, but we have been invited to present this model at the 2015 American Nurses Association National Quality Conference, positioning New Hanover Regional Medical Center as a national leader in this care transformation.
This process began with a group of nurses, nurse assistants, physicians, pharmacists, therapists, case managers and unit clerks employing the Lean methodology we now use to guide us through workflow evaluations. The goal was to find a way for the patient to get the right care by the right person at the right time – every time.
What do we mean by that?
Historically, it has been far too easy for nurses to get caught up in the task of the moment, regardless of whether it adds value to the patient. The RN on a unit may get pulled and distracted by phone calls, conversations and needs requiring an immediate response. Often the RN finds herself giving a patient a bath, helping a patient get to the bathroom or tidying up a room. All of these are worthwhile and needed tasks … but do we need an RN to do them?
With the SharedCare model, the idea is to build care teams, under the direction of the RN. On the units currently open, we may assign a group of patients to two RNs and two Nurse Assistants, all under the direction of an RN in charge of the entire team. As we roll out this model on future units, the teams will be modeled around the level of patient need or level of illness.
The Nurse Assistants perform the tasks they are trained to do – assist patients with daily living skills, take vital signs, bathe patients, etc. We even assign one Nurse Assistant to scheduled, predictable tasks and the other to unscheduled needs that arise.
Nurses are left to perform the specific tasks their license allows them to perform – assess patients’ condition, administer medications, coordinate care, educate patients and communicate with physicians about patient needs, among many others. They are allowed time to focus on the patient’s care, and take leadership in ensuring that care is exactly what it needs to be.
We call this “working at the top of your license,” for both the RN and the Nurse Assistant. But the SharedCare model is more than clinical staff filling the right roles. It’s designed for many disciplines to work together as a team on behalf of the patient. The physician, pharmacist, case manager, dietician and therapist consistently consult on each patient’s status and proactively address clinical needs. At specific times throughout the shift, all members of the care team have the opportunity to collaborate, or “huddle,” and adjust the patient’s care plan. We recently added the housekeepers to the huddles because they frequently interact with patients and can provide valuable information to the team about the patient’s or family’s needs.
By aligning staff this way, you find that many patient needs – such as toileting - are predictable and can be addressed before the patient has to ask. For example, on our 6th floor, the “call bells” requesting a nurse’s attention decreased by 17% in a year’s time, and falls have improved as well. We’re able to get 100% of eligible patients to “ambulate” or walk around, and we’re consistently gathering key clinical data, such as daily weight, 100% of the time. In most instances, our patients’ experience, as measured through a national survey, has increased as well. We also have staff members experiencing fewer interruptions, working at the top of their license, and working in partnership with other clinical disciplines at the medical center. This team approach has improved employee satisfaction and reduced turnover among nurses.
We still have a ways to go to perfect the SharedCare model, and ensuring that it is staffed correctly is both crucial and challenging. The model has presented additional employment opportunities for Nurse Assistants in this community, and we want to fill those positions as we go forward.
We believe in this model and we’re confident this is the future of patient care. SharedCare refines the patients’ plan of care to focus solely on those duties that benefit the patients’ wellbeing. And that’s the way health care should be..