I am so glad to recount the experience of being present on the units at Norwalk Hospital! I loved to see the shift hand-offs at the bedside as RNs and PCTs shared their large photos (with names) to the magnetized white boards. Patients and families, as well as physicians, love to be able to see who is caring for them and to find that nurse more easily due to those photos! Also the shift change was very quiet due to the rounds in the rooms as well as the use of the Optivox recordings for transfers and shift reports. Patients said they liked being involved in determining the plans and goals for the day, and even those who were not English speaking could tell that the photos meant someone new was caring for them!
Of course I always love to visit our Norwalk RROHC-ers, but it was gratifying to see the steady upward trend of Press Ganey results on the RROHC units also!
Thank you for your hard work in redesigning your delivery system!
Ruth

For those who have not read,  The Starfish and The Spider, Penguin, 2006 (Decentralized Revolution, LLP)

by Brafman and Beckstrom, Kimberly and I were able to attend Rod Beckstrom’s address at the AONE convention in April.  This book outlines the revolution and power of decentralized organizations, such as Ebay, Craigslist, the abolitionist and women’s rights movements, and AA.  It is an amazing way to look at our world. The impact of catalysts who are able to bring people together around shared values is paramount.  A spider, should it lose its head, will die, but if a starfish loses a leg, it not only regenerates a leg, but the amputated leg develops another starfish.  We believe that our methods for developing RROHC organizations is similar to the decentralized networks.  You out there use the principles we bring to you, and adapt them in your own way.  You develop your own care delivery model using these ideas, always sharing the values we offer, and make the best practices work in your particular manner.  Each unit adapts and once they are up and running, these “starfish legs” are able to not only thive, but cut off and reproduce their success!   Rather than a top-down CEO type of organization, we are the catalysts to collaborate behind the scenes, connect you with each other, and hopefully inspire you to greater excellence!  Master coaches and facilitators are catalysts for growth in their own departments.  We cannot count the number of participants in RROHC organizations, similar to the starfish that thrive in clean water.
For those who wish to read this book we think you will love it!

Ruth Hansten

Many hospitals participating in IHI’s Transforming Care at the Bedside Initiative have asked questions related to care modalities.  What works? How can we encourage staff do hourly rounds or shift hand-offs at the bedside?  What if you work with RNs,LPNs, and care aides? Here are some of my thoughts about what supports successful care models, based on experience from over 160 hospitals.

1)  Each care provider (all disciplines) must have a clear template in mind regarding how they proceed through a shift as experts.  Each bedside team member knows that “A day in the life of an expert RN” looks like this from the beginning of the shift to the end, at this facility. This often means new skills and processes must be taught.

2)  The care model must be based on patient/family preferred results, not a fuzzy “patient oriented” basis that does not also help clarify the long term and short term goals the care team and the patient/family are partnering to achieve.  This may seem like a small difference in the way we think; however, shared outcomes allows us to engage in our own healing (as clients) and to recognize our impact on patient’s lives (as providers).  Shared, envisioned results allow our brains to move more quickly to the goal.

3) Staff must be taught how to implement their leadership responsibilities (including delegation/supervision) and how to incorporate times through the shift or episode of care that allows them to efficiently use their time and the time of their assistants.

4)  Coaching of these principles and processes must continue so that the cultural change permeates the entire organization. Educating just a few without sharing concepts and skills with others will not create the same result.

5) The care modality must be one that engages the hearts, minds, and spirits of the providers.  “Team nursing” is not enougn to really excite any nurse. (Can you imagine any nurse saying “wooo hooo! we practice team nursing here!”)  The nurse or other team member’s personal purpose must synergize with that of the organization and that of the patient/family.  The model must also be clear to all involved.

6) As care models are changed, teach staff to use critical thinking and problem solving processes so that they can fix the “system issues” that plague their daily care.

7) Initiatives like hourly rounding or bedside shift report, when applied as a bandaid on an tired care delivery model that excites no one, and is implemented in a variety of ways across the medical center, will not get the results one hopes for.  These initatives become another task to place into an already busy day. Assistive personnel see the rounds as yet another “check off the list” and the turning or positioning or hydration is not a piece of that process, and is not completed. Contrast this picture with an organization in which nurses coordinate and lead the care by first knowing their patient/family preferred outcomes, and at bedside shift hand-off, the patient/family is involved in planning the care for the shift while the RN offers initial direction to assistive staff, planning for checkpoints and team huddles as a PART of meeting that particular patient’s needs, including who/when rounds will be made and for what purpose.

Best team practices, such as celebration checkpoints and offering of feedback, allow for staff to not only develop streamlined teamwork and communication patterns, but help staff learn how to think critically about what worked this shift, as well as what they would want to change in their plans for the next shift.

 I hope this helps!  Please review our RROHC book:  Relationship & Results ORiented Healthcare Planning and Implementation Manual, and contact us for further questions.

We are passionate about changing care at the bedside for the better!

Ruth Hansten

hello to the RROHCers!
Several issues have come foremost to my eyes in the last 3 weeks of travel around the nation:

1)  Transforming Care at the Bedside (TCAB) the IHI initiative presentations that I attended at AONE:  Many of these organizations are using pieces of the RROHC program ideas. YES! There is a subtle difference between what goes on when a patient and family are asked what THEIR intended results are, rather than presenting: “This is our plan of care for you.” I was struck by the impact that it makes when the patient/family truly engages in their own goals and own healing! I hope more of the patient centered organizations see that subtle difference that has such an impact!

2)  Nurses still are not delegating and supervising appropriately.  Assistive personnel must be assigned to nurses, not just to a set of patients, and the plan for the shift must include how a PCT or aide will re-connect with the nurse(s).  Often the whole day’s success or failure boils down to the assignments at the beginning of the shift.

Your Thoughts?

3)  We had a great response to the Webinar we offered on Friday: Linda Pullins joined us to discuss case studies for Leveraging the power of nursing in this economy. Thank you to all the current RROHC folks who joined us and added comments and questions! We are glad to use this format in the future!
Ruth

As I was reading an article in Healthcare Executive about promoting a culture of patient safety (March/April 2009), I reflected on the idea of “read back” for physician verbal orders.  We all learned this was necessary in nursing school, so that we would be sure to get the correct medication and treatment orders at 0300 from a sleepy physician.  This safety practice means that a patient will receive 14 mg instead of 40 mg! As I read this article, however, I was struck by a common lack of respect for the crucial nature of delegation and supervision communications from RNs to assistive personnel.  Just as essential for patient safety is the idea of obtaining the correct glucose stick result at the right time, so that insulin can be administered optimally! Just as essential is the actual turning, ambulating, toileting, and hydration of our patients!  But how often do we ask NAs to repeat back the nursing orders?  As I travel about the nation working with hospitals, I discover that still….in 2009….NAs are functioning independently, and RNs are not giving adequate or accurate initial direction…or feedback to the team.  What is the cost of this for each patient, and for our nation, annually?  How long does it take for an stationary patient to develop an ulcer that will cost many thousands of unreimbursed dollars?  What is the impact of our supposition as RNs that “They know their jobs!”  What about the cost of nurses being too busy….an not instructing assistive personnel to observe and obtain patient data…the imminent dangers and failures to rescue?  The RROHC bundle of best practices includes a recipe for initial direction and incorporation of assistive personnel into the team, checkpoints and timelines, and specific times for feedback, critically thinking and reviewing the patient outcomes, the teams performance, and the degrees of success of the plan for the day. 
Change the culture to one of safety! The best teamwork saves lives!
Ruth Hansten

Today at Cedarbrook with the background of the sunny Seattle skyline, gourmet food, babbling brooks, art, and stone fireplaces, the group studied their own contributions to their organizations through their presence, dealing with challenging participants, encountering and embracing resistance, and worked in groups to develop their assigned RROHC concepts. We appreciate that long term care and home health specialist have joined us to help further develop that portion of our program and work with others throughout the continuum of care.
Always, we focus on the relationship of the professional with the patient, developing critical thinking skills. Tomorrow the group will present their educational concepts and we will stress the implementation plans.
What a wonderful group in a beautiful, graceful, peaceful setting! We are fortunate to work with all of them. Ruth

Kimberly and I and particpants from six organizations are here in Seattle at Cedarbrook retreat center and enjoying leading the Facilitator Intensive Training Session.  There has been rare Sun in Seattle!  We will add photos and video clips over the next few days.  Tomorrow the group will be working together to plan their presentations about RROHC:  the end results we expect at their organizations will be better patient satisfaction, nurse retention, employee engagement, better delegation and supervision and better critical thinking skills development!
Ruth Hansten and Kimberly McNally

 RNs See Eye to Eye With Patients
Nursing care model at Oakwood Hospital brings personal touch back to bedside.
By Catherine Spader, RN | Nurse.com

Pull up a chair with the nurses at Oakwood Hospital in Dearborn, Mich., to discover how they have improved relationships with patients through a program called Relationship & Results Oriented Healthcare.

“It’s all about bringing the basics back to nursing. As opposed to standing and towering over patients, we’re pulling up a chair, talking to patients at eye level, holding their hands, and bringing that personal touch back to the bedside,” says Diane Lopez, RN, clinical manager of Oakwood’s intermediate care unit.

Communicating at eye level is only one facet of RROHC’s adaptable, goal-oriented approach to improving patient safety, clinical outcomes, and staff and patient satisfaction.

“Healthcare professionals are often not functioning within a conceptual framework that allows them to most quickly learn and use expert practice, such as how to best connect with patients and families,” says Ruth I. Hansten, RN, PhD, FACHE, principal consultant at Hansten Healthcare PLLC, the developer of RROHC. “RROHC teaches the skills to build relationships, maximize productivity, and help patients and staff focus on the result they are looking for.”

Communication Is Key

RROHC incorporates a bundle of best practices and skills, including therapeutic eye contact and focused listening, which focus on improving patient and family communication with staff.

The bundle also contains elements that foster a consistent team approach to goal setting and outcomes. These include —

• Consistent introductions to patients and families that include name and position.

• A goal-planning session with each patient on each shift.

• Regular meetings in which care teams share feedback and update goals and plans of care.

• Interdisciplinary rounding and bedside handoffs that focus on goals and outcomes.

Bedside Shift Change

Oakwood Hospital has instituted bedside handoffs, which the staff dubbed Relationship Oriented Care, as another facet of its RROHC program.

“As opposed to being away in another room giving report for 15 minutes, we’re doing it right at the bedside, which is more patient-focused,” says Lopez, adding it also saves nurses time.

Handoff reports consistently focus on the four “Ps” — purpose, picture, plan, and part.

• Purpose: To stabilize Mr. Smith’s blood sugar and help him to better manage it at home.

• Picture: To discharge Mr. Smith home within two days.

• Plan: Monitor glucose levels, adjust insulin regimen, assess learning needs for discharge, meet with diabetic educator and dietician.

• Part: A nurse assesses Mr. Smith, monitors glucose levels and dietary intake, administers insulin, facilitates communication and coordinates care with other professionals, and reinforces teaching done by diabetic educator and dietician.

All Eyes on the Patient

The program focuses on having nurses at the bedside, at eye level to the patient, when helping determine short- and long-term goals.

“Too many times nurses multitask, taking vital signs, doing paperwork, checking medication sheets, and are not focusing on the patient. We recognize patients and families need more than that, and goal identification is the whole basis of this program,” says Kari Szczechowski, RN, BSN, staff nurse on the intermediate ICU.

Daily goals, such as getting out of bed or getting a good night’s sleep, are written on a patient care communication board located at each bedside.

“It reaffirms to everyone what the focus of the day is,” says Lopez.

Hourly Rounding

In addition, nurses are generally assigned to patients with whom they have established a rapport. Nurses complete an hourly rounding process in which they assess and address pain control, positioning, and elimination needs. The unit manager rounds daily with the charge nurse to meet all patients to ensure they feel as though they are getting what they need.

At St. Joseph Mercy Health System, Ann Arbor, Mich., the staff has dubbed their RROHC program Relationship Centered Care. A key element of the program on the general surgery unit is a unit council that is open to all staff, says Pat Merlo, RN, MSN, the organization’s service delivery leader.

One of the projects conducted by the council is a monthly audit in which one of the council members interviews every patient on the unit about their care with questions such as, “Are you happy with your care?” and “Do the nurses treat you with respect?”

“I can intervene immediately from there, if needed,” says Merlo. “It’s so proactive, and the patients really appreciate it.”

HC Pro Features the RROHCs care delivery model.  

A new nursing care model has staff at Oakwood Hospital in Dearborn, MI literally pulling up a chair to improve patient care delivery.

Relationship & Results Oriented Healthcare—created by Hansten Healthcare PLLC, a healthcare firm based in Port Ludlow, WA—aims to strengthen staff members’ connection with patients and families by adding a personal touch to the delivery of results-oriented care.

The multifaceted, but adaptable model incorporates a number of practices to assist nurses in providing safe patient-centered care. One practice has nurses communicate with patients at eye level while sitting beside them, rather than towering over them when standing. They are also taught to practice focused listening skills and therapeutic eye contact.

Under the model, nurses also hold goal-planning sessions with patients each shift, perform bedside handoffs, and meet to discuss care plans for patients regularly.