Care Models: Thoughts regarding what’s needed for success!

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.

8) 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


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