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Care Team Architecture

Jim Molpus, for HealthLeaders Magazine, October 8, 2009
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Creativity and flexibility count, sure. But underlying the successful care team design is a foundation of essential and lasting values.

A few years ago the leaders at Baptist Health South Florida had an idea for a new member of the care team. This was an innovation to finally make the patient care team work to its full potential. They were surprised when it failed.

The experiment was what they called the "12-bed hospital," in which a senior-level nurse—called a "patient care facilitator"—was assigned to a limited number of patients and became their "be all and end all," says Becky Montesino, chief nursing officer of Baptist Health South Florida, a five-hospital nonprofit system with 1,590 beds.

"They knew everything about those patients," Montesino says. "They planned their discharge. They did their teaching. Even though there were nurses and techs assigned to that patient, the PCF managed all of that. It really worked quite well for us."

But healthcare has a way of making innovations in the care team obsolete quickly. As more pressure grew from CMS and other quality bodies to track indicators, the PCFs increasingly found themselves responsible for chasing data. The other fracture was more cultural; the regular staff nurses who were not PCFs found themselves relegated to tasks and procedures. They hated it.

The care team at a hospital—the nurses, physicians, technicians, therapists, social workers—are the physical reflection of demand on the system. Members flow and go depending on a variety of breezes that push for higher patient satisfaction, lower costs, and more coordination. The right mix is right only according to local conditions. The mix must often balance competing needs—including resource allocation for specialized versus general care. Any change represents a substantive shift in somebody's job description, so embarking on any reinvention of the care team is inviting a cultural clash.

In the miasma, there are some solid lessons being learned as the pieces more closely resemble a team that can remain relevant in a modern healthcare mix:

1. Free the nurse
Barbara Stumpo, RN, BSN, MPA, vice president of patient care services at Derby, CT-based Griffin Health, remembers the bad old days with three registered nurses on a med-surg floor with 55 patients. The medical staff was a mix of community physicians, with the teaching staff in medicine and surgery.

The team was more like an assembly line.

"The care was very separated," Stumpo says. "One nurse would deliver the meds. One treatment nurse would take care of the wound. And if you thought changing the dressing would cause some pain, you would have to go get the medication nurse."

Care team structure was redesigned when Griffin built its new hospital in the mid-1990s with a floor plan that decentralized the nursing station into care "pods," where a nurse is situated within sight of four patient beds.

Now, the care team at the 160-licensed-bed nonprofit hospital arranges the nurses in pods around four patient rooms, with a primary care nurse and an associate nurse. The primary nurse customizes the patient's care plan based on Griffin's guidelines and is generally the nurse on the day shift. Certified nurse assistants have been replaced with "multi-skill techs," or MSTs, who are able to do routine care such as drawing blood, EKGs, and minor breathing treatments.

The arrangement leads to a nursing-rich patient-to-nurse ratio of 4-to-1 or 5-to-1 during the day, 6-to-1 during the evening shift, and 8-to-1 during the night shift, says Griffin Vice President Bill Powanda. The decision to benchmark Griffin with 50 other hospitals and stay below their median is an intentional one, he says, and fits with Griffin's patient-centric Planetree philosophy of care. But the ratio itself is a contributing element of the care design team, not its sole root.

"Throwing more nurses at it is not the solution," Stumpo says. "The design we have is based on each nurse having a description of what they do in the primary patient care model."

One of the drawbacks to deploying nurses in concentrated teams around small groups of patients is that you lose system navigators for complex patients, a problem that Virginia Mason Medical Center in Seattle tackled by adding nine "clinical nurse leaders," says Charleen Tachibana, RN, senior vice president, hospital administrator and chief nursing officer for the nonprofit 292-staffed-bed facility.

"What we found is that these complex patients were falling through the cracks in our system in things such as nutrition not being started early enough or ambulation not being carried out. So we put in the role of clinical nurse leader who really was intended to be the 'red thread' throughout the hospital stay and would follow that complex patient—not delivering the hands-on frontline care but almost as the nurse concierge—going through and smoothing the way. It's almost a concept of the attending nurse."

The CNLs play a key generalist role in spotting systemwide issues. When the CNLs noticed too many patients were not being fed early enough and that was delaying their care progression, they had the pull to bring in the dietary staff to refocus, create new dietary calculations, and then have physicians approve, Tachibana says. The results "trimmed days off the nutritional deficits," she says.

But the hospital did not deploy CNLs when the concept first came up in the literature, says Donna Smith, MD, medical director of Virginia Mason Hospital.

"Then about a year and a half later we heard from the patients about having to tell their story every shift, that there was the lack of the 'red thread' following them through the course of their hospitalization," Smith says. "Even the providers couldn't provide that red thread for them and their families. So we took another look at CNL role and decided this wasn't a role that existed within any one person on the team. It was an additional role that needed to be added to support the patient care experience. It has been a phenomenal success."

Baptist Health South Florida's next iteration after the "12-bed hospital experiment" was to add the role of advanced registered nurse practitioner to help manage more complex patients by coordinating their care, and even writing orders, which must be cosigned by a physician. That frees the patient care facilitators to concentrate on quality metrics, while the addition of a nurse educator on every floor allows staff nurses to concentrate on care, Montesino says.

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