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Time to Put Patients First

Gienna Shaw, for HealthLeaders Magazine, May 12, 2010
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The program puts equipment such as IVs and blood pressure pumps and supplies such as linens in or outside of every room. The hospitals also cut nonclinical time with preprinted order sets and patient care pathways. Both nurses and patients have cell phones so that nurses spend less time running to answer call buttons or looking for a free phone to call a physician for a verbal order. They also conduct hourly nursing rounds.

Nurses at 11 member hospitals in Georgia have been keeping track of the time they've spent on direct care and indirect care to determine time saved with the program. They use PDAs to keep track of time spent away from their patients, performing tasks such as calling doctors for verbal orders. During a 90-day period, one of the hospitals using the RetuRN to Care model increased the time nurses spent directly caring for patients—taking vital signs, feeding, or starting an IV, for example—from 30% to 61%.

Other benefits include reduced readmissions, avoiding nursing-sensitive never events such as hospital-acquired infections, and better satisfaction scores. Physician satisfaction has also improved.

The idea is to "make the right thing to do the easy thing to do for the nurses," she says. "The right thing to do for the nurse is the right thing to do for the patient. And we throw so many barriers in front of the nurse—so much so that we've now created this laughable nursing model named 'FRED.' We can either laugh about it or roll our sleeves up and get started. Because this new era of consumer-driven care, which mandates excellence, is going to demand a whole different way that we approach care."

The regional health system: Relationship-based care
"At this organization, the old definition [of patient-centered care] used to be bringing care of the patient to the bedside," says Maria Brennan, CNO and vice president of patient care services at the three-hospital St. Joseph's Healthcare System in Paterson, NJ. But for St. Joseph's, that model—which included pharmacies, equipment, and supply rooms on each floor—proved too costly. Instead, they moved to a relationship-based care model.

The first of three tenets of the relationship-based model is the nurse's relationship with him- or herself. The second is the caregiver's relationship with the patient and family, which is at the center of everything, says Brennan. The third is the caregiver's relationship within the interdisciplinary team and how the members of that team work together to deliver the best care possible to the patient. "That's our take on patient-centered care today," Brennan says.

"Patients really want really to be heard by their caregivers, and I think this model really encourages that you build a relationship with the patient and family. And you really think about what their needs are and how we can best meet their needs. It's about the joint relationship between the caregiver and the patient."

Programs in place at St. Joseph's that support the relationship-based model include the "Watson Room," named for Jean Watson, PhD, a professor and author whose work in the philosophy and theory of caring helped inform the St. Joseph's relationship-based model. It's a place that nurses can go to de-stress "so that they're really prepared to give their 200%" when they get to the patient's bedside, Brennan says. Nurses must be prepared to give their all to every patient and every family, and stressed-out nurses simply aren't able to do that, she adds.

Another tactic is to align nurse's schedules to their patient assignments so that nurses stay with the same patients for as many days in a row as possible. "I'm not saying it works 100% of the time, but even if we get it right 80% of the time that makes a huge difference," Brennan says. "The patients like seeing the same caregiver day after day. Again, you're building that relationship of trust."

Like VHA, St. Joseph's has programs in place to allow nurses more time with patients.

"That is really the performance improvement arm of everything we're doing. The whole theory behind that is problem-solving truly with your frontline staff," she says. That includes not only nurses but also patient care assistants and nonclinical workers, such as unit secretaries. The team identifies a problem, chooses a strategy to solve it, does a small test, and gradually expands initiatives that show signs of success. "They are very engaged in making processes better for their unit, which I do believe will lead to patient safety initiatives, more rounding with the patient," Brennan says. "I don't see how you could go wrong with this."

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