HIT Support for Safe HIT Support for Safe Nursing CareNursing Care

2004-20072004-2007Gail Keenan, Ph.D., R.N.Gail Keenan, Ph.D., R.N.Elizabeth Yakel, Ph.D.Elizabeth Yakel, Ph.D.

R01 HS015054-01

NIH- Agency for Health Research and Quality (AHRQ)

HANDS Core Project Team HANDS Core Project Team

Team SupportTeam Support Annie Browning, MSPHAnnie Browning, MSPH Sharie Falan, MS, RNSharie Falan, MS, RN Yvonne Ford, MS, RNYvonne Ford, MS, RN Crystal Heath, MS, RNCrystal Heath, MS, RN Deanna Marriott, PhD Deanna Marriott, PhD Rachelle Ramos, BSN, RNRachelle Ramos, BSN, RN Emily Springfield, MSEmily Springfield, MS Marcy Treder, BSNMarcy Treder, BSN Dana Tschannen, PhD, Dana Tschannen, PhD,

RNRN Santosh Udupi, MSSantosh Udupi, MS

Administrative TeamAdministrative Team Gail Keenan, PhD, RN – PIGail Keenan, PhD, RN – PI Elizabeth Yakel, PhD, Co-PIElizabeth Yakel, PhD, Co-PI Mary Mandeville, MBA, Mary Mandeville, MBA,

DirectorDirector Advisory / Consultant Advisory / Consultant

MembersMembers Connie Delaney, PhD, RNConnie Delaney, PhD, RN Ada Sue Hinshaw, PhD, RNAda Sue Hinshaw, PhD, RN Mary Killeen, PhD, RNMary Killeen, PhD, RN Sally Decker, PhD, RNSally Decker, PhD, RN Linda Scott, PhD, RNLinda Scott, PhD, RN Julia Stocker, PhD, RNJulia Stocker, PhD, RN Kathleen Sutcliffe, PhDKathleen Sutcliffe, PhD

Study AimsStudy Aims

To demonstrate that Health To demonstrate that Health Information Technology (HIT) Information Technology (HIT) (Hands-on Automated Nursing Data (Hands-on Automated Nursing Data System (HANDS)System (HANDS) Method)Method) can be can be successfully implemented to support successfully implemented to support nurses in a dynamic Care Planning nurses in a dynamic Care Planning Process (CPP) encompassing both the Process (CPP) encompassing both the planning and provision of careplanning and provision of care

To demonstrate that implementation To demonstrate that implementation of the of the HANDS MethodHANDS Method increases the increases the safety culture of diverse nursing unitssafety culture of diverse nursing units

Hypotheses Hypotheses

Our HANDS Care Planning Process Our HANDS Care Planning Process (CPP) Method (CPP) Method H1.1 satisfactorily represents the H1.1 satisfactorily represents the collective collective

mindmind of nurses across time and of nurses across time and settingssettings

H1.2 sustains H1.2 sustains mindfulnessmindfulness in the CPP across in the CPP across timetime

and settingsand settings

H1.3 supports H1.3 supports heedfulheedful interrelating about the interrelating about the

CPP across time and settingsCPP across time and settings

Lessons Learned from Lessons Learned from Earlier Projects Earlier Projects

Competency in use of NNN builds over time Competency in use of NNN builds over time USE to FRAME HAND-OVER (Report)USE to FRAME HAND-OVER (Report)

Care Plan application must be easy and Care Plan application must be easy and accessibleaccessible

Convert to WEB-BASED VersionConvert to WEB-BASED Version IT is a MAJOR CHANGEIT is a MAJOR CHANGE

Unit to OWN changeUnit to OWN change Include RNs ALL ROLES as CHAMPIONSInclude RNs ALL ROLES as CHAMPIONS Create STRATEGY to Continuously Nurture until Create STRATEGY to Continuously Nurture until

SUSTAINEDSUSTAINED Users must LOVE itUsers must LOVE it

Focus on making it VALUABLE TO RN USERS Focus on making it VALUABLE TO RN USERS

Core Framework:Core Framework:HANDS Care Planning HANDS Care Planning

MethodMethod

(Keenan & Yakel, 2005)

HANDS Care Planning HANDS Care Planning Method and Positive Method and Positive

OutcomesOutcomes

(Keenan & Yakel, 2005)

HANDS MethodHANDS Method

Mindful Care PlanningMindful Care Planning

+ Heedful Interrelating in Report+ Heedful Interrelating in Report

= Collective Mind of RNs in HANDS= Collective Mind of RNs in HANDS

Subjects & RequirementsSubjects & Requirements

8 nursing units (4 in Year 1, 4 in Year 2) 8 nursing units (4 in Year 1, 4 in Year 2) located in 4-5 health care systems in located in 4-5 health care systems in Michigan Michigan

RNs employed on the units (n = 400+)RNs employed on the units (n = 400+) Participate in orientation to HANDS Tool and Participate in orientation to HANDS Tool and

NANDA, NOC, and NIC terminologies (8 NANDA, NOC, and NIC terminologies (8 hours)hours)

At “go live” create admission or update At “go live” create admission or update HANDS CPs on all patients for each shift HANDS CPs on all patients for each shift

RNs MUST use HANDS Care Plan in ReportRNs MUST use HANDS Care Plan in Report

Strategy with Test SitesStrategy with Test Sites

Train Champions (Across Sites)Train Champions (Across Sites) Nurse ManagersNurse Managers Clinical SpecialistsClinical Specialists Nurse EducatorsNurse Educators Nurse CliniciansNurse Clinicians

Champions Train Remaining RN Champions Train Remaining RN ColleaguesColleagues

Units Collaborate with Other Test UnitsUnits Collaborate with Other Test Units Test Units Own Care Planning Method Test Units Own Care Planning Method

Competency: HANDS Care Competency: HANDS Care Planning Methodology Planning Methodology

Definition: Definition: integration of integration of mindfulmindful care care

planning using NANDA, NOC, planning using NANDA, NOC, and NIC (N3) knowledgeand NIC (N3) knowledge

technical skills in use of HANDS technical skills in use of HANDS application (application (collective mindcollective mind), ), and and

heedful interrelating during heedful interrelating during report and other handoversreport and other handovers

Competency: HANDS Care Competency: HANDS Care Planning Methodology (Pre- Planning Methodology (Pre-

GO LIVE)GO LIVE)RN Objectives:RN Objectives: Successfully creates admission and update Successfully creates admission and update

care plans with HANDS applicationcare plans with HANDS application Demonstrates appropriate use of N3 search Demonstrates appropriate use of N3 search

modes to locate termsmodes to locate terms Uses a broad range of NANDA Diagnoses, Uses a broad range of NANDA Diagnoses,

NOC Outcomes and ratings, and NIC NOC Outcomes and ratings, and NIC Interventions and tallies appropriately in Interventions and tallies appropriately in Care PlanningCare Planning

Demonstrates knowledge and behaviors Demonstrates knowledge and behaviors supportive of a strong safety culturesupportive of a strong safety culture

Routinely engages in heedful interrelating Routinely engages in heedful interrelating with colleagues during patient report and with colleagues during patient report and handovershandovers

HANDS Care Planning HANDS Care Planning Method Method

Post – GO LIVEPost – GO LIVE Create Create admissionadmission or or updateupdate Care Plan on Care Plan on

every patient q shiftevery patient q shift Add, subtract, retain, change status of N3 as Add, subtract, retain, change status of N3 as

needed q shiftneeded q shift Rate NOC outcomes q shiftRate NOC outcomes q shift Ensure NIC tallies are correct q shiftEnsure NIC tallies are correct q shift Complete anonymous error reportingComplete anonymous error reporting Enter 1) nurse shift info, 2) patient care time Enter 1) nurse shift info, 2) patient care time

Use your submitted Care Plans in report to Use your submitted Care Plans in report to structure information shared (STICC)structure information shared (STICC)

Complete short DC form when patient leaves Complete short DC form when patient leaves unitunit

Heedful Interrelating Heedful Interrelating Nurse to Nurse Communication in Nurse to Nurse Communication in

ReportReportS-ituation S-ituation What is the patient’s situation?What is the patient’s situation?

Use current care plan and care plan history Use current care plan and care plan history

T-rajectory T-rajectory What needs to be done?What needs to be done? NANDAs, NOCs, and NICs, and other NANDAs, NOCs, and NICs, and other

important details important details

I-ntent I-ntent Why?Why? Refer to historical care plans and patient Refer to historical care plans and patient

progress noted progress noted across time, explain rationale across time, explain rationale

C-oncern C-oncern What are the priority/iesWhat are the priority/ies?? Refer to most important priority/ies to be Refer to most important priority/ies to be

attended to in attended to in next shift next shift

C-allibrate C-allibrate Invite questions to clarify and enhance Invite questions to clarify and enhance plan!plan!

What’s not clear? What do you disagree with?What’s not clear? What do you disagree with?

Aim 1: Methods & Aim 1: Methods & MeasuresMeasures

H 1.1 Collective MindH 1.1 Collective Mind Usefulness survey; Usefulness survey;

Pre-Tr, 12 moPre-Tr, 12 mo Term meaning reliabilities; Term meaning reliabilities;

Post-Trng, 6mo, 12mo, 24moPost-Trng, 6mo, 12mo, 24mo NOC rating reliabilities; NOC rating reliabilities;

Post-Tr, 6mo, 12mo, 24moPost-Tr, 6mo, 12mo, 24mo Isolate patterns of accessing hx data in Isolate patterns of accessing hx data in

HANDS;HANDS; 6mo, 12 mo, 24 mo6mo, 12 mo, 24 mo

Aim 1: Methods & Aim 1: Methods & Measure (Cont)Measure (Cont)

H1.2 MindfulnessH1.2 Mindfulness Conduct think-alouds – Post-Tr, 12 moConduct think-alouds – Post-Tr, 12 mo Examine patterns in using HANDS; Examine patterns in using HANDS;

6mo, 12 mo, 24 mo6mo, 12 mo, 24 mo Adjustments nurse makes to NCPAdjustments nurse makes to NCP Nurse use of HANDS “Help” functionsNurse use of HANDS “Help” functions Temporal pattern of data entryTemporal pattern of data entry Discrepancies between actual versus Discrepancies between actual versus

expected NOC outcome ratingsexpected NOC outcome ratings

Aim 1: Methods & Aim 1: Methods & Measures (Cont.)Measures (Cont.)

Heedful Interrelating Heedful Interrelating Observations of patient hand-offs (e.g., Observations of patient hand-offs (e.g.,

report, breaks) report, breaks) 6 mo, 12 mo, 24 mo6 mo, 12 mo, 24 mo

Focus groupsFocus groups 6 mo. 12 mo, 24 mo6 mo. 12 mo, 24 mo

Aim 2 Aim 2 HANDS CPP Method HANDS CPP Method

Enhances Safety CultureEnhances Safety Culture Criterion Measures – Safety CultureCriterion Measures – Safety Culture

Trust survey, Trust survey, Pre-HANDS, 12 mo post, 24 mo postPre-HANDS, 12 mo post, 24 mo post

Culture survey, Culture survey, Pre-HANDS, 12 mo post, 24 mo postPre-HANDS, 12 mo post, 24 mo post

Nursing errors and near errors; Nursing errors and near errors; Pre-HANDS, and 3, 6, 12, 18, 24 months Pre-HANDS, and 3, 6, 12, 18, 24 months

postpost

Preliminary Findings Preliminary Findings

Observations (Baseline)Observations (Baseline) Use of computerized documentationUse of computerized documentation

3 sites rely substantially on computerized 3 sites rely substantially on computerized documentation systemsdocumentation systems

Practices of charting differ leading to Practices of charting differ leading to different levels of efficiencies of different levels of efficiencies of documentationdocumentation

Nature of report Nature of report Varies among sitesVaries among sites One site uses taped reportsOne site uses taped reports

Care planningCare planning Meets minimal requirementsMeets minimal requirements Piece of paper in the chartPiece of paper in the chart

Preliminary Findings Preliminary Findings

Quantitative measuresQuantitative measures Organizational culture (Sutcliffe)Organizational culture (Sutcliffe) Trust (Mishra and Mishra)Trust (Mishra and Mishra)

Importance of being open to Importance of being open to organizational change organizational change

HANDS ChampionsHANDS Champions

AdministratorsAdministrators Michelle Michelle

Aebersold Nurse Aebersold Nurse ManagerManager

Jean Shlafer Jean Shlafer LiaisonLiaison

Cinda Loik Cinda Loik ManagerManager

Mary Jo Kocan, Mary Jo Kocan, Clinical SpecialistClinical Specialist

Clinician ChampionsClinician Champions Sandra LivaSandra Liva Marianne ArandaMarianne Aranda Cathleen Cathleen

GuerrieroGuerriero Sue McMahonSue McMahon Meiqing WangMeiqing Wang Sandra HatchSandra Hatch Katherine WilsonKatherine Wilson

HANDS Method Framework (Keenan & Yakel, 2005)

HANDS CPPMethod

Tool (HANDS) Computerized Standard Format N3 Terms Focus on OutcomesTraining Tool CPP Rules Expected Outcomes Safety EmphasisImplementation

EFFECTIVE CPP

RNs’ Collective Mind Representation Accurate Useful RNs Heedfully Interrelating To achieve desired outcomes RN’ Mindfulness In identifying & documenting patient problems, interventions and outcomes

SAFETY CULTURE

•Improved communication•Reduced errors•Continuity of care•Positive patient outcomes

Copyright 2000 The Regents of The University of Michigan

Objectives of the HANDS Objectives of the HANDS ProjectProject

To provide: To provide: Hands-on automated support for the care Hands-on automated support for the care

planning processplanning process An “external memory” of the patient’s care An “external memory” of the patient’s care

plan that allows easy monitoring and plan that allows easy monitoring and adjustment of the care of multiple clinicians adjustment of the care of multiple clinicians to achieve desired outcomes to achieve desired outcomes

To simultaneously identify and To simultaneously identify and promote:promote: Strategies that sustain ongoing Strategies that sustain ongoing

“mindfulness” of the clinician in the care “mindfulness” of the clinician in the care planning process across planning process across

AssumptionsAssumptions Use of standardized nursing languages (SNLs) is Use of standardized nursing languages (SNLs) is

desirable because it brings visibility and desirable because it brings visibility and accountability to nursing accountability to nursing Atomic level (assessments and discrete tasks)Atomic level (assessments and discrete tasks) Meta level (judgments)Meta level (judgments)

Use of SNLs in computer systems supports the Use of SNLs in computer systems supports the generation of nursing data for multiple purposes generation of nursing data for multiple purposes

The structure and content of SNLs need to be The structure and content of SNLs need to be continuously refined to improve the data quality continuously refined to improve the data quality of information captured in computersof information captured in computers

CONTINUOUS IMPROVEMENT AND CONTINUOUS IMPROVEMENT AND DIFFUSION OF THE SNLs WILL OCCUR WITH DIFFUSION OF THE SNLs WILL OCCUR WITH USE AND REFINEMENT UNDER “REAL TIME” USE AND REFINEMENT UNDER “REAL TIME” CONDITIONSCONDITIONS