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Transcript of Change Proposal:
Goals & Evaluation
Enhance patient safety by providing increasing RN presence.
Increase patient satisfaction by increasing time spent by RN on patient care and education.
Increase RN satisfaction by decreasing workload and allowing them more time to spend with their patients.
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-Identify need for change (phase 1)
-Gather data, create proposal, and present it to affected parties (phase2)
-Choose a change agent (nurse manager for med/surg floor) (phase 3)
-Write final policy, guideline, job description for new position. Hire or reassign RN to new role. Create a timeline for implementation. (phase 4)
-Focus on manager's role in change implementation - hire/train new staff, manage and direct roles, etc. (phase 5)
-Maintain the change. Provide ongoing feedback and documentation to support how the new role is positively affecting the unit. (phase 6)
-Less intervention by the change agent but continued support/encouragement/feedback may be needed (phase 7)
Morgan Scott, RN
40-bed medical/surgical (med/surg) unit in an acute-care hospital.
Unspecialized unit: provides care for cardiology, orthopedic, surgical, oncology, neurology, etc. patients
High-turnover unit: Lots of patient movement (admits, discharges, transfers, and intra-hospital movement (to OR, radiology, cardiac catheterization lab, etc)
Current 5:1 patient to nurse ratio
What's the problem?
All of these issues create a unit with a labile census that increases the potential for patient safety issues, decreased patient & staff satisfaction, and less than exceptional quality of care.
Acutely ill or post-procedural patients require frequent registered nurse (RN) assessment and intervention.
Nurses with 5 or more patients are often unable to provide the care or have the time to perform frequent assessments on patients; therefore, a change in patient condition may not be detected soon enough.
Non-licensed members of the care team (like nurse aides) cannot provide this level of care (Texas Nurse Practice Act, 2013).
Example: post-cardiac catheterization patients are at an increased risk of developing life-threatening conditions like retriperitoneal bleeding, stroke, or arrhythmias. These patients have orders for nurse assessment of insertion site every 15 minutes for the first hour.
Example: patients with impaired judgement from sedatives or dementia are at an increased risk for falls. Every patient needs a fall-risk assessment and hourly rounding to prevent falls.
Addition of 1 RN to work the peak hours of 11am-7pm Monday through Friday as the admit/discharge nurse.
Primary role will be the intake of new admissions from the emergency department, operating room, clinic, and cardiac-catheterization lab.
Admit/discharge nurse will also discharge patients from floor to facilitate quicker discharge times and provide better patient education.
Quality of Care
Measure HCAHPS scores for patient satisfaction
Track discharge times, lengths-of-stay, re-admissions, adverse events, hospital-acquired infections
Measure staff satisfaction through surveys & job retention
Phase 1: Develop a detailed plan to address the issue
Phase 2: Communicate with the affected parties to justify need for change, concerns, and possible resistance.
Phase 3: Identify a change agent (nurse manager) who will help direct and facilitate the change implementation.
Phase 4: Define change process and write a formal policy or guideline. Assign roles & responsibilities. Create a timeline for implementation and success.
Phase 5: Define role of change agent during implementation process.
Phase 6: Maintain change; continued support by change agent needed.
Phase 7: Change agent withdraws from the process once fully implemented.
Lippitt's Change Theory:
7 phases, very similar to nursing process (Mitchell, 2013)
Planning, organizing, staffing, directing, and controlling (Clark, 2009).
-Act as the "change agent."
-Provide information to staff
-Anticipate and mitigate resistance to change
-Assign roles and responsibilities; hire or reassign RN for admit/discharge position
-Encourage staff, reinforce behaviors
With a 5:1 patient to nurse ratio, each nurse has 144 minutes per patient or 12 minutes per patient each hour.
The average admission process for a new patient takes 45 minutes (includes assessment, medication reconciliation, order review, vitals signs, etc.).
The average discharge process takes 20-45 minutes (includes in depth education, provision of home equipment, etc.)
Admissions and discharges require over 600 minutes (10 hours!) of direct nursing care each day!
Medical errors and adverse events cost hospitals money and directly contribute to increased risk of death or permanent injury to patients.
Many errors can be directly contributed to nursing care - nearly 1/4 of all sentinel events can be attributed to nurse staffing levels (Rothberg, Abraham, Lindenauer, & Rose, 2005).
Other nurse-related adverse events include falls, hospital-acquired infections, and pressure ulcers.
Readmissions due to poor nursing care of inadequate patient education are also quality concerns.
Reimbursement for services provided by hospitals is becoming increasingly dependent on patient satisfaction scores.
Hospital Consumer Assessment of Healthcare Providers (HCAHPS) surveys are used to determine patient satisfaction. Most of the questions are directly related to nursing care (HCAHPS, 2013).
Patient satisfaction scores are also published and can positively or negatively affect a hospital's ability to attract patients (and revenue) to their facility.
One of the most cited causes of decreased job satisfaction among hospital nurses is an increased patient to nurse ratio (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011).
Nurses need more time for each patient to provide the quality of care they WANT to provide. Nursing is a profession of caring and not having time to commit to their patients makes nurses unhappy.
*Data based on current staffing grid, shift times, and interviews with current staff