The goals of improving the quality of patient care and enhancing the patient experience lie at the core of healthcare reform. Patient-centered care (PCC) is the framework for achieving these goals. In the 1990s, Lehigh Valley Health Network (LVHN) in Pennsylvania, a full-service health network with two academic community Magnet® hospitals, adopted PCC as its care delivery model. Within LVHN, PCC was defined by research conducted by the Picker Commonwealth Program for Patient Centered Care.
Since then, PCC has served as the foundation to guide actions by all disciplines. The eight dimensions of care in PCC are the foundation of all LVHN quality-improvement efforts. The dimensions help staff stay focused on keeping patients and families informed through use of an electronic navigation tool called ROADMAP—Review Of All My Daily Medical Actions and Plans. This article describes development, implementation, and evaluation of this forward-thinking tool. (See Eight dimensions of patient-centered care by clicking the PDF icon above.)
In 2006, LVHN began an initiative to partner with community members to take PCC to the next level. The first step was a strategic process to define how the ideal patient-centered experience should look and where it should be in upcoming years. The outcome was a formal PCC vision document with 38 vision statements. A subsequent activity to bring the new PCC vision alive generated 4,059 ideas. The ideas were categorized into themes and screened, resulting in a robust list of newly created projects. Key themes identified within these ideas were that patients and families perceived they weren’t being informed and that variations existed in how providers verbally communicated plans of care to patients and families.
These themes were further supported by relatively low patient-satisfaction scores on LVHN’s Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Specific questions we needed to address pertained to how well nurses kept patients informed and how often nurses explained things in a way patients could understand.
At the same time, we became aware of the Daily CARE Plan designed and implemented by Abington Memorial Hospital in Abington, Pennsylvania, which had earned the Magnet Prize® in 2008. A fact sheet prepared daily via an electronic medical record, this plan gives patients and families easy-to-understand information about the patient’s care. It’s also used as a communication tool among multidisciplinary care team members.
ROADMAP project begins
To address the themes and patient-satisfaction opportunities, and with the Abington Daily CARE Plan as a prototype, the Patient Daily Plan of Care was chartered. The goal was to design a daily electronic plan of care that incorporated standard work. Project co-leaders included the manager of nursing informatics, who is a master’s-prepared registered nurse (RN), and a medical-surgical unit-based staff development specialist. The project sponsor was the senior vice president for patient care services, who is LVHN’s chief nursing officer. Team members included representatives from all interprofessional stakeholders: direct-care RNs, nurse managers, physicians, pharmacist, case manager, service excellence representative, public affairs and marketing staff member, and information services personnel. Our charge was to develop a user-friendly, electronic plan of care that could be given to patients and families daily to keep them informed and involved in their care.
LVHN is committed to the Toyota Production System "lean principles" for continuous improvement, so the team was expected to demonstrate lean methods in its problem-solving process. It began its work in November 2009, holding biweekly meetings and using a lean tool called an A3 report to guide project development and analysis. A3 elements include background, current conditions, goals and targets, analysis, proposed countermeasures, plan, and follow-up.
The team used another lean concept called going to the gemba (gemba is Japanese for “the real place,” where the actual work is done) to determine content and standard work. We interviewed patients, families, and caregivers on multiple adult and pediatric medical-surgical, step-down, and critical care units to determine current and ideal methods for providers to communicate the daily plan of care to patients and their families.
We took a gemba walk to LVHN’s Patient and Family Advisory Council, composed of former patients and their families and representatives of community service agencies. We also went to the designated shared governance councils to seek members’ input and feedback. Key issues identified during these walks included confidentiality concerns and variations in plans of care.
Initially, we had to make two major decisions. The first was whether to use paper instructions manually transcribed by a caregiver, or an electronically compiled report with populated data retrieved from the hospital information system (HIS). The team chose the electronic option for reliability and consistency of information, readability, and auto-
population of information within the document.
The second decision was which vendor to use. The vendor had to meet three major requirements:
- ability to produce our desired format in at least 14-point font size
- familiarity with our HIS database structure
- ability to deliver the product within an identified time frame.
We chose a vendor that had created several other applications for our network. This meant the end-product’s “look and feel” would resemble that of other applications our clinicians already were using.
In the ROADMAP template we created, content is organized by information category in a format our stakeholders believed was a natural flow, to enhance patient knowledge. Most content fields are populated automatically from HIS information. The nurse enters the remainder using a charting screen.
Diagnostic tests are defined in simple terms that patients and families can easily understand. For example, "BMP" is defined as "basic metabolic panel—a group of tests to examine the current status of your kidneys, blood sugar, and electrolytes." (See ROADMAP template by clicking the PDF icon above.)
Standard work for utilization
The ROADMAP is explained to the patient at admission. A folder and pen are kept at the bedside. The ROADMAP is printed daily, before the morning bedside shift report, and distributed to the patient and family at that time. As the nurse and other care team members visit the patient throughout the day, the ROADMAP is reviewed continuously. Patients are encouraged to keep copies of their ROADMAP in the folder and take them home at discharge.
We piloted the ROADMAP on a 30-bed med-surg unit, chosen for its strong nursing leadership and because its physician stakeholders were primarily a single hospitalist group. The unit-based staff development specialist provided the required 30-minute, small-group inservice sessions before implementation. Content included project background and standard work for ROADMAP use. Posters were displayed in physician work areas on the unit, detailing the project and the physician’s role in daily ROADMAP review. Both the nursing staff and physicians enthusiastically embraced the concept.
At "go live" time, unit leaders and nursing informatics personnel were present on the unit, serving as resources to reinforce standard work, answer questions, and examine opportunities for improvement. After ROADMAP implementation, it became standard work to assess compliance by nursing staff with distribution and review through the daily leadership team rounds to patients and staff.
Measurements and outcomes
ROADMAP evaluation involves both quantitative and qualitative metrics. Quantitative measures include a staff survey adapted in part from the staff survey used to evaluate bedside shift report. A seven-question paper survey was given to staff RNs in the ROADMAP pilot unit 1 month before and 6 months after ROADMAP implementation. Before implementation, the response rate was 83% (n = 30); after implementation, 53% (n = 32). Since ROADMAP implementation, our Press Ganey
data show improved scores in several areas—the extent to which patients felt ready for discharge, and information given to family about tests and treatment.
Qualitatively, comments from staff, patients and families, physicians, and other interprofessional team members have been unanimously enthusiastic. We’re particularly pleased with responses from home health and ambulatory services staff, who report that ROADMAP improves their knowledge, responsibility, and accountability for patient care after discharge from acute-care settings. Enthusiasm for ROADMAP has been contagious in the inpatient setting; staff on other patient-care units eagerly awaited its implementation on their own units.
To date, ROADMAP has been implemented on 15 med-surg units in LVHN’s two hospitals. Before the "go-live" date on each patient-care unit, project leaders meet with unit leaders to discuss an educational and implementation plan and to identify and address anticipated barriers.
Lessons learned and implications for other organizations
Several key aspects of the ROADMAP plan contributed to its success and can be replicated by other organizations. Because it was designated a formal, sanctioned PCC project, it gained LVHN priority status, attention, and resources. The PCC project framework required ROADMAP coleaders to offer a quarterly update to the PCC implementation team, composed of more than 40 LVHN staff representing a wide range of roles. These team members provided a wealth of sound advice.
The CNO who served as project sponsor was actively involved from the start, supporting the project team and helping to remove barriers. Choosing project team co-leaders with divergent knowledge and skills also proved crucial. The nursing informatics manager contributed informatics comprehension, while the unit-based staff development specialist provided clinical expertise. Involving bedside nurses as project team members promoted their buy-in and validated content needs identified by patients and families.
Reinforcing standard work
We found we needed to reinforce standard work continuously and hold people accountable for it. For example, after initial ROADMAP implementation on each unit, compliance must be monitored. Strategies include management team rounds to observe ROADMAP distribution and communication processes, and follow-up discussions by the unit manager with patients and families to evaluate their satisfaction.
We took care to ensure the initiative was aligned with other strategies that support LVHN’s PCC delivery model. For example, we considered how ROADMAP would complement hourly patient rounds and bedside shift report. Bedside shift report had been implemented about 2 years earlier, creating a precedent, mechanism, and comfort level for our staff to formally communicate the plan of care to the patient and family.
The final lesson we learned is perhaps the most important. Going to the gemba to involve patients and families in process design was critical to ROADMAP success. If we hadn’t taken that step, many suggestions by primary stakeholders may have been ignored, or at least not recognized as high priorities by the project team.
Healthcare regulatory agencies now require organizations to take actions that enhance patient centeredness. But even if they didn’t, involving patients and families in daily medical activities and plans is simply the right thing to do. ROADMAP has helped make that involvement happen and can be used to create seamless transitions at any point within the care continuum.
For the survey given to nurses before and after ROADMAP implementation, information obtained during gemba walks, please click the PDF icon above
Visit www.AmericanNurseToday.com for a complete list of references.
The authors work at Lehigh Valley Health Network in Allentown, Pennsylvania. Kristina Holleran is a patient-care specialist. Janice Wilson is the manager of nursing informatics. Anne Panik is senior vice president of patient-care services.