Practice Matters

In with care boards, out with care plans

care boards

To promote patient-centered care, healthcare professionals are striving to find new ways to respond to individual patient preferences, needs, and values. Traditionally, nurses created the patient’s plan of care using a generalized approach; today’s electronic medical records propagate generic care plans.

Ideally, the entire interprofessional team, working in tandem with the patient, develops the plan of care collaboratively. This team should include all personnel who interact with the patient and family—physicians; nurses; nurses’ aides; staff from environmental, chaplain, rehabilitation, and environmental services; and other relevant personnel.

This article describes how nurses in one hospital implemented a new kind of communication board in patient rooms to promote effective, individualized, and interprofessional care planning. Called CareBoards, they are used by all interprofessional team members—and the patient—to keep everyone informed of the plan throughout the patient’s stay. The CareBoards concept grew out of an individual care plan model that merges our hospital network’s vision of relationship-based care with a commitment to safe, high-quality, person-centric care.

Literature search for care-planning communication devices

Using the key words whiteboard, white board, and communication, we searched peer-reviewed healthcare articles on planning published between 2007 and 2013. We found three articles that described interactive whiteboards as patient-tracking devices that can improve logistics activity and the patient experience. “Displaying” the patient on the board allows patient tracking throughout the hospital. We found other articles that described communication with ventilated patients or those with learning or cognitive disabilities, but we didn’t find literature on other communication devices for care planning.

An idea is born

Nurses have observed that physicians’ morning rounding seems to promote interprofessional care planning, providing a time to discuss and outline the plan for the day and the patient’s stay. We reasoned that using a board on which everyone recorded key points could help ensure that the patient, nurse, and physician are all “on the same page” and that goals are mutually agreed-upon.

The traditional 18″ x 24″ dry-erase board has space only for the date, day, and names of the patient’s nurse, physician, and clinical assistant. Based on a nurse executive’s recommendation, groups of interested educators and staff at our hospital brainstormed ideas for a larger board. Eventually, they came up with and designed the CareBoard with input from nurses.


Available in both English and Spanish versions, the CareBoard is large enough to record the patient’s preferred name, interprofessional team members’ names, ordered tests, diet, family contact information, discharge plans, and a pain rating scale. Measuring 24″ x 36″, it also has space for the patient’s responses to these important questions:
• Excellent care for you means ____________.
• What is the most important thing we can do for you today? (See Visualizing the CareBoard.)

Educational plan and pilot project

Before CareBoards were installed in patient rooms, a team of educators and project coordinators provided education about the goals of their use to all patient-care team associates who enter patient-care areas. A collaborative approach toward education encouraged coordination of care. Besides introducing the CareBoard, the educational plan stressed the art of listening, the language of caring, and effective pain management. It also emphasized the importance of fostering the partnership between the patient and interprofessional team to enhance trust.

For the pilot, CareBoards were installed in 96 patient-care rooms in the medical-surgical, telemetry, intermediate care, and intensive care units. This project was an opportunity to test the visionary premise of relationship-based care while piloting the CareBoard as a new type of care plan. The chief nursing officer, with engagement of the chief operating officer and vice president of medical affairs, supported the endeavor. Conducted in 2012-2013, the pilot lasted 90 days, with monthly updates for progress checks. CareBoards quickly became an agenda and discussion item at team meetings and physician councils.

Recruiting physician leaders and champions was crucial to pilot success. Our surgeon champions used CareBoards to explain and illustrate procedures, review patient status and plans, and locate family contact information. One surgeon commented, “I like all the information in a snapshot.”

Nurses who used CareBoards during the pilot project reported it improved their ability to actively engage patients in planning care. Instead of writing the plan of care at the nurses’ station, they developed the plan in the patient’s room with his or her active participation. They reported that patients who participated in such planning were more likely to succeed at self-care management and engage further with the care team.

Care plan in a snapshot

At the end of the pilot program, findings and lessons learned were shared with nursing leaders and interprofessional team members. The pilot and education provided by the team were deemed successful. At the end of fiscal year 2013, relationship-based care was implemented further by purchase and installation of CareBoards across all acute-care units of 10 hospitals (1,615 beds) in our network. Every nurse has received education on their use.

CareBoards serve as constant visual reminder of care goals and clearly identify interprofessional team members. They have proven to be an easy, efficient format for communicating goals and engaging patients and their families. Cardiac rehabilitation and respiratory therapy associates were early interprofessional adopters. They like the ease of viewing it allows, as well as the ability to share vital information in a “snapshot.” Patients appreciate the ability to see the plan recorded on their CareBoard. Their comments include:
“I like being able to see what’s coming up.”
“I appreciate it when you write that up there because I know what’s going on and what I need to do.”
“It really makes things clearer.”

The process of adopting and using CareBoards has promoted a relationship between patients and exercise coordinators that extends beyond discharge into the outpatient setting. Exercise coordinators have shared constructive ideas for possible CareBoard enhancements.

Challenges

During the first month of the pilot, two main challenges to using the CareBoard surfaced.

  • Staff nurses said they’d like to see a larger space set aside for writing the plan of care during discussions with patients, or to use in whatever way is most useful for that particular patient—for example, drawing a picture to illustrate a procedure, jotting down questions for the physician or other team members, or leaving space for a grandchild to draw a picture or leave a note.
  • CareBoard contents must be transferred to the written or electronic health record if they’re to be used as the patient’s plan of care. Although staff have suggested various ways to do this, the issue remains unresolved. One suggestion was to photograph the CareBoard and place copies of the photograph in the patient’s paper chart.

Putting the patient at the core

CareBoards promote relationship-based care, cultivate interprofessional relationships, and empower patients by encouraging discussion, collaboration, and communication. All interprofessional team members contribute to CareBoards to keep patients well-informed and involved with the plan of care throughout their stay. This approach links patient-centered initiatives to compliance with the Hospital Consumer Assessment of Healthcare Providers and Systems and The Joint Commission.

Creation of the CareBoard is an example of nurses at the forefront of care coordination, interprofessional collaboration, and delivery of person-centric care. The CareBoard helps put the patient at the core of the healthcare delivery system.

Selected references

American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Silver Spring, MD: American Nurses Publishing; 2015.

Chewning B, Bylund CL, Shah B, et al. Patient preferences for shared decisions: a systematic review. Patient Educ Couns. 2012;86(1):9-18.

Davis C. Touch-screen technology frees nurses to spend more quality time with patients. Nursing Manag (Harrow). 2011;18(5):6-7.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. www.nap.edu/openbook.php?record_id=10027

Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. October 5, 2010. http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/workforce/IOM-Future-of-Nursing-Report-1

Platzke SA, Andrabi IA. Focusing on white space to improve patient throughput. Healthc Financ Manage. 2012;66(8):102-6, 108.

Safeek YM, Padaco GS. Red plan, white boards, blue huddles, & clear pathways: synopsis of a length of stay reduction strategy. Physician Exec. 2010;36(5):34-8, 40-1.

Sherman RO, Hilton N. The patient engagement imperative. Am Nurse Today. 2014;9(2).

Three of the authors work at Seton Southwest Hospital in Austin, Texas. Theresa H. Mackie is a quality operations and improvement specialist; Sara Shannon is a registered nurse (RN); and Valerie Subia is a clinical documentation specialist RN. Christina Howard is a critical products manager at University Medical Center Brackenridge in Austin, Texas.

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