# Presentation: 668179

## Culture, Change, & Standardization of Key Care Information Gail Keenan, PhD, RN 

- HANDS

## Does anyone disagree with:

***There is a critical need to standardize the format and content of key care information across EHRs to decrease errors and increase continuity.***

## About the HANDS Project 

- Research team dedicated to producing
- an electronic “short/story/synopsis”
- of a patient’s care that is always in the
- same format (STANDARDIZED) and
- accessible quickly (since 1997) whenever
- and wherever the patient presents.

## What is the HANDS Mission? 

**To prevent**/minimize** ** the **MILLIONS**  of communication misunderstandings among members of the health care team that result in **patient care errors** each year by standardizing key aspects of documentation and communication (the patient’s short story)

## Goals of HANDS Project

- 	Standardize a method for collecting and communicating plan of care information that:
**Is useful to clinicians**
**Promotes** **continuity of care at all handovers**
**Creates a national database** of _comparable, valid, and rich_ nursing data
**Supports research** to continuously improve nursing care and practice

## Current AHRQ Study

- HIT Support for Safe Nursing Care
- Multi-site study (8 unit – 4 organizations) and refinement of the Hands-on Automated Nursing Data System (HANDS) Method.
*1 R01 HS015054-01- HHS PHS National Institutes of *
*Health 2004-07, Agency of Health Research and Quality *

## Study Aims

- 	To demonstrate that HANDS – plan of care method  (built on pilot)
- can be successfully implemented and standardization maintained across diverse units and organizations supporting
- Mindfulness
- Heedful interrelating
- Collective mind
- increases the safety culture of diverse nursing units

## Study Intervention: HANDS Method 

- All RNs on all study units were required to:
- Complete HANDS training protocol (7-8 hours)
- Demonstrate competency in use of HANDS before go-live
- Enter an admission or update plan of care on each of ones  patients into HANDS (electronic tool ) at every handoff
- Use the plan to structure “report/handoff” communication (SHARE)

## Sample

- _Selected 8 units / 4 diverse organizations / 700 RNs_
- Stable staff, motivated to be part of study, no other major changes occurring, willingness to mandate use of HANDS by all personnel
- _4 organizations_
- 1 university, 2 community (part of multi-hospital systems), 1 small community
- _8 units_  - 4 Y1 (24 mo)  and 4 Y2 (12 months)
- Med-surg (2), neuro, thoracic, medical ICU, progressive care, older adult/stroke, acute care elderly

## Sample (cont.)

| Unit | Yr | Beds | RNs | Consent % |
| --- | --- | --- | --- | --- |
| A | 1 | 32/48 | 60/71 | 70-80% |
| B | 1 | 42 | 48 | 70-80% |
| C  | 1 | 22 | 32 | 70-80% |
| D   | 1 | 22 | 26 | 70-80% |
| A2 | 2 | 60/44 | 120/93 | 70-80% |
| B2 | 2 | 42 | 79 | 70-80% |
| B3 | 2 | 10 | 36 | 70-80% |
| C2 | 2 | 23 | 22 | 70-80% |

## At Baseline 

- Enormous variation in documentation and communication practices within units &  organizations, and across individuals and organizations
- RNs focus on the details can’t see big picture

## Training and support 

- Trained champions (opinion leaders) - nurse managers required to be part of champion training
- Held regular champion calls by category of champion (educator, clinical specialist, staff nurses, managers) to address problems relative to role – problem solve together
- Used Socio technical approach – involved users with designing identifying problems and designing solutions
- Most of solutions came from RNs – we had resources in place to address most solutions /or told why couldn’t

## Multiple Methods Used

- Surveys (R)–  skills, trust, culture, knowledge,  satisfaction with care planning method
- Observations documentation and communication (R)
- Interviews, Meetings, Focus Groups (R)
- Inter-rater reliability checks of outcome ratings (R)
- Term meaning reliability checks (R)
- Think-alouds
- Analysis of transaction logs (R)
- (R) = Repeated

## Safety Culture Tool (Vogus, 2004) 

- 21 Items  (1-5 scale)
*	**strongly disagree to strongly agree*
- 3 Factors
- _Mindfulness_ -  5 items
- 	respect individual colleagues contributions and take actions that help members build on each others care
- _Heedful interrelating_ – 10 items
-       communicate honestly with the team, talk about and learn from mistakes,  share strengths and weaknesses
- _Collective mind_ – 6 items
- 	Understand how all team members contribute to care, align actions to support team goals

## Trust Survey (Mishra, 1992)

- 16 items (1-5 scale)
*	**strongly disagree to strongly agree*
- 4 Factors* (4 items each)*
- _Concern _for organization and vice versa
- _Openness_ in communication
- _Competence_  of colleagues
- _Reliability _of colleagues

## Safety Survey (Anonymous)

- 5 items  (1 X per shift )
*	**	**Response applies to time since last completed survey**  *
*Can select 1 or 2 or any combo of 3,4, & 5:*
*	** *_*Do not wish to respond*_* *
*    *_*No*_ *Awareness of Error*
*3.     Awareness-error Made by self*
*4.     Awareness-Avoided and Error*
*5.     Awareness-Observed an Error*

## Slide 17

## Slide 18

## Culture remains consistently high pre (Green) and post (Red)

## Trust, Safety Survey, & Other 

- Trust items correlated with safety culture
- Safety survey not fully analyzed, note a significant increase in % of RNs selecting  “willing to to respond” options
- > interest in improving care planning & documentation positively correlated with > trust &  > culture scores (correlation doubled at x 2)

##  Associated Findings

- All units want to keep HANDS “post” study
- 90% care periods have care plans (all units)
- RNs more satisfied with HANDS than previous method (p<.05)
- RNs more familiar & satisfied with NNN (p<.05)
- Significant increase in RN willingness to respond to safety survey over time
- RNs very pleased with HANDS team responsivity to requested changes

##  Associated Findings

- RNs in orgs independently
- instituted user group
- integrated into multi-disciplinary rounds
- lobbied to have HANDS instituted on new unit
- Care planning activity remain consistent (changes e.g, add, resolve NNN etc.)

## Other Considerations

- Standardization across all units in org would bring many more benefits (study costs prohibitive)
- HANDS generates data for describing care, progress toward outcomes, meeting goals, RN patient load, benchmarking best practices
- EHRs are costly spend billions of dollars (over and above software costs) training and tailoring to foster variation in look and feel...away from standardization

## Recommendations

- Put strategies and resources in place to;
- support staff to own change
- enables staff to design solutions
- to sustain change across time (orgs tend to move on to next change)
- select best units (those most likely to succeed) to lead the change
- when goal is to standardize across organization (need buy in and commitment of top levels)

## Conclusions 

- We need _big picture_ in standardized language and format
- _HANDS “can do it”_ and cost effectively—but s difficult to make the case with traditional measures
- Multiple methods can provide the pieces that when combined will explain the impact

## Revised HANDS Framework

- Organization
***Factors***

**Communication**
***Intervention***

** ****Clinician & Care **
***Outcomes***

- Culture Readiness
*High Trust *
*Safety Culture Focus *
*Expects Clinician Mindfulness, Heedful Interrelating, and Collective Mind*
*Infrastructure Supports Change*
*Engages in Continuous Learning*
- Commits to Change* *
*Adopts Standardized Plan of Care Method  *
*Provides Ongoing Education*
*Provides Resources to Implement*
*Provides Resources to Sustain*

- Standardized Handoff Structure Using HANDS
*Promotes Heedful  Interrelating & Mindfulness about HANDS story   and Future Care among inter and intra-disicplinary team members*

- Standardized Documentation in HANDS Electronic Tool
*Provides a  Consistent , Dynamic,  Up-to-date Synopsis of  Care: The Clinicians’ Collective Mind*

- Patient:
- Care Continuity
- Care Quality
- Satisfaction
- Safety
- Nurse:
- Job Satisfaction
- Visibility of Work
- Evidence Based
-        Practice

- © G.Keenan, E.Yakel, D. Tschannen, & M. Mandeville, 2007

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## Definition: Organizational Culture