Innovation in Care Delivery: The Patient Journey


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  • MGH has identified 12 inpatient units as “Innovation Units”. Each of these units submitted proposals seeking to participate and represent a cross section of patient populations (e.g. Surgery, Oncology, Medicine, Orthopedics, Pediatrics, Obstetrics, and Psychiatry). These innovation units will allow changes to the care delivery model to be tested and outcomes to be measured.
  • Best to say that your presentation is based on the current patient journey and that as the strategic plan unfolds additional ones will be added and the evaluation schema will be modified.
  • Innovation unit performance will be monitored via a dashboard of quality core measures, LOS, throughput, and satisfaction scores. Baseline data will be used to identify the impact changes have made on care delivery.
  • Innovation in Care Delivery: The Patient Journey

    1. 1. Innovation in Care Delivery: The Patient Journey Jeanette Ives Erickson, RN, DNP, FAAN Senior Vice President for Patient Care and Chief Nurse Massachusetts General Hospital Boston, MA
    2. 2. Objectives At the completion of this workshop participants will: 1. Illustrate the impact that innovation units have in making care delivery safe, effective, efficient, timely, equitable and patient- and family-centered. 2. Describe the role of the attending nurse in promoting continuity of care. 3. Identify strategies to promote patient and family involvement in the plan of care. -2-
    3. 3. Waste in the US Healthcare System: A Story Emerges JAMA 2012;307:1513-6 -3-
    4. 4. Rising health care costs are a problem • Per capita health care costs have grown steadily for 40 years 2500 2000 Per Capita Growth In Health Expenditures Has Increased at 2% Above Inflation For 40 Years 1500 1000 500 0 (adjusted for inflation) 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 • Expanding health insurance coverage magnifies cost pressures 3000 Per Capita NHE in $ • Unmet need is perpetual 3500 • The US employer-based health insurance system is a handicap in a global economy Source: 2009 presentation by Stuart Altman, PhD titled Growing Healthcare Spending: Can or Should It Be Controlled to Prevent a Health System “Meltdown” ? -4-
    5. 5. Here’s What Is Happening in Health Care in the US Michael Porter, Harvard Business School 2011 -5-
    6. 6. Here’s Where We Need to Go A need to innovate new ways of being Michael Porter, Harvard Business School, 2011
    7. 7. Positioning MGH for The Future Care Redesign: Population Management: Reducing the Trend of Healthcare Costs, Long-term Outpatient Care Multidisciplinary Services, Large Patient Population, Big $ $$ The Patient Journey Patient Affordability For MGH & Payers: Direct Patient Care: ED, Periop, Inpatient (Innovation Units) Overhead (NonLabor costs) Incentives: Intrinsic and Extrinsic Technology Application: Partners E-Care, Outcomes Registries -7-
    8. 8. -8-
    9. 9. Innovating Care at MGH We are attempting transformational change. Innovation Units are tests of change that will help us quickly identify what works and what does not work to improve the quality of care delivered to our patients.  High performing interdisciplinary teams that deliver safe, effective, efficient, timely, equitable care, that is patient- and family-centered  Standardization of processes and care reduces variation and introduces a systematic approach to improving quality and safety in the inpatient setting  Identify and prioritize hazards and opportunities for standardization, then implement evidence based methods to rectify the problem -9-
    10. 10. Guiding Principles  Care delivery should always be: patient and family-focused, evidence-based, accountable and autonomous, coordinated and continuous.  It’s important to know the patient.  Inpatient and family care is provided by a designated nurse and physician who are accountable and responsible for continuity of care.  Continuity of the team is a basic precept.  Every novice team member deserves mentoring from an experienced clinician.  Every patient deserves the opportunity to participate in the planning of his/her care.  Advancements in technology create opportunity for improved provider communication and efficiency.  Revised 2013 10 Care should be delivered in the most -cost-effective manner.
    11. 11. “Patient Journey” Framework Before Preadmission Care During Admission Process: ED, Direct Admits, Transfers Patient Stay; Direct Patient Care, Tests, Treatments, Procedures, Clinical Support, Operational Support Post Discharge Process Support Functions: Finance, Information Systems, HR Goal: High-performing interdisciplinary teams that deliver safe, effective, timely, efficient and equitable care that is patient and family centered. Where Are There Opportunities to Reduce Costs Across These Processes of Care? Copyright Partners HealthCare 2011 - 11 - Post Discharge Care
    12. 12. Innovations in Care Delivery “Patient Journey” Framework – Initial 15 Interventions Patient stay; direct patient care; tests; treatments; procedures; clinical support; operational support Discharg e process Intervention Admission process: ED, direct admits, transfers After Intervention Intervention Preadmission care During Intervention Before Postdischarge care Goal: High-performing, inter-disciplinary teams that deliver safe, effective, timely, efficient, and equitable care that is patient- and family-centered Discharge Planning: -Est. discharge date -Discharge disposition Domains of Practice Daily Interdisciplinary Team Rounds Electronic Unit Whiteboards In-Room Whiteboards Smart Phones Wireless laptop computers/tablets Business cards Hourly rounding Quiet hours Welcome Packet (notebook and discharge envelope) Relationship-based care ♦ The Attending Nurse role Copyright MGH 2012 - 12 - ♦ Discharge -Follow-up Call Program Hand-Over Rounding Checklist
    13. 13. Three Key Areas of Focus and Four Desired Outcomes Focus 1. New Culture through Relationship-Based Care 2. New Role of Attending Nurse; Domains of Practice 3. Standardized Processes  Throughput and LOS Reduction  Technology  Controlling Variation  Implementing Evidence-Based Practice Outcomes 1. 2. 3. 4. Patient Satisfaction: care is equitable and patient- and family-focused Clinical Quality: to improve quality and to make care safer Unit Cost Reductions: to make care more cost effective Staff Satisfaction: to remain a great place to practice - 13 -
    14. 14. Roll-Out of Innovation Units • Wave I: 12 Units launched March 10, 2012 Unit Types: General Surgery; Vascular Surgery; General Medicine; Orthopaedics; Oncology; Newborn/Family; Pediatrics; Psychiatry; Neonatal ICU; Cardiac ICU; Surgical ICU • Wave II: 27 Units launched April 1, 2013 Unit Types: General Medicine; Medical ICU; Cardiac Surgery (ICU and Intermediate); Cardiac Telemetry and Intervention; Orthopaedics; General Surgery; Thoracic Surgery; Gynecology; Oncology; Newborn/Family; Pediatrics; Burns/Plastics; Transplant; Neuroscience (ICU and General); Respiratory Acute Care • Wave III: 4 Units launched September 24, 2013 Unit Types: General Medicine; Surgical ICU; Short-Stay Unit; Observation Unit - 14 -
    15. 15. Intervention: Relationship-Based Care Relationship-Based Care Relationship-based care is a transformation model and intervention that improves key care improves outcomes: provider relationships within an organization:  Relationships with Patients and Families  Relationship with Self  Relationships with Colleagues - 15 -  Enhanced Quality  Improved Clinical Safety  Increased Patient and Family Satisfaction  Increased Physician and Staff Satisfaction  Greater Efficiency  Improved Resource Management
    16. 16. Relationship-Based Care – Three Key Care Provider Relationships Patients & Families Self Colleagues The relationship between patients and their families and members of the clinical team belongs at the heart of care delivery.  Patient and family as the central focus  Respect and personal concern  Protection of dignity and well-being  Active engagement  Intention to connect The relationship with self is essential to maintaining each individual’s optimum health, for having empathy for the experience of others, and for being a productive member of an organization.  Skills and knowledge to manage stress  Ability to recognize personal needs and values  Willingness to balance work demands with one’s own physical and emotional health and well-being The delivery of compassionate care requires a commitment by all members of the health care team to accept responsibly for establishing and maintaining healthy interpersonal relationships.  Open and honest communication  Respect  Trust  Consistent and visible support - 16 -
    17. 17. Intervention: Attending Nurse Role Responsible Nurse/Attending Nurse Expand staff nurse role.  Accountable for patient/family continuity and progression along the developed overall plan of care from admission to discharge  Ensures, along with the Attending MD, that patient care meets the unit’s clinical standards and vision of patient- and family-centered care  Develops and revises the patient care goals with the clinical care team daily  Coordinates meetings with clinicians for timely decision making and connects nurses to optimize handoffs across the continuum  Is the primary bedside communicator with the patient and family, discussing plan of the day, care progress, potential discharge, and answers questions/teaches/coaches - 17 -
    18. 18. Intervention: Hand-Over Communication  Passing patient-specific information:  From one caregiver to another  From caregiver to patient and family  Transfer of information from one type of organization to another or to the patient’s home SBAR: Hand-Over Communication Tool This format should be used whenever a “hand-over” of patient responsibility occurs, i.e. shift to shift report, etc. S-Situation: Identify yourself and position, patient’s name and the current situation. Describe what is going on with the patient. B-Background: State the relevant history and physical (H&P), physical assessment pertinent to the problem, treatment/clinical course summary and any pertinent changes. A-Assessment: Offer your conclusion about the present situation. R-Recommendations: Explain what you think needs to be done, what the patient needs and when. Verify any critical information received, review the history, seek clarification, ask questions, and read back critical test results. Goal: To ensure patient care continuity and safety - 18 -
    19. 19. Intervention: Clinical data collection pre-admit  Pre-admission clinical data collection, along with screening and patient education, are key components of “knowing our patients”  Current data collection standards and tools vary for different populations (e.g. ED, Same-Day Surgery, Transfers)  At minimum, estimated discharge date and discharge disposition should be documented upon admission. - 19 -
    20. 20. Intervention: Welcome Packet Discharge Information Envelope Checklist Patient and Family Notebook    Informs patients and families of goals Designed to invite feedback Includes patient and clinician compact - 20 -
    21. 21. Intervention: Domains of Practice Each clinical discipline articulated Domains of Practice - A sphere of activity or knowledge, the perspective and territory, which includes subject matter, the main agreed-on values and beliefs, the central concepts, the phenomena of interest and the methods used to provide answers in the discipline Disciplines: Nursing, Chaplaincy, Child-Life, Dieticians, Medical Interpretation, Occupational Therapy, Pharmacy, Physical Therapy, Respiratory Care, Social Work, Speech-Language Pathology, Volunteers Example 1 – Nursing: Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations (ANA).  Creation of a caring, individualized therapeutic relationship with patients and families that promotes health and healing   Assessment, diagnosis, plan, implementation and evaluation of interventions to promote the best possible outcome; this  process is done in partnership with patients, families and the health care team  Health teaching and promotion   Delivery of safe, quality and evidence-based practice   Collaboration and communication with all members of the health care team   Clinical inquiry and ongoing professional development  Example 2 – Respiratory Care: Respiratory therapists focus on improving and maintaining the cardiopulmonary health of patients.  Set-up management and discontinuation of mechanical ventilation (both via artificial airway and face mask)   Administration and evaluation of the efficacy of aerosolized pharmacological agents   Set-up management and discontinuation of extracorporeal life-support to patients in the ICUs   Obtaining and analysis of arterial blood for gas exchange, pH and electrolytes   Assessment, maintenance, replacement, reposition and discontinuation of artificial airways   Education of patients and families on all aspects of respiratory care  - 21 -
    22. 22. Intervention: Interdisciplinary Team Rounds “Interdisciplinary rounds keeps everyone on the same page. We all hear the same information at the same time so we can craft our plan of care in a way that’s best for the patient. It has had a noticeable impact on communication on our Unit.” Team member, White 6 - Orthopaedics  Create formal mechanism for daily communication between all members of the care team  Facilitate concise and timely communication  Communicate clear picture of patient’s planned course among all members of the care team - 22 -
    23. 23. Communication: In-Room White Boards         A “communication basic” Supports knowledge of care team Builds relationships Articulates patient’s goal Keeps an eye on discharge Can be integrated with notebook and other teaching tools Keeping the board current is critical It’s only as good a resource as it is used… - 23 -
    24. 24. Enabling Technology: Smartphones  iPhone and web application for sending/receiving instant messages to specific individuals or groups. Users can write their own message or use the Quick Messages available in the system.  Voalté iPhones send/receive phone calls over MGH secure wifi (no cell plan used).  Sender selects staff they are trying to reach via a list with their name/role and picture so no need to memorize who is carrying which phone - 24 -
    25. 25. Intervention: Quiet Times  Designated hours on inpatient units where activity and conversation is minimized to allow patients to rest  Most effective model is to have a period in the afternoon and during the night when quiet hours are observed - 25 -
    26. 26. Intervention: Discharge Follow-up Calls  100% of patients in the inpatient setting being discharged to home will be asked to consent to receiving a discharge follow-up call.  Calls are made within 24-48 hours  We estimate 3-5 calls per day per nurse or attending nurse  Average call time is 3-5 minutes  Standard is two attempts to reach patient  Scripts are utilized - 26 -
    27. 27. Intervention: Discharge Planning/Discharge Readiness Tool  Guides proactive discharge planning and is comprised of:       General Information Work-up Functional Requirements Educational material Post-Discharge instructions Discharge Information  Discharge Checklist  Tools and workflow procedures, including checklists incorporating LEAN principles from Toyota  Other relevant information - 27 -
    28. 28. Intervention: Hourly Rounds – The Four Ps Evidence-based research indicates that hourly rounding increases patient satisfaction, decreases fall rates, decreases skin breakdown rates, and increases staff satisfaction. The Four Ps Presence: Establish personal connection at the beginning and end of each shift and with each hourly round Pain: Assess and address patient’s pain Positioning: Patient’s physical position and comfort; Positioning of needed items within reach Personal Hygiene: Help with toileting - 28 -
    29. 29. Intervention: Business cards - 29 -
    30. 30. – Evaluation Innovation Cluster Focus Areas * Interventions ** Evaluation (Pre, During, Post) Throughout Admission Relationship-Based Care Attending Nurse Handover Rounding Checklist Patient Engagement Quantitative •HCAHPS Pre-Admission •Leadership Influence over Professional Practice Environments (LIPPES) Pre-Admit Data Collection Welcome Packet During Admission Roles & Structures Education Communication Domains of Practice Interdisciplinary Rounds Business Cards Quiet Hours Hourly Rounding Electronic White Boards In Room White Boards Smart Phones Hand Held/ Tablets Post-Discharge Discharge Follow-up Phone Calls Others as identified •LOS •Quality Indicators •Patients Perceptions of Feeling Known (PPFKN) •Readmissions Qualitative •Focus Groups (Staff, Patients, Families, etc) •Observations •Survey of the Innovation Unit Expectations (SIUE-pre) •Survey of the Innovation Unit Experiences (SIUE-post) •Revised Perceptions of Practice Environment Scale (RPPE) •Cost per Case Mix * The clusters are a lens with which we gain perspective on any particular intervention. •Staff Retention Other measures as identified ** May apply to any or all 3 of the cluster focus areas June 2013
    31. 31. Innovation Unit Metrics Throughput and Efficiency  LOS  Average Cost per Case Mix Adjusted Discharge (CMAD)  TSI bud/flex  Wait time for bed to be ready  Admits Patient & Staff Satisfaction  MD & RN Communication  Responsiveness  Cleanliness  Noise reduction  Staff satisfaction Quality and Safety  Readmission Rate  Restraint Free Rate  Falls/Pressure Ulcer Reduction  Foley Catheter Days Massachusetts General Hospital - PCS Innovation Units Dashboard Measures Ortho White 6 Pediatrics Oncology Medicine NICU Lunder 9 Ellison 16 Blake 10 Ellison 17 Ellison 18 Surgery White 7 CICU ICU Obstetrics Psych Vascular Ellison 9 Blake 12 Blake 13 Blake 11 Bigelow 14 QUALITY AND SAFETY Patient-Centered Outcome Measures Falls per 1,000 Patient Days Total Fall Rate Observed (N) Falls with Injury per 1,000 Patient Days Falls with Injury Rate Observed (N) 4.50 11 1.46 3 4.95 13 0.77 1 1.92 2 1.32 2 2.16 5 1.79 2 TBD 0.65 2 4.85 10 0.45 1 0.41 1 0.49 1 1.52 4 0.00 0 0.96 1 0.00 0 0.00 0 0.89 1 TBD 0.00 0 1.45 3 0.45 1 0.0% 0 6.9% 2 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 4.8% 1 4.2% 1 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 4.8% 1 4.2% 1 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 7.7% 1 TBD NA 0.0% 0 0.0% 0 NA NA 0.0% 0 0.0% 0 0.0% 0 NA NA NA NA NA NA 2.90 1 4.76 1 0.00 0 1.10 1 1.70 2 TBD NA 0.00 0 0.00 0 Hospital Acquired (HA) Pressure Ulcers Total HA Pressure Ulcer Prevalence Rate 0.0% Observed (N) 0 Hospital Acquired (HA) Pressure Ulcers Type II or Greater Total HA Pressure Ulcer Type II or Greater Prevalence Rate 0.0% Observed (N) 0 Restraints Total Restraint Prevalence Rate Observed (N) 0.0% 0 Peripheral Intravenous (PIV) Infiltrations - Pediatric/Neonatal Total PIV Infiltration Prevalence NA Observed (N) Central Line-associated Bloodstream Infections per 1,000 Line Days (CLABSI) Total CLABSI Rate 6.54 NA 1.36 Observed (N) 1 1 Note: metrics to be reported beginning FY 2012 Catheter-associated Urinary Tract Infections per 1,000 Device Days Ventilator-associated Pneumonia per 1,000 Vent Days Color Shading relative to Benchmark: Rate is worse (higher) than benchmark. Rate is better (lower) than benchmark. Innovation Unit Dashboard sample - 31 -
    32. 32. Outcomes - Phase I ALOS April 2012-September 2013; Readmits April 2012– June 2013 Average Length of Stay (ALOS) in Days Baseline Innovation Period Change Phase I Innovation Units 5.5 5.2 -5% TOTAL MGH 5.9 5.9 0% 30-Day All Cause Readmission Rates Baseline Phase I Innovation Units TOTAL MGH Innovation Period Change 9.9% 8.9% -1.0 11.3% 11.0% -0.3 Data Sources: PATCOM, EPSI Time Periods: Baseline FY11; Innovation Period begins March 2012. Average length of stay data include patient discharges through September 2013. Readmission data expressed as a percent of patient discharges beginning April 2012 through June 2013 with readmissions through July 2013. - 32 -
    33. 33. ALOS - Phase II Early Results Overall Discharge ALOS, April-September 2013 Average Length of Stay (ALOS) in Days Baseline Total Phase II Units TOTAL MGH Innovation Period 6.1 5.9 6.0 5.9 Change -2% 0% Data Sources: PATCOM, TSI Time Periods: Baseline -Year ending March 2013; Innovation Period begins April 2013. Average length of stay data include patient discharges through October 2013. - 33 -
    34. 34. Cost Impact – Phase I Inpatient Direct Cost per Case Mix Adjusted Discharge (CMAD) $8,000 $7,219 $7,000 $6,000 $5,469 $5,848 $5,351 $5,595 $5,394 $5,000 $4,000 $3,000 $2,000 $1,000 $0 Phase I Innovation UnitsGeneral Care Phase I Innovation UnitsICUs Pre Total Phase I Innovation Units Post  Average Direct Cost per Case Mix Adjusted Discharge (CMAD) decreased 3.6% for Innovation units between October 2011-March 2012 (Pre) and April 2012-June 2013 (Post). Source: Direct Cost per CMAD data from PHS Finance (EPSI). Case mix adjusted using AP21 NY DRG weights. - 34 -
    35. 35. Quality & Safety Outcomes - Phase I Falls, Pressure ulcers, CY13Q2 Falls with Injury per 1,000 Patient Days 1.00  0.90 0.80 0.70 0.60 Fall rate decreased 23% over baseline FY11 on Phase I Innovation units. 0.50 0.40 0.30 0.20 0.10 0.00 CY10 Q4 CY11 Q1 CY11 Q2 CY11 Q3 CY11 Q4 CY12 Q1 CY12 Q2 CY12 Q3 CY12 Q4 CY13 Q1 CY13 Q2 Pressure Ulcer Prevalence (Stage II or Greater) 4.0%  Pressure ulcer prevalence decreased from 1.75% to 1.41% of patients on Phase I units. 3.5% 3.0% 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% CY10 Q4 CY11 Q1 CY11 Q2 CY11 Q3 CY11 Q4 Data Source: NDNQI Time Periods: Baseline FY11; Innovation Period April 2012 through June 2013. Notes: Data displayed are Falls with Injury and Pressure Ulcer Stage II or greater. ICUs excluded. - 35 - CY12 Q1 CY12 Q2 CY12 Q3 CY12 Q4 CY13 Q1 CY13 Q2
    36. 36. HCAHPS Results – 2011 vs. 2012 MGH-wide vs. Phase 1 Innovation Units Survey Measure Nurse Communication Composite Doctor Communication Composite Room Clean Quiet at Night Cleanliness/Quiet Composite Staff Responsiveness Composite Pain Management Composite Communication About Meds Composite Discharge Information Composite Overall Rating Likelihood to Recommend • • MGH 2012 81.0 81.6 72.9 48.5 60.7 64.9 71.9 64.0 91.2 80.1 90.5 HCAHPS Data for Innovation Units includes 6 units for which data is available – Bigelow 14, Blake 13, Ellison 16, Lunder 9, White 6 and White. Data not available for ICU’s and Psych. Date pull: 3.04.13 Change (2011 - 2012) +1.6 -0.3 +3.1 +3.3 +3.2 +1.3 +0.4 +1.3 +1.4 +1.0 +1.1 Innovation Change Units 2012 (2011 - 2012) 80.8 82.0 70.6 49.8 60.2 64.0 73.3 65.7 92.3 78.5 90.3 +4.5 +0.5 +4.2 +6.2 +5.2 +1.7 +3.7 +6.8 +2.7 +2.4 +2.4 KEY 2012 Score exceeds that of entire hospital Rate of Improvement Exceeds that of the entire hospital - 36 -
    37. 37. HCAHPS Results – 2012 vs. 2013 YTD MGH-wide vs. Phase 2 Innovation Units Survey Measure Nurse Communication Composite Doctor Communication Composite Room Clean Quiet at Night Cleanliness/Quiet Composite Staff Responsiveness Composite Pain Management Composite Communication About Meds Composite Discharge Information Composite Overall Rating Likelihood to Recommend • • Phase 2 Units Change Change 2013 MGH 2013 YTD (2012 – April (2012-2013) April YTD 2013 YTD) Score 81.5 82.2 74.3 50.3 62.3 64.3 71.9 64.6 91.3 80.7 90.3 * HCAHPS Data for Innovation Units includes 21 units for which data is available – Blake 6, Bigelow 9,11, Ellison 6,7,8,10,11,13, 14,19, Lunder 7,8,10, Philips House 20,21,22, White 8,9,10,11 Date pull: 10.18.13 +0.5 +0.6 +1.4 +1.8 +1.6 -0.6 No Change +0.6 +0.1 +0.6 -0.2 82.0 81.8 75.0 51.4 63.2 64.5 73.4 65.5 91.6 80.3 90.5 +1.2 +0.4 +1.6 +3.5 +2.5 -0.3 +2.3 +2.2 +0.7 -0.2 -0.1 KEY Rate of Improvement Exceeds that of the entire hospital - 37 -
    38. 38. Intervention: Discharge Follow-up Calls Goal: 100% of patients in the inpatient setting being discharged to home will be asked to consent to receiving a discharge follow-up call. Patient Call Manager Results (Discharges 4/5/13-10/18/13 from units live with PCM) Number of units live (as of 10/18) 38 Calls made (since first go-live) 16,157 (23,000+ calls since program inception) Call attempt rate 96% Call completion rate 65% Average call length ~5 minutes Peak calling times 11:00 AM – 3:00 PM Percent of calls with clinical advice or care coordination provided 22% Percent of patients with questions about their discharge instructions 11% Themes for Reward/Recognition Nursing Care (44%) Doctors (10%) - 38 -
    39. 39. Innovation Units  Are attempting transformational change  Will help us quickly identify what works and what doesn’t without ever losing sight of our patients goals  Innovation and care redesign moving us closer to efficient, cost-effective, high quality care that is patient- and familycentered and responsive.  Create the opportunity for evaluation and research inquiry that can to link patient-sensitive interventions specific to populations, enhancing care and potentially sustaining behavior over time. “We experience the essence of care in the moment when one human being connects to another. When compassion and care are conveyed through touch, a kind act, through competent clinical interventions, or through listening and seeking to understand the other’s experience, a healing relationship in created. This is the heart of Relationship-Based Care.” ”Relationship-Based Care, A Model for Transforming Practice” Mary Koloroutis, 2004 - 39 -
    40. 40. The Voice of the Attending Nurse  Michelle Anderson, RN White 7 General Surgery Unit  Sarah Ballard Molway, RN Ellison 19 Thoracic Surgery Unit  Kelly Brown, RN White 6 Orthopaedics Unit  Betty Ann Burns-Britton, RN Lunder 9 Hematology/Oncology Unit  Claire Paras, RN Phillips House 22 Medical/Surgical Unit - 40 -
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