course materials

1. NURSING ADMINISTRATION Care Redesign Discussion
NURSING ADMINISTRATION Care Redesign DiscussionNURSING ADMINISTRATION Care
Redesign DiscussionA Higher-Quality, Lower-Cost Model for Acute Care Pamela T. Rudisill,
DNP, RN, NEA-BC, FAAN Carlene Callis, BS, MHA Sonya R. Hardin, PhD, RN, CCRN, NP-C
Jacqueline Dienemann, PhD, RN, NEA-BC, FAAN Melissa Samuelson, DNP, RN, NEA, BC
OBJECTIVE: The aims of this study were to design, pilot, and evaluate a care team model of
shared accountability on medical-surgical units. BACKGROUND: American healthcare
systems must optimize professional nursing services and staff due to economic
constraints, evolving Federal regulations and increased nurse capabilities. METHODS: A
redesigned model of RN-led teams with shared accountability was piloted on 3
medical/surgical units in sample hospitals for 6 months. Nursing staff were trained for all
functions within their scope of practice and provided education and for implementation.
RESULTS: Clinical outcomes and patient experience scores improved with the exception of
falls. Nurse satisfaction demonstrated statistically significant improvement. Cost outcomes
resulted in reduced total salary dollars per day, and case mixYadjusted length of stay
decreased by 0.38. CONCLUSION: Innovative changes in nursing care delivery can maintain
clinical quality and nurse and patient satisfaction while decreasing costs. Healthcare
systems in the United States must bridge the transition from volume to value-based models.
Components required to succeed include clinical integration, implementation of technology,
and clinical performance improvement with operational efficiencies to manage financial
constraints.1 Nursing services encompass the majority of the workforce in today’s acute
care hospitals.2 Historically, models of care have been based on a mix of registered nurses
(RNs) and unlicensed assistive personnel (UAP) with occasional reference to licensed
practical nurses (LPNs) and the assignment of workload. Evidence s that patient needs are
best met by planned skill mix and recognition that nurses are knowledge workers and need
to be utilized in that manner.3,4 Models-of-care redesign that embeds improving efficiency
and increasing accountability to patients’ clinical outcomes requires a cultural
transformation.1 All major changes in care design should be evaluated for their evidence-
based and desired changes. The purpose of this study was to evaluate a pilot
implementation of a shared accountability delivery model for medical-surgical patients that
allowed licensed nurses and UAP to practice at their full authority through delegation and
collaboration in RN-led teams. Author Affiliations: Senior Vice President and Chief Nursing
Officer (Dr Rudisill), Community Health Systems, Franklin; and Assistant Vice President
Strategic Resource Group, Vice President Strategic Planning American Group (Ms Callis),

2. HCA, Nashville, Tennessee; Professor (Dr Hardin), College of Nursing, East Carolina
University, Greenville, North Carolina; and Professor Emeritus (Dr Dienemann), School of
Nursing, UNC Charlotte and Nurse Researcher Carolinas Medical Center University, North
Carolina; and Chief Nursing Executive (Dr Samuelson), NURSING ADMINISTRATION Care
Redesign DiscussionORDER NOW FOR CUSTOMIZED, PLAGIARISM-FREE PAPERSPoplar
Bluff Regional Medical Center, Missouri. Community Health Systems is a registered trade
name of Community Health Systems Professional Services Corporation. The authors declare
no conflicts of interest. Correspondence: Dr Rudisill, Community Health Systems, 4000
Meridian Blvd, Franklin, TN 37067 (pamela.rudisill@hma.com or pam_rudisill@chs.net).
DOI: 10.1097/NNA.0000000000000088 388 Background The healthcare system in the
United States is in a state of rapid and unprecedented change with pressures to improve
clinical quality and patient health and increase patient satisfaction, while curtailing costs.
The Institute of Medicine report5 cites 10 recommendations to ensure better health, higher-
quality care, and lower costs. One recommendation was to optimize operations by
continually improving healthcare operations to reduce waste, streamline care delivery, and
focus on activities that improve patient health. The primary challenge of delivering care in
acute settings is managing increasingly JONA Vol. 44, No. 7/8 July/August 2014 Copyright
© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction
of this article is prohibited. complex patients with shorter lengths of stay (LOSs) while
ensuring integration of care upon discharge and beyond. Recent studies demonstrate that
lowering costs is dependent on increasing patient safety rather than changing nursing
salary or staffing expenses.6 Nursing factors influencing patient outcomes include number
of hours per patient-day (number of staff), quality of work environment, educational level of
nurses, and mix of skills among nursing staff. These factors interact among each other with
varying effects on patient outcomes.7-11 Increasingly, nurse satisfaction is related to
recognition that RNs are knowledge workers whose time should be utilized in decision
making regarding patient care and safety.4 team realized several approaches underutilized
RN delegation, did not utilize LPNs at all, and did not require RNs, UAPs, or LPNs to practice
to their full scope. We did identify 1 computer simulation model utilizing the RN, LPN, and
UAP, which incorporated principles of the lean to enhance the role of the RN, LPN, and UAP
in the care delivery of patients.20 Lean is a concept adapted from manufacturing to
streamline processes, reduce cost, and improve care delivery. Each process must add value
or be eliminated as waste (or muda in Japanese) so that ultimately every step adds value to
the process.21 The simulation demonstrated that teams of RN, LPN, and UAP assigned in a
mix to fit patient acuity of a group of patients wasted less time than patient allocation
assignments. Nursing Care Delivery Models Delivery of nursing care has traditionally been
delivered in 1 of 4 ways.12-14 Shirey14 discusses the advantages and disadvantages of
various models. The earliest model is patient allocation or total patient care with groups of
patients assigned to 1 nurse with no UAPs. NURSING ADMINISTRATION Care Redesign
DiscussionBecause of shortages during and after World War II, task or functional nursing
was emphasized, allocating more complex care to RNs and routine care to UAPs. Team
nursing evolved with RNs as leaders of UAPs for a group of patients. Primary nursing
identified 1 nurse to assume 24-hour responsibility for a patient with communication to

3. RNs, LPNs, and UAPs who participated in care throughout the patient stay. This model of
care has been coined relationship-based care.12 One new, novel approach is to expand
primary care to coordinating care after discharge, with the RN assuming care as the primary
nurse for readmissions.14,15 This model of care fits in the new modes of accountable care
transition coordination. The recent Institute of Medicine report on the future of nursing16
advocates for RNs to perform to their fullest potential and to become effective leaders and
partners in the organization. This parallels the American Organization of Nurse Executives
guiding principles for the role of the nurse in future patient care delivery.17 These position
statements call for new innovative models of nursing care delivery. In 2005, Partners
Healthcare in Boston, Massachusetts, conducted a search of innovative nursing care
delivery models for adult, acute care patients that integrated technology, systems, and
new roles to improve quality, efficiency, and cost. They identified over 40 models that
shared common elements of an elevated RN role, sharpened focus on the patient, smoothed
patient transitions and handoffs, leveraged technology, driven by results that were
measured systematically, and used for feedback to improve the innovations.18 A few new
models emerged requiring shared accountability.19 In reviewing these models, our
Development of Novel Nursing Care Redesign We decided to develop a shared
accountability model utilizing RN-led teams with LPNs and UAPs, functioning to their fullest
potential, matching the skillmix potential to meet the patient’s needs. We piloted the model
on medical-surgical units in 3 community hospitals in 3 states. NURSING ADMINISTRATION
Care Redesign DiscussionThe goals were to improve clinical quality of care and nurse job
satisfaction through use of accountable teams and balanced caregiver workload while
controlling or reducing costs. JONA Vol. 44, No. 7/8 July/August 2014 Methods The pilot
was implemented on 1 medical-surgical unit at each of 3 hospital sites in Alabama,
Tennessee, and Mississippi. Each hospital differed in overall bed size and urban/rural
market location. The leadership in administration (chief executive officer, chief nursing
officer) was ive and knowledgeable of lean principles, the purpose of the nursing care
redesign, and the importance of evaluation. Our 1st step was to review the scope of practice
for RNs, LPNs, and UAPs in each state where we planned to pilot the program (Alabama,
Tennessee, and Mississippi). We then reviewed the job descriptions at the hospitals and
found that all legal functions were not included. Policies, competencies, and job descriptions
were revised for the LPN and UAP to ensure highest level of practice. To ensure patient
safety, education was developed and provided to UAPs and LPNs to achieve competencies in
all functions. Examples of the enhanced competencies for the UAPs included simple
dressing change, oxygen setup, performing blood sugars, discontinuing Foley catheters, and
discontinuing peripheral intravenous lines. The LPN-enhanced competencies varied the
most among the selected states. Some included administering intravenous medications and
starting intravenous lines. 389 Copyright © 2014 Wolters Kluwer Health | Lippincott
Williams & Wilkins. NURSING ADMINISTRATION Care Redesign DiscussionUnauthorized
reproduction of this article is prohibited. In order to assess level of patient needs, an acuity
tool was needed that was valid, efficient, portable between units, reliable, and
maintainable.22 Duke University Hospital System had designed and evaluated a tool
beginning in 2003 that assesses patient’s acuity based on the complexity of care or

4. instability of a patient’s health status. Nurses used it with a personal digital device. In time,
it had been modified to reduce input while maintaining validity for multiple settings.
Patients are assessed on 6 patient factors and 4 nursing care demand factors, resulting in 1
of 4 levels of complexity of care. The results are to ensure balance of workload with
competency level of staff and patient acuity. The tool was used with permission (e-mail
communication, August 2012, November 2012, August 2013). The Morse falls risk
assessment23 and Braden skin care assessment24 were added to the tool. No formal
evaluation of the modified tool has been made. New processes adopted were bedside shift
report for all caregivers of the team and formal bed huddles for teams to be done at a
minimum of every 4 hours with new acuity assessment, daily patient goals, and expected
LOS review, as well as any identified patient safety issues (Figure 1). The clinical outcome
data chosen for evaluation were based on existing methodologies and collection practices
reported to the Centers for Medicare & Medicaid Services and other national organizations.
These included falls per 1,000 patient-days, falls with injury severity of greater than 1, rate
of hospital-acquired pressure ulcers, medication errors per 10,000 doses, number of
sentinel events, and number of near misses. Unit LOS; rate of readmissions for congestive
heart failure (CHF), myocardial infarction (MI), and pneumonia within 30 days; and core
measure scores were also collected. Cost was based on average LOS and cost per patient-
day. Patient satisfaction used the Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS) data across the 8 domains.25 New survey questionnaires on nurse
and physician satisfaction were developed for the specific medical-surgical units that
reflected key elements on the model design and based on the hospital-wide surveys
performed by Press Ganey.25 Preimplementation Institutional review board approval was
received from the University of North Carolina at Charlotte, Charlotte, NC. Materials were
prepared, and site coordinators were trained in data collection of patient outcomes and
confidentiality processes to distribute and collect questionnaires. Upon collection, data and
questionnaires were forwarded to the office of the corporate chief nurse executive for data
entry. Original forms were stored in a locked cabinet. To establish a baseline for all key
metrics prior to implementation, the following were collected: (1) 390 nurse/staff and
physician satisfaction, (2) patient outcomes and patient safety indicators, (3) financial
information, and (4) patient satisfaction. For the clinical outcome and financial metrics, data
for the same 6 months of the planned pilot in the previous year were used.NURSING
ADMINISTRATION Care Redesign DiscussionEach pilot hospital assumed responsibility for
implementing the education in new skills and verifying that all UAPs and LPNs had
mastered the identified competencies prior to initiating the model. Job descriptions were
updated. RNs’ job expectations shifted to focus on decision making for delegation and
assurance of quality, patient teaching, patient care coordination, and collaboration with
other health professionals. Each team had an RN leader and either 2 UAPs or 1 LPN and 1
UAP. Patient assignments were for that shift. Each job description was reviewed to ensure
clarity of role function. An 8-hour course for all the nursing staff on the pilot medical-
surgical units at the 3 hospitals was designed and led by the research team. The course
began with an overview of the new delivery model and job descriptions for RNs, LPNs, and
UAPs. The new acuity tool was reviewed, and its purpose to share workload fairly

5. discussed. The plan to assess patient care needs and review in huddles every 4 hours to
maintain equity was reviewed. Delegation and collaboration were then discussed with case
examples. Emphasis was placed on each person working to their enhanced scope of practice
and to share accountability for patient outcomes. This was followed by a simulation exercise
where staff was assigned teams with case scenarios. Nurses left expressing enthusiasm for
their new roles. Implementation and Evaluation The new model was introduced, and all
staff was provided to comply. When turnover occurred during the 6 months of the study,
categories of new hires were chosen to the model implementation. At the end of the 6-
month period, all metrics were collected and measured against the established baseline.
Findings Nurse satisfaction showed the most statistically significant improvement in
comparison to all other measures included in the study. Forty-four nurses (86%) completed
the presurvey, and 36 (69%) completed the postsurvey. A paired-samples test was
performed to identify any significant change from the implementation of the new care
model. While all responses demonstrated a positive trend, 6 items showed statistically
significant improvement: teamwork among coworkers, appropriate delegation, sense of
accomplishment in their work, enjoyment coming to work, satisfaction with JONA Vol. 44,
No. 7/8 July/August 2014 Copyright © 2014 Wolters Kluwer Health | Lippincott Williams &
Wilkins.NURSING ADMINISTRATION Care Redesign DiscussionUnauthorized reproduction
of this article is prohibited. Figure 1. Bed huddle. workload, and satisfaction with job (Table
1). Patient satisfaction showed slight improvement according to the HCAHPS scores in 3 of
the 8 domains. JONA Vol. 44, No. 7/8 July/August 2014 Within the 8 domains, physician
communication resulted in a statistically significant improvement at P = 0.013 when an
analysis of variance was performed. 391 Copyright © 2014 Wolters Kluwer Health |
Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table
1. Paired-Samples Test Nurse Survey Paired Differences 95% Confidence Interval of the
Difference Pre-Post Response Items (n = 36) Pair Pair Pair Pair Pair Pair 1: good teamwork
2: delegation appropriate 3: sense of accomplishment 7: enjoy coming to work 9: satisfied
with workload 11: satisfied with job Mean SD SE Mean Lower Upper t df P (2-Tailed)
0.69444 0.75000 0.41667 0.47222 0.68571 0.44444 1.26083 1.25071 0.99642 1.13354
1.47072 1.25230 0.21014 0.20845 0.16607 0.18892 0.24860 0.20872 0.26784 0.32682
0.07953 0.08869 0.18050 0.02073 1.12105 1.17318 0.75381 0.85576 1.19093 0.86816
3.305 3.598 2.509 2.500 2.758 2.129 35 35 35 35 34 35 .002 .001 .017 .017 .009 .040 P e
0.05. Most clinical quality indicators showed signs of improvement, including core
measures, hospital-acquired pressure ulcers, medication errors, near misses, and CHF, MI,
and pneumonia readmissions. Independent t tests of samples were performed to examine
the difference between the mean of incidence of indicator before and after the intervention.
Although improved, none were statistically significant (Table 2). A composite core measure
score for the hospitals, excluding elements of care provided in the emergency department,
revealed improvements in the pilot hospitals. Financially, the pilot resulted in reductions in
costs. NURSING ADMINISTRATION Care Redesign Discussion