Recommended
More Related Content
What's hot
What's hot (20)
Similar to Press Ganey Webinar
Similar to Press Ganey Webinar (20)
Press Ganey Webinar
- 1. Taking Care of Patients, their Families and Each Other The Secret to a Successful NICU
- 2. Objectives: Discuss the implementation of best practices that allow us to take care of patients, their families and each other; SFR environment Shared Governance Med Teams Training Leadership Rounding Bedside Shift Change Improved Breastfeeding Support Discuss how implementing best practices has impacted the satisfaction of our NICU families and staff
- 3. About our NICU 80 bed SFR Two floors 3 multidisciplinary teams Staffing 1-3 babies/families: 1 nurse
- 5. Moved to new SFR NICU in October Implemented Shared Governance Focus Groups Increased Accountability Press Ganey Yearly Mean Trend Med Teams Training Leadership Rounding and Partnering with Parents at bedside shift change Improved Breast feeding Support Mean 88.3 83.6 84.4 90.1 99.8 90.3 90.6 82 84 88 82 86 90 92 2008 n=236 2009 n=235 2010 n=280 2011 n=223 2012 n=230 2013 n=190 2014 n=0 n = number of respondents
- 6. Old NICU
- 7. Create a family centered developmentally supportive environment Goal for New NICU
- 8. Using Process to Drive Change Involvement of families in design Large involvement of staff in sub- committees looking at process changes for the new NICU Using simulation to work out the kinks Using scenarios to set expectations
- 9. Millennium Neonatology: A Building for the Future, Padbury, Taub, Bender 2010 Effect of SFR on infant Outcomes
- 10. Improved Parental Participation Increase number of parental visits Increased time spent doing infant’s care Increased time doing Kangaroo Care Increased number of opportunities to feed infant Millennium Neonatology: A Building for the Future, Padbury, Taub, Bender 2010
- 11. Effect on Parental Outcomes Open Bay (n = 151) Single Room (n = 252) P< Parent Satisfaction Press Ganey NICU Score 4.4 (0.7) 4.9 (0.3) .001 Parent Stress Parent Stressor Scale NICU 3.1 (0.8) 2.8 (0.8) .001 Maternal Depression Beck Depression Inventory 13.1 (9.3) 11.9 (8.7) ---- Millennium Neonatology: A Building for the Future, Padbury, Taub, Bender 2010
- 12. Parental Care Millennium Neonatology: A Building for the Future, Padbury, Taub, Bender 2010
- 13. Benefits of Working with Shared Governance Empowers staff Bottom up vs. top down process of implementation Buy-in because it is their project
- 14. Brainstorming with staff/Shared Governance Need to reframe the concept of family centered care to creating partnerships with parents Preferred providing tools for staff vs. scripting Way to formalizing something we did already when parents came to the NICU
- 15. Focus Groups Purpose was to identify new or unknown concerns of parents in the new SFR environment and gather suggestions for improvement from the perspective of the parent. Two groups were formed; Newcomers < 2 weeks in the NICU Veterans 5 weeks to 6 months in the NICU
- 16. Results of the Focus Groups Opportunities included; Supporting siblings at home and at hospital Sharing the information of the Primary RN Predicting timing of rounds Sharing the plan of care Easing the financial burden of eating at the hospital Connecting with other parents Improving the orientation of new families
- 17. Accountability Setting expectations of staff and holding staff accountable for their actions helps to value your best staff
- 18. Med Teams Training Objectives Identify the essential elements and benefits of teamwork Recognize standards of service and effective communication within a team Utilize and demonstrate teamwork, communication and service recovery strategies
- 19. p <0.01 p<0.01 Pre-Intervention 3 Months 12 Months Post-Intervention Post-Intervention PercentofRespondentswho AgreeorStronglyAgree NICU: “Staff feel free to question the decisions or actions of those with more authority” National Average 90th % Nationally >MAX% Nationally Med Teams Effectiveness
- 20. Leadership Rounding To connect with patients to make sure that we are meeting their needs Provide service recovery when needed To identify/track areas requiring improvement To connect with staff to make sure we are meeting their needs To recognize employees for work well done
- 21. Partnering with Parents at Bedside Shift Change “Improve the experience of care through mutually beneficial partnerships.” Griffin, Bringing Change-of-Shift Report to the Bedside A Patient- and Family-Centered Approach, Journal of Perinatal Nursing, Vol 24, No 4, pp 348-353. 2010
- 22. Partnering with Parents supports the four core principles of Family Centered Care “Partnering with parents is the respectful exchange of information where the nurse and the parent collaborate to develop a plan of care that encourages parent’s participation.”
- 23. Communication uses words and phrases that the patient understands and meets their emotional needs. Patients and families are part of the care team and participate at the level the patient chooses. Care for each patient is based on a customized interdisciplinary shared care plan with patients educated, enabled and confident to carry out their care plans. Every care interaction is anchored in a respectful partnership anticipating and responding to patient and family needs Institute for Healthcare Improvement, Driver Diagram: Improving the Patient Experience of Inpatient Care, 90-Day Project Team (October 2008)
- 24. Partnering with Parents will improve our compliance with the new JCAHO patient safety goals of; Improving the effectiveness of communication among caregivers Encouraging patients’ active involvement in their own care as a patient safety strategy The Joint Commission. National Patient Safety Goals. www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals. Accessed April 23, 2010
- 25. Partnering with Patients has been shown to improve patient care by; Decreasing adverse events and medication errors Increasing the patient’s adherence to care plan Decreasing re-admissions Decreasing the number of days on ventilator Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-first Century. Washington, DC: National Academies Press; 2001
- 26. What’s in it for me? Benefits for staff! 1. Having parents that are less anxious and therefore less needy. 2. Decreasing the risk of medication error and adverse events by using parents as a double check. 3. Decrease risk of litigation. 4. Having parents that are engaged in reaching their care goal, a goal that has been mutually agreed upon. 5. Having parents help facilitate their own discharge process.
- 27. Partnering helps to meet our needs of NICU parents 1. For accurate information and inclusion in the infant’s care and decision making 2. To be vigilant and to watch over and protect the infant 3. For contact with the infant 4. To be positively perceived by the nursery staff 5. For individualized care 6. For a therapeutic relationship with the nursing staff Cleavland, Parenting in the Neonatal Intensive Care Unit, JOGNN, Vol 37, Issue 6, pp 666-691, 2008
- 28. Seeing the process in action… on a field trip White boards helped to guide patient participation in nursing rounds White boards were a great way to audit for accountability Setting expectations was critical to success Auditing with friendly reminders helped to get everyone on board Scripting…
- 29. Improved Breastfeeding Support Instead of focusing on the volume of milk a mom pumps and that a baby is gets at breast we need to focus on; 1. Giving mom the tools she needs to establish a robust milk supply. 2. Encouraging mom to practice milk transfer (movement of milk from breast into baby) 3. Bolstering maternal confidence Pediatrics Vol. 107 No. 3 March 1, 2001 pp. 543 -548 The timing and predictors of early termination of breastfeeding IO Ertem, N Votto, JM Leventhal
- 30. Six Steps to Successful Breastfeeding in the NICU 1. Establish and maintain a robust milk supply 2. Provide frequent Kangaroo Care 3. Provide Kangaroo Care while infant is tube fed 4. Allow infant to nuzzle or play at the breast during Kangaroo Care 5. Allow infant to begin to snack and breastfeed when ready 6. Prepare mom and baby for breastfeeding after discharge
- 31. Overcoming Challenges Consistency of the message “taking care of babies, families and each other” Working with staff to craft the model Working to get buy-in from the medical team Explaining why change is mission critical Making practice changes expectations and holding staff accountable
- 32. “Family Centered Care is less a destination than a journey.” Implementing Potentially Better Practices for Improving Family Centered Care in Neonatal intensive Care Units: Successes and Challenges Cisneros Moore et al, PEDIATRICS, Vol. 111,No. Supplement E1 April 2003, pp.e450-e460
Editor's Notes
- First I would like to introduce myself, I am Stephanie Adam. I have worked in the NICU at Women & Infants for the last 24 years. I started out as a full time staff nurse on the evening shift for 5 years and then became an Assistant Nurse Manager. I took a new position this past September as manager of patient and family centered care a subject I have been passionate about for years. It is my pleasure to introduce Beth Taub, the current nurse manager in the NICU. She started out as a staff nurse on the night shift, became an Assistant Nurse manager and has been the manager for the past __ years. Our mission in our NICU has been to take care of patients, families and each other. It has been Beth’s tag line for many years. Over the years this tag line has become who we are in the NICU. It is important to mention that while taking care of patients and families is important it can’t be done well unless we take care of each other too.
- So how have we operationalized “taking care of patients, families and each other”? There are many nuances that may not be captured here but after looking at our yearly goals, the major initiatives that have impacted our press ganey scores include; Moving to a single family room environment Implementing a model of Shared Governance Providing Med Teams Training Engaging staff and Patients in leadership rounding Educating Staff on Bedside Shift change Improving Breast feeding support for our families.
- Our NICU has undergone a transformation. In October of 2009 we moved from a very crowded bay style NICU to an 80 bed single family room NICU that spans two floors. We have a team of care for each floor and a team that cares for our short stay infants on both floors. This third team was a developed two years ago in response to lower Press Ganey scores for our short stay patients. We found they were not getting the attention that they needed from the teams that were caring for the more acute patients as the more acute patients demand more attention.
- This is model of our second floor however it is very similar to our third floor. We spent a lot of time developing the layout of our new unit. We flew families and staff across the country to tour other single family room NICU’s and incorporated their feedback into the design. We also had the blue prints posted for staff feedback every step of the way. This project, while frightening for some, was empowering as it required staff to become involved in the transformation.
- This slide is a road map for the work we have done over the last five years. In 2008 our peer group ranking was between 10 and 40% however by the third quarter of 2009 we were ranked at 88.9% and by the second quarter in 2010 we had a peer group ranking of 99.9%. Inserted into this graph is the timeline of the projects we have done in the NICU during this time. The intervention with the biggest effect on our Press Ganey scores was our move to single family rooms.
- Does this look like your NICU? If it does then I feel your pain. As much as we were aware of developmental interventions and family centered care it was difficult to provide the care we wanted to in the constrained environment of our old NICU. If you look closely at the picture in the upper right corner you can appreciate how little space we had. It was often difficult to have a parent visit their baby and try to provide care to the infant in the next bed. Our parents often felt in the way. It was also not an ideal environment of skin to skin or attempting breastfeeding.
- The transformation was remarkable. We went from an environment where nursing had all the control to an environment where the babies were part of their family unit. Parents felt empowered, felt comfortable providing care, felt ownership.
- The chief of neonatology stated that the transformation was 20% bricks and mortar and 80% process. The first thing that was done in this process was to create a NICU family advisory council. Looking back we should have created a slide just to discuss the benefits of having a family advisory council. What a gift it has been to have access to our families perspective over the years. Not only does our NICU family advisory council support programs to make our parent’s stay in the NICU easier, they are a sounding board for all of our new initiatives. We do not do anything new in our NICU without having the NICU FAC vet it first. We also had more staff involved in subcommittees then anytime previously or since. Staff involvement is empowering. Empowered staff feel valued. There can not be enough said about the importance of having an empowered staff. Not only were our staff on committees to develop new processes they were asked for their feedback on everything from the blue prints, to the layout of the room (we developed a mock room), to just logging in their questions and concerns which were answered along the way. Staff often brought up areas we had not thought about or prepared for. We also used simulation to assist in the transition. We asked staff for their worst case scenarios and used them to develop our program. Before we actually moved into the new space we opened a neighborhood and using a full cast of charecters, we worked in our space using two scenarios. The first was under normal conditions, which allowed staff to get their bearings and get comfortable then we debriefed to find out what worked well and what did not. We did a second scenario under more challenging conditions and debriefed after that as well. The result was being able to work out some of the kinks prior to the move but more important was the transformation that took place with the staff involved. Staff who were nervous about the move now felt confident, a change that did not go unnoticed when we oriented the staff to the new environment. Instead of using a didactic class we walked staff through two scenarios as well. One brought staff through the start of their shift and one that walked them through an admission that ended up coding. What we were able to incorporate into the scenarios is what family centered care would look like in the new environment. It provided scripting that they had not been exposed to.
- Beyond looking at the process of moving, the results of the move were even more inspiring. When we moved to single family rooms in the NICU we found that there was that the increased opportunities that families had to be involved in the care of their infant improved their medical and their neurodevelopmental outcomes. It wasn’t the room, it was how the room influenced families involvement.
- We studied the outcomes of our move and found a significant increase in the number of parental visits, The time parents spent doing infant’s care, doing Kangaroo Care, and the number of opportunities parents had to feed their infant.
- We had improved parents satisfaction, parents had less stress and less maternal depression.
- Parents were also comfortable spending significantly more time with their infants.
- In 2010 we developed a Shared Governance committee. Porter-O’Grady (2001) states that shared governance is a way to provide empowerment and it provides the structures to support empowerment. He also states that Shared Governance embodies four principles: partnership, accountability, equity, and ownership. We have hit some bumps in the road with our council however we are growing stronger with our journey.
- As we have moved forward with family centered initiatives our Shared Governance has guided us. They have recommended that we; Need to reframe the concept of family centered care to creating partnerships with parents Preferred providing tools for staff vs. scripting Way to formalizing something we did already when parents came to the NICU
- Another project from 2010 was a gift from one of our NICU family advisory members who works for a PR firm. She assisted us in looking at our new environment from the perspective of parents who were new to the NICU and those that were veterans. Since most of our advisory hailed from the old NICU we needed a way to ensure that we were still capturing and responding to the needs of our families.
- Understanding the needs of our families is essential to helping them be satisfied with their experience of care. ? Add more detail?
- I think that it is safe to say that discipline is not the highlight of our work. It was in 2010 that our NICU management team took a closer look at what we were doing in regards to setting expectations for staff and holding our staff accountable for their actions. We knew that by letting things slide we were not valuing the staff who gave high quality care everyday. Staff were actually looking to us(the management team) to do a better job of stepping up to the plate and dealing with the staff that were not meeting expectations. This wasn’t easy but the management team worked together to coach staff. We provided staff that needed help with the tools to improve and an action plan to get it done. Most staff were happy for our interest and support and grew to become excellent nurses but there were some that choose not to change. They are not with us anymore.
- Bedside shift change…we have done a lot of education around bedside shift change in our NICU, however the process is not yet a consistent part of our practice. What has become a consistent part of our practice is the concept of partnering with parents and how developing partnerships has rewards for all parties involved. I have included some of our slides from our staff education as it will provide you an understanding of the perspective that we share in the NICU.
- This collaboration values equally the input of both family and staff Respect and Dignity Information Sharing Collaboration Participation
- This is a snippet from the IHI’s driver diagram that was published in 2008, there is not a part of it that I don’t love.
- If staff doesn’t want to embrace the concept for me, they might do it because JCAHO says so.
- There has been a lot of studies lately that demonstrate the relationship between partnering with patients and their families and improved quality of care and safety.
- When you are in a partnership with a family there is a level of comfort and often this allows for families to be less anxious and less needy.
- A systematic review of 60 studies done by Lisa Cleveland entitled “Parenting in the Neonatal Intensive Care Unit” finds that parents in the NICU have six critical needs. For accurate information and inclusion in the infant’s care and decision making To be vigilant and to watch over and protect the infant For contact with the infant To be positively perceived by the nursery staff For individualized care For a therapeutic relationship with the nursing staff It was interesting how our NICU FAC responded to this slide as we were looking for their feedback on this initiative…So many of our parents could really identify with these six critical needs.
- As part of the research we did to prepare for incorporating parents into bedside shift change we went on a field trip to a local hospital which was using this practice and we learned a lot from them. We have recently developed a “Shared Care Plan” style white board that can be used by nursing and their patient’s families. We are hoping to share information that the parents and the primary nurse know about their infant with staff that may not have cared for their baby before. As we role out this new white board we will be using a process similar to what we found at South Coast hospital that uses the white board to guide participation in bedside shift change.
- Again, with help from our FAC, we learned that our families experience a great sense of failure when they can not successfully breastfeed their infant. When we looked at what we were doing we found that we were focused more on the numbers than on actually supporting the process of milk transfer at the breast. Just a side note: our NICU FAC actually wrote a letter to administration asking for more lactation support in the NICU and we were able to hire 2 FTEs.
- Our education for both staff and families was based on six steps that we identified after performing a literature review.
- In hind site this looks easy but there were a lot of challenging moments. Beth and I have listed some of the factors here that assisted us in our success.
- Thanks you for giving us the opportunity to talk about a subject that is such a passion for us. Good luck on your journey. I believe we have a few minutes left and are happy to answer any questions you might have.