The issues around poor skill mix and the potential for nursing shortages, plus the impetus from planning the new children’s hospital led the nursing executive to explore and implement a contemporary nursing model of care at Princess Margaret Hospital.
hjy Safety, Performance and Quality Nursing quality indicators Medication audit data Nursing Governance Coordination of nursing KPIs Frontline Accountability NCH Inpatient unit design and function Medication Working Party Clinical transformation stream Nursing Education Professional Development Framework Practice Development Multidisciplinary teams Clinical Planning and Reform Unit
Sue Peter - Enhancing the Quality & Safety og the Nursing Model of Care: Planning for A New Children's Hospital in Western Australia
Enhancing the quality and safety ofthe nursing model of care: planning for a new children’s hospital in Western Australia Sue Peter Princess Margaret Hospital for Children Child and Adolescent Health ServiceDelivering a Healthy WA
Background• Impetus for change – Nursing shortage and skill mix – New Childrens Hospital (NCH) Project – Accreditation – Clinical incidents
Nursing Model of Care ProjectAim: The delivery of safe, quality care by nurses who critically think, analyse, openly question and challenge.• Practice Environment• Leadership• Frontline accountability and local ownership• Culture and practice development• Integration
Practice Environment Survey –Nursing Workforce Index (PES-NWI)Subscales1. Nurse Participation in Hospital Affairs 2.432. Nursing Foundations for Quality of Care 2.783. CNM Ability, Leadership and Support of Nurses 2.794. Staffing and Resource Adequacy 2.445. Collegial Nurse-Doctor Relations 2.93Result in 2011 MIXED
Actions from the PES-NWI results• Nursing executive visibility – EDON Communication meetings – Members from Nursing Executive attending ward/local area meetings – NUM strategic planning forums• Rewards and recognition – Letter of acknowledgement to all nursing staff – Nurses Round Table
Daily Activity Breakdown (8A & 5C) Motion Admin Handovers Medicines Management Discussion PPE Patient Flow Other Direct Care
Direct Care Breakdown (8A & 5C) Ward Round Medicine Round Toileting Meal Round Nutritional Management Mobilising Observations Assessments Nursing Procedure Hygiene Bed Making Social Care Parent/Patient Communicatin Relative Liasion Documentation
Topic of Interruption Patient Status Patient Flow Clinical Advice/support Location of Equipment Location of Information Clinical Education Other
Practice Environment• Partnership model - Nurses working in skill matched pairs - Mutual planning and organisation - Critical conversation and communication - “Its about sharing the care safely” Joint hourly worksheet Hourly rounding
Hourly Rounding• Hourly the partnership will meet to critically discuss patient care and at least one of the nurses will visit all the patients in the allocated group utilising PROACT.
Components of Hourly Rounding• PROACT – Patient medications – Review clinical status – Observations – Anticipate next hour’s patient needs – Communicate with the patient/family – Teach
Staff Feedback – More conversations about patients – More aware of partners workload – Nurse specialling a patient felt more supported – Families feedback they feel reassured having two nurses – Junior staff know who to go to for support … “I used to feel like I was bothering the coordinator all the time, now I don’t”
Staff Feedback – Experienced staff able to identify partners teaching needs for that shift, including how to support communication with patients family – Staff feel that there is more forward planning – Definitely less call bells when we do hourly rounding … “I know now, that when I am with a really sick patient, someone else is there and will look after my other patients”
Practice Environment• Geographical patient allocation• Devolved nursing stations and consumables• Medication management• Electronic journey board
Patient Status at a Glance Visual management is used to communicate the status of a patient within 3 seconds.
Leadership and Support• CNM Leadership – Review of the CNM role to enable expertise and leadership to drive safety and quality – Availability of CNM to facilitate organisational change – Introduction of administrative support 0.5 EFT Activity % Pre % Post Admin Admin Clinical Leadership 28% 45% Managerial/Administrative 72% 55%
CNM Ability, Leadership and Support September May Sig 2011 2012A supervisory staff that is 2.91 3.27 .068supportive of the nursesSupervisors use mistakes as 2.62 3.11 .029learning opportunities, notcriticismA Clinical Nurse Manager is a 3.05 3.38 .206good manager and leader.I receive praise and recognition 2.24 2.97 .007for a job well doneA Clinical Nurse Manager who 2.99 3.27 .182backs up the nursing staff indecision making, even if theconflict is with a physician OVERALL TOTAL 2.76 3.19 .049
Frontline Accountability• Nursing Governance reformed – Defined process for nurses – Using Nursing Quality Indicator data to identify areas for improvement and activate organisational support for change required at local level – Focus of the week/month, ”reminders on handover sheet”
Culture and Practice Development• Facilitates a “bottom up” approach to identify the values and current practices at ward/unit level• Culture change from “this is how things are done around here” to zero tolerance to unsafe practice where anyone can speak up and question• Provides a platform: – Enable nurses to refine and reform nursing work – Critically analyse – Support organisational change – High challenge, high support environment
What did we agree on at PD School?• Common goal - high quality and safe care• Nurses who are empowered and supported and accountable at ward level through: – Shared vision for nursing care locally and organisation wide – A safety culture – Empowering nurses to drive change at ward level – High challenge/high support environments – Two-way communication throughout the organisation – Nurturing critical thinking and innovation
Integration• Multidisciplinary teams• Safety, Performance and Quality Department• Nursing Governance• New Childrens Hospital Project• Nursing Education• Clinical Planning and Reform Unit