Nursing rounds Partners HealthCare’s member hospitals rely on nurses to deliver high quality patient care every day. Nurses are valued members of the interdisciplinary care team and recently have been involved in the roll out of Innovation Units across the Partners HealthCare System. These Innovation Units are piloting the use of new roles and care delivery models in an effort to improve the quality of care patients receive by ensuring it is safe, effective, timely, efficient, and equitable, as well as patient- and family-centered. Many of these initiatives relate closely to one another.

Each of the more than 50 Innovation Units currently in place has a goal of creating a set of emerging best practices that can be shared and replicated across hospitals and the System.

Let’s take a look at how some of the Partners hospitals are piloting new roles and responsibilities for nurses as part of the care team:

Brigham and Women's Hospital (BWH)

The BWH Innovation Units were identified in September 2011. One of the innovation units’ areas of focus was discharge of the patient. A discharge “bundle” packages together certain tasks associated with discharging a patient to make it more likely that he or she will successfully recover upon leaving the hospital, whether the patient is going home or to another facility. Six units were selected to test, pilot, and implement the discharge bundle, as well as unit-specific ideas that support care transitions. One of these, specifically around the proper discharge of a patient, was piloted on 16 A/B, the orthopedic surgery unit. On this unit, nurses have instituted a discharge bundle that involves four main elements:

  1. Discharge phone calls: Following up with the patient on the phone once he or she has returned home.
  2. Warm handoffs: If a patient is being transferred to a nursing or rehabilitation facility, connecting with staff at the facility prior to the patient’s transfer to make sure all pertinent information has been communicated.
  3. High-risk medication discussion: Making sure patients and family members understand what their medications are, how to take them, and why they are important before and after discharge.
  4. Validation of a follow-up appointment: Scheduling orthopedic surgery patients for a follow-up appointment when they book their surgery so they can plan for it ahead of time.

Thanks to two years of work that the orthopedics care redesign team has implemented, 70 percent of orthopedic surgery patients now go home within two days, up from 40 percent prior to their work. The first item on the discharge bundle list, discharge phone calls, really helped the staff on 16 A/B validate that the work they had undertaken was making a positive difference in the lives of patients and staff.  It also helps validate the staff’s multidisciplinary approach to caring for the elective total joint replacement patient population. At first, staff needed to be convinced that discharging patients within two days was the right thing to do for the patient.

"This discharge phone call is as much about making sure the patient and family transition home safely and comfortably, as well as how nurses can make that better for them, as it is about giving the nurses peace of mind to see that the patient really is doing well at home,” says Mary Anne Kenyon, MPH, MS, BSN, RN, ONC, Nursing Director of 16AB - Orthopedic Surgery.

Kenyon described how the nurses crafted a standard set of questions to guide discussions with patients during the summer of 2012. This set was based off of some trial runs of the discharge call to specific types of patients, such as those who have had total hip or knee replacements. She and her staff found that patients often had similar questions, and eventually staff knew ahead of time what answers to have and what specific questions to touch on.

"We ask things like 'How are you feeling today? How is your pain being managed?' It sounds silly, but we often have to reiterate how important ice is and how often they need to ice," says Kenyon. They also check on other items from the discharge bundle, such as how they are doing with their high-risk medications (usually anticoagulants for orthopedic surgery patients) and where they will be seeing their doctors for their follow-up appointment.

One of the challenges with the project was making sure calls could be kept short enough so that they did not interfere with staff nurses’ other daily tasks. Through an evolving process, they have found that nurses are able to have meaningful discharge phone calls in an average of six minutes.

"I'm very proud of the project, but we have a long way to go. Our goal is that every nurse will call one patient once a week, which would equal about 30 patients per week, and we discharge about 36 per week,” says Kenyon. "It’s important that the staff know that the patient is successful at home, and if they‘re not, we have an opportunity to fix that."

As of October 2013, BWH Innovation Units have completed their projects and shared their successes and outcomes with the BWH community. Staff are now moving the discharge bundle into the mainstream through the Patient Progression Program and looking forward to continuing the excellent work of the Innovation Units across all practice areas.

Brigham and Women's Faulkner Hospital (BWFH)

On BWFH’s Innovation Unit, located on 6 North, the new role of Patient Care Facilitator is an important part of the interdisciplinary team care for each patient. The hospital has begun using the FACT model for care, which stands for the Faulkner Attending  Clinician Team model. This model enhances communication among the team, increases patient safety, promotes interdisciplinary collaboration, and improves patient outcomes.

As a part of the FACT model, the Patient Care Facilitator is a Registered Nurse, who works closely with the clinical care team on the unit. He or she participates every day in goal setting for the patient, bedside rounding, and facilitating communication for the entire team. Generally, the Patient Care Facilitator is an experienced and knowledgeable nurse who can provide care recommendations to the attending physician. He or she is involved in discussions about the goals of care and identifying needs, such as education and access to resources. The Patient Care Facilitator works closely with the primary Nurse to communicate and coordinate care.

"This helps tie things together for the individual patient, as well as the FACT team in total," says Suzelle Saint-Eloi, RN, MS, nurse director for the unit. "It’s been well received here. There has been a lot of support for the success of this model, and senior leadership is supporting its further evolution. It’s nice to have that support and know that our leadership team is confident in us to have autonomy and empower us to find new models that work."

Massachusetts General Hospital (MGH)

As of October 2013, the Innovation Units initiative consists of a set of 15 interventions implemented across 41 units. The Innovation Units were rolled out in three phases beginning in 2012, and the majority focused on inpatient units. Phase four, which will launch in 2014, will be hosted in outpatient and procedural areas.

At the heart of the Innovation Unit model is the new Attending Registered Nurse (ARN) role. The ARN functions as a clinical leader, managing the care of patients on a single unit from admission to discharge. This unique position interacts with the interdisciplinary team, the patient, and the family to foster continuity, responsiveness, quality, safety, effectiveness, and efficiency.

The role requires a dynamic set of individual competencies, knowledge, and an approach that is tailored to the particular needs of each patient care unit. Ideal ARN candidates are experienced, highly regarded, inquisitive nurses, who are committed to advancing change. They also commit to work schedules designed to promote continuity and relationship-based care for patients, families, and care team members alike.

According to Gina Chan, RN, ARN, on the Bigelow 14 Vascular Surgery Unit, “Being able to follow patients daily and share information with the whole team has improved communication, improved care, and most importantly, improved patient outcomes.”

MGH has received positive feedback from patients on the attending nurse role and on many of the other interventions it has incorporated into its Innovation Units. Measures of patient satisfaction showed improvement on Phase I Innovation units at twice the rate of other units. Through focus groups held with nursing staff on the Innovation Units, MGH administrators discovered a common theme: participants feel they are part of an important, positive initiative that improves patient care, relationships with patients and colleagues, patient and staff satisfaction and outcome metrics. They perceive a strong personal role and connection to the Innovation Unit process of transforming care.

The Innovation Unit work has begun to attract national interest and has been featured in the documentary “NURSES: If Florence Could See Us Now,” recognized by the Robert Wood Johnson Foundation’s “Transitions to Better Care” video contest. It also has been reported in a variety of publications, including:

  • "Nurse Leadership from Bedside to Boardroom," Patient Safety & Quality Healthcare
  • "Attending Registered Nurse, an Innovative Role to Manage Between the Spaces," Nursing Economics
  • "Nurses Leading Through Innovation," The American Nurse
  • "Innovation Advisers’ Chosen for Ideas to Improve Health Care, Cut Costs," The Washington Post

In October of 2013, the MGH Innovation Unit initiative was presented at the American Nurses Credentialing Center’s National Magnet Meeting (Orlando, FL) and was the basis of the symposium entitled, "Innovation in Care Delivery: Advancing a Professional Practice Environment," presented by MGH’s Institute for Patient Care.

Newton-Wellesley Hospital (NWH)

At NWH, care coordination rounds have been taking place for five years as a part of a comprehensive approach to patient progression, from admission through discharge.  With the launch of innovation units, the hospital decided to recast an existing nursing role, the Permanent Charge Nurse role.

The Permanent Charge Nurse role has evolved so that he or she facilitates the interdisciplinary communication among the care team, serves as a clinical resource for staff nurses, and is in charge of patient flow/throughput on his or her floor. One of the day-shift Permanent Charge Nurses’ chief responsibilities is to facilitate Structured Interdisciplinary bedside Rounds (SIbR), which take place each morning on the unit, and involve the medical resident, hospitalist, case manager, staff nurse, social worker, and the permanent charge nurse. The team spends 5-7 minutes discussing the status of each patient on the floor, any issues, and the potential for discharge.

“A number of benefits have resulted from this rounding process,” says Jessie Munn, RN, associate chief nurse for NWH’s medical/surgical areas. “We transitioned from a single care coordination round occurring in a conference room to a more consistent, at- or near-the-bedside round approach, using the Permanent Charge Nurse as the facilitator, and incorporating the direct or represented participation of the patient/family in each discussion." Participating staff nurses circle back with their assigned patients/families, who were not present for rounds, in order to update them on the interdisciplinary plan of care and highlight key points on the patient’s white boards. A second round or “huddle” occurs at 4 p.m. with the evening Permanent Charge Nurse, case manager, and physician. It is at this time that any changes to discharge disposition, date, and time are confirmed, discussed with the patient/family, and entered on the patient’s white board and into NWH's patient access bed management system.

Munn says that although the SIbR rounds require additional time, the effectiveness of the communication and end result is far superior. The entire team acknowledges the value of the process and are committed to the time required because “wasted time” has been eliminated.  NWH has seen a reduction in work interruptions associated with the clarification of pages among interdisciplinary team members. Less time is spent tracking down accurate information, and more time is spent in effective team communication with the patient and family. Projected accuracy of patient discharge date and time has increased.

In addition, patients have indicated they are more satisfied with the communication they received from nurses and doctors in the latest patient satisfaction survey. NWH's results have shown that the expanded role of the Permanent Charge Nurse and the incorporation of SIbR have positively impacted patient and family care, interdisciplinary effectiveness and patient throughput.

North Shore Medical Center (NSMC)

NSMC's Innovation Unit, taking place on a 15-bed cardiac unit with private rooms, utilizes a team model for patient care, one which staff nurses helped to design. Staff nurses, case managers, physicians, nursing assistants, and secretaries all play a part on the care team.

One of the main changes in practice involves the team huddle, which is led by the patient’s nurse. Teams meet four times each day to talk about the patient’s care and progression. At each meeting, all team members hear the same information at the same time, which is vital in ensuring patient safety. Nurses like the new model because they have regular communication with the physician throughout the day, communication is improved among the care team, and everyone is working toward the same goals.

“The goal is to transform the culture and care delivery model into a patient- and family-centered care approach that achieves the ultimate patient and provider experience,” says Rosemary Henchey, MHA, BSN, Director of Cardiac Services at NSMC. "Patients like this model as well because they are receiving the same message from all caregivers, and caregivers have more time to spend with patients to support and educate them.”

In addition, NSMC has begun implementation of the Patient-Centered Partnership Model (PCPM) on six other inpatient units. A team of key stakeholders developed this model to redefine the patient and family experience at the hospital and optimize the work experience for the nurse. There are four components of the PCPM, each implemented sequentially: A staffing model (composed of a team of caregivers: two nurses, and one nursing assistant to care for a geographically co-located group of 8 - 10 patients), standardized huddles throughout each shift, purposeful patient rounding, and leader rounding. Each team is considered an autonomous process decision-making unit driven by clear, consistent communication throughout the shift.

Each team huddles after receiving their assignments to discuss key individual patient issues, including personal care, safety, diet, and mobility. The huddle creates a base of information about patients, and communication continues throughout the shift. The model supports paired care for patients with higher acuity, allows all team members to have some knowledge about each of the eight to ten patients, facilitates easy coverage for staff breaks, and provides readily available patient information in the absence of one team member.

Part of the PCPM philosophy includes hourly rounding, during which the team opens up a dialogue with the patient about his or her needs, such as mobility (positioning), interventions for comfort (pain), toileting (personal) and assuring that the environment is clean and safe (place). To reduce the potential for artificial regimentation, the team has adapted a model of Purposeful Rounding, where each team supports the guideline of having at least one person interacting with a patient and family every hour. Using the RELATE model of structured communication, staff are consistent in their messages as a means to inform the patient about interventions and partner with them for the ongoing sharing of information.

All of the activities within the PCPM are assessed and enhanced through systematic leader rounding on patients using a scripted framework to reinforce the model and solicit patient feedback. Should the patient or family express concern about interactions, care, or other hospital experiences, the PCPM gives the leader an opportunity for service recovery prior to discharge. Leaders then use the feedback for both recognition and/or coaching up of the staff, both of which reinforce the importance of the process to their local leader, as well as the organization.