Enhancing the quality and safety of the 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 Service
Delivering a Healthy WA
Background
• Impetus for change– Nursing shortage and skill mix– New Children's Hospital (NCH) Project – Accreditation– Clinical incidents
Nursing Model of Care Project Aim: 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 2.93
Result 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
Patient Experience Trackers
Staff Tracking – Direct care time
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
Interruption Tracking
0
5
10
15
20
25
7:00
:00
AM
8:00
:00
AM
9:00
:00
AM
10:0
0:00
AM
11:0
0:00
AM
12:0
0:00
PM
1:00
:00
PM
2:00
:00
PM
3:00
:00
PM
Coodintator (5C)
RN (8A)
GN (8A)
EN (5C)
RN (5C)
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 worksheetHourly 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 Admin
% Post Admin
Clinical Leadership 28% 45%
Managerial/Administrative 72% 55%
CNM Ability, Leadership and SupportSeptember
2011May
2012Sig
A supervisory staff that is supportive of the nurses
2.91 3.27 .068
Supervisors use mistakes as learning opportunities, not criticism
2.62 3.11 .029
A Clinical Nurse Manager is a good manager and leader.
3.05 3.38 .206
I receive praise and recognition
for a job well done 2.24 2.97 .007
A Clinical Nurse Manager who backs up the nursing staff in decision making, even if the conflict is with a physician
2.99 3.27 .182
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 Children's Hospital Project • Nursing Education• Clinical Planning and Reform Unit