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