EP4 Nurses create partnerships with patients and families to establish goals and plans for delivery of patient-centered care.
Provide one example, with supporting evidence, of nurses partnering with patients and families to develop an individualized plan of care based on the unique needs of the patient.
AND
Provide one example, with supporting evidence, of nurses partnering with patients and families to improve systems of care at the unit, service line, or organizational level.
Example 1
NAME OF INITIATIVE
Palliative Care Services: A Patient- and Family-Centered Approach to Establishing Goals of Care
BACKGROUND & PURPOSE
In acute care hospitals throughout America, the number of patients who have not established advance directives remains high. Not infrequently, patients suffer sudden life-threatening conditions or exacerbations of chronic life-limiting illnesses. Yet neither the patient nor the family has a good understanding of the disease process, risks or benefits of treatment options. Additionally, these patients and families have not considered what constitutes acceptable versus burdensome care, and in what situations they might want to limit care. As a result, discordance between patient/family preferences and the treatment plan are common; communication is deficient among the multiple care providers; and patients suffer inadequate symptom management. Nationwide, specialty palliative care has emerged among the best practice approaches to assist providers in identifying and meeting patient/family needs; improving patient/family satisfaction; and promoting favorable clinical and utilization outcomes. Palliative care is a clinical specialty that focuses on the care of patients and families facing serious and complex illness. It is an interdisciplinary model of care that is integrated and offered simultaneously with all other appropriate medical treatments for cure, disease-modification and measures to prolong life. For survivors, as well as non-survivors, palliative care can improve symptom management, communication, coordination, continuity of care and decision-making. For those near or at end-of-life, this specialty service assists to transition appropriate patients to hospice services or to withhold or withdraw life-sustaining treatment that no longer meets patient-family goals of care.
After conducting a needs assessment of the patient population served by Homestead Hospital, a nurse-led palliative care service was started in 2006 with one full time equivalent (FTE) Registered Nurse. Palliative Care Manager Linda Long, ARNP, who is both manager and care provider, initially planned, developed and implemented the service. She adopted the National Quality Forum (NQF) Preferred Practices for Palliative Care Quality as the model for service line development. Data from volume, process and outcome measures that have been collected since inception of the palliative care service at Homestead Hospital were used for quality improvement and comparative analysis as recommended by the Center to Advance Palliative Care (CAPC). While outcomes measured demonstrated patient and organizational benefits of palliative care services, growth in the volume of patients referred to this service has increased every year since inception. By the end of fiscal year 2011, the palliative care services department at Homestead Hospital had grown to 3.9 FTEs. In addition to the original FTE, one full time Advanced Registered Nurse Practitioner (ARNP), a full time Chaplain and a modified full time (0.9 FTE) Licensed Clinical Social Worker (LCSW) were added to the department. As a result of the additional resources, the Palliative Care Services department is now staffed seven days a week. The department’s seven day-a-week availability has led to an increase in more timely referrals to Palliative Care Services. Analysis of data collected by Long demonstrates that early referrals result in earlier determinations of patient/family goals of care and aid organizational goals to decrease ICU days and overall length of stay. The addition of a board certified Palliative Medicine physician is planned for fiscal year 2015 in order to meet growing demands for referrals. Through tuition reimbursement provided by Baptist Health South Florida (BHSF), Long completed a post graduate certificate program and became a board certified adult/gerontological ARNP in December 2012.
Homestead Hospital’s Palliative Care Services assists the care team with the recognition of inadequately managed symptoms; makes treatment recommendations to medical staff; and/or assists nursing staff with the management of analgesics or other indicated medications. Especially in patients for whom life prolonging treatment(s) are being withdrawn, symptom management is a core competency for palliative care specialists. All staff members of this nurse-led specialty service are widely respected and serve as a valuable resource that is available to all medical and hospital staff. Additionally, the department has provided a number of education programs to improve the primary palliative care provided by all care providers. Programs range from evidence-based patient-family communication models to pharmacologic and non-pharmacologic management of pain and non-pain symptoms and withdrawal of ventilator support to allow natural death. Additionally, Palliative Care Nurse Practitioner Blanca Chavez, ARNP and Palliative Care Social Worker Dell Slavin, LCSW, educate all new nurses about the services provided by the department and teach core pain management principles and practices during monthly nursing orientation. To ensure primary palliative care is improved throughout BHSF, Long participates as a subject matter expert in BHSF’s critical care, progressive care and emergency care resident training programs.
After Baptist Health South Florida was awarded a grant in 2008, Long participated in the development and production of the “Intercultural Palliative Training Program”. Designed as a blended learning program, web-based learning modules are followed by an interactive classroom roll play experience. The number of modules required depends upon the participant’s professional discipline. (EP4 01 Homestead Hospital Intercultural Palliative Training Program completion report) This program has been made available to other area hospitals and is now part of the curriculum at Florida International University’s school of medicine. It is because of this commitment to providing excellent palliative care that Long was named Nurse of the Year for Palliative Care by the Miami March of Dimes in November of 2012.
Exhibit EP4a: Linda Long, ARNP Recognized as Nurse of the Year during March of Dimes Award Ceremony in November 2012
The following exemplar describes how palliative care nurses are involved in interprofessional collaborative practice that exemplified patient-and family-centered care and ensured coordination and continuity of care of a comatose patient.
During the months from July through December of 2012, Homestead Hospital’s Palliative Care Services department staff worked extensively with Mrs. F, a 40 year-old woman, and her family. Originally from Haiti, Mrs. F spoke little English yet worked as a housekeeper to provide for her family. Shortly after the arrival of her 19 year-old son, P and 17 year-old daughter E from Haiti two years earlier, Mrs. F’s husband moved out. Mr. F was the father of Mrs. F’s American born 12 year-old daughter K and 3 boys: 10 year-old H, 9 year-old D and 6 year-old A. He assisted with some of the expenses and visited his children periodically. Mrs. F and her children were active in a local church with a Creole-speaking congregation and Pastor.
Diagnosed with dermatomyositis in August of 2011, Mrs. F spent much of the 10 months following diagnosis in several area hospitals for a variety of issues related to her diagnosis. By early 2012, Mrs. F was wheelchair bound and required tube feedings for adequate nutrition. Apparently Mrs. F relied on her 12 year-old daughter K to translate during visits with care providers. Subsequently, Mrs. F and her family had little insight into her illness or treatment. Mrs. F had been non-adherent to outpatient treatment and follow up care at a tertiary medical center for a variety of reasons.
Following admission to Homestead Hospital in July 2012 for severe recurrent hyponatremia, Mrs. F sustained an asystolic cardiac arrest. The healthcare team performed cardio-pulmonary resuscitation with advanced life support with return of pulse. Then, they placed her on hypothermia protocol. Following rewarming, Mrs. F remained ventilator dependent with persistent myoclonus. She never regained consciousness and ultimately remained in a persistent vegetative state. Previous to this admission, she had designated her 19 year-old son P, who spoke little English, to be her healthcare surrogate. In spite of being shown this document, Mr. F asserted that, as legal husband, he should be the medical decision-maker. P and Mr. F reached an uncomfortable compromise. P chose to remain surrogate but allowed Mr. F to be involved in family meetings and to discuss Mrs. F’s medical information.
METHODS & APPROACH
Nurses Partnering with Patient and Families
Other than school days, it became obvious that all of Mrs. F’s children except P would remain at the hospital for hours if not the entire day. The ICU nursing staff would regularly visit and allowed flexibility with accommodations and visitations. Many times, they made available food, blankets and other forms of entertainment (e.g. crayons, magazines, books, movies). Long noted that the oldest would walk to a nearby grocery store and buy food for their meals. With Mr. F’s permission, she encouraged the children to talk about their mother and answered their questions while taking them on walks around the hospital grounds to watch fish in the ponds, watch birds in the meditation garden and spin circles like helicopters on the helipad. Long received the Daisy Award in September 2012 for the compassion she showed to Mrs. F’s young children. (EP4 02 Long’s DAISY Award Nomination).
Unique Needs of the Patient
The healthcare team utilized Certified Creole translators during family meetings. Between Long and other ICU nursing staff, they made arrangements to have Mrs. F’s father in Haiti included in phone conferences per P’s request. In spite of no signs of improvement and multiple family conferences over several months, Mrs. F’s family in the area and in Haiti wanted full aggressive care and offered prayers for a miraculous recovery. During individual meetings with various palliative care staff, the team learned that family blamed Mr. F for Mrs. F’s illness. And, Mr. F was very concerned that if Mrs. F died, her family would kill him. P privately agreed Mr. F’s fears were real. P also felt that he needed his maternal grandfather’s approval to either limit or withdraw life sustaining treatment. While P did not believe that family would harm him personally, he was concerned that family in Haiti would “say bad things” about him and was concerned that someone would put a Voodoo spell on him. Similarly concerned, Mr. F attempted to prevent church members from visiting the patient. A full code, Mrs. F underwent tracheotomy, percutaneous endoscopic gastrostomy (PEG) tube placement, multiple line insertions for medication administration and blood draws, treatment for infections and endured finger sticks for blood sugar daily until December 2012. (EP4 03 Palliative Care Notes)
Individualized Plan of Care
By November, 2012, many of the nursing and medical staff members caring for Mrs. F were suffering moral distress for providing what they saw as futile care that subjected the patient to uncomfortable procedures such as finger sticks for blood sugars; line replacements to maintain venous access and for blood draws. An ethics panel was convened at the request of an ICU nurse. The panel consisted of nurses, physicians, a chaplain and palliative care team members. Ultimately, 2 members of the panel met jointly with P, who was clearly distressed by his mother’s plight. Using knowledge of family, economic, social and cultural dynamics, the team realized that P simply could not be deemed responsible by others for the decision to withhold or withdraw aggressive care. However, P did agree that if Mrs. F should arrest again, she would not want to be resuscitated. As a result, the team removed the burden from P by telling him that, because resuscitation would not help Mrs. F get better and return to normal life, it would not be provided. P was comfortable with this and agreed. (EP4 04 Bioethics Family Meeting Progress Note)
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Linda Long, MSN, MBA, ARNP, ANP-BC, GNP-BC, CHPN |
Manager |
Palliative Care |
Facilitated discussions regarding goals of care / ongoing support |
Blanca Chavez, MSN, ARNP, FNP-BC, CHPN |
ARNP |
Palliative Care |
Facilitated discussions regarding goals of care / ongoing support |
ICU / PCU Nurses |
RN/ Patient Care Supervisors/ Manager |
Critical Care/ Progressive Care |
Patient Care/ ongoing support |
Tracey Seidman, RN, CPHM |
Case Manager |
Case Management |
Ongoing support/ facilitate meetings & phone calls |
Evelyn Quinones, BSN, RN |
Case Manager |
Case Management |
Ongoing support/ facilitate meetings & phone calls |
Laurel Clark, MSN, RN |
Bioethics and Patients Rights Coordinator |
Corporate Bioethics |
Bioethics evaluation and support |
Ethics Committee |
Members |
Interprofessional |
Ethics consultation and support |
Dell Slavin, MSW, LCSW, AHPC-SW |
Social Worker |
Palliative Care |
Ongoing support |
Gregorio Marin |
Chaplain and Pastoral Care Director |
Pastoral Care/ Palliative Care |
Emotional & spiritual support to both family and staff |
Eliane Menezes |
Chaplain |
Pastoral Care/ Palliative Care |
Emotional & spiritual support to both family and staff |
Mark Hernandez, MD |
Attending physician |
Medical Staff |
Attending physician/ collaborative |
OUTCOMES
Mrs. F. stabilized and did not die while she continued to be maintained on ventilator support. As P and other family found it quite painful to see Mrs. F, visits became less and less frequent. Ultimately, Mrs. F developed necrotic areas on her fingertips and ears. Once again, ICU/PCU Nurse Manager Leslie Everett, RN, contacted Bioethics and Palliative Care for a follow up conference due to ongoing moral distress from the staff. Long asked P for a family conference. The team asked P’s permission to look at his mother and to see what concerned the staff. Gently guiding P as he thought through the options available for Mrs. F’s care, P was able to verbalize that his mother was “dying” and that the family should “let her go.” In December 2012, Mrs. F was disconnected from the ventilator to allow natural death. Palliative care assisted in enrolling Mrs. F to hospice services so that her children would be able to participate in the bereavement benefit available up to 1 year after her demise.
To promote further learning and reflection among the staff in providing culturally-sensitive and competent care, this case became the inspiration for the November 2013 Conversation in Ethics series. The class was offered live in Homestead Hospital and video-conferenced to 5 different locations. (EP4 05 Conversations in Ethics November 2013 Flyer and Roster) Perhaps the most valuable service provided by palliative care specialists is to assist patients/families to define their specific goals of care and facilitate individualized plans of care.
Summary of Attachments/Hyperlinks/Evidences:
EP4 01 Homestead Hospital Intercultural Palliative Training Program completion report
EP4 02 Long’s DAISY Award Nomination
EP4 03 Palliative Care Notes
EP4 04 Bioethics Family Meeting Progress Note
EP4 05 Conversations in Ethics November 2013 Flyer and Roster
Exhibit EP4a: Linda Long, ARNP Recognized as Nurse of the Year during March of Dimes Award Ceremony in November 2012
Example 2
NAME OF INITIATIVE
Patient- and Family-Centered Care Steering Council
BACKGROUND & PURPOSE
From a patient’s perspective, excellent medical care is the least a healthcare organization should offer. Homestead Hospital recognizes the importance of the patient experience and is moving towards a culture that incorporates the insights and perspectives of patients and families into facility design, program development, policy development, health education, and care delivery. This type of philosophy is an established national movement called patient- and family‐centered care. Adopted by hospitals across the United States, it involves truly partnering with patients and families. It not only involves them in decisions about their care, but also adds the benefit of their help and insight as a way to better plan, deliver and evaluate their health care. According to the Institute of Patient- and Family-Centered Care (IPFCC), “It is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. It leads to better health outcomes and wiser allocation of resources, and greater patient and family satisfaction.”
Utilizing evidence-based approaches in advancing patient- and family-centered care, a Patient-and Family-Centered Steering Council, that included patient and family advisors, was initially established at the corporate level. The advisor role enabled patients and families to have direct input and influence on policies, programs, and practices that affect the care and services individuals and families receive (Institute for Family-Centered Care). The steering council was charged with driving patient- and family-centered care philosophy across the system. This thrust was very much aligned with the Nursing Professional Practice Model (PPM) which underscored patient and family at its center as the recipients of care. Additionally, the Care Delivery System (CDS) also highlighted patient- and family-centered care as one of its frameworks. Homestead Hospital started its Patient- and Family-Centered Care Council (PFCC) in January 2012. It aimed to: (1) promote a better understanding of the principles of family-centered healthcare and the services and policies of Homestead Hospital among patients, patients’ families, patients’ guardians, patient groups, support groups and the community; (2) assist in the promotion of positive relationships between Homestead Hospital and community members.; and (3) channel information, needs and concerns to Homestead Hospital administration and staff. (EP4 06 PFCC Charter)
METHODS & APPROACH
Partnering with Patients and Families
PFCC consisted of interprofessional team members from various nursing specialties, pastoral care, dietary, risk management, marketing, and patient and guest services. Susie Accursio-Ebersole and Marlene Porter initially served as the family advisors for Homestead Hospital. Eventually, Porter became the standing family advisor. Incidentally, she was also a member of the system steering council which enabled her to bring information and communication back and forth from hospital-based PFCC to the system steering council. As an advisor, she served as an active consultant with regards to decisions and plans that affected Homestead Hospital’s patients and families. Marlene Porter was born in Homestead. She worked for First National Bank of Homestead from 1955 – 1968. She left the area for 10 years after the death of her husband. She lived in Mississippi, Louisiana and Texas. She returned to Homestead in 1982, and began working for the Community Bank of Homestead. She now is President of her own company, PPFL, Inc. a Management and Leadership Consulting. Marlene Porter became involved as a Patient and Family Advisor after she had an unpleasant experience in one of the BHSF hospitals. She was in a nail salon complaining about her experience. Marlene was approached by Corporate Assistant Vice President Yvonne Zawodny, RN, and asked to use her bad experience to be a Patient and Family Advisor at BHSF. She started as a council member for the BHSF Patient- and Family-Centered Care Steering Council. Then she became part of the PFCC Council in Homestead Hospital. She wanted to get involved to assist BHSF become more patient-and family-centered. As a long time community member in Homestead, she was the ideal person to be on the Homestead Hospital PFCC.
Improving Systems of Care at the Organizational Level
In order to be systematic in their approach, the PFCC members conducted a gap analysis during their initial meetings utilizing an organizational assessment tool developed by the Institute for Family-Centered Care. (EP4 07 PFCC Meeting Minutes 1/18/12) Based on highest perceived need with lowest current status, the top 5 areas identified were:
|
Category |
Question |
1 |
Information/Education for Patients and Families |
There is a patient and family resource center accessible to patients, families, and staff with: |
2 |
Patients and Families as Advisors |
Patients and families serve on hospital committees and task forces such as: |
3 |
Patients and Families as Advisors |
Patients and families serve on hospital committees and task forces such as: |
4 |
Environment and Design |
There is a space away from the bedside/exam room that supports family learning and practice |
5 |
Patient and Family Support |
Patients and families are involved in developing and evaluation peer support programs. |
To address the number 1 priority identified above, the council pushed for the inclusion of a patient and family resource center in the renovation of an office into a medical library. This was made possible through a donation from Foundation and coordination of Magnet Project Director Julie David, ARNP, who was a member of the PFCC. (EP4 08 PFCC Meeting Minutes 7/18/12) The Medical Library and Family Resource Center opened in August 2012 and welcomed patients, families and their visitors to come in during office hours to access reliable supplemental patient education materials or to use the internet to connect with family and friends. A library coordinator or medical librarian staffed the area Monday – Friday, 8 hours per day. The library was available to staff 24 hours a day through badge swipe access. Another one of PFCC’s early initiatives was modifying the nightly overhead announcement to eliminate the phrase “visiting hours” and better reflect the open visitation policy. At 8:45 p.m., instead of announcing “visiting hours are now over”, the switchboard operator started announcing in January 2013:
“Attention families, friends and guests: Thank you for visiting Homestead Hospital. The time is now 8:45 pm. In fifteen minutes we will be securing the hospital for the evening. Those who wish to stay overnight, please see a unit member to make arrangements. We appreciate your assistance in maintaining a healing environment during this time. Thank You.”
The council also worked on revising the hospital map to make it more user-friendly to families and visitors. Through the efforts of the Pastoral Care department, Homestead Hospital acquired 2 baby grand pianos. They were positioned in central and high-traffic areas. Volunteer Services departments provided pianists who played soothing music that patients, visitors and staff could enjoy. This lent to a welcoming ambiance and leveraged the soothing and healing effects of music.
Establishing Goals and Plans for the Delivery of Patient-Centered Care
Another initiative the council has approved was family presence during resuscitation (FPDR) such as code blue (cardiac arrest emergency code) in the Intensive Care Unit (ICU). Critical Care Clinical Nurse Specialist Rosemary Lee, ARNP, presented evidence-based literature during the council meeting in early 2012 on how family presence can help families understand the gravity of their loved one’s condition and recognize that the medical staff is doing everything possible. Starting in September 2012 Critical care staff assigned a team member to be with the family to explain what was happening for families who chose to be present during a code blue. The families who requested this appreciated the opportunity to watch the efforts of the clinical team in reviving their loved ones and comforted in the knowledge that nothing was hidden from them.
PFCC’s overarching goal was to incorporate or enhance the delivery of patient- and family-centered care at the bedside. To accomplish this, the council reviewed the proposed changes to Perinatal services visitation policy. Through the policy approval process, the revised policy was vetted among different councils and committees and eventually approved by the Clinical Practice Committee in March 2013. (EP4 09 HH-400-2630-400-15 Visitation Policy for Perinatal Unit). Additionally, to provide diversional and art therapy to patients, the council decided the purchase of an Art Cart along with supplies, such as crayons, coloring books, playing cards, crossword puzzles, Sudoku books, paper, paints, and paint supplies. (EP4 10 PFCC Meeting Minutes 9/11/13) Since there was no cost center designated to support the council’s expenses, Surgical Services Director and PFCC Chair Carmen Bouchard, RN, advocated to Chief Executive Officer William Duquette to finance the initial cost of the cart and ongoing expenses for the supplies. Duquette agreed to support the project expense from the Administration cost center. Bouchard then collaborated with Volunteer Manager Kathryn Smith who recruited 2 volunteer art teachers to pass the supplies and assist the patients with drawing and painting. The Art Cart started its rounds in October 2013 twice a week. The cart was manned by a volunteer, who happened to be a certified arts teacher. Patients gave positive anecdotal feedback. So, in the summer, Smith recruited junior volunteers who were able to take the cart out more frequently.
PARTICIPANTS
The PFCC members were:
Name/Credentials |
Years of Experience |
Title |
Department
|
Role in the Team |
Carmen Bouchard, MSN, RN, CNOR |
28 |
Director |
Surgical Services |
Chair |
Gail Gordon, MSN, RN, NEA-BC |
45 |
Vice President and Chief Nursing Officer |
Administration |
Member |
Maureen Allen, BSN, MSHA, RN |
21 |
Nurse Manager |
MS4 |
Member |
Hector Aleman, MSN, RN |
18 |
Nurse Manager |
MS5 |
Member |
Rosemary Lee, DNP, ARNP, ACNP-BC, CCNS, CCRN |
41 |
Clinical Nurse Specialist |
ICU/PCU |
Member |
Julie David, MSN, ARNP, ANP-BC |
21 |
Director |
Magnet Designation |
Member |
Jennifer Pages |
16 |
Manager |
Marketing and Public Relations |
Member |
Susan Bunting |
30 |
Risk Manager |
Risk Management |
Member |
Mary Shaw, RD |
9 |
Clinical Dietitian |
Food |
Member |
Marlene Porter |
3 |
Patient and Family Advisor |
Former Patient |
Member; Patient and Family Advisor |
Maria Nunez |
8 |
Supervisor |
Patient and Guest Services |
Member |
Gregorio Marin, BCC |
12 |
Director |
Pastoral Care |
Member |
Emelyn Suarez |
|
Administrative Assistant |
Infection Control |
Secretary |
OUTCOMES
To improve the patient experience, Homestead Hospital recognized that providing exemplary medical care was not enough to engage hospitalized patients and their families. With the changes in health care reform, elevating the patient experience became even more critical to the organization’s ongoing success and reputation in the community. By incorporating a patient‐ and family‐centered care approach, the staff not only improved patient engagement, but significantly increased the quality, safety and service at the bedside. PFCC was the vehicle for enhancing the patient‐ and family‐centered care philosophy in various areas of hospital operations through the involvement of a family advisor and the efforts of the interprofessional team. Since the inception of PFCC in January 2012 to September 2014, the mean patient satisfaction score on “Accommodation and comfort of visitors” has remained above the national benchmark at 90.3 (Press Ganey mean for 150-299 bed size = 86).
Summary Attachments/Hyperlinks/Evidences
EP4 06 PFCC Charter
EP4 07 PFCC Meeting Minutes 1/18/12
EP4 08 PFCC Meeting Minutes 7/18/12
EP4 09 HH-400-2630-400-15 Visitation Policy for Perinatal Unit
EP4 10 PFCC Meeting Minutes 9/11/13