Quality and Safety

Six major themes associated with interruptions

(1) employees asking questions, (2) distracting peripheral conversations, (3) supplies not on hand requiring the nurse to go elsewhere to acquire them, (4) phone calls, (5) family questions, (6) patient call lights.

COST CONTROL IN HEALTHCARE Contributing Factors in Rising Healthcare Costs

1. Price of new technology 2. Construction of new facilities 3. Higher survival rates, leading to greater need for costly intensive or long-term care 4. Growing population of the elderly adults requiring healthcare 5. Rise in salaries for healthcare workers 6. High costs of drugs and health-related equipment

Nurses' Role in Medication Safety

1. Primarily the responsibility of nurses 2. 40% of time spent in this activity. 3. Administration errors: a. As the healthcare environment has become more complex and demanding, the error rate has increased. b. Common Areas that Contribute to Medication - calculation errors - look-alike, sound-alike meds, similar packages - catheter and tubing misconnections - interruptions and distractions - illegible written med orders - unclear verbal orders - failure to check pt's name with MAR - overly tired nurses - inadequate stuffing and increased pt-nurse ratios - dispensing of med - not verifying drug allergy - absence of pharmacists - confusing drug labels

National Patient Safety Goals (NPSG).

There is a separate set of safety goals for each type of agency providing care; the goals are structured in the same way for each type of agency and have used a consistent numbering system. Each year, the Joint Commission reexamines the sentinel event data and the safety goals and revises them by deleting those that have been largely achieved and adding new safety goals.

Centers for Medicare and Medicaid Services

They would not reimburse hospitals for the costs associated with six serious hospital-acquired complications: 1. Pressure ulcers 2. Catheter-associated urinary tract infections [CAUTIs] 3. Staphylococcus aureus septicemia— methicillin-resistant Staphylococcus aureus [MRSA]) Three "never events": 4. Air embolism 5. Blood incompatibility 6. Foreign object left behind in a surgical patient

Controlling Fraud and Abuse

HIPAA created a federal Healthcare Fraud and Abuse Control Program that coordinates federal, state, and local law enforcement activities in fighting healthcare fraud and abuse.

Near Miss Event

- Also called "close cal" or "good catch" - A pt safety event that did not reach pt - This good fortune might reflect: fortuitous, timely intervention (eg. nurse realizes that a physician wrote an order in the wrong chart)

Managed Health Care Plan

A group of medical providers contracts with a group to provide medical care for its members at prices both agree to and are lower than the traditional cost of insurance HMO is the original managed health care model

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*** Lecture Notes ***

Root Cause Analysis (RCA)

A comprehensive, in depth process that seeks to identify all the underlying factors that contribute to an error and to identify their role in causing error.

Move to just, not shame/blame

A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control. • A just culture also recognizes many errors represent predictable interactions between human operators and the systems in which they work. Recognizes that competent professionals make mistakes. • Acknowledges that even competent professionals will develop unhealthy norms (shortcuts, "routine rule violations"). • A just culture has zero tolerance for reckless behavior.

Patterns of Nursing Care Delivery 7. Partnership models

Co-primary Nursing - RN is partnered with an LPN/LVN or a nursing assistant, pair work together consistently Its a modification of the primary nursing model To ensure more efficient use of RN Advantages: - More cost-effective than the primary care system - RN can encourage training and growth of partner Disadvantages: - RN may have difficulty delegating to the partner - Consistent partnerships are difficult to maintain on the basis of varied staff schedule - RN responsible for planning care, assigning duties, coordinating care and supervising the partner - RN is accountable for patient care for all assigned patients

Culture of Safety Models Swiss cheese model

Every step in a process has the potential for failure, to varying degrees. The ideal system is analogous to a stack of slices of Swiss cheese. Consider the holes to be opportunities for a process to fail, and each of the slices as "defensive layers" in the process. An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. Each layer is a defense against potential error impacting the outcome.

Other Cost-Containment Measures

In medical facilities, personnel now are asked to be more cost conscious. Nursing personnel must be aware of the tremendous cost of any complication or prolonged length of stay. Preventing complications and getting clients ready for early discharge have become a major focus of care. Being conservative with telephone use, canceling meal trays when clients are discharged, and using expensive supplies with care. 1. Prevent complications 2. Early discharge 3. Ensure resources used wisely

Complex Work Environment

Requires both detailed, standard procedures and improvisation

Patterns of Nursing Care Delivery 4. Total pt care

• Nurse responsible for total care for patient assignment for shift being worked • Advantage: - Consistency of one nurse caring for same patient - RN maintains a high degree of practice autonomy - Lines of responsibility and accountability are clear - Patient receives holistic, unfragmented care - Communication at shift change is simple and direct • Disadvantages: - High level of RN nursing hours, Increased cost - Some task could be accomplished by a caregiver with less training and at a lower cost - Nursing shortage will affect RN availability

Patterns of Nursing Care Delivery 1. Case method

• Oldest model for nursing care delivery • Nurses care for one patient exclusively • Total patient care (Modern day version)

No-Harm Event

- A pt safety event that reaches the pt but does not cause harm - This good fortune might reflect the robustness of the pt (eg. pt with penicillin allergy receives penicillin but has no reaction)

Sentinel Event

- A sub category of adverse events (Serious Reportable Events or Never Events) - A pt safety event that reaches the pt and results in: * death * permanent harm * severe temp. harm - Never Events: * Surgery performed on the wrong body part * Surgery performed on the wrong pt * Infant discharged to the wrong person * Pt death after pt elopement (disappearance) * Pt suicide * Abduction of pt of any age * Sexual assault on a pt within or on the grounds of the facility * Death or significant injury of a pt or stuff member resulting from a physical assault

Culture of Safety

- An attitude to foster learning from mistakes or near mistakes made - The focus is on prevention of future errors, for the health and safety of pts

Failure to Rescue

- Deaths d/t specific complications of care during hosp-tion - Tied to the amount of time a nurse spends at bedside

Root Cause Definition per TJC

- Fundamental reason(s) for the failure or inefficiency of one or more processes - ID points in the process where an intervention could reasonably be implemented to change performance and prevent undesirable outcome - The majority of events have multiple root causes

Just Culture

- Healthcare workers are encouraged to report all clinical errors and near misses without fear of reprisal - Recognize that errors are system failures rather than individual failures

Activities that pulled nurses away from the bedside

- Hunting, gathering, and waiting for information - Looking for equipment - Going to the pharmacy to get drugs - Waiting for doctors or another department (such as the laboratory or x-ray) to call back results - Picking up any tasks that other departments cannot complete

Mindfulness

- The quality of being fully present and attentive in the moment during every day activities. - Collective Mindfulness: * Realization that systems have the potential to fail * Staff are focused on reporting near misses in order to cont. to improve the safety systems in place * Trust, Improve report

Patterns of Nursing Care Delivery 6. Modular care

-Kind of team nursing that divides geographic space into modules of patients -Each module has team of staff led by RN -Useful with decentralized nursing stations

Addressing Substandard Care

1. A Basic Pattern for Action. Do not make decisions based on gossip, Understand both the formal and the informal systems of authority and responsibility within your facility and the laws of the state in which you practice. When you approach a supervisor, give specific information that includes the dates, the situations, and the action you took. 2. Alternative Approaches for Action. Checking back with a manager, acknowledging that information may be confidential, and asking for reassurance that the matter is being addressed may be an appropriate action. After discussing your concern with your immediate supervisor and receiving no satisfactory response, tell the supervisor formally that you intend to carry your concern to the next higher authority. action. Another route for seeking further change is through designated committees or procedures within your facility. Informal: You may discuss your concern with a trusted person (or mentor) who has influence within the system. To offer your resignation if a change is not made. Reporting directly to a state licensing board or professional organization's disciplinary committee is an avenue of action outside of the employment setting. 3. Personal Risks in Reporting. You may lose the opportunity to be promoted because you are seen as being antagonistic to the system or lose your job. be certain that your perceptions are correct and that your concerns are well grounded. 4. Whistleblowing. Is an effort made by a member or past member of an organization to warn the public about a serious wrongdoing or danger created or masked by the organization a. Consider contacting an attorney before taking any steps. b. Learn as much as you can about your state's policies by contacting your state nurses association, the ANA, or your state board of nursing. c. Be certain of your facts and have them well documented. Be confident that a wrongdoing has occurred. d. As you pursue your concern within the system, follow the healthcare organization's chain of command. e. Be professional when dealing with others.

ADDRESSING SAFETY CONCERNS Organizational Culture - Important Organization Attributes

1. Actively encourage and support people who report situations that threaten or could threaten the safety of patients or care givers, and providers, 2. View errors as opportunities to improve the delivery of care. 3. Root cause analysis a. Comprehensive process to identify all the underlying factors that contribute to an error to b. Identify their role in causing the error. c. Non-punitive actions d. Report "near-miss"

Preventing Falls

1. Common cause of morbidity and the leading cause of nonfatal injuries and trauma-related hospitalizations Fall prevention Protocols: a. Environmental changes such as bed or chair alarms, placing the bed in a low position and putting foam pads on the floor, or locating the patient next to the nurses' station. b. Nursing care modifications might be instituted such as toileting every 2 hours, visual checks at least hourly, or the provision of assistance any time the patient gets out of bed.

IMPLICATIONS FOR NURSES Financing and Control Healthcare

1. Cost control 2. Well-being client 3. Effective use of resources 4. Changing healthcare system

Strategies to Increase Nurses' Time at the Bedside and Benefits

1. Hourly rounding 2. Bedside reporting 3. Bedside documentation 4. Electronic medication administration records 5. Bedside medication administration 6. Bedside medication administration 7. Keep supplies in close reach 8. Outsource discharge follow-up calls 9. Seek physician input 10. Ask nurses

Institute of Medicine - Recommendations

1. Interdisciplinary Common Language 2. Develop Core Competencies: a. Evidence-based practice b. Informatics c. Patient centered-care practice d. Quality improvement e. Safety f. Teamwork and collaboration 3. Require outcomes related to core competercies

Other Adverse Effects

1. More overtime hours were associated with an increase in: - hospital-related mortality - nosocomial infections - shock - bloodstream infections 2. Fatigue: the incidence of errors increases with fatigue. 3. Nurse- patient ratios, staffing, and safety is the matter of patient satisfaction. 4. ANA advocates solving the problem by requiring hospitals to set nurse staffing plans for each hospital unit based on changing conditions: 1. Patient acuity (severity of illness) 2. Patient numbers 3. Nurse skills and experience 4. Support staff 5. Technology Legislation that empowers direct care nurses to contribute to staffing plan development through hospital staffing committees.

Additional Responsibilities of the Nurse for Safety

1. Safety of all patients: - An example is the storage locations for look-alike or sound-alike drugs, especially in emergency areas. Look-alike drugs may be mistakenly confused and administered. 2. Avoid work-around: - short-cuts. Omitting safety features or bypassing system safeguards puts the patient in jeopardy.

The National Quality Forum

1. Serious reportable events (SRE)— "never events" - to increase public accountability and consumer access to critical information about healthcare performance. Six categories: a. Surgical b. Product of device c. Patient protection d. Care management e. Environment f. Criminal.

Third-Party Payer Power

1. Third-party payers have the power to demand changes in the healthcare system. 2. These agencies began looking for ways of controlling costs to maintain their competitive place in the insurance market and have set increasingly rigid criteria for payment for services. 3. By determining whom they will pay for services, insurance companies reduce the choices available to those who carry insurance, and subscribers usually must select from the choices available if they wish to be reimbursed.

ADDRESSING SAFETY CONCERNS Organizational Culture - Culture of Safety

1. Trust and mutual respect 2. Report errors, near misses, and other adverse events without fear of retribution. 3. Seven properties in culture of safety: a. Leadership b. Teamwork c. Evidence-based practices d. Communication e. Hospital that learns from its mistakes f. System that recognizes errors as system failures rather than individual failures (referred to as a "just culture") g. Patient-centered care.

Adopting Safe Practices in Specific Clinical Care Settings

1. Universal Protocol - three steps to be taken prior to the surgery and includes conducting a preprocedure verification process, marking the procedure site, and performing a "time-out" 2. Time-out - the patient identity is correct as is the site and the procedure to be done.

Medicare

A program added to the Social Security system in 1965 that provides hospitalization insurance for the elderly and permits older Americans to purchase inexpensive coverage for doctor fees and other health expenses. Payment for hospitalization (Part A) Insurance that could be purchased to meet physicians' fees and outpatient costs (Part B) for people over age 65 and certain others who were receiving Social Security payments. Medicare Part D covers prescription drugs. Participation in Medicare Part A is automatic for those on Social Security, whereas participation in Medicare Part B is optional and a premium is deducted from the Social Security check to pay for Part B. Medicare Part A pays only for acute hospitalization and a limited amount of rehabilitative care that may occur in a nursing home. Medicare does not pay for any long-term or custodial care in a nursing home. Part B reimburses for physician care and outpatient services based on a fixed schedule of payments.

Case management

A technique used to efficiently move an individual requiring major health services through the system resulting in more effective use of services and reduced cost. According to the Case Management Society of America (CMSA), case management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes.

Patient Safety Events

Adverse event - a patient safety event that resulted in harm to pt

The Joint Commission

Agencies that were accredited by The Joint Commission were required to begin targeting high-incidence preventable safety problems, such as falls, misread physician orders, and communication errors. Sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Occurrences considered sentinel events: 1. Surgery on the wrong body part 2. Tubing and catheter misconnections 3. Overdosing with commonly used anticoagulants 4. Death resulting from a treatment-related or medication error 5. Patient suicide occurring in a setting in which around-the-clock care is provided 6. Assault, rape, or homicide of patients or visitors perpetrated by staff, other patients, visitors, or intruders 7. A maternal death 8. Discharge of an infant to the wrong family 9. Unprofessional provider behavior

State administered health plans

All 50 states provide health insurance coverage for their state employees. Most have done so for decades. However, the amount of coverage, who is eligible to enroll, and the portions paid by the state employer and by the individual worker always have varied from state to state. In the past five years these state benefit plans have attracted much more attention among legislators, governors and policymakers. Often, this is because: Rapidly rising commercial premiums are impacting state budgets; State fiscal pressures are leading to more proposals to increase employee share of costs; Co-payments and deductibles are on the rise in many places, separate from the established premiums.

third-party payers

Consumers often pay less than full price because the health insurance may pay part or all of the costs. with health insurance, the consumer may perceive health care as cheaper than it is and may be motivated to over consume. entities other than the patient that assume responsibility for payment. interfere with common principles of a competitive market system. Any payer of health care services other than the insured person. This can be an insurance company, HMO, PPO, or the federal government.

Personal Pay

Deductable, co-payment, Paycheck deductions

Failure to Rescue

Defined as "deaths per 1,000 patients having developed specified complications of care during hospitalization" Incidence of failure to rescue decreasing when nurses spend more time at the bedside Direct correlation between increasing the number of nursing hours spent with patients and the reduction of complications

Charitable care

Example Shriners Childrens Hospital. Shriners: Masonic members of Ancient Arabic Order of the Nobles of the Mystic Shrine; work in children's hospitals and burn centers Free clinics, donations

Addressing concern

In some facilities, nurses are addressing this concern by alerting others that they are not to be interrupted during the time they are administering medications. Some hospitals have set aside areas for medication preparation that are not to be entered by those not preparing a medication. Posting "Please do not disturb" signs on the automated medication dispensing machines and medication carts has proved helpful

Preferred provider organizations (PPOs)

Include hospitals, nursing homes, corporations employing care providers, or groups of care providers who have cooperated to negotiate more successfully with third-party payers for these special contracts. The advantage to the provider is the ensured number of clients and the guaranteed income that in a time of competition in healthcare may be significant. Each PPO operates independently without government regulation.

Increasing Safe Medication Administration

Medication errors were among the most common medical errors. Key Recommendations: 1. Elimination of ambiguous abbreviations 2. Computerized physician order entry (CPOE) 3. Computerized decision support systems (CDSS) 4. Computerized adverse drug event monitoring (CADM) 5. Barcode point-of-care (BPOC) medication safety systems 6. IV administration "smart pumps."

Federal Safety Legislation

Patient Safety and Quality Improvement Act, 2005 1. Goal: To improve patient safety by encouraging voluntary and confidential reporting of events that adversely affect patients. 2. Provides: a. Protection for individually identifiable healthcare data b. Certification of Patient Safety Organizations to collect, aggregate, and analyze confidential information reported by healthcare providers. c. Network of patient safety databases that could be used for research and development without fear of disclosure of data

Health Insurance Plan

Person pays for coverage weather or not using healthcare. When healthcare is needed, insurance pays for it. Disadvantage: Customers pay the same weather they are using it or not. Neglect of preventive healthcare that has to be paid out-of-pocket A plan in which private companies or government programs pay for part or all of a person's medical costs Deductible - Amount paid by the patient before the policy pays Co-payment - A patient's payment of a portion of the cost at the time the service is rendered.

Safe Practices

Practices that reduce the risk of harm from the processes, systems, or environments of healthcare Seven Categories: a. Creating and sustaining a culture of safety b. b. Informed consent, life-sustaining treatment, disclosure, and care of the caregiver c. Matching healthcare needs with service delivery capability d. Facilitating information transfer and clear communication e. Medication management f. Prevention of healthcare-associated infections g. Condition- and site-specific practices

Quality Improvement Organizations (QIO)

Private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other healthcare professionals, who are trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care Areas of concern: 1. Patient safety 2. Care coordination or transitions 3. Clinical treatment advancement 4. Preventive care methods. Promote: 1. Best practice models 2. Serve as a resource in the areas of health information technology and electronic health records.

Medicaid

Provides financial assistance to states and counties to pay for medical services for poor older adults, the blind and families with dependent children. Provides funds for healthcare for those dependent on public assistance and certain other low-income individuals. Costs for Medicaid are shared between the federal government and each state. Each state is responsible for administering Medicaid: The state determines eligibility and level of coverage.

Nurse Staffing

Registered nurses comprise the largest single component of hospital staff and are the primary providers of hospital patient care. The key role nurses play in patient safety and quality of care. Higher registered nurse staffing was associated with less: - hospital-related mortality - failure to rescue - cardiac arrest - hospital-acquired pneumonia

Outcome Measures for Evaluation

Some outcomes have been designated key indicators, also termed quality indicators (QIs), which are specific, measurable aspects of healthcare that show the effectiveness of the system as a whole. 1. Hospital Healthcare Outcomes: One result of outcome studies has been the recommendation that only hospitals that perform a specified number of highly technical surgeries (eg, cardiac surgeries) each year should offer those procedures. Hospitals that perform fewer procedures per year have higher complication and mortality rates. Three groups of QIs: prevention QIs, inpatient QIs, and patient safety QIs. 2. Institutional Outcomes Measurement: Outcomes here refers to data such as the number of clients admitted with a fractured hip who had uncomplicated recoveries leading to effective rehabilitation and the number of clients who had complications or did not recover. The clinical pathway describes the optimum progression through the system of the individual with a particular health problem. The advantage for the client is that care can be modified immediately to address the problem. The advantage for the system is the ability to aggregate data across all clients and examine what is working well and what needs to be changed. 3. Long-Term Care Quality Measures: "Measures are values that are based upon sufficiently credible data to allow the user to make an informed, appropriate decision regarding the process under consideration based upon the data alone, without further investigation" 4. Home Care Quality Indicators: They are based on assessments using the MDS for home care. These indicators can be monitored to evaluate the performance of a home care agency. Examples of indicators are "prevalence of weight loss in individuals who are not palliative care clients" and "prevalence of decrease in ability to dress one's upper body." Concern in comparing agencies based on these indicators is that the population served by the agency affects the outcomes of care. 5. National Health Indicators: In 1992, DHHS and the Public Health Service published Healthy People 2000, National Health Promotion and Disease Prevention Objectives. The purpose of this document was to establish national goals to serve as a focus for health promotion and disease prevention activities by individuals, organizations, and the federal government.

Culture of Safety Models Blunt End vs Sharp End

The Blunt End/Sharp End model provides a framework for evaluating a clinical error like the one described above. Sharp End: Investigating the sharp end of the error focuses on the actions of the clinicians in direct contact with the patient. Here are some sharp end investigation questions for this case: Blunt End: Investigating the blunt end of the error focuses on the policies, procedures, systems, resources, and constraints surrounding the incident. Here are some blunt end investigation questions for this case: From Blunt to Sharp: Regulations -> Environment -> Processes -> People/Teamwork -> Patient is here

Changing Fee Structures

The federal government has sought to control costs for Medicare and Medicaid by establishing higher deductibles (the portions that individual clients must pay) and by limiting the fees that the government will pay. MDs cover these costs by collecting higher fees from those who do pay their bills. Hospitals, physicians, and pharmacies argue that as more limits have been imposed, the limited reimbursement no longer covers the actual costs of care. This jeopardizes the entire system.

Federal Government Program

The six major government health care programs—Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), the Department of Defense TRICARE and TRICARE for Life programs (DOD TRICARE), the Veterans Health Administration (VHA) program, and the Indian Health Service (IHS) program—provide health care services to about one-third of Americans. The federal government has a responsibility to ensure that the more than $500 billion invested annually in these programs is used wisely to reduce the burden of illness, injury, and disability and to improve the health and functioning of the population. It is imperative that the federal government exercise strong leadership in addressing serious shortcomings in the safety and quality of health care in the United States. The six major government health care programs serve older persons, persons with disabilities, low-income mothers and children, veterans, active-duty military personnel and their dependents, and Native Americans.

Vigilance

The state of being alertly watchful esp. to avoid danger

HMOs

a group program that provides health care at its own center with its own doctors for a fixed fee per month 1) A type of health insurance plan. For a monthly fee, a person receives health care from affiliated health care providers. 2) Provides managed care plan for the delivery of health care services. 3) Self-employed disadvantage: you can only go to certain HMO physicians if not you have to PAY!

Safety in Healthcare The Institute of Medicine Study

a. 44,000 and 98,000 patients die as the result of preventable medical errors in hospitals each year b. Hospital-acquired infections, many of which can be prevented, take another 100,000 lives c. Mistakes involving medication injure 1.3 million patients annually in the United States d. The human suffering and/ or deaths that result, errors are tremendously costly. e. Underlying cause: fragmented care system and ineffective communication

Communications

a. Breakdowns in communication have been cited as a root cause in the majority of cases reported to and studied by the Joint Commission's Sentinel Event Database b. Communication failures can result from a variety of issues: 1. hierarchy differences 2. conflicting roles 3. ambiguity in responsibilities 4. power struggles c. Patient Safety During Handoffs 1. Handoff— a process in which information about the patient, client, or resident is communicated from one healthcare provider to another. 2. SBAR: Situation Background Assessment Recommendation d. Tools to Improve Communication 1. Ineffective communication between physicians and nurses resulted in job dissatisfaction and safety breaches on the part of nurses. - TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). * team leadership focusing on a positive environment * situation monitoring in which the entire team must be aware of the environment and team performance at all times * mutual support * communication.

Infection Control

a. Hospital-acquired, or nosocomial, infection with is the most common serious hospital complication. b. 36% of these infections are preventable through the adherence to strict guidelines c. Three most frequently reported HAIs: 1. urinary tract infection 2. wound infection 3. pneumonia. d. "Bundle" - to decrease the incidence of the target infection 1. Failure to use all the measures prescribed in the "bundle"to take to reduce the incidence of infection. 3. Practice all the precautions you have been taught 4. Avoid short cuts 5. Wash and sanitize hands 6. Remember all steps of bundle

Patterns of Nursing Care Delivery 3. Team nursing

• Assign staff to teams responsible for group of patients ○ Team leader supervises and coordinates all care provided by those on team • Advantage: - Getting work done through others - High-quality, comprehensive care can be provided with a relative high proportion of ancillary staff - Each member participates in decision making, problem solving - Each member contributes his/her own special expertise or skills • Disadvantage: - Communication often fragmented - Continuity of care may suffer with daily learn assignments - Team leader may not have the leadership skills required to effectively direct the team - Insufficient time for care planning and communication leads to unclear goals and fragmented care

Patterns of Nursing Care Delivery 5. Primary care nursing

• Clearly delineates responsibility and accountability of RN • Places RN as primary provide of care to patients • Patients assigned primary nurse ○ Primary nurse responsible for developing plan of care with patient ○ Other nurses caring for patient follow this plan ○ Primary nurse has authority, accountability, and responsibility to provide care for group of patients Advantages: ○ Patients and families able to develop trusting relationship with nurse ○ Accountability and responsibility of nurse developing plan of care with patient and family defined ○ Facilitates continuity of care ○ Authority for decision making given to nurse at bedside Disadvantages: ○ High cost ○ Person making assignments must be knowledgeable about all patients and staff to ensure appropriate matching of nurse to patient ○ Lack of geographical boundaries within unit may require nursing staff to travel long distances at unit level to care for primary patients ○ Nursing time often used in functions that could be completed by other staff ○ Nurse-to-patient ratios must be realistic

Patterns of Nursing Care Delivery 2. Functional method

• Divides nursing work into functional roles assigned to one team member ○ Each care provider responsible for specific duties/tasks ○ Utilizes other types of less skilled workers • Often results in technical nursing care, rather than professional • Decision making usually at a level of charge nurse * Pts didn't know who is their nurse. Planning of care and communication are not there

Patterns of Nursing Care Delivery 8. Case management

• Strategy to improve patient care and reduce hospital costs through coordination of care Collaborative approach to providing and coordinating health care services, identifying and facilitating options and services for meeting health needs, decreasing fragmentation and duplication of care and enhancing quality, cost-effective clinical outcomes