FEATURES

In Pursuit of Nursing's Preferred Future

COMING: To a hospital near you

Adapted from an address by Tami Merryman in 2004 at the Robert Wood Johnson Foundation Nurse Leaders meeting

For eight years, the University of Pittsburgh Medical Center (UPMC)-Shadyside in Pittsburgh, Pa., has passionately pursued creation of the optimum environment for patients and care delivery. About two years ago, the Robert Wood Johnson Foundation (RWJF) and Institute for Healthcare Improvement (IHI) approached us about incorporating their Transforming Care at the Bedside (TCAB) initiatives into our program. Adoption of TCAB was the perfect next step in advancing the clinical design initiative already undertaken by our own organization to create the hospital of the future.*

Hospital of the Future is the name we as an organization have chosen for our vision: a facility where every patient receives the right care, at the right time, in the right way, every time. Though simple to state, we recognize that fulfillment of this vision is no small task for a large tertiary facility. As a storyteller, I’d like to describe a day in the life of a nurse at the UPMC-Shadyside hospital of the future.

The first thing our nurse of the future does upon arriving at work is to pick up her personal, non-cellular phone. Until now, nurses depended on their feet for vital communication, running back and forth, up and down halls, trying to do their jobs. Our research shows that using a personal phone to take calls immediately saves every nurse 20 minutes on every shift. Housewide, this practice returns $420,000 of time to the bedside.

For shift-to-shift reports, the nurse takes her phone to a place of privacy and dials Voice Care, an automated, password-protected, voice-mail/message system. If she has not previously provided care for a particular patient, it’s no problem. Patient histories, including recent clinical information, are permanently stored in the system. Attending physicians in the emergency department also use Voice Care to provide admission reports to nurses, thus assuring smoother handoffs.

With a single call, the nurse manager can reach all staff and provide pertinent safety updates and reminders about care. Voice Care saves every nurse roughly eight minutes on every shift. Housewide, this innovation returns $267,000 to the bedside.

When this nurse of the future does her morning assessment and discovers care needs in patients’ rooms, supplies are immediately available. The savings? Six trips to the supply room or about 18 minutes a day for every nurse. That returns another $400,000 to the bedside.

The nursing station has undergone and is continuing a “5S” process. The five S’s stand for sort, set in order, shine, sustain and standardize, and they refer to the five steps used to create and maintain organization and to improve nurses’ access to essential information and supplies. With this system in place, the right supplies are in the right place on an ongoing basis, thus providing order to the busy nursing unit.

Newly instituted documentation practices have reduced paperwork for this nurse by 50 percent. Because of the new admission assessment form that reduced recordkeeping from 48 minutes per episode of care to 24 minutes and the “daily nurse’s notes” that reduced paperwork from five pages to one, work has become more meaningful. Cost savings returned to the bedside: $480,000.

If this bedside nurse determines that there are too many admissions or emergent situations on her floor, she pulls a chain, thus notifying other hospital personnel that the unit is on yellow or red status and is unable to accept additional patients for a period of 30 to 60 minutes. By empowering the bedside nurse to control the flow of patients, patient care needs are better met.

If a patient begins to deteriorate rapidly and the nurse needs assistance, she calls a “Condition C” on her personal phone, and a rapid-response team of experts comes to support her in meeting the patient’s needs. (This innovation, already instituted, saved 13 lives last year in our organization.)

In this hospital of the future, patients facilitate effective communication by writing notes and/or questions they would like addressed during rounds by physicians and other caregivers. The tablets, provided by the hospital, include a list of questions that the patient might consider asking. A liberalized diet format that provides healthy menu choices further contributes to patient satisfaction.

Every day, from 2 to 2:30 p.m., the lights are dimmed, soft music is played and, while care continues, peace and quiet prevail in the department, adding to the healing nature of the environment. This is calming for all and breaks the monotony in a daily hospital routine.

A new admission is scheduled for later in the day. The admission team will conduct initial patient assessment, reviewing in detail and itemizing on a single sheet the medications the patient is presently taking at home. This becomes an order sheet for the physician, eliminating the need to reconcile home medications with hospital medications. In addition to saving physician time, this practice assures patient safety and continuity of care. More than 50 percent of adverse drug events (ADEs) occur at these transfer points.

Discharges are communicated to the nurse on a timely basis by the care team by means of a simple discharge flag mounted on the door of every room. The housekeeper also finds this useful in planning her day and organizing her work.

The nurse we are observing no longer needs to do routine capillary blood sugars on her patients at 9 p.m. Research shows that this long-standing practice has no clinical merit. Eliminating the step returns $25,000 to the bedside.

When an issue adversely affects the nurse’s ability to provide care and her unit director is not immediately available, the nurse communicates her dilemma via the ASSIST hot line, monitored by the vice president of Patient Care Services. An e-mail is sent to the caller acknowledging her concern and to the leadership responsible for addressing the problem.

You see from this story that when we fix nursing, we fix health care. Every minute returned to the bedside is time that the nurse can reinvest in providing value-added services back to her patients, improving care and saving lives. In this example, we have returned $1,592,000 of time to the bedside.

Removing waste, listening to patients and employees, and acting upon their suggestions are all part of creating the hospital of the future. Most hospital care is still provided in a medical/surgical unit. Caregivers who work on these units live in a world of broken systems, wasted energy and desperately frustrating situations. Our vision is for hospital care to be provided in a patient-centered, reliable environment where nurses are valued and they love their jobs. It’s what the Transforming Care at the Bedside initiative is all about. RNL

* UPMC-Shadyside was one of three hospitals recruited by RWJF and IHI to assist in development and testing of the TCAB program. The other hospitals were Seton Northwest Hospital in Austin, Texas, part of the Ascension Health System, and Kaiser Foundaton Hospital in Roseville, Calif., part of Kaiser Permanente. Since then, 10 other sites have been included in the expanded pilot phase.

Tami Merryman, RN, MS, ACHCE, is vice president, Patient Care Services, University of Pittsburgh Medical Center, Shadyside Campus, Pittsburgh, Pa.