BACKGROUND/RATIONALE:
More than 98,000 people die each year due to medical errors (IOM, 2000). Currently, nearly 3 million registered nurses provide 80% of all direct "hands-on" care. In 2005, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reported that communication problems accounted for nearly 70% of sentinel events in accredited health care facilities (JCAHO, 2007) and that ineffective handoff communication was responsible for nearly 50% of the communication breakdowns. Existing methods of care planning are static and do little to enhance the flow of information and clinical decision-making. Hand Off communication is further complicated by multiple changes in personnel within and across disciplines and shifts during the patient health care encounter.

Currently, there is no "gold standard" for care-planning or hand off nursing communication, putting patients and nurses at significant risk for less than optimal health care outcomes. This lack of standardized methods for nurses to "hand-off" patient care within and across patient care units and disciplines increases the risk for error and poor patient outcomes. Recognizing the lack of a standardized nursing communication across a healthcare system, the Joint Commission has named effective communication as a top priority. Innovative health information technology will attract, engage, and stimulate high nursing performance and will support patient safety. Nurse executives must include a macro and micro systems analysis approach when forecasting a successful HIT implementation. Successful HIT implementations include proper assessment of the work environment and identifying potential risks related to patient safety.

The HANDS Method is a research-tested intervention designed to enable evidence-based practice through improving the consistency and quality of the process and the content of clinician-to-clinician communication which has been supported through AHRQ funding. The Quality Enhancement Research Initiative (QUERI) grant focused on translation science in strategic planning to investigate the use of an evidence-based system known as Hands-on Automated Nursing Data System (HANDS)





OBJECTIVE(S):
1) To identify barriers, facilitators and approaches to the successful implementation of the HANDS method and care plan.
2) To develop an implementation plan, technical plan, and a sustainable funding strategy that will inform future implementation of an evidence-based patient care plan.
3) To establish a framework for implementation of the HANDS method of care planning throughout VHA.

METHODS:
The project included strategic planning methodology which occurred over a six-month time frame. Miami VA Healthcare System Nursing Staff lead this effort and serve as liaisons to the other VHA health care facilities in partnership with senior members of the HANDS research team. A Core Executive Team that comprised local and national Nursing Leadership included the Principal Investigator, Associate Director for Patient Care Services/Chief Nurse Executive, Office of Nursing Service (ONS) Program Director, and the HANDS (Contractors) Research Team Principal Investigator and HANDS Grant coordinator.


The Core Executive committee included VA CNO leadership, Chief Nurse Executives and HANDS Consultants, acute care, long term care, specialty and outpatient facilities representing VHA complexity levels (1A= high complexity, volume, & patient risk, includes teaching and research; 3 = low complexity, volume, risk, limited or no teaching & research, limited critical care capacity).

Three multidisciplinary planning committees included more than forty eight members from across VHA healthcare, business and IT domains and seven VA departments were represented, including compliance and security. Eighteen VHA departments were represented in the planning effort.

The overall strategic implementation plan included development of three interdisciplinary committees to address developing: a) strategic plan; b) technical plan; and c) a long-term sustainable funding strategy. A strategic vision and charter was developed for each of the three committees. Agendas were developed in advance of each meeting.

Committee meetings were held using various teleconference and web conferencing technologies each week. Teleconferences were audiotaped and minutes were transcribed and reviewed for accuracy by committee members. Transcriptions were revewed by committee members for accuracy and ammended as indicated.

Each of the committees received either a virtual group demonstration using "LIVE meeting" or an individual interactive virtual demonstration of the HANDS program. The PI and the HANDS team led committees in conducting an organizational infrastructure assessment. A gap analysis was and organizational readiness assessment for implementation was to identify potential and real barriers. Techniques used to identify specific planning strategies and methods included management coaching, demonstration, education, think-aloud technique, and self-assessment.

The virtual strategic planning process was used, including: preplanned structured agendas and minutes, teleconferencing, email communication, MS LiveMeeting, synchronous one to one and group virtual demonstrations, and the use of an Internet mass collaboration tool.

FINDINGS/RESULTS:
HANDS functionality and technical requirements was assessed. The selection, adoption and use of standardized nursing language was discussed. The Technical planning committee explored issues surrounding three main conceptual areas: a) data integration, b) data structure c) data access and security. Gaps were identified in these areas and subcommittees explored each of the three areas in depth. Strategic Planning committee has formed and discussed issues related to previous VA health information technologies (BCMA, CPRS). The funding committee developed a cost model.

Three main conceptual areas were identified in the technical domain: Data Access & Security, Data Integration, and 508 Compliance. Five main technical categories emerged for exploration: standardized language, data access/integration, compliance, security and privacy. Strategic implications identified impact on workflow & workload (reducing redundant documentation), functionality and usability & staff interdisciplinary readiness for innovation. Bidirectional data flow was a major point of issue in both strategic & technical groups. Absent standardized bidirectional data flow, Long Term Care MDS documentation requirements create documentation redundancy and were identified as an area for resolution, prior to implementation by Nurse Executives. The funding model developed demonstrated proposed costs related to infrastructure, hardware, software & licensing, implementation and human resource needs relevant across settings. The lifecycle cost model is robust and can be generalized for use to any health information or adapted for use with health technology. Groups experienced dynamics reported in Gartner's Hype cycle model.










IMPACT:
Improving care planning and hand-off communication is a JCAHO National Patient Safety Goal and keeping patients safe can occur by transforming the nursing work environment. Evidence-based technologic solutions must be implemented to support improved patient safety in nursing hand -off- communication using the nursing process.

The Hands-on Automated Nursing Data System (HANDS) uniquely represents nursing care through regular capture and display of the status of the clinical problems, care provided, and progress toward outcomes. The dynamic nature of the system supports early intervention and revision of care when progress toward outcomes is not moving in desired directions, ultimately reducing length of stay, readmission rates, and care errors.

Currently, there is no standardized system in VA for tracking nursing interventions based on an assessment of patient care needs to meet patient care goals and specifically addressing patient outcomes in relation to nursing interventions. HANDS is evidence-based and demonstrates success in standardizing nursing communication and providing patient centric decision support for use across all health care settings.

Project Implications:
HIT implementations require a dedicated team with strong executive leadership, administrative support and project management skills are critical to success of the process.

Broad support exists for the introduction of standardized terminology, structured nursing language and decision support in HIT systems to support the nursing documentation and continuity of patient care in the electronic medical record.

Organizational readiness for change is a key driver to the success of healthcare implementations and patient safety

Staffing, resource availability and workflow redesign must be assessed across the technology life cycle

Broad organizational understanding range and implications of varying technology adoption phases is needed

The process developed can serve as a model/blueprint for any HIT or technology implementation in an organization or at the enterprise level

Cost models are necessary to identify fiscal impact and sustainability across the life cycle

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External Links for this Project

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PUBLICATIONS:

Conference Presentations

1. Sapnas K. Strategic Plan to Implement An Evidenced-Based "Hand Off" to Improve Outcomes. Poster session presented at: VA Nursing Leadership Annual Conference; 2008 Nov 11; San Antonio, TX. [view]
2. Sapnas K. Strategic Plan to Implement and Evidence-Based "hand off" to Improve Outcomes. Paper presented at: VA Nursing and Healthcare Informatics Alliance Annual Meeting; 2008 Sep 13; Salt Lake City, UT. [view]
3. Sapnas K, Moorer O, Ward-Presson K, Monzeglio C, Martin W, Gilzean C. Strategic Plan to Improve Evidenced-Based Hand-Off and Improve Outcomes. Poster session presented at: VA Miami VAMC Annual Research Week; 2009 May 12; Miami, FL. [view]
4. Sapnas K, Moorer O, Ward-Presson K, Monzeglio C, Martin W, Gilzean C. Strategic Pre-Acquisition Planning for Health Information Technology: Using the AONE Guiding Principles. Poster session presented at: VA Leadership Board Annual Meeting; 2009 Apr 22; San Antonio, TX. [view]
5. Sapnas K, Moorer O, Ward-Presson K, Monzeglio C, Martin W, Gilzean C. Strategic Pre-Acquisition Planning for Health Information Technology: Using the AONE Guiding Principles. Poster session presented at: American Organization of Nurse Executives Annual Meeting; 2009 Apr 15; San Antonio, TX. [view]

DRA: Health Systems
DRE: none
Keywords: Management, Organizational issues, Staffing
MeSH Terms: none