Chapter 23 – ASSIGNMENT

Chapter 23 – AssignmentInstructions:Read the Care Redesign ArticleAnswer the following questions:Which four (4) components does the article point out are needed for the U.S. healthcare system to succeed?The one recommendation form the ten cited in the Institute of Medicine Report to improve quality and reduce cost that is described in the article?A recent factor to be identified of reducing cost is?Name four (4) factors that influence patient outcomes described in the article.Name the four (4) different nursing care delivery models and give a short description of each.What is the meaning of the term “lean” as described in the article.Summarize the method utilized in the study to offer a higher-quality and lower cost method for acute care in just a few sentences. Your paper should be:
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Volume 44, Number 7/8, pp 388-394
Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Care Redesign
A Higher-Quality, Lower-Cost Model for Acute Care
Pamela T. Rudisill, DNP, RN, NEA-BC, FAAN
Carlene Callis, BS, MHA
Sonya R. Hardin, PhD, RN, CCRN, NP-C
Jacqueline Dienemann, PhD, RN, NEA-BC, FAAN
Melissa Samuelson, DNP, RN, NEA, BC
OBJECTIVE: The aims of this study were to design,
pilot, and evaluate a care team model of shared accountability on medical-surgical units.
BACKGROUND: American healthcare systems must
optimize professional nursing services and support
staff due to economic constraints, evolving Federal
regulations and increased nurse capabilities.
METHODS: A redesigned model of RN-led teams with
shared accountability was piloted on 3 medical/surgical
units in sample hospitals for 6 months. Nursing staff
were trained for all functions within their scope of
practice and provided education and support for
RESULTS: Clinical outcomes and patient experience
scores improved with the exception of falls. Nurse
satisfaction demonstrated statistically significant improvement. Cost outcomes resulted in reduced total
salary dollars per day, and case mixYadjusted length
of stay decreased by 0.38.
CONCLUSION: Innovative changes in nursing care
delivery can maintain clinical quality and nurse and
patient satisfaction while decreasing costs.
Healthcare systems in the United States must bridge
the transition from volume to value-based models. Components required to succeed include clinical integration,
implementation of technology, and clinical performance
improvement with operational efficiencies to manage
financial constraints.1 Nursing services encompass the
majority of the workforce in today’s acute care hospitals.2 Historically, models of care have been based on
a mix of registered nurses (RNs) and unlicensed assistive
personnel (UAP) with occasional reference to licensed
practical nurses (LPNs) and the assignment of workload. Evidence supports that patient needs are best
met by planned skill mix and recognition that nurses
are knowledge workers and need to be utilized in that
manner.3,4 Models-of-care redesign that embeds improving efficiency and increasing accountability to
patients’ clinical outcomes requires a cultural transformation.1 All major changes in care design should be
evaluated for their evidence-based and desired changes.
The purpose of this study was to evaluate a pilot implementation of a shared accountability delivery model
for medical-surgical patients that allowed licensed
nurses and UAP to practice at their full authority
through delegation and collaboration in RN-led teams.
Author Affiliations: Senior Vice President and Chief Nursing
Officer (Dr Rudisill), Community Health Systems, Franklin; and
Assistant Vice President Strategic Resource Group, Vice President
Strategic Planning American Group (Ms Callis), HCA, Nashville,
Tennessee; Professor (Dr Hardin), College of Nursing, East Carolina
University, Greenville, North Carolina; and Professor Emeritus
(Dr Dienemann), School of Nursing, UNC Charlotte and Nurse
Researcher Carolinas Medical Center University, North Carolina;
and Chief Nursing Executive (Dr Samuelson), Poplar Bluff Regional
Medical Center, Missouri.
Community Health Systems is a registered trade name of
Community Health Systems Professional Services Corporation.
The authors declare no conflicts of interest.
Correspondence: Dr Rudisill, Community Health Systems, 4000
Meridian Blvd, Franklin, TN 37067 (
DOI: 10.1097/NNA.0000000000000088
The healthcare system in the United States is in a state
of rapid and unprecedented change with pressures to
improve clinical quality and patient health and increase
patient satisfaction, while curtailing costs. The Institute
of Medicine report5 cites 10 recommendations to ensure better health, higher-quality care, and lower costs.
One recommendation was to optimize operations by
continually improving healthcare operations to reduce
waste, streamline care delivery, and focus on activities
that improve patient health. The primary challenge of
delivering care in acute settings is managing increasingly
JONA Vol. 44, No. 7/8 July/August 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
complex patients with shorter lengths of stay (LOSs)
while ensuring integration of care upon discharge
and beyond.
Recent studies demonstrate that lowering costs is
dependent on increasing patient safety rather than
changing nursing salary or staffing expenses.6 Nursing factors influencing patient outcomes include number of hours per patient-day (number of staff), quality
of work environment, educational level of nurses, and
mix of skills among nursing staff. These factors interact among each other with varying effects on patient
outcomes.7-11 Increasingly, nurse satisfaction is related
to recognition that RNs are knowledge workers whose
time should be utilized in decision making regarding
patient care and safety.4
team realized several approaches underutilized RN delegation, did not utilize LPNs at all, and did not require
RNs, UAPs, or LPNs to practice to their full scope.
We did identify 1 computer simulation model utilizing the RN, LPN, and UAP, which incorporated
principles of the lean to enhance the role of the RN,
LPN, and UAP in the care delivery of patients.20 Lean
is a concept adapted from manufacturing to streamline processes, reduce cost, and improve care delivery.
Each process must add value or be eliminated as waste
(or muda in Japanese) so that ultimately every step
adds value to the process.21 The simulation demonstrated that teams of RN, LPN, and UAP assigned
in a mix to fit patient acuity of a group of patients
wasted less time than patient allocation assignments.
Nursing Care Delivery Models
Delivery of nursing care has traditionally been delivered
in 1 of 4 ways.12-14 Shirey14 discusses the advantages
and disadvantages of various models. The earliest model
is patient allocation or total patient care with groups of
patients assigned to 1 nurse with no UAPs. Because of
shortages during and after World War II, task or functional nursing was emphasized, allocating more complex care to RNs and routine care to UAPs. Team nursing
evolved with RNs as leaders of UAPs for a group of
patients. Primary nursing identified 1 nurse to assume
24-hour responsibility for a patient with communication to RNs, LPNs, and UAPs who participated in care
throughout the patient stay. This model of care has been
coined relationship-based care.12 One new, novel approach is to expand primary care to coordinating care
after discharge, with the RN assuming care as the primary nurse for readmissions.14,15 This model of care
fits in the new modes of accountable care transition
The recent Institute of Medicine report on the future of nursing16 advocates for RNs to perform to their
fullest potential and to become effective leaders and partners in the organization. This parallels the American
Organization of Nurse Executives guiding principles
for the role of the nurse in future patient care delivery.17
These position statements call for new innovative models of nursing care delivery. In 2005, Partners Healthcare
in Boston, Massachusetts, conducted a search of innovative nursing care delivery models for adult, acute care
patients that integrated technology, support systems,
and new roles to improve quality, efficiency, and cost.
They identified over 40 models that shared common
elements of an elevated RN role, sharpened focus on
the patient, smoothed patient transitions and handoffs,
leveraged technology, driven by results that were measured systematically, and used for feedback to improve
the innovations.18 A few new models emerged requiring
shared accountability.19 In reviewing these models, our
Development of Novel Nursing Care Redesign
We decided to develop a shared accountability model
utilizing RN-led teams with LPNs and UAPs, functioning to their fullest potential, matching the skillmix potential to meet the patient’s needs. We piloted
the model on medical-surgical units in 3 community
hospitals in 3 states.
The goals were to improve clinical quality of care
and nurse job satisfaction through use of accountable
teams and balanced caregiver workload while controlling or reducing costs.
JONA Vol. 44, No. 7/8 July/August 2014
The pilot was implemented on 1 medical-surgical
unit at each of 3 hospital sites in Alabama, Tennessee,
and Mississippi. Each hospital differed in overall bed
size and urban/rural market location. The leadership
in administration (chief executive officer, chief nursing
officer) was supportive and knowledgeable of lean
principles, the purpose of the nursing care redesign,
and the importance of evaluation.
Our 1st step was to review the scope of practice for
RNs, LPNs, and UAPs in each state where we planned to
pilot the program (Alabama, Tennessee, and Mississippi).
We then reviewed the job descriptions at the hospitals
and found that all legal functions were not included.
Policies, competencies, and job descriptions were revised
for the LPN and UAP to ensure highest level of practice. To ensure patient safety, education was developed
and provided to UAPs and LPNs to achieve competencies in all functions. Examples of the enhanced competencies for the UAPs included simple dressing change,
oxygen setup, performing blood sugars, discontinuing
Foley catheters, and discontinuing peripheral intravenous lines. The LPN-enhanced competencies varied the
most among the selected states. Some included administering intravenous medications and starting intravenous lines.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
In order to assess level of patient needs, an acuity
tool was needed that was valid, efficient, portable between units, reliable, and maintainable.22 Duke University Hospital System had designed and evaluated a
tool beginning in 2003 that assesses patient’s acuity
based on the complexity of care or instability of a patient’s health status. Nurses used it with a personal
digital device. In time, it had been modified to reduce
input while maintaining validity for multiple settings.
Patients are assessed on 6 patient factors and 4 nursing
care demand factors, resulting in 1 of 4 levels of complexity of care. The results are to ensure balance of workload with competency level of staff and patient acuity.
The tool was used with permission (e-mail communication, August 2012, November 2012, August 2013).
The Morse falls risk assessment23 and Braden skin care
assessment24 were added to the tool. No formal evaluation of the modified tool has been made. New processes
adopted were bedside shift report for all caregivers of
the team and formal bed huddles for teams to be done
at a minimum of every 4 hours with new acuity assessment, daily patient goals, and expected LOS review, as
well as any identified patient safety issues (Figure 1).
The clinical outcome data chosen for evaluation
were based on existing methodologies and collection practices reported to the Centers for Medicare &
Medicaid Services and other national organizations.
These included falls per 1,000 patient-days, falls with
injury severity of greater than 1, rate of hospital-acquired
pressure ulcers, medication errors per 10,000 doses, number of sentinel events, and number of near misses. Unit
LOS; rate of readmissions for congestive heart failure
(CHF), myocardial infarction (MI), and pneumonia
within 30 days; and core measure scores were also collected. Cost was based on average LOS and cost per
patient-day. Patient satisfaction used the Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) data across the 8 domains.25 New survey
questionnaires on nurse and physician satisfaction were
developed for the specific medical-surgical units that reflected key elements on the model design and based on
the hospital-wide surveys performed by Press Ganey.25
Institutional review board approval was received from
the University of North Carolina at Charlotte, Charlotte,
NC. Materials were prepared, and site coordinators
were trained in data collection of patient outcomes and
confidentiality processes to distribute and collect questionnaires. Upon collection, data and questionnaires
were forwarded to the office of the corporate chief nurse
executive for data entry. Original forms were stored in
a locked cabinet.
To establish a baseline for all key metrics prior
to implementation, the following were collected: (1)
nurse/staff and physician satisfaction, (2) patient
outcomes and patient safety indicators, (3) financial
information, and (4) patient satisfaction. For the clinical outcome and financial metrics, data for the same
6 months of the planned pilot in the previous year
were used.
Each pilot hospital assumed responsibility for implementing the education in new skills and verifying
that all UAPs and LPNs had mastered the identified
competencies prior to initiating the model. Job descriptions were updated. RNs’ job expectations shifted to
focus on decision making for delegation and assurance
of quality, patient teaching, patient care coordination,
and collaboration with other health professionals. Each
team had an RN leader and either 2 UAPs or 1 LPN
and 1 UAP. Patient assignments were for that shift.
Each job description was reviewed to ensure clarity
of role function.
An 8-hour course for all the nursing staff on the
pilot medical-surgical units at the 3 hospitals was designed and led by the research team. The course began
with an overview of the new delivery model and job
descriptions for RNs, LPNs, and UAPs. The new acuity
tool was reviewed, and its purpose to share workload
fairly discussed. The plan to assess patient care needs
and review in huddles every 4 hours to maintain equity
was reviewed. Delegation and collaboration were then
discussed with case examples. Emphasis was placed on
each person working to their enhanced scope of practice and to share accountability for patient outcomes.
This was followed by a simulation exercise where staff
was assigned teams with case scenarios. Nurses left expressing enthusiasm for their new roles.
Implementation and Evaluation
The new model was introduced, and all staff was provided support to comply. When turnover occurred during the 6 months of the study, categories of new hires
were chosen to support the model implementation. At
the end of the 6-month period, all metrics were collected
and measured against the established baseline.
Nurse satisfaction showed the most statistically significant improvement in comparison to all other measures
included in the study. Forty-four nurses (86%) completed the presurvey, and 36 (69%) completed the postsurvey. A paired-samples test was performed to identify
any significant change from the implementation of the
new care model. While all responses demonstrated a
positive trend, 6 items showed statistically significant
improvement: teamwork among coworkers, appropriate delegation, sense of accomplishment in their
work, enjoyment coming to work, satisfaction with
JONA Vol. 44, No. 7/8 July/August 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1. Bed huddle.
workload, and satisfaction with job (Table 1). Patient satisfaction showed slight improvement according to the HCAHPS scores in 3 of the 8 domains.
JONA Vol. 44, No. 7/8 July/August 2014
Within the 8 domains, physician communication resulted in a statistically significant improvement at P =
0.013 when an analysis of variance was performed.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1. Paired-Samples Test Nurse Survey
Paired Differences
95% Confidence
Interval of the
Pre-Post Response Items (n = 36)
1: good teamwork
2: delegation appropriate
3: sense of accomplishment
7: enjoy coming to work
9: satisfied with workload
11: satisfied with job
SE Mean
P (2-Tailed)
P e 0.05.
Most clinical quality indicators showed signs of
improvement, including core measures, hospital-acquired
pressure ulcers, medication errors, near misses, and
CHF, MI, and pneumonia readmissions. Independent
t tests of samples were performed to examine the difference between the mean of incidence of indicator
before and after the intervention. Although improved,
none were statistically significant (Table 2). A composite core measure score for the hospitals, excluding
elements of care provided in the emergency department, revealed improvements in the pilot hospitals.
Financially, the pilot resulted in reductions in
costs. Cost reduction was realized through the use of
proper discharge of lower-acuity patients, proper work
allocation, and staffing-mix allocations resulting from
workload rebalancing. Based on analysis on each unit,
using year-over-year comparison, case mixYadjusted
LOS decreased by 0.39 days on average for all 3 units.
In addition, the ALOS average for the 3 units was
below the mean LOS by 0.38. In addition, all 3 units
resulted in reductions in salary per patient-day of approximately 2% to 3%. One of the 3 units proved to
be the best comparative model, as it had the most
stability in its workforce and adhered closely to the
staffing workload balance guidelines. This unit reported
an equivalent decrease in RN hours to the increase in
LPN and UAP hours (a rebalance of approximately
5.0 full-time equivalents).
Improving the Environment of the Workplace
Although the study did not set out to improve the
workplace environment, the achievements in this area
Table 2. Independent-Samples Test of Quality Indicators
Levene Test
for Equality
of Variances
Equal Variances
Assumed or
Not Assumeda
Acute MI
Fall rate
Fall injury
t Test for Equality of Means
95% Confidence
Interval of the
P (2-Tailed)
Abbreviations: CHF, chronic heart failure; MI, myocardial infarction; PN, pneumonia.
P e 0.05.
(1) Equal variances assumed, (2) equal variances not assumed.
JONA Vol. 44, No. 7/8 July/August 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
deserve special recognition. It was noted by all 3 pilot
sites that the engagement in innovation, education,
and new tools and methodologies brought about an
e …
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