ABSTRACT
By definition, a patient’s plan of care should be centered on and tailored to the
individual needs of that person and/or their family. All too often, however, what
is represented as a plan of care is actually a generic checklist of activities and
reminders for nurses that has little to do with driving improved outcomes for
patients, or helping them transition to the next level of care. Use of generic plans
also does little to ensure evidence-based clinical information is being applied and
carried forward so that care can be coordinated within or across disciplines or
care settings.
This lack of care coordination leaves patients vulnerable, especially during
transitions. According to The Joint Commission, 80 percent of serious medical
errors involve miscommunication between caregivers during the transfer of
patients.
This paper describes the process that prompted White Plains Hospital, White
Plains, N. Y., to realize the limitations of its generic plans of care and their
marginal ability to influence quality, patient safety and the cost of delivering
care. It describes how the hospital implemented a new system of evidence-based, interdisciplinary plans of care (informed by informatics) that required
customization to the specific needs and goals of each patient, resulting in:
• Increased collaboration between clinical disciplines
• 95 percent utilization of interdisciplinary plans of care
• Meaningful documentation of patient goals
• Reduction in length of stay from 4.81 to 4.75 days
• Meeting the criteria for Meaningful Use Stage 2
• Meeting Magnet® designation for evidence-based practice
KEYWORDS
Interdisciplinary Plan of Care, Continuity of Care, Patient Safety, Care Transitions,
Evidence-based Practice, Collaboration.
tor at Syracuse University, who wrote about
the subject in an article published in the
April 1930 issue of The American Journal
of Nursing. 4 The paper, which focused on
using case studies to train nurses in public health settings, included references to
teaching comprehensive and systematic
thinking and care planning to new nurses.
INTEGRATING INTO THE CARE PROCESS
Nursing plans of care began to evolve from
mere training tools to an integral part of the
care process in the post-World War II era,
when nursing shortages required supple-
menting the registered nurse workforce
with practical nurses who had received less
training. 5 Several articles were written in
the 1950s and 1960s regarding the proper
format for a plan of care and its presumed
benefits for both nursing students and staff
nurses. The goal was to use the plan of care
to help students view the patient as a whole
person, share clinical information with the
team, and promote continuity of care. 6 The
plan of care also was suggested as a tool to
move nurses away from tasks that were
treated as ends unto themselves rather than
being part of a larger care process. 7
The use of nurse plans of care expand-
ed greatly through the 1960s and 1970s,
becoming a standard component of nursing
education. They were codified into hospi-
tals when plans of care became a regula-
tory requirement for participation in the
Medicare program in 1967, and two years
later when The Joint Commission made it
part of their hospital accreditation process
in 1969.8 Nurses were taught how to develop
a plan of care (and continue to be until this
day) and came to accept them as part of the
job. The idea of using written plans of care
to improve coordination of patient care 24/7
was introduced in 1973, 9 and in 1974 the lan-
guage around them evolved from “nursing
plan of care” to “patient plan of care” as a
result of new CMS requirements. 10
LOW RATE OF COMPLIANCE
Yet despite these efforts and requirements,
traditional plans of care historically have
had very low rates of acceptance and compliance among nurses. One of the most
common reasons is the question of relevance. Generic plans of care often bear
little relationship to the patient’s specific
condition(s) and treatment goals. Generic
plans of care can also add significantly to
the already high burden of documentation
nurses face. A 2008 time-motion study of
36 hospitals showed more than one-third
of nurses’ time ( 35. 3 percent) was spent
on documentation. 11 This study was prior
to the widespread use of electronic health
records (EHRs). It is safe to assume that
percentage has increased in the ensuing
years.
When they are used, traditional plans of
care often serve primarily as task-oriented
checklists for nurses. Nurses will refer to
the plan of care to ensure that the required
steps have been followed, but the plans
themselves have little impact on the decision regarding which evidence-based interventions to undertake in specific conditions
for that specific patient.
Another limitation of these traditional
nurse plans of care is inherent in the name:
they are designed specifically for the nursing staff. They are developed and used in
siloes, contributing little to the goal of helping the caregiving team transition patients
and their families to the next level of care.
Other disciplines, such as physical and
respiratory therapists, often have their
own independent plans of care as well.
Little information is shared about patient
needs or progress, resulting in issues such
