relevance to the specific patient in front of
them. Nurses often didn’t see the value of
certain actions and found the follow-up
documentation confusing.
The White Plains Hospital team
addressed these issues in two ways. One
was the incorporation of evidence into
the plan of care workflow. Rather than
the interdisciplinary plans of care simply
indicating a task should be performed, they
provided evidence of the value an intervention would yield such as reducing length
of stay. By focusing on interventions that
were proven to help move patients to the
next level of care, the nurses and other caregivers were more inclined to refer to and
follow the interdisciplinary plans of care.
Documentation around the plans of care
was also changed. All plans were built into
the hospital’s EMR, guided by the evidence-based clinical decision support technology
the hospital was using; documentation was
designed to be entered into the EMR as
well. Team members across all disciplines
are able to enter their documentation in
the same plan of care and share their outcomes with one another. This collaboration also enables team members to review
the outcomes that are being measured to
determine whether they are appropriate to
that specific patient or need to be changed.
Everyone on the team owns the care plans,
not just the nurses, which has built greater
cooperation and sharing of responsibilities
across disciplines (see Figure 2).
These changes resulted in simplifying
how plans of care are enacted. Previously,
White Plains Hospital used a four-step
process that required a registered nurse to
enter a standard of care and plan of care
based on the patient’s condition, match
the standard of care to the plan of care,
identify patient problems and adjust for
comorbidities. Since the interdisciplinary
plans of care were enacted in the EMR, it
is now a two-step process: the nurse enters
the standard of care and appropriate plan
of care for the patient, then customizes the
plan of care based on additional patient
issues. This simplified process has resulted
in measurably greater efficiency and, ulti-
mately, greater compliance, with the inter-
disciplinary plans of care.
CULTURE SHIFT
While there would be many benefits, it
was also recognized that moving to interdisciplinary plans of care would represent
a significant culture shift within White
Plains Hospital. A specific concern was that
veteran nurses and other clinicians who
were accustomed to the old processes that
focused on including any and all problems
in the plans (whether they were relevant
or not) might have trouble adjusting to the
new focus on getting patients to the next
level of care. They might also resist having other disciplines entering documentation into what had previously been owned
exclusively by the nursing staff.
To overcome any potential nurse resis-
tance, the members of the Nursing Infor-
matics Council acted as super users, pro-
viding not just training but an explanation
of the evidence-based reasoning behind
the change. They worked to motivate their
peers and get them excited about the dif-
ference having one standard of care and an
interdisciplinary approach would make.
Particular attention was paid to gaining
buy-in from key influencers within various
departments. These were not necessarily
managers, but nurses who were highly
respected by others in their department.
As leaders, their adoption was key to get-
ting others on board.
Having the full and enthusiastic support
of chief nursing officer Leigh Anne McMahon gave the program a huge boost as well.
If more time or resources were required for
training, she ensured that they were made
available.
The representatives from non-nursing
areas were charged with generating support and buy-in within their own departments. Here again, the opportunity to contribute to the plan of care on a more meaningful level, and the ability to demonstrate
evidence-based reasons behind everything
that was being done, made a significant difference in driving acceptance.
The support of the technology vendor
was also important, especially in terms of
training. They made their subject matter
experts available throughout the build and
go-live process, and continued to provide a
high level of support as users became acclimated to the new patient-focused, interdisciplinary plans of care and the thinking
behind them.
MEASUREABLE RESULTS
By the time the project went live on October 8, 2013, White Plains Hospital had
developed 60 interdisciplinary plans of
care covering a wide range of conditions,
55 of which were completed in just three
days. It also narrowed its standards of
care from 30 to 4: adult, pediatric, newborn and OB. There is now meaningful
documentation of patient goals and much
greater collaboration between disciplines.
Nurses appreciate the participation of other
caregivers in updating the plans of care and
the enhanced communication. Provider-to-provider communications has been
improved as well.
Shortly after the initial launch, compliance with using the plans of care rose
