Baird, Sylvia K. MM, BSN, RN; Turbin, Lynn Bobel MSN, RN, CCRN, NE-BC
IN RECENT YEARS there has been a growing interest in hospital-based initiatives focused on increasing and maintaining patient safety.1 In fact, patient safety is rapidly becoming the domain of all health care personnel, regardless of their position, role, or responsibilities. All health care providers clearly have an obligation to report and respond to patient care concerns that could have a deleterious outcome if undetected, and this responsibility must be encouraged and supported throughout the health care community.
At the same time, an equally important opportunity to enhance safety can be found by encouraging patients and their families/friends to assert their concerns when clinical issues appear to be unresolved. Patients and their families/friends can often detect subtle changes that may not be obvious or immediately perceived by health care providers. When this happens, they need to be encouraged to openly communicate their perceptions and concerns to their primary health team members.
Involving patients and their loved ones in personal safety matters was the impetus behind Spectrum Health's creation and implementation of a program called “Condition Concern.” Spectrum Health, a not-for-profit health system, is headquartered in Grand Rapids, Michigan. It includes 8 hospitals and more than 140 service sites in the West Michigan region, with 1,500 medical staff members and 16,000 employees.
In July 2009, Spectrum Health implemented the Condition Concern program to provide inpatients and their families/friends with an enhanced mechanism to communicate care concerns that they felt were not being properly addressed. In part, the program was developed in response to Goal 13 of the Joint Commission National Patient Safety Goals 2008: “Encourage patients’ active involvement in their own care as a patient safety strategy.”2 Although this national goal gave additional credence to the planning and implementation process, an organizational drive for increased patient safety was the primary motivation. Around that same time, Spectrum Health began laying the foundation for a transformation in its culture of safety. This included efforts to capitalize on the partnership established between health care consumers and hospital personnel, promoting a culture of safety that would support everyone's ability to speak up and freely communicate.
PROGRAM CREATION AND IMPLEMENTATION
A Condition Concern program task force was established, made up of department representatives from Patient Relations, Nursing Quality, the Rapid Response Team, Critical Care, and hospital management staff. This task force was responsible for creating the program framework and identifying deliverables.
It was decided that the primary goal of this initiative was to provide patients and their families/friends with a practical safety net for reporting perceived clinical and safety concerns that were not being addressed by hospital personnel. The program was primarily focused on the adult and pediatric inpatient units at 3 major hospitals in Grand Rapids, ultimately affecting a total of 1061 beds.
In preparation for program design, the critical care director attended a rapid response team session during the 2008 Institute for Healthcare Improvement Conference. At this seminar, Virginia Mason Medical Center in Seattle, Washington, presented its family-activated response plan. The Josie King Foundation was another source of information during the design phase.3 Finally, a literature search was conducted, but very few published articles were found at the time about this subject.
After the program's fundamentals were established, the Condition Concern program concept was introduced in a variety of hospital venues. Quality committees, leadership meetings, physician boards, and patient and family advisory councils were some of the forums used to communicate about the proposed program and solicit feedback. The overall plan produced considerable favorable interaction and dialogue, and it ultimately received full concept endorsement and support for implementation.
The primary aim of the Condition Concern program was to provide patients and their families/friends with an effective safety net for reporting their perceived unattended clinical care and safety issues. To help meet this goal, the program task force decided to establish some volume statistics and categorize and assess the nature of calls received.
The proposed program model opted to use the house supervision staff as “first responders” to Condition Concern calls rather than immediately deploying existing rapid response team resources. The intent was to have these supervisory staff quickly determine whether the patient/family/friend concern required the more sophisticated emergent intervention capabilities of a rapid response team. As part of the implementation process, the task force wanted to understand the issues that actually surfaced before deciding whether the hospital's rapid response system should always be deployed in response to a Condition Concern call.
After support for the concept had been given, an implementation target date was established for July 1, 2009, and preliminary plans were solidified. Education packets were constructed, which consisted of (1) a manager “To Do” checklist, (2) a policy document, (3) talking points for staff, (4) talking points for physicians, (5) an audit tool, and (6) a copy of proposed patient room signage. The management team members received their initial instructions during a patient care leadership meeting. In addition, the education packets were reviewed with each manager during small group sessions so that individual instruction could occur and specific questions could be answered.
Patients and their families/friends receive orientation to the Condition Concern program during the unit admission process. They are informed that the first recommended course of action is to share any clinical care or safety concerns with their hospital primary care providers, regardless of the nature of those concerns. The Condition Concern program comes into play when the best efforts of these front-line providers do not meet the expectations of patients or their families/friends, or when their concerns are not recognized or resolved to their satisfaction.
Condition Concern process
The Condition Concern process is initiated when the patient/family/friend calls an emergency alert number, which is answered by the hospital operator and directed to the Administrative Associate Manager (AAM, comparable to a house supervisor). The AAM does the initial assessment and determines the type of intervention required. Observations and interventions are documented; the information is provided to appropriate internal departments for analysis and any necessary follow-up (Table).
TABLE. Steps in Cond...Image Tools
The procedures in this program differ somewhat from those of other institutions that use rapid response teams to respond to these types of calls. Although the AAMs who act as first responders serve primarily in an administrative liaison role, they are clinically competent and maintain advanced cardiac life support credentials. An AAM can initiate a rapid response team call if clinical signs of decline are present.
The task force realized early in the program design process that additional stress could be created through activation of this alert system. There is inherent anxiety when patients or families/friends feel the need to bring in reinforcements to have their concerns acknowledged and addressed. Feedback received from Spectrum Health's Patient and Family Advisory Council revealed a concern about staff retaliation or retribution toward patients and families/friends seeking assistance outside of their immediate providers. To address this concern, a nonjudgmental approach and open, secure communication were built into the program process. For example, the AAM always concludes each intervention by personally asking the patients and/or their families/friends, “Is there anything else I can do for you?” In addition, patients are always thanked for placing the call to activate the response system. To date, no evidence of staff retaliation resulting from a Condition Concern call has been substantiated.
Finally, as part of the Condition Concern process, the AAM conducts situational debriefings with the health care team involved to review the situation, outcomes, intervention plan, and lessons learned. The unit manager and Patient Relations Department provide additional support to patients and staff as necessary.
The Condition Concern Audit Tool (Figure 1) was created during the program design phase. It uses an SBAR (Situation, Background, Assessment, and Recommendation) format, a structured communication approach used to facilitate and enhance accurate, thorough communication. This technique facilitates the process for important information to be delivered in a clear, succinct manner, promoting an overall culture of safety.
The key SBAR elements are as follows:
* The Situation identifies the reason for the call and categorizes the characteristics and common factors contributing to the call.
* The Background provides some patient history and the hospital course of care.
* The Assessment is based on the AAM's evaluation.
* The Recommendation outlines the plan for action and includes a communication tree to acknowledge the other health team members used to resolve the concern.
Outcomes measurement and data collection
Outcomes measurement was a key discussion point during the development of the Condition Concern program. The program task force brainstormed about appropriate metrics and how information could be obtained in a timely manner for effective program evaluation. Using a classic model for quality improvement, questions were asked such as the following: “What are we trying to accomplish?” “How will we know that a change is an improvement?” “What changes (action plans) can we make that will result in an improvement in the process?” This structured approach to determine the outcomes contributed to the design of the audit tool.
While the number of reported concerns was an important factor, the task force did not want to use this as the sole barometer of the program's outcomes. The deliverables for the program were identified as follows:
* Demonstrate patient and family/friend awareness of the Condition Concern program.
* Track the volume of calls over time.
* Identify any trended concerns.
* Track the number of concerns immediately resolved.
* Track the number of concerns that were resolved with additional action planning and those that remained unresolved to patient or family/friend satisfaction.
After much discussion, the task force chose the following metrics to evaluate the outcomes of the program:
* Percentage of calls resolved by the end of the Condition Concern visit
* Percentage of calls resolved with an action plan
* Percentage of calls unresolved despite intervention or an action plan
* Zero defects in the number of calls that resulted in a code.
After these metrics were identified, a process had to be created for obtaining accurate data to evaluate outcomes. The planning needed to address not only the technical details of accurate data gathering, but also the reasons for collecting the data and how they would be used. It was determined that the data collected would be used for analysis to evaluate if the specific outcome metrics were met. This, in turn, would be critical in determining whether the program was a success or failure.
Because Condition Concern calls would not be part of the standard electronic medical record, the electronic medical record could not be used as a complete data source. However, the program task force members agreed that if the team performed any interventions, there would be documentation in the electronic medical record. Thus the question became, “What is the simplest way to obtain useful, nonintervention-related data?” Suggestions included patient and family/friend feedback through surveys or comment cards, or having staff members collect the data.
The decision was made to obtain the needed data from the completed audit tools collected by the AAMs. The rationale for this decision included the following: (1) the data cues on the audit tool contained information directly relevant to the definition of the program's outcomes, and (2) there would be decreased variability in the data collection process because the audit tool was limited to one role.
After several months of data collection and analysis using the audit tool, 7 categories of Condition Concern calls became evident. These categories included (1) pain management, (2) plan of care, (3) coordination of care, (4) dissatisfied with staff, (5) response to call light, (6) other, and (7) not a valid concern. Dissatisfied with staff was separated into 3 subcategories: (1) physician/mid-level provider, (2) staff RN, and (3) other. The initial audit tool was then revised to include these categories as checkbox entries, decreasing the need for handwritten text and the potential for misinterpreting handwritten information.
Data gathered from July 1 to December 31, 2009, indicated that there were 69 Condition Concern calls (Figure 2). During the evaluation, the program task force was surprised by the number of concerns generated during a 6-month period of time. This was almost 3 times more than the number of calls in a similar program, as indicated at the 2008 Institute for Healthcare Improvement conference.
After some discussion, the task force concluded that calls were promoted by the visibility of the signage in patient rooms bearing the Condition Concern number. Typically, the sign was placed on the wall across from the patient bed. This location was easily visible to the patient laying in bed and the visiting family/friends at the bedside. As Ogrinc and Batalden have noted: “Evaluation frameworks often seek to identify whether an intervention is successful or not. They ask the question ‘Was this intervention successful?,’ which is a basic yes or no proposition.”4(p662) In light of this question, the sign placement was a successful intervention in advertising the Condition Concern program to patients and their families/friends.
Sixty-five percent (n = 45) of the 69 calls were resolved at the completion of the team intervention, and 10% (n = 7) were resolved with additional action plans (Figure 3). This was viewed positively because rapid satisfactory resolution of a problem (in this case, the Condition Concern call) is important in any quality improvement effort.5
Examples of the remaining 25% (n = 17) of unresolved calls included (1) patient requests for a private room when none was available, (2) family member requests to have access to the medical record when they were not the legal guardian or patient advocate, and (3) patient requests for specific treatments or interventions that were not appropriate for their diagnosis and treatment plan.
Analysis of the data revealed that the single item generating the greatest patient concern was the plan of care (n = 24; 34.8%). When this metric was further investigated, lack of communication among the patient, family/friends, and health care providers was identified as a contributing factor. As a posting for the 2010 Patient and Safety Awareness week underscores,
Without quality communication, even the most perfectly executed technical skills and most advanced medical knowledge can be undone. Clear, effective communication is essential between patients and providers, among providers themselves, and in some cases between different organizations.6
The sample size of 69 Condition Concern calls received during the first 6 months of the program at the 3 hospitals is too small to trend system process issues. However, pain management appears to be a trend in the data gathered to date. Some concerns came from patients or families/friends, indicating that when pain was a chronic condition, their current pain management was felt to be less than they received prior to hospitalization. Patients requesting specific narcotics, an increased dosage, or shorter intervals between dosages than recommended were other contributing factors to the pain management category.
One surprise in the data was that response to call lights was not seen as a major concern. This could be attributed to the Spectrum Health Relationship Based Care patient care model. One of the Relationship Based Care principles is hourly rounding on patients, which has established a precedent for attending to each patient's common needs at that time. With this proactive approach, patients' questions and needs are fulfilled without the need to use a call light.
Another concern that recurred within the first 6 months postimplementation related to communication between patients/family/friends and health care providers regarding discharge timing. On the day of discharge, patients and family/friends wait for a final assessment by the physician or mid-level provider before the actual discharge order is written. This continues to be a challenge for physicians and mid-level providers as they attempt to see every patient “first thing” in the morning. Keeping the Condition Concern results in mind, nurses and physicians continue to work collaboratively to establish effective communication with patients and family/friends about the discharge process. On a final, positive note, none of the Condition Concern calls within the first 6 months resulted in a rapid response team intervention or other type of emergency response.
The Condition Concern program appears to be successful on the basis of an initial analysis of the data available, promoting a greater sense of safety and security in the provision of patient care. In addition, satisfaction can be gained from the fact that none of the calls to date have resulted in a need for emergency intervention, and most of the requests generated immediate resolution and patient appreciation. The Condition Concern program, although in its early stages, is being continued because, ultimately, it is the right thing to do for patients and their loved ones.
© 2011 Lippincott Williams & Wilkins, Inc.