Actively including patients in their care and educating them about what will occur during hospitalization can help improve patient safety. It has been noted that the patient is the only constant in the healthcare system and the patient's vigilance is a critical aspect of patient safety.1 Simple mistakes that lead to patient harm may be prevented when the patient is part of the checks and balances of the healthcare system.1 A meaningful phrase, credited to an English midwife, “nothing about me without me,” has been used many times to reflect the importance of patients and healthcare professionals working together.2
Several nationally recognized organizations have provided publications advising patients to participate in patient safety. Among them was The Joint Commission's Speak Up and the Agency for Healthcare Research and Quality's 20 Tips.3,4 These documents encourage patients to ask questions of their healthcare providers.5 It has been reported that patients are less willing to ask health professionals challenging questions than factual questions about their condition and treatment.6
The success of efforts to partner with patients to improve safety depends largely on the attitudes and actions of healthcare professionals, not the consumers.1 Although most medical literature supports patient involvement for patient safety, healthcare professionals still need to define successful, workable approaches to involve patients in their care. One of our approaches is called The Daily Plan®.
The Daily Plan was created by extracting patient-specific provider orders from the electronic medical record (EMR) and printing a summary each day. Items on The Daily Plan included the patient's medications, appointments, and diagnostic tests. Nurses reviewed The Daily Plan with the patient during each day of hospitalization. Evaluations focused on whether this discussion between the nurse and patient would identify and prevent potential medical errors of omission and/or commission. We were primarily interested in the patient safety impact (whether potential medical errors would be identified and prevented by reviewing The Daily Plan with the patient).
Following the initial study of The Daily Plan, information was disseminated to VA Medical Centers in a variety of ways, including conference calls with nurse executives, informational brochures, and word of mouth. Nurse executives or nurse managers from interested facilities and units were involved in calls with staff from the VA National Center for Patient Safety (NCPS). The calls provided an overview of the benefits of The Daily Plan and included instructions on how to get started on the unit. A getting started booklet and other supporting documentation were also shared with each unit.
Several factors appeared to influence whether a facility chose to implement The Daily Plan. One factor that was consistent among successful sites included interest and support from leadership. Conversely, facilities in which leadership didn't support the intervention were less successful. At the time of this study, 12 facilities were piloting The Daily Plan.
Although the plan can be customized, several components were defined as mandatory by the NCPS, including the patient's full name and date of birth, the date, the time that The Daily Plan was printed, the treatment location or unit, and the patient's active medications, allergies, lab orders, imaging status/radiology orders, current diet, and scheduled appointments/visits/admissions. Optional components included emergency contact/next of kin, healthcare provider name(s), outside medications, nursing orders, active problems, vital signs, advance directives, code status, admitting diagnosis, fall risk, and infection control status. The optional components are dependent on facility-specific information entered in the EMR.
The plan was usually printed after physician rounds; however, several sites used the plan for multidisciplinary rounds, so it was sometimes printed before. The patient's nurse typically reviewed the plan with the patient. Patients were encouraged to ask questions if there was something they didn't understand or if something seemed different than expected. The patient was also encouraged to retain the plan and refer to it as needed throughout the day. An opaque envelope or folder was provided to protect patient confidentiality. Patients who received the plan were also given a letter about the program, a journal to write down questions, and information about patient safety.
The Daily Plan was designed to be printed on the unit each day (every 24 hours) and the nurse was to review the plan with his or her patients. This was done on many pilot units; however, notable changes have occurred on several units. Some units used The Daily Plan as a tool for multidisciplinary rounds. In addition, although the plan was originally designed to be used every 24 hours, community living centers may only use the plan once a week. Furthermore, each unit is given the flexibility to include different components from the EMR to suit the needs of the patient population. Additional documented use of The Daily Plan included utilizing it as a shift-to-shift hand-off tool.
Studying the intervention
All units participating in The Daily Plan before June 2009 were invited to participate in the study. Ten of the 12 sites chose to participate. Data were collected using patient and staff evaluations. Patients were asked to complete the evaluation at the hospital before discharge. Nursing staff members were asked to complete one cumulative evaluation, including information for all their patients who used The Daily Plan, at the end of each shift. All evaluations were voluntary and anonymous.
The mixed-method evaluation instrument included quantitative questions, using a five-point Likert scale, in addition to open-ended questions. The instrument was designed to measure the impact of The Daily Plan on patient safety. All evaluations were mailed to the NCPS without patient or staff identifiers; only the name of the pilot site was known.
Additional feedback was obtained during collaboration with My HealtheVet, a website where veterans can access healthcare information. Specific questions about The Daily Plan were incorporated in My HealtheVet's American Customer Satisfaction Survey (ACSI), an industry standard tool used to measure satisfaction.7 A random sample of 4% of My HealtheVet users who had visited four or more pages on the site were invited to take the survey. This tool focused primarily on obtaining feedback from site visitors and their interest in receiving The Daily Plan should they be hospitalized.
Descriptive information from the patient and nurse surveys was calculated, and data about the medical units, length of stay, and patient demographics were reported. Descriptive data from the ACSI web-based survey were also aggregated and reported.
Data from 198 patients at 10 pilot sites were collected. The patients were inpatients an average of 8.2 days (SD = 10.7 days) and had received The Daily Plan an average of 5 days (SD = 6.9 days) when they completed the evaluation. They were hospitalized on medical units (41.4%), medical-surgical units (18.2%), ICUs (3.0%), surgical units (0.5%), and other units (26.8%); the type of unit wasn't reported for 10.6%. In addition, 70.7% were age 55 or older, 86.4% were men, and 82.3% had at least a high school diploma or GED. Figure 1 displays the primary responses to the questionnaire; note that 47.5% of patients reported that either they or their family found a discrepancy between the physician's report and The Daily Plan.
Data from 85 nurses were also collected; 81.25% were RNs and 11.2% were LPNs. The results indicated that 72.9% of the nurses were between the ages 35 and 65, 81.2% were women, and 61.2% had a 4-year college education or higher. In addition, 54.1% worked 8-hour day shifts; 31.8%, 12-hour day shifts; and 8.2% worked other shifts, and 37.6% reported working on medical-surgical Units, 8.2% on medical units, 3.5% on long-term care units, and 36.5% on other types of units. The average number of patients on a shift was 4.8 (SD = 3.1), the average number of patients given The Daily Plan per shift was 3.4 (SD = 1.6), and the average percentage of patients given the Daily Plan was 77.0% (SD = 32.6%).
More than 60% (64.9%) of nurses also reported using The Daily Plan to provide education to at least one patient, and 51.8% of the nursing evaluations reported that at least one patient used the provided journal to write questions or take notes. Of note is the fact that 15.3% of nurses reported at least one error of omission and 10.6% reported at least one error of commission that was identified using The Daily Plan, resulting in a total of 17.6% of the nurses finding at least one error as the result of the plan. Figure 2 displays the nurse's responses to the rest of the survey.
The response rate for the My HealtheVet survey (17%) exceeded the average response rate for all ACSI surveys (6.5%). The survey period was from August 12, 2009 to September 25, 2009, with 14,449 responses. Ninety-six percent of respondents described themselves as a veteran, 59% were between ages 55 and 69, and 91% were men. In addition, 61% rated their overall health as good or better.
The Daily Plan was briefly described to respondents before asking if they'd be interested in using the plan if they were admitted to a VA hospital. (See Table 1.) Eighty-nine percent reported that they would like to see current, active, and pending orders; 85% wanted to view upcoming procedures; and 80% wanted to view upcoming appointments. In addition, 62% of respondents reported that they'd be interested in having access to an electronic copy of The Daily Plan on the TV in their room.
Informed patients are safe patients
One of the most striking findings in this study is that 17.6% of nurses using The Daily Plan reported finding at least one error in the treatment plan while using it over a course of 1,623.6 patient days. Moreover, 47.5% of the patients reported that The Daily Plan helped them identify discrepancies in their treatment plan. Although not all discrepancies raised were potential errors, having a common understanding of the plan for the day was important. In addition, the current results indicate that the majority of patients reported that The Daily Plan increased their understanding of their treatment, made it easier to ask their healthcare providers questions, and helped them feel more comfortable. Nurses who used The Daily Plan also felt that it was easy to use and improved patient satisfaction, although many didn't agree that it helped increase efficiency.
The web-based survey of veterans gives us information about how to develop The Daily Plan into a more useful tool. Most respondents said that they'd want to see their orders, upcoming procedures, medications, and upcoming appointments. In addition, most respondents wanted access to an electronic version of The Daily Plan and would be interested in an interactive patient-TV system.
Our results support other studies that found written plans, involving the patient, enhance patient education, facilitate self-management of care, decrease missed appointments, and most importantly improve outcomes.8–15 However, despite positive responses, this study has several limitations. We don't have data on patient characteristics or comorbidities, nor do we have data on response rate to the survey or the rate of patients that agreed to use The Daily Plan. In addition, facilities expanded the content of The Daily Plan to fit their local needs, so although the spirit of communicating the treatment plan to the patient was met, the process wasn't the same for all facilities in the study. Regardless of these limitations, this study gives us preliminary evidence that providing patients with information about their treatment plan each day can improve patient safety and satisfaction during a hospital stay.
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