Nurse managers across the country are facing the challenge of doing more, and not necessarily with more resources at their disposal. For the manager of a 19-bed general medical unit located in the inland Northwest, the “more” involved improving Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores in the area of staff responsiveness to patients. Within the “response of hospital staff” category, there are three questions: 1. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? 2. During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan? 3. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?1
This article describes the process of implementing certified nursing assistant (CNA) care zones as an effective measure to improve HCAHPS staff responsiveness scores and the lessons learned along the way.
The unit had already implemented many of the best practices known to improve responsiveness.2,3 Both nurses and CNAs were doing hourly rounding the majority of the time, and during patient rounds the staff addressed the 5 Ps (pain, potty, position, personal items within reach, and promise to return).2-4 Nurses completed bedside report for each shift change. Staff members also utilized portable IP phones linked to the patient call light system as another method to aid in responsiveness. When the call light is pressed, the alert automatically rings to the assigned CNA's phone first. If the CNA is unable to answer within 30 seconds, the alert is automatically sent to the primary nurse's phone. And if the primary nurse is unable to answer within 30 seconds, the alert is then sent to the unit secretary.
Concerns about the perception of varying care quality surrounding poor responsiveness scores on this medical unit's HCAHPS surveys prompted the restructuring of CNA assignments. The unit manager used the shared governance process to utilize the unit practice council to share the idea with frontline clinical nurses, clinical coordinators, and CNAs; present the background HCAHPS data; and gain support.
A small group of frontline staff members worked on the new design, which became known as CNA care zones and clearly established that staff members who work on the unit don't just care for “their” patients but have equal responsibility for all 19 patients on the unit. The team established goals and outcome measures. The manager took on the role of running and compiling reports to showcase the data in a meaningful and understandable way and assist with breaking down barriers if they occurred.
Of the unit's 19 beds, 11 are single-bed rooms and 4 are double-bed rooms. The nurse-to-patient ratio on the day shift is 1:5 and on the night shift, 1:6. The CNA-to-patient ratio on the day shift is 1:8 and on the night shift, 1:9. The general medical unit staffs 10.6 RNs and 5.6 CNA full-time equivalents (FTEs) on the day shift and 14.3 RN and 5.4 CNA FTEs on the night shift.
The unit has two halls that unite in the middle with a nurses' station. The staff perception was that single-bed occupancy rooms often had patients with isolation precautions or patients who required greater lift assistance. Conversely, staff members felt that it was difficult to care for two patients in the same room, especially when ensuring privacy and making sure the needs of both patients were met. This task became even more difficult when both patients were confused. These were all concerns that needed to be addressed when planning the project's design.
Design and methods
The team created a design for assignments and developed the plan for full integration of the CNA care zones. The initial room division for this project consisted of the first CNA having 10 patients in single-bed occupancy rooms and the second CNA having 9 patients (8 patients total in double-bed occupancy rooms and 1 patient in a single-bed occupancy room). The care zones model assigns the CNAs to a series of rooms that are sequential to each other as opposed to the previous method in which assignments were based more on nursing assignment and acuity. The design was also thought to improve communication between the CNA and the nurse.
After a 1-month trial, the assignments were changed based on feedback from the CNAs, as well as from the team and the manager who also rounded and gathered information. The team decided that the first CNA should have one less patient given the reality that the assigned room usually had isolation and lift patients.
The CNA care zones project was moving forward, the manager was giving monthly feedback, charge nurses were ensuring that assignments were being delegated appropriately, and nurses and CNAs were communicating better throughout their shifts. And then a totally unexpected change in the unit culture occurred 2 months into the process. The observation unit merged with the general medical unit, which changed the department dynamics. This transition involved integrating two unit's cultures and staff members, and learning new responsibilities.
The team met and decided that the second CNA would have all of the observation patients (eight of the nine patient beds were in double-occupancy rooms), which meant more frequent vital signs assessment compared with the first CNA's assignment. The total observation patient bed allowance count stayed the same, whereas the number of single-bed occupancy rooms increased to five of the nine patient beds. This allowed for the observation patient load to be shared almost equally between the two CNAs.
The project team came together 4 months after implementation to review the data and discuss any issues. The CNA care zones established assignments that allow the nurses and CNAs to work more collaboratively. The care zones help the nurses be more aware of where the CNAs are, which improves both nurse and CNA responsiveness.
The reported HCAHPS survey scores showed an improvement in the responsiveness metric after the implementation of CNA care zones. (See Figure 1.) Between January and June 2017, the unit's average score was 52.8; from July to December 2017, the score was 59.4. The unit also reduced the number of falls per patient days during this same period from 17 to 14. (See Figure 2.) Staff members' initial concerns about the introduction of this model of care shifted to acceptance and recognition of the benefits to both their workflow and their patients. Despite the changes that the unit faced during the 4-month trial, they attained positive results.
Data analysis and interpretation
HCAHPS data interpretation often requires some explanation so that staff members can see the information as meaningful and useful. The manager shared simple bar charts with minimal information and provided a key for understanding what top box, rank, and N represent. Top box defines the most positive responses to survey questions and requires an “always” answer to six of the seven composite measures, rank indicates performance relative to other units in the peer group, and N represents the total number of patients who responded during the report's time frame.1 The P-value for each table was calculated using the two-proportions test found in spreadsheet quality improvement macros. The P-values don't show statistical significance; however, the outcomes were positive and clinically relevant for this unit.
The results of this project demonstrate that a CNA care zones model is an effective method to improve the consistency and quality of patient care related to staff responsiveness. The process wasn't without its struggles, but obtaining buy-in from staff members who embrace change and are known as early adopters was a key to success.
Another added benefit was the reduction in falls. Although not statistically significant, we hope that the CNA care zones will continue to aid in reducing falls.5 We believe that falls were impacted because both the nurses and the CNAs became aware of one another's location and through that knowledge, a quicker response was achieved for not only call lights, but also bed/chair alarms.
In with the new
CNA care zones are applicable to the general medical environment and may be a new design that can lead to improved responsiveness to better meet patient needs.
2. Yang L, Liu C, Huang C, Mukamel DB. Patients' perceptions of interactions with hospital staff are associated with hospital readmissions: a national survey of 4535 hospitals. BMC Health Serv Res
3. Long L. Impressing patients while improving HCAHPS. Nurs Manage
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4. Friese CR, Grunawalt JC, Bhullar S, Bihlmeyer K, Chang R, Wood W. Pod nursing on a medical/surgical unit: implementation and outcomes evaluation. J Nurs Adm