Direct Care RNs and Patient Care Technicians (PCTs) work together as a synchronized primary pair to provide care for a U-shaped geographic “cell” of patients. The model’s goal is that every cell will serve the same number of patients, and that patients in the same room will be assigned to one nurse. Shift reports take place in patient rooms using a standardized SBAR (situation/ background/ assessment/ recommendation) format. Work is standardized for the first cycle of the day (7 a.m. - 11 a.m.). Wall sconces are lit when a nurse needs additional support or is falling behind.
PCTs are the front line “eyes” for the patient. A six-step checklist was developed to minimize falls, reduce call lights, minimize errors of omission, and increase visibility of care to patients and family members. With the standardized Progressive Activity Plan, PCTs focus on activity progression in the areas of feeding, walking, and toileting to improve independence, mobility, and length of stay. PCTs have implemented hourly rounding to reduce call lights by anticipating patient needs regarding pain, positioning, and toileting.
The unit-based team also includes the Clinical Nurse Leader, the Patient Flow Coordinator, and a full compliment of interdisciplinary team members (hospitalists, social workers, discharge planners, dieticians, pharmacists, therapists, etc.). RNs, pharmacists, and dieticians have the authority to intervene without physician approval for issues related to nutrition and mobility.
Clinical Nurse Leaders are unit based clinical experts that screen for and follow those patients at risk for higher lengths of stay. They coordinate patient transfers, handoffs between units and patient family communications.
Assistant Nurse Managers are unit-based clinical experts that function to provide just-in-time support personnel to their staff. They provide communication on organizational needs and issues and charge nurse responsibilities. Assistant nurse managers also assess and monitor staff performance, skills and needs for additional education and training.
Patient Flow Coordinators facilitate the non-clinical activities of the patient care unit: greet patients and visitors, answer phones, respond to complaints, maintain information on boards, assist with bed placement, process charts and serve as a liaison with nurses, physicians, and ancillary staff.
Patient Flow Assistants help with patient flow on a single patient care unit including appropriate room setup, supplies at point of use, maintaining bedside visual controls, providing water, and answering call lights.
The Flow supervisor is responsible for maintaining the flow of patients throughout hospital inpatient units and the emergency department. This new role monitors and manages the overall patient flow and provides communication alerts to key personnel based on defined criteria.
The Flow Supervisor deploys telemetry-certified BSNs in Rapid Response Nurse Teams to assist direct care RNs and relieve bottlenecks that delay patient treatment. Rapid Response Team Nurses make rounds when not deployed.
The Rapid Response Medical Emergency Team is comprised of a critical care nurse, physician and respiratory therapist. Nursing staff can request a team consult when patients meet pre-code emergency criteria or when nurses are concerned about a patient’s status. The team assesses and transfers patients as necessary. A Stroke Team provides similar support for patients specifically at risk for stroke.
Patients are actively involved in the implementation of changes developed in Rapid Process Improvement Workshops (RPIWs). Charting and shift reports (RN-to-RN handoff) occur in patient rooms with patient participation, increasing clarity and quality of understanding regarding the plan of care.
A large white board is placed in every patient room to display important medical and patient goals that must be achieved before discharge (e.g. nutrition goals, lab values). This tool increases patient involvement and facilitates the review and updating of goals in caregiver handoffs.
Virginia Mason Medical Center developed the Falling Stars system to help prevent patient falls. The program provides visual cues on patient room door frames for patients at a higher risk for falls. In each of these cases, a specialized nursing order set has been activated, and the orders include anticipatory care interventions such as more frequent rounds. If a patient falls, a Falling Star evaluation team is summoned immediately to identify the root cause.
Patient Flow Coordinators stock standardized supply setups in patient rooms to minimize RN and PCT movement. Housekeepers use standard work for delivering linens and bathing supply cache, according to the newly developed protocol.
VMMC has implemented an Electronic Medical Record (EMR) that integrates data from inpatient and outpatient settings so that hospitalists have access to primary care records and vice versa. Computer terminals on wheels are moved into patient rooms for documentation with patient input, increasing both perception and accuracy. Screening tools in the EMR help identify patients at risk for complications or unanticipated events so they can be moved to a higher level of care.
The KPO serves as the dedicated resource and internal change agency for the Virginia Mason Production System (VMPS). One to 5 percent of all Virginia Mason staff work full-time (in two to three year rotations) in KPO designing and implementing change.