A three-person team provides care for a cohort of ten to twelve patients. All team members care for every patient assigned to the team. Team composition is varied on any given day with respect to staff mix, and team members function within their defined roles and scope of practice. Charge nurse roles and nursing case manager roles were eliminated and essential elements of these job functions were transferred to the team.
Each team contains an expert nurse to ensure every patient is cared for by an experienced nurse. The bedside nurse is the professional role, and the professional nursing role is defined by decision-making responsibility and accountability, not by specialty and education. For example, a registered nurse could float from another unit to the medical surgical unit and assume the care tech role on the team instead of the professional nursing role because they lack essential competencies for medical surgical decision-making.
The agile team works in small cycles of planning and changes their approach to fit what needs to be done for the cohort of patients on their specific shift.
The Self-Organized Agile Team model includes a new nurse role of Resource Nurse. An experienced RN who works 12-hour shifts, the Resource Nurse partners with the primary nurse caregiver to complete all admissions. As a team, they initiate all orders, IVs, and medications; in addition, complete documentation requirements in real-time on a wireless laptop. Time spent processing an admission has been reduced from 90 minutes to 15 minutes in 40 percent of the unit’s admissions. This new position was created without adding any new FTEs by eliminating the charge nurse position and the afternoon house supervisor position.
This model also created the new role of Care Technician by combining the unit secretary and the nursing assistant role. The care technicians process orders, provide basic care and carry a mobile phone so they are not sitting at the nurses’ station when there are patient needs to be met. If a care tech is processing orders and needs to be assigned to patient care duties, the order processing work may be transferred to the telemetry technician in the intensive care unit to allow the care tech to participate in bedside care.
Prairie Lakes Health System (PLHS) has implemented an integrated, electronic medical record enabling staff to access current patient care information from any workstation or laptop. In preparation for an electronic record, PLHS examined documentation practices and eliminated significant redundancies, waste, and non-value added practices. For example, the traditional nursing care plan report was eliminated. Easy access to patient information and use of the system’s applications supports a care planning process integrated into routine patient care documentation. Standards of care are “built into” order sets and assessment tools to provide easy integration of best practices into the nurse’s work activities.
Nurses also have wireless laptops they bring with them into patient rooms for documentation and medication administration. PLHS also used the EMR to enable Remote Order Processing. By using the electronic medical record, order processing can be shifted to staff in other departments with down time during peak times on the medical surgical unit.
PLHS performed an objective cost benefit analysis of the value of Joint Commission accreditation. It was determined the Medicare Conditions of Participation provided standards and expectations for performance comparable to the Joint Commission. Compliance with Medicare standards consumed fewer resources than the Joint Commission process allowing time and money to be redirected to quality improvements in patient care.
Each staff member carries a walkie-talkie tuned to a designated station for the entirety of her or his shift. The walkies enhanced the ability of caregivers to share information among team members and decreased the time spent searching for other team members.
PLHS installed Patient Servers for medications and patient supplies in each room. The servers are accessible from the hallway for stocking supplies and medications. Using the servers improved nurse productivity in three ways: first, by eliminating the hunting and gathering activity required to obtain supplies and medications for bedside use; second, by eliminating interruptions during medication preparation; and third, by offloading restocking work to other departments.
PLHS implemented the Interdisciplinary Care Conference (ICC), a daily meeting of nurses, utilization reviewers, social workers, physical therapists, unit-based pharmacists and home health nurses. The ICC’s goal is to promote comprehensive care planning for each patient, from admission to post-discharge. This represents a shift from the “plan for the day model” of the primary nurse to the “plan for patient transition” of the interdisciplinary team. Discussion is limited to one minute per patient. Team input is documented real-time on the electronic medical record so that it is accessible to all.
To further support a culture that emphasizes partnership and collaborative teams, PLHS is piloting the elimination of annual performance reviews. The idea is to emphasize team and system performance rather than individual performance. Staff are still expected to demonstrate competence with specific skills, but documentation of individual performance is reserved for poor performance. The elimination of annual performance reviews also simplified the nurse manager job providing more time for direct contact with the patient care team.
