Case managers work on the unit with staff nurses

Initiative improves patient care

At Delnor Community Hospital in Geneva, IL, case managers work side by side with the clinical staff nurses, an arrangement that has helped earn the hospital the coveted "magnet" designation from the American Nurses Association in Washington, DC.

The process started five years ago when a group of discharge planning RNs and staff nurses met to discuss how well they were or were not meeting the needs for patient care, according to Linda Deering, the hospital’s vice president and chief nursing officer. The new model was designed jointly by the nursing staff and the discharge planning staff during a series of meetings.

"We worked to eliminate territorial attitudes that have developed in health care over the years. We feel pretty confident that we broke down the walls between one clinical service and the next," she explains.

Under the new model, the discharge planners, all RNs, are assigned by unit and work on the floor directly with the staff nurses.

An experienced nurse on each unit has been designated a patient care coordinator and works closely with the discharge planning nurse.

The patient care coordinators are involved in direct patient care every day and are selected to take on the role of the more expert clinician. They have been on the unit longer and provide expertise for the novice nurses. "They are more involved in knowing what happens in the day-to-day plan of care as opposed to a nurse who comes in, and can only focus on one shift," Deering says.

The discharge planning RNs and staff nurses make rounds together every day and jointly develop a plan of care and discharge plan for each patient. They pull in social workers, therapists, and other ancillary staff when appropriate. They check on the patient’s progress toward discharge daily and, as a team, collaborate about progress on the plan of care. "It’s a just-in-time’ relationship. They act on things in a more timely manner rather than chasing each other and trying to catch up," Deering notes.

The team takes a computer terminal into the patient room and has access to laboratory results, X-rays, and other information during the visit. "Instead of sitting in the break room together and talking about the patients, we take the team together to the patient bedside. They communicate throughout the day consistently and in real time," she says.

Since the integrated program began, the hospital has seen a decrease in length of stay compared with the severity of illness and increases in patient satisfaction, physician satisfaction, and employee satisfaction.

Results of all three satisfaction surveys generally range in the 98th to 99th percentile, she adds.

"All of the measures together show that we are meeting and exceeding the needs of the patients, physicians, and employees," Deering says.

In addition to measuring patient satisfaction, the clinical staff at Delnor rate their satisfaction with other disciplines. The hospital has developed satisfaction surveys on which the physicians rate the nursing staff and similar surveys that nurses use to rate individual physicians. "When you start measuring satisfaction regularly, everybody’s behavior improves," she says.

The department began measuring nurses’ satisfaction with physicians about 18 months ago and re-measures every six months.

"We took about six months building it and getting the medical staff concurrent," Deering says.

The five-question survey rates physicians on overall quality of care and communications skills and is similar to the survey that physicians use to rate nurses. The nurses receive a survey sheet for all of the active practicing physicians with a minimum admission rate. They rate only the ones with whom they have personal practice experience.

The physician satisfaction report includes aggregate scores, and each individual physician gets to see his or her own score.

After experiencing the benefit of physicians rating nurses and nurses rating physicians, the medical staff have decided to start having physicians rate physicians as well.

The discharge planners don’t report to the nursing unit. "They report to the utilization review/discharge planning department, but that doesn’t give us excuses not to be partners," Deering says.

The physicians depend on the discharge planning nurses and have expressed a preference to work with them every step of the way, she adds. "It’s totally a two-way street. We went back to rounding with the physicians and being of service. We realize that their time is money, and we try to make their job efficient by maximizing the amount of clinical information available to them."

The hospital has developed a shared decision-making model for each unit. Unit-based councils identify performance improvement efforts for their team. "We have a structured accountability model. It starts with an annual set of organizational goals, and each team across the whole organization is supposed to develop team goals that support the organizational goals," she says.

Typically, there are five organization goals. The team goals comprise 25% of an employee’s merit evaluation. An additional 25% of the merit evaluation depends on the organization’s outcomes toward the goals, Deering explains. "The fact that 50% of an employee’s merit increase hinges on the results of an organization encourages teamwork."

Achieving magnet designation was a three-year process that involved all of the clinical staff. The standards require that nurses be allowed and expected to work autonomously and that members of all the hospital disciplines treat each other with respect. Among the other standards for magnet designation are:

  • quality nursing leaders who are strong advocates for their staff;
  • professional models of care in which nurses have responsibilities, accountability, and authority in providing patient care;
  • a strong organizational structure that includes nurses in decision making;
  • quality improvement initiatives that involve nurses;
  • professional development opportunities including inservice education, continuing education, and career development;
  • personnel policies that offer competitive salaries and benefits, creative and flexible staffing, and opportunities for promotions.