Critical Decisions in Measuring Care Coordination at the Microsystem Level

1. Critical Decisions in Measuring Care Coordination at the Microsystem Level Gerri Lamb, PhD, Madeline Schmitt, PhD, Paula Edwards, PhD, Francois Sainfort, PhD, Ingrid Duva, MS Emory University, Georgia Institute of Technology, University of Rochester June 9, 2008

2. Nurse Care Coordination • Our Goal: • To capture what nurses do when they coordinate care for patients in the hospital. • Offer nurses words to describe this work • Begin to show the relationship betweena core nursing process and quality and safety outcomes

3. Nurse Care Coordination • “You want to measure what!!!!????” • Care Coordination is: • very popular right now • viewed as important to quality and safety • defined in many different ways • applied ubiquitously to many phenomena • in health care, e.g. discharge planning, • hand-offs, team collaboration, ….

4. Nurse Care Coordination • For Nurses • Care Coordination is: • a core function with rich history • at a complex interface between independent and interdependent actions • “It’s the most important thing we do” • “We do it all the time”

5. Nurse Care Coordination • How do you catch • a cloud and pin it down? • How do you keep a wave • upon the sand? “Maria” from Sound of Music

6. Nurse Care Coordination • Major Decisions In Measuring Nurse Care Coordination in the Hospital • Unit of analysis • Qualitative Methods • Instrument Development – Moving from qualitative to quantitative methods

7. Nurse Care Coordination • Decision 1: Microsystem=Nursing Unit Unit and Organization Care Coordination Mechanisms Patient Outcomes LOS, Readmissions, Medication Errors Patient Experience Nurse Care Coordination Activities

8. Nurse Care Coordination • Decision 2: The Choice of Mixed Methods • Qualitative Quantitative Illumination Magnification Confirmation Improvement

9. Nurse Care Coordination • The role of magnification: • “All of O’Keefe’s flowers render the microcosm of the flower world as a macrocosm. She focuses us down to the level of the object to confront its rhythms and movement.” • Pyne, 2007

10. Nurse Care Coordination • Decision 3: Magnification via Triangulation Focus Groups – In concert with others Interviews – As thought about individually Observation – As Practiced

11. Nurse Care Coordination • Observation: Change in patient status, Mobilizing • Unit clerk tells RN she has a call. RN gets on the phone. After a brief conversation identifies the speaker as the patient’s physician. Tells the MD that the patient’s blood sugar is low. They talk about the patient’s blood sugar and medications for diabetes. RN gets off phone. She puts a verbal order in the computer and walks to the medication room. • Focus Groups: More time spent on change in patient status, mobilizing at night • RN 1: “Coordination is the most important thing of your day – whether it’s getting this procedure, getting this patient stable, getting them discharged…” • RN 2: “I think our coordination is different on my shift than dayshift. At night, we coordinate care but a lot of our care that we coordinate is emergent. Instead of a day or two to plan, you have to be on top of – ok, this guy isn’t looking good so I’m going to call…

12. Nurse Care Coordination • Decision 4: Focus on the “total” process of care coordination rather than the component parts • Versus Medication Administration Nurse Care Coordination Change in Patient Status Transitions & Handoffs

13. Nurse Care Coordination Nutrition Assisting Labs/Procedures Chg in Pt Status Medication Checking Interdependent Nursing Work Mobilizing Exchanging Information Transitions & Handoffs Organizing Shift Change Transfers Discharge Backfilling Admission NCC Processes NCC Activities

14. Nurse Care Coordination • Checking out our “story” with RNs • Does this capture what you do? • Does it feel right? • What are we missing? • “You got it!” • “Why not the ER, ICU, the clinics?”

15. Nurse Care Coordination • Decision 5: Response sets • Frequency: • How much time on a usual shift? • Choice 1: Never to always • Choice 2: > 30 min to >120 min • Choice 3: less than I should to more than I should • How important? • Choice 4: How much of a priority on a usual shift? • How effective? • Choice 5: How often does it result in intended outcome?

16. Nurse Care Coordination • Decision 6: Keeping process and care coordination activities balanced • When I notify a team member that a patient is not progressing as expected, I recommend actions that I think will get the patient back on track • Process: Change in Patient Status • Nurse Care Coordination Activity:Mobilizing

17. Nurse Care Coordination Nutrition Assisting Labs/Procedures Chg in Pt Status Medication Checking Interdependent Nursing Work Mobilizing Exchanging Information Transitions & Handoffs Organizing Shift Change Transfers Discharge Backfilling Admission NCC Processes NCC Activities

18. Nurse Care Coordination • Summary • Multi-method approach essential to capture abstract yet vital processes like care coordination • Complex decisions inevitable

19. Nurse Care Coordination • Significance • Nurse Care Coordination: to tell the story and find the words to improve practice and quality of patient care. • Our definition: • “Actions initiated by nurses with • patients, families, and other members • of their healthcare team to manage • and correct the sequence, timing, • and effectiveness of patient care • from hospital admission to • discharge”