Tactics in Action:
Bringing High Reliability to the Bedside
by Lyn Ketelsen, RN, MBA, Studer Group coach and national speaker
Imagine a 400-bed hospital, Safe Hospital USA, with six different med-surg units, eight orthopedic/teleoncology/OB units, and several ICUs. The incidence of Stage 3 and Stage 4 pressure ulcers has nearly doubled from six to 12 per month over the most recent 12-month period, compromising both clinical quality for patients and families and hospital reimbursement (due to financial incentives on this process-of-care measure under value-based care). Despite several efforts, Safe Hospital has been unsuccessful in their efforts to reduce them.
Diagnosing the Challenge
When a quality impact team at Safe Hospital interviewed nurses as part of their root cause analysis diagnoses, they identified communication and a lack of consistent visual validation/assessment of their wounds as a central challenge. They recommended a more structured and routine method of sharing information to ensure these assessments were completed with every patient, every shift change.
While the organization had already implemented bedside report, everyone agreed that staff were still primarily exchanging most information outside the room and using the bedside for introductions. Because the team agreed that several components of the best practice had not been fully executed, they recommended a new commitment to executing bedside shift report correctly, with full and ongoing validation of the practice by nursing leaders.
Validating Best Practice
Once staff were re-engaged to focus on the enhancements to their report, leaders committed to direct observation and coaching them regularly to validate that the new process was being executed. Nurse leaders also rounded on patients to further assess staff compliance with execution and also harvest information about the value of the process for patients and their families. Nurse leaders asked questions, like “Mrs. Smith, this morning when the nurses changed shifts…Did they come into your room and include you in the report?” and “Can you tell me about the value you see in being included in the process?”
Nurse leaders also managed up the process of bedside report during their nurse leader rounds so the patients understood why, when, and how it would occur. As a result, patients felt good about inclusion in an important meeting about their care rather than unnecessarily interrupted.
Safe Hospital’s nurse leaders also used quantitative methods to validate execution. These included review of quality reports that document compliance of skin assessments and the monitoring of patient experience results (i.e., patient perception of care with respect to the HCAHPS question, “I always received help when I wanted it.”)
Getting Results
As the staff increased their focus on execution of bedside shift report and held themselves more accountable for best practice levels of skill and frequency, results improved. Within three months, they had experienced just three pressure ulcers in the entire organization and felt a renewed commitment to sustain this new level of performance.
4 Essential Tips: Maximize Bedside Shift Report |
1. Use the SBART (Situation—Background—Assessment—Recommendation—Thanks) framework for communication. It’s a concrete, easy-to-use tool to frame any conversation, set expectations, and relay important information to patients. Tip: Hardwire patient skin assessment and evidence of any pressure ulcers by including this in the Assessment portion of the SBART report tool and ensure it is specifically written as a mandatory component of the report.
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2. Use Report as Show n’ Tell. Bedside report is the best opportunity for the off-going nurse to show exactly what the status of the wound looks like and describe the improvement seen or the change noted so the oncoming nurse and patient understand. Example: “Mrs. Gonzales, as you know, we are working on getting your sore healed. I want to show Sarah how it’s doing, if you don’t mind.”
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3. Use the “teach-back” methodology and include the patient to ensure he or she fully understands the explanations given. Example: “Mrs. Gonzales, can you share with Sarah (the oncoming nurse) what we talked about regarding your wound care so she knows the plan for ensuring it continues to heal?”
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4. Validate for patients that expected care has occurred during bedside shift report. Example: “Mrs. Gonzales, as you know, we’ve been repositioning you every hour to two hours to be sure we give that wound the best chance to heal. Sarah, she’s most comfortable on her right side.”
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