Health Information Technology Support for Safe Nursing Care (Michigan)

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To enhance safety culture and reduce errors in hospital units, lessons from high-risk industries can increase effectiveness of health information technology (health IT)-supported nurse care-planning and record-keeping. This three-year project supported the care planning process by standardizing and structuring the activities surrounding it, and making it transferable between nurses on one unit, between units, and among health care settings.

The central hypothesis was that the reengineered health IT-supported care planning process leads to a safety culture through the development of greater "collective mind," "mindfulness," and "heedful interrelating" among nurses across time and settings by to facilitate information flow. This study addressed AHRQ Objective 5, relating to the creation and diffusion of knowledge regarding the value of HIT, and to the creation of new knowledge and evidence regarding the benefits of health IT in various health care settings.

The specific aims of this project were: 1) to demonstrate that health IT can be successfully implemented to support nurses in a dynamic care planning process encompassing both the planning and provision of care within units and across healthcare settings; and 2) to demonstrate that a health IT-supported care planning process leads to a stronger safety culture. A convenience sample of eight nursing units (four units in year one, four units in year two) in five health care organizations completed the care planning training and implemented the Hands-on Automated Nursing Data System (HANDS) care planning process under real-time conditions to test standardization and improvement in communication and enhancement of a safety culture. Data analysis and interpretation informed the long-range goal of a future real-time implementation in settings across the country, leading to interdisciplinary integration and informing execution of an Electronic Health Record (EHR).

Health Information Technology Support for Safe Nursing Care - 2008

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS04-012: Demonstrating the Value of Health Information Technology (THQIT)
  • Grant Number: 
    R01 HS 015054
  • Project Period: 
    09/04 – 08/08, Including No-cost Extension
  • AHRQ Funding Amount: 
  • PDF Version: 
    (PDF, 52.02 KB)

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Summary: In today’s health systems, a patient’s care can involve a large number of clinicians, due to both specialization and shift rotations, whose actions are interdependent. In health care organizations, the term “collective mind” refers to this concept. Ideally, members of a patient’s interdependent team, which may include numerous clinicians caring for patients in a hospital setting, will function as a team using a collective mind with respect to having a shared understanding of the patient’s care. The focus of this completed study was on enabling the collective mind, since it is a vital precursor to continuity, safety, and quality of care. Without a collective mind, the patient’s care team is not operating with reliable and valid information necessary to make optimal decisions about care.

The “HANDS” Plan of Care (POC) Method was previously developed and refined through 8 years of research that included a real-time pilot on one intensive care unit (ICU). The HANDS POC Method consists of an electronic application (standardized database and user interface), rules for data entry to create and update POCs in the electronic application (what, how, when), and a standardized handoff procedure. The user interface, database, and rules for use were carefully refined over the years through iterative research. The HANDS design reduces cognitive load by providing an external memory aid that facilitates quick understanding of large amounts of information. As part of HANDS, the nurse is taught and expected to mindfully create and update a patient’s plan and “heedfully interrelate” about it at every handoff.

The main research question for this study was: “Does the previously piloted HANDS intervention successfully represent the “collective mind” of a patient’s team in diverse settings across time?” This concept could not be captured by any single measure or even a single type of analysis; therefore, a variety of cross-sectional and repeated measures, both quantitative and qualitative, were used to assess goals of the system, including mindfulness; heedful interrelating; and a culture of safety, trust, and error reduction. The sample selected for this study consisted of eight diverse acute care units located in four organizations. Units were chosen to represent a wide range of: patient types, including medical-surgical, neurology, neurosurgery, thoracic surgery, progressive care, older adult/stroke, cardiac, and acute care elderly; organization types; geographic locations; unit physical setups, including large, small, ICU, step-down, and regular; cultures; nurse characteristics; and staffing patterns.

Specific Aims

  • Support nurse mindfulness in planning care. (Achieved)
  • Assist nurses during handoffs by emphasizing continuity of care. (Achieved)
  • Develop electronic documentation to accurately and consistently reflect the plan of care. (Achieved)

2008 Activities: Analyses of some data were still ongoing at the end of 2008, with dissemination efforts to follow.

Impact and Findings: Several components of the study used pre- and post-implementation comparisons, including workflow observation and a survey of the culture of safety, while other analytic tools were deployed after go-live, including error reporting and interviews. The project was able to implement and sustain the HANDS POC Method in all of the targeted clinical units for the duration of the study. Registered nurses (RNs) indicated that HANDS was significantly more useful than previous POC methods and were also significantly more familiar and satisfied with the standardized terminologies used within HANDS. Compliance rates for POC submission to the electronic application were extraordinarily impressive and ranged from 78 to 91 percent among the 8 study units, providing evidence of ongoing mindfulness. Additionally, patterns of changes made to the plans by the RNs also provided evidence of the sustained mindfulness in the process. However, compliance in the handoff protocol was less robust, suggesting that there remains more progress to be made. Although observations of handoff instructions demonstrated a body of common knowledge and terminology, many of the features of the software system were underutilized.

This study demonstrated that when the POC is not used as a major driver of team communication, it can become a secondary source that is not kept fully current and is thus a less-useful archive. In contrast, primary sources are kept fully current, reliable, and valid because they are seen as essential to care decisions. Developing the POC, and in particular the HANDS method, into a primary source of information is expected to improve its content and thus improve patient safety. The RNs in this study were fully supportive of using the related handoff protocol, but they indicated a need for better training and support to fulfill its potential. In conclusion, this study has helped make progress toward understanding what is needed to create a valid and reliable representation of the team’s collective mind, improving the culture of patient safety.

Selected Outputs

Anderson C, Keenan G, Jones J. Using bibliometrics to support your selection of a nursing terminology set. Computers Informatics Nursing 2009 Mar;27(2):82-90.

Keenan G, Tschannen D, Wesley M. Standardized nursing terminologies can transform practice. J Nurs Adm 2008 Mar;38(3):103-6.

Westra B, Delaney C, Konicek D, Keenan G. Nursing standards to support the electronic health record. Nurs Outlook 2008;56(5):258-66.

Keenan G, Yakel E, Tschannen D, et al. In: Hughes R, editor. Patient safety and quality: An evidence based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality, 2008. Chapter 49, Documentation and the nurse care planning process.

Keenan G, Yakel E, Marriott D. HANDS: A revitalized technology supported care planning method to improve nursing handoffs. Stud Health Technol Inform 2006;122:580-4.

Grantee’s Most Recent Self-Reported Quarterly Status: The grant term has ended with all major aims achieved.

Milestones: Progress is mostly on track.

Budget: On target.

HIT Support for Safe Nursing Care - Final Report

Keenan G. HIT Support for Safe Nursing Care - Final Report. (Prepared by University of Michigan at Ann Arbor under Grant No. R01 HS015054). Rockville, MD: Agency for Healthcare Research and Quality, 2008. (PDF, 147.61 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
This project does not have any related resource.
This project does not have any related survey.
This project does not have any related project spotlight.
This project does not have any related survey.

HANDS Care Plan Tool Seeks to Improve Nurse Communication at Handoff in AHRQ-Funded Study

Gail Keenan, Ph.D, R.N.The handoff is one of the most critical points in inpatient care: Think of it as a clinical brain dump. When a nurse ends her shift, she updates her replacements on the status of each of her patients' care and outcomes. Incoming staff use this information to devise care for their shift.

Sounds simple? It isn't.

Communication at handoff is far from standardized. In fact, extreme variation in the ways clinicians share information with each other causes an untold number of errors. What's supposed to be a concise briefing may turn into an information overload for incoming staff. However, what they really need are the highlights that will help them quickly understand what care is optimal to achieve desired outcomes over the next shift.

Now a project supported by the Agency for Healthcare Research and Quality (AHRQ) is testing whether a standardized, computerized tool can help nurses not only document patient care and outcomes better but also communicate more effectively and efficiently at handoff. To date, nurses participating in the project report that the new tool -- called HANDS -- has been a boon in terms of documenting patient care. The next step: using HANDS to guide communication at handoff.

"Every patient has a story," says principal investigator Gail Keenan, Ph.D., R.N., of the College of Nursing at the University of Illinois, Chicago. "As a health care provider, you need to be able to get that story quickly and understand it immediately."

"Nurses need to know the big picture rather than get lost in all the details," agrees Dana Tschannen, Ph.D., R.N., field site director for the project. "Used properly," she says, "HANDS should make nurses' jobs easier."

HANDS provides a standardized, electronic "short story" of each patient's care. Essentially, it's a shift-by-shift update of the patient's care plan. The HANDS report reviews the patient's clinical problems, the patient's outcomes, and the interventions provided to address the patient's problems. There are standardized terms in HANDS for more than 160 clinical problems, 400 patient outcomes, and 600 possible interventions.

The HANDS application is available through a secure web link that's password-protected and encrypted. Nurses can create patient plans from their local units and either view them on their computer screens or print them out for use at handoff.

Through the AHRQ grant, Keenan and her colleagues have been implementing the HANDS tool among eight units at four hospitals in Michigan. The researchers wanted to test the instrument in a variety of settings, so they included one university hospital and three community hospitals; the hospitals also vary in size. Participating units include medical, intensive care, surgical (cardiovascular and neurosurgical), and rehabilitation.

Half of the units began the implementation at start up; the other four joined a year later.

The initial goal, Keenan says, was to get nurses using the HANDS tool. To date, compliance is running at about 90 percent -- meaning that 90 percent of all care periods -- patient shifts -- have a HANDS-based care plan.

Feedback from nurses has been very positive, Keenan says. "They like it better than any care planning system they've ever had, and it's easy to use."

But there has been a significant glitch: The nurses aren't using the tool to guide discussions of patient care at handoff.

That's because handoffs are all managed differently, depending on the type of unit, the practice culture of the nursing team, staff experience, the time of day, and the patient involved.

It's not that difficult to standardize charting, Keenan says. But standardizing communication around patient care is an entirely different -- and much more complex -- matter.

"We didn't think that the communication part would be so difficult," says Tschannen. "We initially were very focused on the technology."

Yet she and Keenan are optimistic that HANDS can -- and will be -- accepted by nurses as both a documentation tool and a communication guide.

They're not alone. One of the participating study units isdownsizing; nurses in the new cardiovascular subunit wanted to bring HANDS with them. To that end, they've received training to use HANDS at handoff based on mock patient care scenarios. In these training scenarios, departing shift nurses brief their replacements by referring to the HANDS care plans.

"Once they've done the training, they tell me how much more smoothly it seems to flow and how much less time it takes," says Melissa Ackron, R.N., a quality improvement nurse at the new unit.

In the new unit, each patient room has a computer at the bedside. In this way, nurses can update their HANDS plans while they talk to patients and their family members. The nurses may ask them what their goals are for the day, learn whether they're aware of new medications that the patient may be taking, and gather other information that can be incorporated into the HANDS report. Ackron says that having this type of information can help prevent medical errors.

She notes that use of HANDS at handoff is a requirement in her unit -- one that will be monitored to ensure compliance. In Keenan's view, that's key. "A change like what we're asking for at handoff needs to be mandated or it won't get standardized," she says. "You have to get agreement across the organization."

Keenan's team is working with nurses in two other study units to train them to use the HANDS reports at handoff with mock scenarios. "It's a matter of working with the nurses and helping them move forward," Tschannen says. "The value is there."

Ultimately, Keenan and her core leadership team (co-PI Elizabeth Yakel, project director Mary Mandeville, and Tschannen) are working to make HANDS a vendor-neutral standard for interdisciplinary communication. As such, the HANDS application would connect with any electronic health record and be used to create and communicate the patient's "short story" across the full spectrumof care -- from acute care to home care to ambulatory care settings. Already, more than 200 hospitals across the country have expressed interest in making HANDS their care planning system, she says. Given that level of interest and the team's commitment to continuously improving HANDS, Keenan plans to take two immediate next steps:

  1. Complete development needed to make HANDS available commercially at a low cost and able to integrate easily with existing electronic health record systems.
  2. Attract additional funding to support continuous refinement and extension of HANDS' capabilities over time. 
This project does not have any related emerging lesson.