Redefine care delivery and documentation

• Published in: Nursing management 2004-02, Vol.35 (2), p.34-38
• Main Authors: Huffman, Melinda H, Cowan, Jennie Anderton
• Format: Article
• Language: English
• Subjects: Accountability; Activities of daily living; Caregivers; Case studies; Clinical nursing; Clinical outcomes; Compliance; Data Collection - standards; Datasets; Design; Discharge planning; Documentation; Documentation - standards; Education; Evidence-Based Medicine - standards; Evidence-based nursing; Forms and Records Control; Hospitals; Humans; Length of stay; Models, Nursing; Nurses; Nursing; Nursing administration; Nursing Assessment - standards; Nursing care; Nursing Records - standards; Outcome Assessment (Health Care) - organization & administration; Patient Care Planning - standards; Patient Care Team - organization & administration; Patient Discharge - standards; Patient education; Patient satisfaction; Patients; Performance evaluation; Planning; Practice Guidelines as Topic; Quality Indicators, Health Care; Quality of service; Tennessee; Total Quality Management - organization & administration
• ISSN: 0744-6314; 1538-8670
• DOI: 10.1097/00006247-200402000-00011

Senior nurse managers at Southern Tennessee Medical Center were concerned about the state of their nursing departments. Some units lacked adequate care continuity, outcomes measurement, and clearly defined clinical standards. Determined to change these inadequacies, the facility's nurse leaders developed a new care delivery system that served as the basis for performance improvement, one that: 1. incorporated care standards into bedside clinical nursing documentation, 2. improved patient education efforts, 3. reflected the nursing process and emphasized nurses' accountability, 4. increased care continuity and staff communication, 5. offered meaningful outcomes measurement and met accreditation standards, and 6. prompted multidisciplinary referrals and drove performance evaluations. System implementation at the facility yielded immediate, observable results. During the initial several months, patient falls were reduced by 60%. Staff members implemented infection control precautions appropriately 95% of the time, without direction from the infection-control practitioner. Hospital-acquired constipation/impaction for patients over 65 years old fell from 25% to less than 3%.