Organization of Nursing and Health Care Delivery Systems

The hospital where I have dedicated my twelve year nursing career has gone through a massive change. When I started working there in 1999, it was a small, independent 168 bed community not-for-profit hospital. The expectations of healthcare today were and continue to be a costly venture to a non-corporate facility, which is why the hospital was struggling financially. It simply could not meet the needs of the growing community. As a result, it was purchased by a corporate healthcare entity based in North Carolina that owned several other hospitals. This merger brought about massive changes to the community hospital.

Their policies, practices, benefits and overall mission and vision have been redefined. The introduction of the newly adopted mission, “We exist to improve the health of communities, one person at a time” (Novant health, n. d. ) and, the vision, “We, the employees and our physician partners, will deliver the most remarkable patient experience, in every dimension, every time” (Novant health, n. d. ) were one of the first initiatives undertaken. In alignment with this new vision, the culture of the community hospital was going to have to change. In the Spring of 2010, “Bundle One” was first introduced.

They defined a bundle as a package of solutions with collective impact. (Novant health, n. d. ) The premise was that with each of these solutions working together they became more powerful and created something special for the patient. Included in this bundle were the following: First Do No Harm; Standards of Excellence; Bedside Reporting; and, Ask Me 3 Teach Back. Each of these initiatives had been tested across the other hospitals in the system, the healthcare industry and throughout the country. The focus of this paper will be on the part of the “bundle one” series called Ask Me 3 Teach Back (AM3).

AM3 is a discharge teaching process that takes into account the educational needs of the patient. In nursing school we are taught that patient education and teaching is a primary role of a nurse. However, we are also taught medical terminology, disease process and anatomy/physiology. We tend to take that knowledge for granted and forget that it is not always shared by our patients. As many as 27 million American adults, one in five, are likely to be unable to read basic discharge instructions (Remshardt, 2011).

The National Center for Educational Statistics estimates that approximately 40 million U. S. adults have literacy skills at the “lowest level. ” (Remshardt, 2011) The strong promotion of health literacy across the United States was the driving force behind this change in discharge teaching. The Healthy People (2011) project is a government program aimed at health promotion and disease prevention that has included improving health literacy as one of their objectives for 2020. Everyone in the U. S. is susceptible to low health literacy (reading, understanding and acting upon health information) regardless of age, race, education or income.

According to the U. S. Department of Health and Human Services, literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education level or racial/ethnic group. (Vernon, et al, 2007) The change was to adopt the practice of AM3 as the standardized discharge teaching process hospital-wide. The goal was to keep the patients in the center of care, support more effective communication and allow staff to develop authentic relationships with the patients. This was an integral part of the foundation being formed to achieve the organization’s new vision.

The Ask Me 3 Teach Back process was developed by The Partnership for Clear Health Communication as a solution to improve America’s silent crisis of low health literacy. (Vernon, et al, 2007) The program encourages patients to understand the answers to these 3 questions: 1. What is my main problem? 2. What do I need to do about it? 3. Why is it important for me to do this? Studies have shown that 40-80 percent of the medical information patients receive is forgotten immediately and nearly half of the information retained is incorrect. Novant health, n. d. ) The teach back portion is also called “show me”, or return demonstration, method because it is a way to confirm that providers have explained to the patient what they need to know in a manner the patient can understand. Patient understanding is confirmed when they explain it back to the provider. It gives a chance to re-teach the information if necessary. The teach back method is simply asking the patients to repeat and/or demonstrate what they have just learned, in their own words, from their medical encounter.

Using this process evaluates the patient’s understanding and comprehension of what has been shared and allows the educator the opportunity to validate comprehension of the message or the need for another approach to educating the patient. According to the National Patient Safety Foundation (2011), AM3 has been proven to: 1. Improve patient understanding of their diagnosis, treatment plan and importance of the treatment plan 2. Improve patient satisfaction scores 3. Improve clinical results evidenced by a reduction in readmissions 4. Instill patient/family empowerment.

This change in practice has affected the clinical staff, physicians and organization as a whole but I feel the greatest effect has been on the patients themselves. We as nurses have always been required to give our patients discharge instructions. We were trained in school that the process of education is part of our jobs as health care providers. This change was procedural for us but more importantly it became psychological as well. We are reminded that to be a good teacher you have to do more than just the basics, but to think outside the box.

By using this model, they are allowing us to tailor our teaching style to the patient’s individual needs. An intentional aside of this new process is that it is directly on course with our new vision. What one patient understands, the next may not. By utilizing the AM3 model for discharging, we are taking into account the individual’s comprehension of their diagnosis and medications, abilities to follow their plan of care (i. e. finances, transportation, etc) and answering any additional questions or concerns they may have.

All of these steps help create a team approach between the nurse and patient, promotes quality of care provided by the hospital and a reduction in costs to the patient. For the patient, it empowers them to be their own healthcare advocate. Successful organizational change according to Kotter (2008) is based on these eight strategies: 1. Creating a sense of urgency and the need for change 2. Organizing an effort to lead the change 3. Set the vision and identify tactics for the change 4. Communicate with everyone 5. Enable staff to take action for change . Celebrate short term wins 7. Keep the momentum for change going 8. Promote the new way as “habit” In the implementation of the AM3 process the organization has successfully utilized the first 6 of these strategies so far in this journey. The sense of urgency and the need for the change was communicated very clearly with all staff. Specifically highlighting the issue of low health literacy through videos, stories and written materials Paid educational classes were made mandatory and set the vision and outlined the tactics for the change.

The nursing leadership team was tasked with displaying their dedication, commitment and belief in the new mission and vision. They “walked the walk” allowing staff a window into the future. Once staff were brought into the picture they allowed opportunities for staff members to become champions of change along with leadership. They were tasked with doing some of the training for their colleagues, promoting the new process on the units and relaying “wins” back to their peers and the leadership team. This approach allowed for participation in all levels of the nursing department and promoted “buy in” of the staff.

A literature search reveals significant support for the AM3 implementation. I will address a couple of those search results. The IOM report: Crossing the Quality Chasm (2001) refers to six specific aims for improvement. One of those is related to providing patient centered care which is described as care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. The new discharge teaching plan of AM3 encompasses all of those criteria thereby supporting this organizational change.

Also a research study published in the American Journal of Health Behavior in 2007 titled Ask Me 3: Improving Communication in a Hispanic Outpatient Pediatric Practice found that the implementation of the Ask Me 3 program was successful in getting approximately 20% of parents to ask their physician specific questions about their child’s health. Parents found the physicians to be more responsive and they learned more about their child’s health. This study was conducted in pediatric walk-in clinics at the Children’s Health Center at Christus Santa Rosa Children’s Hospital in San Antonio, Texas. Mika, et al, 2007) However, in a study posted on the Annals of Family Medicine Website in March/April 2010 the AM3 interventions did not prove significantly effective. (Galliber, et al, 2010)

The purpose of this study was to evaluate whether implementing AM3 improves patients’ question-asking behavior and increases adherence to prescription medications and lifestyle recommendations. (Galliber, et al, 2010) The conclusion was that the use of the AM3 process during primary care visits had no significant difference between the AM3 group and control group in the rate of asking questions. Galliber, et al, 2010) There also were no differences in rates of either group filling or taking prescriptions or adhering to lifestyle changes. (Galliber, et al, 2010) Of interest in this study is that the rate of asking questions and prescription use was high in both groups leading to the conclusion that, “in a patient population in which asking questions and compliance was already at a high rate, there was no evidence that the AM3 intervention results in patient’s asking specific or more questions, or in better adherence to medications and lifestyle recommendations”.

Healthcare reform has a strong influence on the future of nursing. We need to retrain our thinking to be more cognitive of evidence based, quality care and the promotion of wellness. Providing discharge teaching in a way that is comprehended by our patients will show improvement in all of those areas. The issue of low health literacy has become an obstacle for nursing so it is important to begin now to teach future generations of nurses to be aware of this obstacle and communicate effectively both orally and in writing with patients.

Teaching students and practicing nurses how to utilize processes that address low health literacy in patients will not only benefit individual patients, but will also help reduce health disparities in the future. General Systems Theory refers to the fact that the system is greater than the sum of its parts. By bringing all the employees of the organizations together in a clear mission and vision, we are becoming stronger which is the basis of the General Systems Theory. The change made for the discharge teaching process has links to all of the elements of General Systems Theory.

The external environment of this change relates to healthcare reform and reimbursement. Medicare and Medicaid are looking closely at reimbursements. Quality of care has become a foundation for payment. To be financially stable, we must be providing quality care to our patients. The internal environment is affected by the external environmental initiatives as referenced above. Nursing has been faced with a lot of change during this transition. Since nursing leadership approached these changes in a positive manner and with strong support, it has in turn produced support from the staff nurses as well.

The primary input relates to the patients who are becoming educated by the healthcare movement to expect the quality of care. AM3 is a step closer to providing the type of care that our patients deserve. Throughputs include the integration of structure, people and tasks. Our mission statement is clear and the expectation has been set and by providing evidenced based discharge education to our patients, we are meeting the throughput element. The output reflects overall quality improvement and customer satisfaction.

My first recommendation for future organizational change really isn’t change at all but the continued support through the transition that has already been started. Continue to build on the new culture of quality, remarkable care. Leadership needs to hold staff accountable to the new culture the standards of excellence have started while still allowing for the neutral phase to play out. As Bridges (2009) explained, change is situational but transition is the psychological process that people go through as they internalize and come to terms with the details of the new situation that the change brings about.

Getting people through the transition is integral to the success of the change. The organization will need to continue to promote the environment until the new beginning is realized and the new purpose is upheld by all involved. The second recommendation I have is related to the use of electronic medical records. EMR has been a hot topic for many years and the need has been explored and confirmed over and over. Still we have yet to have it implemented. EMR would allow health care providers, especially in the emergency room setting, access to up-to-date health history and medications for our patients.

Even for the patient with high health literacy, when they arrive in the emergency department with an altered level of consciousness, we have no way of obtaining that information. An electronic medical record that is updated and accessible by all the providers of that patient, would provide the history, diagnoses and medications, so desperately needed to provide quality emergent care to that patient. The organizational change of implementing the AM3 teaching process relates to N688 by linking to several of the course objectives.

The new process identified a key factor in the education and discharge care provided to our patients that needed to be addressed and updated. The new process improved the overall quality of care provided by our facility. Healthcare reform has placed a large spotlight on quality of care as well as cost and access to care. The patient’s health literacy of their diagnosis, plan of care and medication regiment has shown to reduce readmission rates thereby reducing costs of healthcare to the patient and insurance companies.

These directly reflect course objectives two and five. This organizational change also links to George Mason’s mission statement because the new AM3 process of discharging patients came about through evidenced based research, the desire to improve the quality of care provided to the patients and promoting patient education so they better understand how to accomplish their own health goals. In turn, George Mason promotes its students to engage in similar behaviors related to research to improve health, quality of life and well-being of all people.

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