Glossary
EP - Exemplary Professional Practice

EP33: Describe and demonstrate the structure(s) and process(es) used by the organization to allocate and/or reallocate resources to monitor and improve the quality of nursing, and total patient care. The nurse has responsibility for ensuring the coordination of care among other disciplines and support staff.

Findings:

Missing:

  • Verifying evidence for the various structures and processes that were described
  • Narrative description and verifying evidence for how the nurse has responsibility for ensuring the coordination of care among other disciplines and support staff

Resolution:

  • Verifying evidence has been provided as a list linking to the original work at the end of this source
  • Information about coordination of care has been added

Coordination of Care

Our nurses at the bedside are responsible for the coordination of care among all members of the interdisciplinary team. Our organizational values incorporate the precepts of teamwork and communication which are essential for collaboration across the continuum of care. This foundation is supported by processes within the Patient Centered, Family Focused Care model.

One example of Coordination of Care is evident by the use of the Interdisciplinary Patient Plan of Care. This form is initiated upon admission of the patient and is based on identifying a list of problems for a particular patient. The nurse then recommends an individualized plan of care for the patient. The form is placed in the patient’s medical record and is continuously updated. The nurse initiates consults for dietary, rehabilitation and case management/social services if appropriate. The interdisciplinary team also accesses this plan of care and signs-off on it when they are consulted. This document is a “work-in-progress” and is updated on a daily basis.

Another example of coordination of care the unit based Troubleshooter form which is utilized as a shift-to-shift hand-off tool. This form identifies issues which occurred during the shift and actions which were taken. It also serves as a reminder of upcoming issues, for example “reserve beds” for Total Hip and Total Knee Replacements following surgery of two of their patients. This requires placing traction on the beds and moving them to the Operating Room prior to the patients moving to the Post Anesthesia Care Unit (PACU). This tool identifies issues and actions and is a collaboration of care between nursing personnel and Patient Care Technicians. (Appendix EP33-A, EP33-B and EP33-C )

Another method that our nurses utilize for care coordination includes the use of the Multidisciplinary Critical Care Daily Goal Checklist (Appendix EP33-D ). The goals identify all core measures and essential elements that the critical care team is focused on. Issues pertaining to blood stream infections (BSI), Ventilator Associated Pneumonia (VAP), deep vein thrombosis (DVT) prophylaxis, skin condition, nutrition and glucose control are some of the measures being addressed. The second page outlines the American Association of Critical Care Nurses (AACN) Synergy Model of Care which is currently being utilized in critical care. This form is on each critical care chart and is used by the nursing team during rounds. It insures that the coordination of care on the unit is consistent for all patients and it keeps the team focused on the Plan of Care.

Our Case Managers, who are nurse’s, are essential in the coordination of care of our patients. Please review Job Description in (Appendix EP33-E ). They are primary components with the integration of social services/case management functions into the patient care, discharge, and the home planning processes.

Our Case Managers apply critical thinking skills in order to manage a patient’s progression and insure the development of an efficient, cost effective plan of care. They collaborate closely with nurses, physicians, family members and Social Workers in order to address all aspects of a patients care and transition to either home or a long-term care facility. They provide ongoing communication to insurance companies to assure proper payment. All Case Managers review 100% of medical charts for appropriateness of admission and continued stay. These individuals function as liaisons interdepartmentally, and to external service organizations and healthcare facilities. The Case Managers mobilize resources in order to achieve the expected goal to assist in attaining the desired outcomes. Please review table below for listing:

Case Management Department list of Case Managers

Case Management Department list of Case Managers

They are liaisons interdepartmentally, and to external service organizations and healthcare facilities. These individuals mobilize resources in order to achieve the expected goal to assist in attaining the desired outcomes. Julie Llagas RN, BSN is one of our Case Managers who states that, “we start planning for the patients discharge as soon as he/she is admitted; we collaborate with Social Services to produce a positive placement outcome.” One patient that Ms. Llagas is working with at the moment has recently had surgery for a Coronary Artery Bypass Graft (CABG). She has reviewed the patient record and she also rounds with the interdisciplinary team on a daily basis. She has made a determination that this patient should be discharged to a sub-acute center based on the fact that his ambulation is not good and he is still reliant on oxygen. She has also worked with the family in order to determine what center they would like him admitted to, and she has obtained the approval from the insurance company.

Recently, Mary Beth Smith was involved in a case where a sixteen year old boy was riding a bike downhill and hit a parked car. He was thrown from his bike and landed on his head without a helmet. He was admitted to the Medical Center in the ICU following this tragic accident. He was deemed to have very low functionality. He remained intubated and unresponsive during his hospital stay. Ms. Smith engaged an interdisciplinary team which included: Occupational Therapy, Physical Therapy, Speech Therapy, and Social Work in order to address issues. She worked very closely with his family members who would not leave his side. The mom stayed day and night in a chair by her son’s side. Ms. Smith lobbied with the insurance company to allow this young man to receive placement in a children’s specialized hospital versus a Long Term Facility. Ms. Smith wanted to provide him with every opportunity to progress. The day before discharge, the insurance company approved of a transfer to a specialized children’s hospital for a 6-8 week period. This was a triumph for Ms. Smith.

  • Please review Appendix EP33-F for evidence of a budgetary addition of 1.50 FTEs for the new program RelayCare
  • Please review Appendix EP33-G for evidence of a log depicting nursing resources being shared between the NICU and the Newborn Nursery
  • Please review Appendix EP33-H for evidence of a report of a “huddle” between PACU nurses and the ED
  • Please review Appendix EP33-I for evidence of an invoice for the development of posters for the Expo
  • Please review Appendix EP33-J for evidence of a transfer of Elizabeth Vocaturo from 7E to Wound Care
  • Please review Appendix EP33-K for evidence of a transfer of Rachele Dalalian from L&D to Performance Improvement
  • Please review Appendix EP33-L for evidence of the daily bed huddle
  • Please review Appendix EP33-M and EP33- N for evidence of a transfer from The Emergency Department to Clinical Informatics