Clean up documentation with care plan education
Do your staff hate the agency's care plans? Do they fail to understand your care plans? Do they write too much, or make plans too complicated, or leave out important details? Regardless of the problem, you can improve care plan documentation by asking nurses to help improve the care plans. Travertine Health Services in Sulphur, OK, successfully took this approach.
"We asked everybody what they didn't like about the care plans," says Judy Hughes, RNC, BSN, an assistant director of nurses and inservice director of the free-standing, full-service agency that serves a mostly rural population in southeastern and south-central Oklahoma.
The agency's care plans mirrored the Medicare 485 forms. But nurses were writing too many problems and interventions on them, Hughes adds. "They weren't carrying out all of the interventions. When we had a state survey, the surveyor said it looked like we weren't following our own plan of care," she explains.
Group identified problems
Travertine managers met with the staff nurses and asked them to brainstorm about why the care plan wasn't working as well as it should. They asked nurses to identify what they didn't like about it and where it failed. "Everyone worked on it as a group, including LPNs, RNs, field staff, and management staff," she says.
First, the group identified problems then found solutions and revised care plan policies accordingly. The final step was to educate staff about how best to complete the care plans. Travertine staff spent four to five hours learning about care plans. Hughes describes the agency's educational focus as follows:
o Give background information.
"We educated our staff about what a care plan is and how all care-planning information has to be co-signed by an RN," Hughes says. "But we felt the LPNs were very capable of participating in the care planning process, although they're not quite as familiar with care plans as are RNs."
She presented some information about care plans from her own research. This included some packaged educational material, regulations of the Baltimore-based Health Care Financing Admin istration, the Medicare Conditions of Participa tion, and other literature.
o Assess care plan competency.
Hughes prepared a tool to assess staff's competency in the care-planning process. "I gave them an example of a patient, with some history on that patient. Then I assigned a couple of nurses to work together to design a care plan for that patient."
The nursing pairs also had to complete a 485 form. Then they had to make sure their care plan correlated with the Medicare 485 form. (See sample nursing worksheet, inserted in this issue.) "We wanted to make sure everyone understood the process and knew what we expected from that process," Hughes says.
o Give staff sample care plans.
Travertine's care planning service council created care plans for a variety of nursing diagnoses, including hypothyroidism, pituitary disorder, skin integrity, nutrition, infection, and alteration in self-care. (See Travertine's care plans, inserted in this issue.) The agency also has care plans for diabetes, anemia, cancer, and congestive heart failure.
"Our quality improvement person periodically conducts a little study to determine our top 10 diagnoses," Hughes says. The agency may add new care plans based on these diagnoses.
o Follow up with trial run and competency test.
"We wanted to make sure we'd get good feedback from employees that these care plans would work," Hughes says. The agency had a team of two RNs and one LPN try out the plans for about a month. "They came back and reported their findings, and we made final changes from their recommendations," she says. "Then everyone began to use this care-planning process."
Some weeks later, she held another education meeting and had the staff take a second competency exam. This time, the exam had 17 questions, including true and false and fill-in-the-blanks. The test results helped staff accept responsibility for their own care plan mistakes. For instance, nurses might say they didn't receive enough education about care plans to know when to update the plans, Hughes explains. "But when you show them the test results and show them that 100% of them knew when to update the care plan and how to do it, then they can't blame it on education because they knew how to do it."
o Make changes according to competency results.
"We found that we had some areas where we were very strong, and we had some areas where we were weak," she says. "By doing the competency test, it made it very clear: you don't have to guess where the weak and strong areas are."
Hughes continues to monitor the staff's progress in using care plans. For the first three months, the staff's care plans were studied on a monthly basis; now they're studied every three months. "We assess a group of patients and have certain questions we ask about the care planning process as we look at the charts."
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