Inpatient Psychiatry Embraces Team Care
Ask the Inpatient Psychiatry Unit leaders why patient and staff satisfaction scores are up and they'll point to Team Care. More specifically, they'll point to the way the unit's implementation of four Team Care measures - patient goals, purposeful rounding, interdisciplinary rounding and nurse knowledge exchange - improve quality by empowering both patients and staff.
Maureen Gardella, RN, MPA, unit nurse manager; Dan Bateman, MD, director of Inpatient Psychiatry; Lisa Chartier, chief mental health therapist, and Dana Alpert, RN, supervisor, realized that Team Care would look a bit different in their unit. "Our patients are generally up and around; we don't have many IV's and other devices to monitor. We looked at what the hospital was doing and thought about how we could add value with the four measures," says Gardella.
They didn't think about it alone. The entire staff has been involved in measure implementation and continual improvement. "We problem solve as a group," says Gardella. "Communication is open. People know that they can voice an opinion and disagree." Diane Andrews, who serves as project director for Team Care, provides welcome advice and coaching. "We tend to go big really fast, and Diane reminds us to use small tests of change," says Gardella. "Her patience and ability to understand and contain us is a big reason for our success."
Patient goals—the first of the four Team Care measures—was a natural for the unit. "Our focus is on empowering patients to meet the goals they set," says Chartier. "Patient goals are based on recognized levels of avoidance. For example, an anxious patient who hasn't been able to engage with people might set a goal to spend the whole day outside of her room. Goals help a patient take charge of their own treatment and move forward. They're a thread that we follow through the day."
Checking progress toward patient goals is an important part of purposeful rounding. "Our patients are up and around, and we don't have many drips and drains to monitor," says Chartier. Nurses typically personalize a rounding script that determines if and how goals are being addressed. Has the patient gone to a group session? Is she up and showered? It also includes a personal needs and safety check (For example, is the patient self-harming or having suicidal thoughts?).
Patient goals are also the foundation of interdisciplinary rounds, a process that includes residents, medical students, therapists, nurses, social workers and patient care managers and, most importantly, the patient. "We do interdisciplinary rounding really well," says Bateman. "We're known for it." Earning that reputation has taken time and real team commitment.
"With a large care team, it's a challenge to complete interdisciplinary rounds within reasonable time frames," says Bateman. "We've tried several small tests of change to create a process that allows everyone to weigh in while staying on schedule." The process also brings in information from consulting providers. "Secretaries and LNAs engage with consultants as they enter the unit," says Alpert. "They ask them who they're seeing and what they're doing. Notes in patient rooms remind consultants to update unit staff about a patient's condition or medication changes."
Shift changes trigger nurse knowledge exchange and another conversation about patient goals and progress. The in-coming and out-going nurses meet with one another and, if he or she is awake and wants to participate, the patient. "They have a safety check, an environment care check and talk about the past 8 hours and the next 8 hours," says Gardella. "Nurses document their exchange with a complete hand-off report."
While positive patient and staff surveys indicate that Team Care is working well in Inpatient Psychiatry, unit leaders are looking for deeper evidence of quality improvement. "The question is ‘How do we know patients are getting better?'" says Bateman. "Leigh Roche and other members of the D-H Quality, Safety and Value team have helped us significantly improve our scores on the Affordable Care Act quality measures for inpatient psychiatry. Now we are looking to take patient care to a higher level and measure how a patient manages his or her own mental health. For example, does he or she understand the medications, and know how to stay out of the hospital? Is he or she confident in their own ability to manage the condition?"
To not only sustain progress but achieve new measures of success, the leadership team will continue to follow the Team Care blueprint they've already established; consult with the Team Care advisors and problem solve as a unit. "We're really invested in making it work," says Gardella.