Taking A Person- Centered Journey Down A Clinical Pathway. Joan Devine,BSN,RN-BC

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1 Taking A Person- Centered Journey Down A Clinical Pathway Joan Devine,BSN,RN-BC

2 Objectives Describe the value of using standardized approaches to resident care Define how to develop practices based on standards of care and practice Understand how to start with the standard of care and incorporate person centered practices Learn from the programs and practices used by LSS Communities.

3 Icebreaker What practices do you have in your home that you always do the same way?

4 Why do you have Standards of Practice? The primary reason for having standards is to promote, guide, direct and regulate professional nursing practice. Standards set out the legal and professional basis for nursing practice: describing the desirable and achievable level of performance expected of registered nurses in their practice, against which actual performance can be measured. Standards also serve as a guide to the professional knowledge, skill, and judgment needed to practice nursing safely.

5 All standards of practice provide a guide to the knowledge, skills, judgment and attitudes that are needed to practice safely. The standards are based on the premise that the registered nurse is responsible for and accountable to the individual patient for the quality of nursing care he or she receives. SOC s provide a means of determining the quality of care which an individual receives regardless of whether intervention is provided solely by a registered nurse or by a registered nurse in conjunction with other licensed or unlicensed personnel.

6 Standards of Nursing Practice A set of guidelines for providing high-quality nursing care and criteria for evaluating care. Such guidelines help assure patients that they are receiving highquality care. The standards are important if a legal dispute arises over the quality of care provided a patient.

7 Principles Related to the Standards apply at all times to all registered nurses in RN practice roles, including nurse practitioners. provide guidance to assist registered nurses in decision-making and selfassessment as part of continuing competence. are the foundation for the development of standards specific to various contexts of practice. may be used in conjunction with other resources to guide nursing practice (e.g., agency mission statements, models of care delivery). may be used to develop position descriptions, and performance appraisal and quality improvement tools. support registered nurses by outlining practice expectations of the profession. inform the public and others about what they can expect from practicing registered nurses. are used as a legal reference for reasonable and prudent practice (e.g., professional conduct processes).

8 The standards of practice shall: Be considered as the baseline for quality nursing care Be developed in relation to the law governing nursing practice Apply to the registered nurse practicing in any setting Govern the practice of the licensee at all levels of practice

9 AALTCN The Long Term Care Nurse: possesses knowledge of the normal aging process and factors that promote a healthy aging. has a wide range of knowledge related to medical and psychiatric conditions, chronicity, and disability.

10 The Long Term Care Nurse: performs a comprehensive assessment that considers the physical, mental/cognitive, psychosocial, cultural, and spiritual aspects of the individual, to identify the resident s unique strengths, needs, and priorities.

11 The Long Term Care Nurse: develops an individualized plan of care for the resident based on assessment data and with the active participation of the resident, the resident s family, and other disciplines functions competently, using evidence-based practice, and assists and guides others in practicing competently.

12 The Long Term Care Nurse: demonstrates and promotes interdisciplinary collaboration. supports holistic, resident-directed care. effectively delegates responsibilities and supervises other nursing staff. fosters a caring culture that promotes a high quality of life for the resident and a high quality of work experience for staff.

13 The Long Term Care Nurse: supports palliative care for residents. assures residents rights are respected. assists residents in safely transitioning among various care settings. is knowledgeable of and complies with regulations governing the practice setting and its practitioners.

14 The Long Term Care Nurse: advocates for long term care residents and practitioners of long term care nursing. takes personal responsibility to maintain and improve competencies

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16 Best Practice A method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark.

17 A best practice is a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark. In addition, a "best" practice can evolve to become better as improvements are discovered. Best practice is considered by some as a business buzzword, used to describe the process of developing and following a standard way of doing things that multiple organizations can use.

18 Evidence Based Practice Applying the best available research results (evidence) when making decisions about health care. Health care professionals who perform evidence-based practice use research evidence along with clinical expertise and patient preferences.

19 Interact

20 Quality Improvement Communication Decision Support Advanced Care Planning

21 Quality Improvement Quality Improvement Tool for Review of Acute Care Transfers Hospitalization Tracking Tools

22 Communication Tools Stop & Watch SBAR Medication Reconciliation Worksheet Acute Care Transfer Checklist Nursing Home Transfer Form / Hospital Transfer Form

23 Decision Support Acute Change in Condition File Cards Care Paths

24 CARE PATH

25 Advanced Care Planning Advanced Care Planning Communication Guide Identifying Residents who may be appropriate for Hospice or Palliative/Comfort Care Comfort Care Order Set

26 Blueprint to a Successful Discharge

27 Charter Opportunity Statement Currently LSS does not have a clearly defined discharge planning process for REACH short stay guests. LSS Recognizes that having a well planned and coordinated discharge is essential to the quality of life for those we service.

28 Project Goals All REACH guests, regardless of where they live, will have a defined discharge plan that is developed with the guest, is individualized to his/her specific needs and is communicated to the guest and/or caregiver, physician and all defined stakeholders in the plan.

29 Project Scope Establish an interdisciplinary process for REACH short stay guests to ensure that within the last 72 hours of their stay, all necessary elements of a successful transition will be in place.

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33 Tools to support the process Discharge Planning Worksheet Guest Education Log Guest Discharge Information Sheet Medication List Discharge letter for PCP

34 Let s talk a little more about standard order sets protocals Why? How? When to use?

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36 AMDA Clinical Practice Guidelines Purpose: To develop and revise guidelines that focus on specific concerns and problems in the LTC setting Emphasize key care process and are organized for incorporation into facilityspecific P&P Appropriate to the population and the community

37 Consistent with fundamental goals of desirable LTC practice Address individual risk factors Adverse consequences of the diseases and conditions on the resident s functioning and quality of life

38 Resources at your fingertips! Interact AMDA National Association of Gerontological Nursing Alzheimer s Association NICHE AALTCN AANAC

39 QAPI Advancing Excellence QIOs Pioneer Network!

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41 Evolution of practice Standard for keeping elderly safe and free from falls Standard for assuring that resident s received adequate nutrition Standards for assuring that hygiene needs were met

42 Best Practices that have come out of the Culture Change Movement New Standards of Practice?

43 Health Promotion Highest Practicable Well-being Institutional Care Individualized Care Iatrogenesis Risk Prevention B&F Consulting 2006

44 Relational Coordination Organizational Practices Dedicated Staffing Huddles CNA in care planning QA Closest to the Resident

45 Pioneer Network to the rescue! Engaging Staff in Individualized Care Dining Practice Standards Promising Practices in Dining Just in Time Toolkits Tools for Change...

46 Reality Check But I don t want to do cookie cutter medicine

47 Mary had a little lamb, Its fleece was white as snow; And everywhere that Mary went, The lamb was sure to go. He followed her to school one day; That was against the rule; It made the children laugh and play; To see a lamb at school. And so the teacher turned it out, But still it lingered near, And waited patiently about Till Mary did appear. "Why does the lamb love Mary so?" The eager children cry; "Why, Mary loves the lamb, you know," The teacher did reply.

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53 Thank you Questions Wishing you much success on your journey!