Skip Navigation
Service Delivery Innovation Profile

Standardized Nursing Terminology and Communication Protocols Lead to Increased Use of Patients' Plan of Care


Tab for The Profile
Comments
(0)
   

Snapshot

Summary

Development and use of standardized plans of care for patients, using the Hands-on Automated Nursing Data System, helps nurses monitor patient progress and facilitates communication during patient handoffs. The standardized plan of care method uses standardized nursing terminology and provides a standardized structure for documentation. An evaluation in four hospitals with diverse patient populations found that the use of Hands-on Automated Nursing Data System helped create and update standardized care plans and promoted standardized documentation.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data for eight units in four organizations on multiple process measures, including the use and updating of care plans and management of communication at handoff.
begin do

Developing Organizations

University of Illinois at Chicago, College of Nursing; University of Michigan, College of Nursing
end do

Use By Other Organizations

The "HANDS Method" has transitioned to a business entity and is available through HealthTeam IQ, LLC. Current users include nursing schools (University of Illinois Chicago, University of Michigan, and Western Michigan University). HealthTeam IQ is currently in negotiation with a number of potential clients from other types of health care organizations (e.g., organizations providing acute care, intensive care, ambulatory care, long-term care, and home care).

Date First Implemented

1997

Problem Addressed

Medical errors are a nationwide problem, costing an estimated $17 billion to $29 billion a year (including both the cost of inappropriate care and the actions taken to fix mistakes).1 One common cause of preventable errors is the lack of consistency in the type and quality of information that clinicians convey to one another.
  • Inconsistent communication and information transfer is a source of errors: Many of the errors that lead to the 57,000 avoidable deaths per year in the United States are due to poor communication.2
  • Lack of standard nursing terminology: Research has shown that there is a lack of interrater reliability when using nursing terminology,3 indicating that nurses often use a mix of terminology and their own words to describe the same event, creating an opportunity for potential miscommunications that could lead to medical errors or even patient harm.
  • Care plans required, yet rarely used: Care plans are required by The Joint Commission, which expects hospitals to develop these plans based on information obtained during patient assessments.4 The care plan outlines how the multidisciplinary team addresses the patient's needs and also includes patient goals and progress toward those goals. Although nurses serve as the care coordinators for patients during hospital stays and provide an estimated 80 percent of the care a patient receives, most hospitals do not have a standardized process for nurses to communicate the care plans with each other. Before implementation of Hands-on Automated Nursing Data System (HANDS) on several pilot units, nursing staff put paper-based care plans in the patient's chart at admission and updated as required (usually every 24 hours) but rarely used the plans again during the admission.5 The plan of care can be a very important tool for keeping the numerous members of a patient's health care team informed but provides little value if not kept current, accurate, readily accessible, and integrated into the workflow.

What They Did

Back to Top

Description of the Innovative Activity

Using HANDS, nurses were encouraged to create and update standardized plans of care, which were intended to improve the collection, documentation, and communication of information about a patient's health status and progress toward treatment goals. In addition, the increased use of care plans is expected to facilitate continuity of care and reduce medical errors. Key elements of the innovation include the following:
  • Creation of standardized plans of care: Care plans are designed to quickly highlight the information that will help nurses on the next shift know what needs to be done to achieve treatment goals during that shift. The system's standardized format allows nurses to provide shift-by-shift updates of each patient's clinical problems, outcomes, and the interventions provided. Nurses are required to enter an update for every patient at the time of handoff. Each care plan allows the nurse and other members of the health care team to view the following kinds of information at a glance:
    • The patient's story: The story includes a "big picture" synopsis of the patient's history, interventions, and the path to achieve desired outcomes.
    • Continuous updates: These updates help to ensure the accuracy of the care plan at every handoff. Updated information includes changes to outcomes, the resolution of problems, the development of new problems, and the recording and tallying of interventions. Each change is associated with the nurse who made the update.
  • Accessing the HANDS tool: Nurses can access the Web-based system through a secure, password-protected, encrypted link. Thus, the system is used wherever a computer is available, either at the bedside or the nursing station. HANDS is also an interoperable system that can link to the electronic medical record and the patient's chart.
  • Standardized nursing terminology: The HANDS care plan uses standardized terminology to reduce potential communication errors. Key elements of the communication process are standardized, as described below:
    • Terminology: HANDS uses the North American Nursing Diagnosis Association International (NANDAI) Classification to represent clinical diagnoses, Nursing Outcomes Classification (NOC) to represent expected outcomes and outcome progress, and Nursing Intervention Classification (NIC) to track the treatments provided. The system contains standardized terms and defining attributes for more than 160 clinical problems, 400 patient outcomes, and 600 possible interventions. To support nurses in learning and accurately using the NANDAI, NOC, and NIC terminology (which are collectively known as "N3" terminology), the HANDS system provides a search for the appropriate N3 term and/or a search function for the definition.

Context of the Innovation

In the 1990s, the HANDS project was developed at the University of Michigan as a strategy to standardize the terminology used in patient care planning. As the effort proceeded, the researchers discovered that standardization was also needed for nursing practices, such as documentation. The project moved to the University of Illinois at Chicago College of Nursing in 2005 to support the additional research and diffusion. By incorporating lessons learned from multiple pilot projects, HANDS has continued to refine the process of standardized nursing terminology and documentation. The most recent 3-year study was conducted in four different health care systems, including a university hospital, two large community hospitals, and a small community hospital. Among the four hospitals, the HANDS method was tested in eight different units of various sizes, staffing levels, and specialties, including medical, surgical, intensive care, and rehabilitation.

Did It Work?

Back to Top

Results

A 3-year study to evaluate HANDS in eight different units across four health systems (including tertiary medical centers and large and small community hospitals) was conducted between 2004 and 2007. In spite of the range of differences in unit and organization types, all eight study units implemented and used HANDS in the same way. Moreover, the nurses were uniformly satisfied with HANDS, indicating standardization of the care planning method across settings is possible. The standardized handoff, however, was not fully realized. Nurses indicated the desire to carry out the HANDS handoff but requested additional training and support for maintaining compliance by all. The HANDS handoff structure and training were modified to address the findings from the analysis of handoff observations and interview data. No data are yet available on the effects of increased plan of care use on patient outcomes.
  • Many more patients have care plans: The evaluation found that 90 percent of patients have a plan of care within the HANDS system, improved from a baseline 50 percent. Evidence suggests that nurses have accepted and routinely use the system to develop and update patient care plans.
  • Improved knowledge and documentation of care plans: Nurses demonstrated a significantly greater knowledge base of the N3 terminology. They reported that it was more useful than other programs previously available to assist with plan of care development, and nurses were more satisfied with the terminology used in the system.
  • Standardization of documentation across diverse settings: Nurses from very diverse units, organizations, and shifts were able to utilize the same plan of care method successfully. Nurses exhibited high rates of adherence to the standardized care plan submission process across all eight units for life of study (approximately 90 percent as compared with 50 percent average with nonstandardized process).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data for eight units in four organizations on multiple process measures, including the use and updating of care plans and management of communication at handoff.

How They Did It

Back to Top

Planning and Development Process

The planning and development process included the following:
  • Selecting units for pilot testing: Researchers chose units with low rates of nursing turnover and a stated willingness by unit leaders to participate in the study.
  • Garnering nurse manager support: Researchers approached nurse managers on participating units with a prototype to demonstrate how the system could be used to improve care. The nurse managers then selected staff members to view the software and help assess frontline staff interest.
  • Training: The initial training, conducted by researchers, focused on nurse managers and champions (who were selected by the managers) as advocates for the system. Once trained, these managers organized and led staff training, with a focus on learning the terminology and system application. The initial 40-hour program combines in-class training, independent study, and group work. Each nurse receives 8 hours of training, consisting of 3 hours of in-class sessions, 3 to 4 hours of online exercises, and a 1-hour competency assessment.
  • Development of data reporting functions: Data analyses and benchmarking functions at the individual, unit, institution, and multiinstitution levels were designed.

Resources Used and Skills Needed

  • Staffing: This innovation requires no additional staff because nurses use the system as a part of their regular duties.
  • Costs: The costs of implementing the HANDS program include a setup charge, fees for use of the embedded terminologies, and a yearly subscription fee for access to the Web-based software and database available through an application server provider. In addition, consultants are typically needed for implementation and ongoing support.
begin fsxml

Funding Sources

Agency for Healthcare Research and Quality
The system has been developed and refined over an approximately 10-year period through support from internal funds, foundation grants, and a 4-year grant from the Agency for Healthcare Research and Quality (Grant #1 R01 HS015054-01-AHRQ) to support the 3-year (2004 to 2007) multisite study.end fs

Tools and Other Resources

Information about the HealthTeam IQ, LLC is available at: http://healthteamiq.com/.

Keenan G, Aquilino M. Standardized nomenclature: keys to continuity of care, nursing accountability, and nursing effectiveness. Outcomes Manag Nurs Pract. 1998;2:82-6. [PubMed]

Keenan G, Stocker J, Geo-Thomas A, et al. The HANDS project: studying and refining the automated collection of a cross-setting clinical data set. Comput Inform Nurs. 2002;20(3):89-100. [PubMed]

Keenan G, Stocker J, Barkauskas V, et al. Toward collecting a standardized nursing data set across the continuum: case of adult care nurse practitioner settings. Outcomes Manage. 2003;7(3):113-20. [PubMed]

Keenan G, Barkauskas V, Johnson M, et al. Establishing the validity, reliability, and sensitivity of NOC in adult care nurse practitioner clinics. Outcomes Manage. 2003;7(2):74-83. [PubMed]

Keenan G, Falan S, Heath C, et al. Establishing competency in the use of NANDA, NOC, and NIC terminology. J Nurs Meas. 2003;11(2):1-16. [PubMed]

Keenan G, Stocker J, Barakauskas V, et al. Assessing the reliability, validity, and sensitivity of nursing outcomes classification in home care settings. J Nurs Meas. 2003;11(2):135-55. [PubMed]

Keenan G, Stocker J, Barkauskas V, et al. Toward integrating a common nursing data set in home care to facilitate monitoring outcomes across settings. J Nurs Meas. 2003;11(2):157-69. [PubMed]

Keenan G, Yakel E. Promoting safe nursing care by bringing visibility to the disciplinary aspects of interdisciplinary care. Peer reviewed paper/Proceeding presented at the American Medical Informatics Association (AMIA) Fall Conference, Washington, DC; 2005. Award Winner.

Keenan G, Tschannen D. How has our knowledge of nurse/physician collaboration grown? In: McCloskey JC, Grace HK, editors. Current issues in nursing, (7th ed). St. Louis: Mosby; 2006.

Schneider J, Barkauskas V, Keenan G. Evaluating home care nursing outcomes with OASIS and NOC. J Nurs Scholarsh. 2008;40(1):76-82. [PubMed]

Adoption Considerations

Back to Top

Getting Started with This Innovation

  • Recruit project champions: Recruit nurse managers and other leaders to serve as champions for the program. Although top-level leadership support is critical for widespread implementation, enlisting the support of nurse managers is also important to success.
  • Ensure appropriate training: Make sure that all nurses complete the training before using the system, so nurses understand how the care plans are developed and the use of N3 terminology.

Sustaining This Innovation

  • Ensure ongoing support: Provide ongoing leadership-level support for the program.
  • Encourage widespread use by nurses: Standardized terminology and documentation is most beneficial on a unit when used by everyone.
  • Involve frontline users of HANDS to solve problems/overcome challenges: This helps build staff commitment to the program.
  • Ensure ongoing champions: Internal staff champions are needed to sustain use of the system.

Use By Other Organizations

The "HANDS Method" has transitioned to a business entity and is available through HealthTeam IQ, LLC. Current users include nursing schools (University of Illinois Chicago, University of Michigan, and Western Michigan University). HealthTeam IQ is currently in negotiation with a number of potential clients from other types of health care organizations (e.g., organizations providing acute care, intensive care, ambulatory care, long-term care, and home care).

Additional Considerations

Standardizing verbal communication during patient care handoffs is more complex than the standardization of patient charting. The HANDS research team is investigating the ways that HANDS' standardized plans of care and use of N3 terminology can improve patient care handoffs.

More Information

Back to Top

Contact the Innovator

Gail Keenan, PhD, RN
University of Illinois-Chicago College of Nursing
845 S. Damen St.
Chicago, IL 60612
(312) 996-7970
E-mail: gmkeenan@uic.edu

Innovator Disclosures

Dr. Keenan has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Keenan GM, Yakel E, Marriott D. HANDS: a revitalized technology supported care planning method to improve nursing handoffs. Proceedings 9th International Conference on Nursing Informatics. Seoul, Korea; June 11-14, 2006.

Keenan G, Tschannen D, Wesley ML. Standardized nursing terminologies can transform practice. J Nurs Adm. 2008;38(3):103-6. [PubMed]

Keenan G, Yakel E, Tschannen D, et al. Documentation and the nurse care planning process. In: Hughes R, editor. Patient safety and quality: an evidence based handbook for nurses. AHRQ Publication No. 08-0043, Rockville, MD: Agency for Healthcare Research and Quality, 2008: Chapter 49. Available at: http://www.ahrq.gov/nurseshdbkch49.

Westra B, Delaney C, Konicek D, et al. Nursing standards to support the electronic health record. Nurs Outlook. 2008;56(5):258-66. [PubMed]

Anderson C, Keenan G, Jones J. Using bibliometrics to support your selection of a nursing terminology set (CE Offering). Computers, Informatics, Nursing (CIN). 2009;27(2):82-92.

Keenan G. AHRQ Final Report, HIT Support for Safe Nursing Care. 1 R01 HS015054-01- HHS PHS, 2009.

Leviss J, Gugerty B, Kaplan B, et al. Edited book: Hit or miss: lessons learned from health information technology implementations. Washington, DC: AHIMA and AMIA; 2009.

Footnotes

1 Institute of Medicine. To err is human: building a safer health system. 1999.
2 The Joint Commission. Patient hand offs: making the hospital to home care transition. Joint Commission Perspectives on Patient Safety. 2008;8(1):1-7.
3 Keenan G, Yakel E, Tschannen D, et al. Documentation and the nurse care planning process. In: Hughes R, editor. Patient safety and quality: an evidence based handbook for nurses. AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
4 Joint Commission on the Accreditation of Healthcare Organizations. 2003 Standards for Home Health, Personal Care and Supportive Services. Oakbrook Terrace, IL: Joint Commission Resources; 2003.
5 Keenan GM, Yakel E, Marriott D. HANDS: a revitalized technology supported care planning method to improve nursing handoffs. Proceedings 9th International Conference on Nursing Informatics. Seoul, Korea; June 11-14, 2006.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 22, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 01, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.