Partnering with patients and families to give them more input into care and learn from their insights
Oct 01, 2015, By: Shannon Parsons, RN, MSN, Cindy Elliott, RN, BSN, Betty Murray, RN
Nurses are partnering with patients and families at Vancouver’s Providence Health Care (PHC) through an initiative called Code Help. Code H, as we often refer to it, is a rapid response system activated by patients and families to connect them to one of our clinical resource nurses (CRNs) 24/7. Code H was initiated by nurses in PHC’s professional practice office as part of a patient- and family-centred strategic direction. The idea, arising from tacit understanding that there were missed opportunities for patient engagement in acute care, was inspired by the experiences of organizations that had implemented similar systems, including Virginia Mason and Cincinnati Children’s hospitals.
At any time during their hospital stay, patients and families can simply pick up the phone at the bedside and speak with a CRN, who is not attached to their care team, to raise concerns they have not been able to resolve with their own care providers. The CRN on Code H duty carries a dedicated cellphone for this purpose.
Code H was originally a pilot project on two medicine units at St. Paul’s Hospital in downtown Vancouver. The steering committee included an interdisciplinary leadership team of CRNs, nursing managers, managers from respiratory therapy and physicians. Also on the committee were two patient and family partners, who are PHC volunteers.
These two individuals worked directly alongside staff in the design, planning and implementation of Code H. Their contributions in helping identify patient and family needs for other members of the committee and in grounding the project were invaluable. For example, the committee’s clinicians assumed that families would use Code H when they noted a physical deterioration in the patient that was not being attended to. Our patient and family partners suggested instead that the calls would likely focus on communication and understanding the plan of care, and they turned out to be right. Their insights are an example of why PHC is dedicated to this level of partnership with patients and families. To date, there have been more than 200 patient and family partners involved in committee work at all levels of the organization.
Our consistent message about Code H has been that it is meant to supplement the care that is provided on acute inpatient units and act as a safety net for patients and families who feel the need to seek additional assistance. Initially, however, some managers and staff expressed concerns that Code H might undermine the work of the teams on the unit. Further, it was suggested that a flood of complaints related to food, housekeeping and staff would be the reality.
As well, because of uncertainty about the volume of calls, CRNs were apprehensive about possibly increasing their workload and about their ability to provide resolution to whatever issues might be brought forward. The steering committee recognized the importance of reassuring the CRNs that the expectation is not to solve issues but to listen, intervene as deemed necessary and be a catalyst in finding resolution by bringing in the appropriate staff members or physician.
Interest in and acceptance of the project grew, with recognition that it could be an enhancement to the existing care rather than a replacement for it. On the other hand, patients and families were excited about Code H from the outset. In fact, some have asked to be able to continue to use it after discharge home.
Since Code H went live in March 2013, 124 calls have been made. Seventy-five of the calls were initiated by patients; family members initiated the rest. While the number of calls has been relatively small, the most important benefit for these individuals is that they feel heard.
It is important to note that patients and families don’t necessarily get what they want when they call. For example, one young woman had repeatedly asked for a particular pain medication that was not available and was not going to be ordered. When she called Code H, she received support from the CRN and a commitment to follow up. The outcome for this patient was that the consulting teams and care providers put in place a consistent plan of care, which was clearly communicated to her.
Most of the Code H calls fall under one of four categories: communication, particularly regarding clarity on the plan of care; conflicts with team members; undermanaged pain; and uncertainty about aspects of discharge. In one instance, a son had not had the opportunity to meet with the care team to discuss his elderly father’s ongoing care needs and the reasons for readmission. He called Code H when he learned discharge was planned for the following day. After the CRN on call contacted the care team, a family meeting was arranged that brought new information to light, and additional discharge supports were put in place. We do receive complaints about the physical environment and housekeeping services as well as reports of subtle changes in the medical status of a loved one.
We gather qualitative and quantitative data on a regular basis to help us analyze the effectiveness of Code H. Content of the calls is confidentially documented by the CRNs. They also track the date, time, unit and amount of time spent on calls, as well as the name of the CRN who responds and any disciplines the CRN consults. On average, time spent on a call ranges from 60 to 75 minutes.
We distribute two surveys, one for patients and families and one for staff and physicians, with questions related to their level of awareness of Code H, perceived benefits and safety. Fifty-seven per cent of the health-care providers who completed the survey indicated that they see benefits to both themselves and the callers; 85 per cent of the patients and families who completed the survey indicated that they feel safer knowing that Code H exists. Staff have also reported that Code H assists them in gaining insight into the patient experience and that the outside perspective of the CRN helps build bridges between the patient and the care team.
After the first evaluation of the pilot, at six months, the decision was made to expand Code H as a permanent initiative on all five acute medicine units at St. Paul’s. Today, it is available on nine units in all.
Code H has been acknowledged as a leading practice by Accreditation Canada, and we are enthusiastic about sharing what we have learned. Internally, we support and encourage teams by speaking about the success of Code H as an example of patient- and family-centred care. In 2014, we presented Code H at the International Conference on Patient- and Family-Centered Care, in Vancouver. That same year, one of our patient and family partners travelled to Europe to present the project at a number of conferences. A Code H poster presentation was featured at the 2015 International Forum on Quality and Safety in Healthcare, held in Hong Kong.
Although most patients and family members may not need to call a Code H during a hospital stay, knowing that the option is there and that staff care so much about their needs provides a sense of comfort and security. We believe that finding ways to involve patients and families should become second nature in nursing research and practice initiatives. Code H is an example of how nurses can effect positive change through collaboration.
The authors thank Candy Garossino, director, Professional Practice & Nursing, Providence Health Care and Sara Charlton, practice consultant for the Care Experience Strategic Direction and lead for Code H.
Shannon Parsons, RN, MSN, is a clinical nurse leader on medicine and a former interim practice consultant for the Care Experience Strategic Direction, Providence Health Care, Vancouver.
Cindy Elliott, RN, BSN, is a practice consultant, Providence Health Care.
Betty Murray, RN, is a patient and family partner, Providence Health Care.