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Changing the Work Environment in ICUs to Achieve Patient-Focused Care^*

The Time Has Come

^* From the University of Pennsylvania School of Nursing and Hospital (Dr. McCauley), Philadelphia, PA; and the University of Massachusetts and UMass Memorial Medical Center (Dr. Irwin), Worcester, MA.

Correspondence to: Kathleen McCauley, RN, BC, PhD, University of Pennsylvania, School of Nursing and Hospital, 31 South Wyoming Ave, Ardmore, PA 19003-1230; e-mail: kmccaule{at}nursing.upenn.edu

Abstract

The American Association of Critical-Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments and the American College of Chest Physicians (ACCP) Patient-Focused Care Project are complementary initiatives that provide a road map for creating practice environments where interdisciplinary, patient-focused care can thrive. Healthy work environments are so influential that failure to address the issue would result in deleterious effects for every aspect of acute care and critical care practice. Skilled communication and true collaboration are crucial for transforming work environments. The ACCP project on patient-focused care was born out of a realization that medicine as currently practiced is too fragmented, too focused on turf battles that hinder communication, and too divorced from a real understanding of what patients expect and need from their health-care providers. Communication as well as continuity and concordance with the patients’ wishes are the foundational premises of care that is patient-focused and safe. Some individuals may achieve some level of genuine patient-focused care even when they practice in a toxic work environment because they are gifted communicators who embrace true collaboration. At best, those efforts will most likely be hit-or-miss, and such heroism will be impossible to sustain if the environment is not transformed into a model that reflects the standards and initiatives set out by the AACN and the ACCP. Other innovative models of care delivery remain unreported. The successes and failures of these models should be shared with the professional community.

Key Words: health administration • ICU • patients

The landmark Institute of Medicine (IOM) document To Err Is Human: Building a Safer Health System¹ transformed the way we think about patients’ safety. By making public the dangers that patients face when they enter the current health-care system, the IOM used its influence effectively to call for dramatic transformations in the way we evaluate errors and changed the focus of error prevention from individual punishment to one of system redesign. In Crossing the Quality Chasm: A New Health System for the Twenty-First Century,² the IOM then attacked the dysfunctional processes of our past and current health-care systems (eg, pervasive poor communication and noninterdisciplinary, often isolationist decision-making behavior). By focusing on effective team performance, data-driven analysis of system failures, and continuous process improvements to reduce risk, the IOM called for a revolution in the way we communicate with each other, anticipate and modify patients’ risk, and evaluate our effectiveness.

The leaders of the American Association of Critical-Care Nurses (AACN) and the American College of Chest Physicians (ACCP) have a long history of thoughtful dialogue about the important issues in critical care practice and have collaborated on key initiatives to enhance the practice knowledge of their members. Over the years, as their relationship has matured, the organizations have come to respect and value each other’s perspective, have benefited from the unique knowledge and worldview each brings to planning for the future, and have used this perspective to grow in ways that would not have been possible without this collaborative relationship.

As past presidents of the AACN (Dr. McCauley) and ACCP (Dr. Irwin), in this article we describe how the AACN Standards for Establishing and Sustaining Healthy Work Environments³ and the ACCP Patient-Focused Care Project⁴ demonstrate true collaboration and synergy of thought. Together, these complementary initiatives provide a road map for creating the kind of practice environment where interdisciplinary, patient-focused care, as called for by the IOM, can thrive.

Response to a Flawed Health System

The decision of the AACN to establish standards for healthy work environments grew from a strategic planning process in which the association identified the three most important issues facing its members and critical care nurses at large on which the voice and actions of the AACN would have the greatest effect. A healthy work environment was one of those issues and was judged to be so influential that the failure to address it would result in deleterious effects for every aspect of critical care practice. A task force and national review panel led by past AACN president Connie Barden developed the standards that were launched at a Washington, DC, press conference in January 2005. More than 30,000 copies of the standards were downloaded from the AACN Web site in the first month after their release; the number of copies downloaded now exceeds 120,000. These standards are guiding the transformation of the care environment in many institutions across the United States.

The standards have been presented in several AACN publications.³⁵ The six standards (addressing skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership) were derived from a strong base of research evidence. Each standard is considered essential, and the standards are designed to be used together, not as stand-alone organizational goals. The standards are forceful statements describing the actions that are required to transform the health of the work environment (Table 1 ).

1. Retention and, indirectly through improved public perception, recruitment of nurses at a time of pervasive and lingering nursing shortages;
   
2. Improved job satisfaction among all members of the health-care team; and, perhaps most importantly,
   
3. Improved outcomes for patients and patients’ families, particularly in the area of patient safety.
   

A growing body of research indicates a link between nurse staffing and patient outcomes⁶⁷; among staffing, nurse burnout, and job satisfaction⁷; and among work environments, nurses’ satisfaction, and nurses’ clinical performance.⁸ The competence of multidisciplinary providers in leadership, care coordination, and conflict resolution behaviors decreased mortality rates and improved other key physiologic risk variables among infants in neonatal ICUs.⁹ Nurse-physician collaboration, specifically, has resulted in improved outcomes for patients,¹⁰¹¹ including a reduction in mortality rates.¹²

Different Views of Collaboration

Evidence suggests, however, that nurses and physicians who work together differ in the way they view the quality of collaboration and communication in their workplace,¹³ with nurses tending to be much less pleased with the quality of collaboration than physicians are in the same setting.¹⁴ A disturbing finding from a 2004 survey¹⁴ of safety attitudes revealed that more than one third of nurses reported finding it difficult to speak up when they detected a problem with a patient. Pronovost and colleagues^{14(p 1028)} have called this "interdependence without integration," which is an apt phrase that describes the critical nature of nurse-physician work, a relationship that must be improved if both nurses and physicians are to be effective.

Perhaps these different views of collaboration are related to the quality of the interaction. True collaboration, as directed by the standards, builds over time, leading to joint decision making that embraces the worldview of each discipline. True collaboration is normal, respectful, and ongoing.³ With true collaboration, each professional is a full partner in the dialogue; loud voices or lofty titles will not dominate the discussion or the decision.

Lip-service collaboration, on the other hand, is halfhearted. When we say that we want to hear the perspectives of others, we must really listen, and our actions must reflect an expanded worldview. Yet, when the stakes are highest and the potential for disagreement is the greatest, we are at the greatest risk for lip-service collaboration.¹⁵

Therefore, we must agree on the best way to help an anxious or angry family support their critically ill loved one, and we must not respond by limiting their access to the patient. With true collaboration, physicians, nurses, and patients’ family members will figure out together the best ways to communicate, to gain the families’ insights into the patients’ needs, and to harness their healing energies.

True collaboration requires communicating effectively. In the book Crucial Conversations: Tools for Talking When Stakes Are High, a highly influential and practical guide to improving relationships and successfully handling difficult interactions, Patterson et al¹⁶ discuss the importance of colleagues agreeing on a mutual purpose in order to link seemingly disparate goals and strategies. A mutual purpose is one that is "more meaningful or more rewarding than the ones that divide the various sides."^{16(p 85–86)} In health care, the most effective mutual focus of purpose is the patient. Hence, we view the connection between care that is truly patient-focused and the creation of healthy work environments as critical to our effectiveness as health-care providers and to our success in transforming our practice environments.

Patient-Focused Care

The concept of patient-focused care was born out of a realization that medicine as currently practiced is too fragmented, too focused on turf battles that hinder communication, and too divorced from a real understanding of what patients expect and need from their health-care providers. The solution lies in viewing every encounter with a patient as an opportunity to deliver the care we would want for our own family members. How could we not want those we love to receive care from competent, well-educated practitioners who embrace evidence-based practice and lifelong learning? Would we not expect that our families be treated with respect, their unique needs identified and met, and their wishes honored at the end of life? Continuous quality improvement efforts would drive care processes, and we would do our best to accommodate patients and their families even when, because of their limited knowledge or broken systems, they contribute to the difficulties we face in doing our job well.⁴

As president of the ACCP from 2003 to 2004, one of us (R.S.I.) challenged the members who were attending the annual meeting to join a revolution in health care, a revolution that refocuses what we do on the patient.⁴ As an organization, the ACCP embraced patient-focused care by having members commit to the following pledge^{4(p 1912)}:

I will strive to provide patient-focused care wherever and whenever I have the privilege of caring for patients. I will also work to ensure that all health-care systems in which I provide care are patient-focused. Patient-focused care is compassionate, is sensitive to the everyday and special needs of patients and their families, and is based on the best available evidence. It is interdisciplinary, safe, and monitored. To ensure the provision of patient-focused care in my professional environments, I shall willingly embrace the concepts of lifelong learning and continuous quality improvement.

The ACCP visibly commemorated its commitment to a patient-focused care initiative in two ways. The organization mailed a "commit to patient-focused care" pin and a copy of the pledge to each ACCP member, urging the members to wear the pin when caring for patients, and to sign, frame, and visibly display the pledge in members’ offices. The ACCP also asked all new fellows of the group to recite the pledge during the convocation ceremony as the final step before induction as fellows. The favorable response provoked by this initiative throughout the United States and worldwide was striking. The concept of seeking to provide every patient with the same kind of care we would want for our family members universally resonated with ACCP members, no matter where the members lived.

Two Critical Standards

We embrace the adoption of all six AACN standards as crucial for transforming the work environment. Yet, two of the standards, skilled communication and true collaboration, seem particularly necessary to achieve the goal of patient-focused care, because communication as well as continuity and concordance with the patients’ wishes are foundational premises of patient-focused care.¹⁷

Some individuals may achieve some level of genuine patient-focused care even when they practice in a toxic work environment because they are gifted communicators who embrace true collaboration. However, we contend that, at best, their efforts will be hit-or-miss, and such heroic efforts will be impossible to sustain if the environment is not transformed into a model that reflects the AACN standards. The barriers to transforming a toxic environment are indeed massive, but if those barriers are not overcome, Pronovost et al’s¹⁴ notion of "interdependence without integration," will prevail.

Imagine, then, working in an environment where skilled communication and true collaboration form the foundation from which to promote patient-focused care. This would be an environment that embodies the following:

The current, common practice of totally separate medical and nursing schools would change. Physicians and nurses have selected classes and clinical experiences together as students so that each group enters practice with a respectful, accurate knowledge of the other’s clinical contribution.

Interdisciplinary patient care rounds are the norm, and each discipline’s contribution is considered so essential that decisions are not made without all care providers weighing in.

Each patient, when able, and the patient’s family are integral members of the decision-making team so that the patient’s values and wishes are key components of the planning process.

All team members feel comfortable and supported in challenging care processes when the processes are perceived to be inaccurate, not evidence-based, or inconsistent with professional values or the patient’s values.

All team members actively seek and engage in educational programs that improve their communication and collaboration skills. Colleagues support each other in skill development and hold each other accountable for correcting lapses in respectful communication and collaboration patterns.

Techniques such as the situation-background-assessment-recommendation (SBAR) model¹⁸ are widely used to increase the effectiveness of communication, especially in critical situations.

Structured forums such as ethics committees are used effectively to support clinicians in resolving disputes, to provide clinicians a broader view of the issues, and to ensure that patients’ values and wishes and, if appropriate, those of the patients’ family members are identified and incorporated.

A high level of personal integrity characterizes the behavior of all team members.

Concerns about competence or the collaborative behaviors of team members are dealt with directly and respectfully so that patients are not harmed and team members receive support to correct communication and practice deficits.

Interdisciplinary educational efforts are the norm for staff education in health care, with research findings from each discipline incorporated into the content of clinical education.

"What is best for the patient" is driven by the patient’s perspective and values, integrating the best practice knowledge of each discipline.

Evaluation of care processes includes the evaluation of the burden that ineffective care systems place on patients and patients’ families, with quality improvement efforts designed to monitor and repair these broken systems.

Ongoing efforts to enhance patients’ safety include monitoring communication and collaboration patterns, and explicitly linking process improvements in these areas with improved outcomes related to patients’ safety.

An organization’s success (or failure) to transform its work environment and achieve patient-focused care is systematically tracked and improved through a comprehensive outcome-monitoring program.

Professional associations and other influential groups with a stake in the process support their members’ efforts to transform the members’ practice environments via Web sites, publications, and other strategies that foster the exchange of best practices, tools for effective transformation, and recognition of centers of excellence (eg, the AACN Beacon Award for Critical Care Excellence).

National regulatory and accrediting organizations such as the Joint Commission on Accreditation of Healthcare Organizations incorporate quality-of-care metrics that support this transformation of culture.

Unit-Based Strategies for the Serious Organization

What interdisciplinary strategies could a critical care unit put into action to indicate its seriousness in implementing the AACN standards for healthy work environments³ with a strong focus on patients and patients’ families? Here are some suggestions for making skilled communication and true collaboration the norm:

Use techniques such as SBAR¹⁸ to guide interdisciplinary communication.

Assemble a small group of nurses, physicians, respiratory care practitioners, pharmacists, and other health-care providers to develop processes for organizing truly collaborative interdisciplinary rounds. Set a 6-month goal by which time no patient will be discussed on rounds without the contribution of the full team.

Plan educational programs about new and interesting care strategies that are taught jointly by representatives from at least two disciplines. Invite representatives from every discipline with a role in patients’ care, and students, not just medicine and nursing, to participate and contribute their perspectives.

Although acute care and critical care units are often considered the home base of nurses, ensure that other team members are considered and are not treated as visitors or interlopers. Invite team members from all disciplines to attend and contribute to unit-based social events, such as potluck meals, and be sure to invite everyone, not just the most collaborative members, who already know and appreciate the valuable input of others. Getting to know each other as people can set or reinforce the tone for true collaboration.

Invite the ethics committee chair to a unit staff meeting and discuss how the committee can offer guidance when tough disagreements happen. Do not focus solely on the familiar issues of discontinuing treatment and end-of-life care; also consider dilemmas such as providing quality care despite limited resources and verbal abuse, which carry equally serious ethical implications. Inviting the unit’s medical director and other team members to participate will create a climate of shared learning.

Develop a welcome-to-our-unit program so that all new caregivers including physicians, nurses, respiratory care practitioners, pharmacists, and others can learn how to contribute in a culture of true collaboration and patient-focused care. Ensure that the unit’s nurse manager and medical director speak with all new care providers about how true collaboration is the standard.

Review all unit-based programs for improving quality and patients’ safety to ensure that collaboration and the evaluation of effectiveness are integral to each program.

Develop a fix-the-ineffective-work-arounds task force to identify and fix as many broken systems as possible. Uncover the root causes of the broken system by inviting and actively listening to input from nurses, physicians, and all affected care providers. Work collaboratively, inviting hospital and nursing administrators to participate in abolishing systems that do not work and designing effective new ones.

Engage the executive leaders of the organization, including, as appropriate, the chief nursing officer, chief executive officer, and medical directors, in the challenge of transforming all systems for evaluating care providers to include the assessment of communication and collaboration skills. Be sure to reward successful skill acquisition in meaningful ways.

A Virtual Critical Care Department

The virtual department of critical care at UMass Memorial Medical Center in Worcester, MA, is an example of creating a better model for delivering critical care services across the 21st century health-care organization. In 2003, chief executive officer John O’Brien identified the need for a better model of delivering critical care. O’Brien charged a strategic planning committee with 21 interdisciplinary members with the daunting task of inventing the model and establishing guiding principles for implementation. After 13 months of deliberation, the committee presented its report to the chief executive officer and a leadership council that included the chairs of all clinical departments and the medical center president. With the unanimous support of the council, a new era of critical care began on September 1, 2004.

Critical care was defined as caring for critically ill patients regardless of the patients’ location in the system through a system-wide virtual department (Fig 1 ) that uses a collaborative, interdisciplinary, and patient-focused approach. All issues related to critical care are discussed by a critical care operations committee that meets every 2 weeks. The committee is composed of the entire critical care community; it is cochaired by a critical care physician specialist and the medical center director for critical care services. The recommendations of the committee are presented to the medical center president and leadership council, who look to the committee for decision-making guidance where critical care is involved.

View larger version (63K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Organizational chart of the "virtual" Department of Critical Care at UMass Memorial Medical Center. The Critical Care Operations Committee is composed of representatives of all groups with a stake in critical care; it is cochaired by a physician critical care specialist and the director of critical care services. Unit staff is composed of nursing and all clinical support services; eICU = a live, real-time telemedicine program; NICU = neonatal ICU; PICU = pediatric ICU; Neuro = neurologic; * = for critical care functions.

UMass Memorial Medical Center has been able to achieve impressive culture transformation and has begun to note measurable improvements in patients’ outcomes through this innovative reorganization of critical care delivery. The model works because it was intentionally designed to support the clinical, teaching, and research missions of the medical center. Through the model, clinicians, faculty members, and researchers collaborate to deliver accessible, excellent, patient-focused care, constantly evaluating and improving processes and services with the goal of achieving evidence-based practice and high levels of satisfaction among patients, patients’ families, and the health-care team.

Since September 2004, the following structural and process changes have been implemented at UMass Memorial Medical Center:

Nurse managers and medical directors of the ICUs are considered to be peers with equal accountability for clinical outcomes and the performance of the professional teams of each group.

A policy applied to the entire medical center requires that the care of every ICU patient be supervised by a critical care specialist.

The care of all critically ill patients will be managed around the clock by a critical care specialist whether on site or via telemedicine. Phasing in of electronic monitoring (eICU; VISICU, Inc; Baltimore, MD) began June 27, 2006; full implementation by February 2007 is anticipated.

Appropriately educated and certified acute care nurse practitioners and physician assistants have been recruited to join the clinical teams and work with intensivists, house staff, and nurses to ensure that standards are consistently applied to achieve expert and rapid responses to patients’ short-term needs. In order to facilitate the entry of these care providers into the system in the future, a close collaborative educational and research partnership has been established with the University of Massachusetts Graduate School of Nursing, and a nurse practitioner/physician assistant critical care mentorship program has been established.

The need for additional ICU and progressive care beds has been identified, and all disciplines are involved in planning for these expanded services.

All disciplines are involved in developing, implementing, and expanding an ever-growing list of clinical practice guidelines so that the care that critically ill patients receive becomes uniformly evidence-based. Frontline providers of patient care give their feedback about the implementation of clinical practice guidelines to the leaders of the critical care operations committee during weekly interdisciplinary bedside rounds. Electronic documentation will be used throughout all ICUs and in the electronic monitoring (eICU) to support and improve communication and adherence to clinical practice guidelines.

A tiered process for responding to the need for critical care beds has been developed and has greatly improved collaboration between the emergency and critical care departments, proactively managing patient throughput on the basis of the census and acuity levels of patients in all areas.

A scorecard for monitoring critical care data is used to track progress and to indicate needed improvements in case mix, outcomes, care processes, and staffing.

In designing a new and more effective structure, the UMass Memorial Medical Center team learned that it needed to communicate more effectively and in the process has strengthened its interdisciplinary relationships. Team members have more consistently come to understand and appreciate the perspective of others and, by constantly focusing on what is best for patients and patients’ families, are better able to resolve conflicts, solve problems, and refocus attention toward teamwork and quality evidence-based, patient-focused care. Only time will tell how successful the virtual department will be. However, it was clearly time for a change because the 20th-century model of delivering critical care has too many flaws, flaws that the IOM says portray all of medicine.

Essential Need for Innovative Care Models
We suspect that other innovative models remain unreported, and we urge readers to communicate their successes and, yes, failures to the professional community. We challenge readers to engage in this essential work of designing innovative care delivery. Consider what is required so that skilled communication, true collaboration, and patient-focused care can become the norm at your institution.

Which colleagues will be your immediate and eager allies in designing, implementing, and evaluating these changes? How will you ensure that all disciplines participate? What resources will be needed to support this transformation? How will the requisite energy and enthusiasm be sustained in order to persevere in such a strategically essential process? How will successes and failures be celebrated and learned from along the journey?

If the health-care system in which you work will not allow the delivery of critical care to be transformed into an efficient, patient-focused, healthy work environment, perhaps it is time for you and your colleagues to suggest to the chief executive officer and other clinical leaders that it might be time to undertake a strategic planning process with the goal of redesigning critical care.

Linking patient-focused care, as defined by the ACCP, with work environment transformation, based on the AACN healthy work environment standards, will strengthen process and outcome by identifying a mutual purpose that unites disciplines in a common effort built on shared values. This framework offers a road map to collaboratively achieve the vision of a health-care system driven by the needs of patients and their families in which each discipline makes its optimal contribution. Pronovost and his colleagues¹⁴ are correct. Our disciplines are interdependent and must be integrated. Only then will we be supported in making our optimal contribution.

Footnotes

Abbreviations: AACN = American Association of Critical-Care Nurses; ACCP = American College of Chest Physicians; IOM = Institute of Medicine; SBAR = situation-background-assessment-recommendation

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Received for publication July 25, 2006. Accepted for publication August 4, 2006.

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This Article Abstract Full Text (PDF) Free Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (4) Citing Articles via Google Scholar Google Scholar Articles by McCauley, K. Articles by Irwin, R. S. Search for Related Content PubMed PubMed Citation Articles by McCauley, K. Articles by Irwin, R. S. Related Content Commentaries