THE CARE FILE - SYNTHESIS OF THE QUALITY AND SAFETY OF NURSING CARE - PowerPoint PPT Presentation

THE CARE FILE - SYNTHESIS OF THE QUALITY AND SAFETY OF NURSING CARE Assoc .Pr of .Ile ana ANT OHE , Cr istina CHIRIAC-RN, PhD MD, PhD He ad Nurse Popa’’ Ia ș i Univ ,,Gr T Clinic al E me rge nc y Hospital ,,Sf Spiridon’’ Ia ș i Clinic al E me rge nc y Hospital ,,Sf Spiridon’’ Ia ș i He a lth se r vic e s e va lua tor ANMCS

Or ganize d pr oc e ss Dynamic Applie d pr oc e ss – e ac h pr oc e ss ste p c an add thr ough the ne w patie nt nur sing plan data T he nur sing pr oc e ss Sc ie ntific me thod to Cyc lic – solve ac uat or inte r r e late d pote ntial ste ps patie nt’s pr oble ms Me thod of planning and pr omoting Individualise d inte r ve ntions

T HE CARE F IL E • CE NT RAL ISE D GE NE RAL DAT A- ADDMISSION PARAME T E RS 1 • INF ORME D CONSE NT 2 • INF ORMAT ION ON HOSPIT AL RUL E S 3 • T HE NURSING PL AN 4 • E VAL UAT ION OF F AL L RISK– DOWNT ON SCAL E 5 • E VAL UAT ION OF PRE SSURE UL CE RS RISK- NORT ON SCAL E 6 • DOCUME NT OF PAT IE NT ’S MOBIL L IT Y 7 • MONIT 8 ORING PE RIPHE RAL VE NOUS CAT HE T E R (PVC) • UNE 9 XPE CT E D PROBL E MS DURING HOSPIT AL ADDMIT T E NCE • SOCIALACT 10 IVIT IE S • HE AL T H PROMOT ION E DUCAT ION 11 • DOCUME NT ON DE L IVE RE D CARE AND RE COMME NDAT IONS ON DISCHARGE 12

T HE ST E PS OF T HE NURSING PROCE SS • PAT IE NT ’S E VAL UAT ION 1 T HE RE GIST E RE D NURSE • CARE PL ANNING 2 • DE L IVE RY OF T HE CARE PL AN 3 • E VAL UAT ION OF CARE RE SUL T S 4

E va lua tion F unda me nta l Nur sing pa tie nt’s diagnostic s ne e ds

NURSING DIAGNOSTICS o Actual diagnostics; o Possible diagnostics; o Increased risk diagnostics; o Wellbeing diagnostics Diagnostic labels –NANDA standardisation

Risks related to not using the care file ´ Disfunctional risk related to incorrect and real time evaluation of the patient ´ Disfunctional risk related to incorrect and real time evaluation of patient care ´ Risk of professional accidents related to biologic exposure ´ Pressure ulcers risk ´ Fall risk

INDICAT ORS OF E VAL UAT ION AND MONIT ORING OF E F F ICIE NCY OF CARE file Indic a tor s for e ffic ie nc y of c a r e file L imit/ a ddmite d inte r va l Min. 80% Nr. Hired nurses/ estimated nr. of needed nurses (according to nursing needs of the patients) Structure indicators Nr. Qualified nurses for a procedureii/Nr. Staff members that perform it Ratio = 1. Whole staff should have 8/10 in the Nr. Care plans/ Nr. Of verified care plans assessment of the procedure related to the use of care plan Nr. Of correct completed care plans/Total Nr. Of verified care plans Process indicators Nr of care plan with nursing objectives in agreement with therapeutic Ratiot = 1. conduct/Total Nr total verified care plans All patient files should have care plans Ratio = 1. All care plans should be complete Nr of patients and family’ complaints related to the received care /Total Nr. Of 0 inpatients Result indicators Nr. EAAAM reported/Nr. In patients/month 0 Nr of pressure ulcers developed during hospital stayTotal nr of inpatients 0

ANMCS ACRE DIT AT ION ST ANDARDS RE F E RE NCE 2 CL INICAL MANAGE ME NT ST ANDARD 0203 Me dic a l pr a c tic e a ddr e sse s holistic a nd spe c ific the pa tie nt e na be ling c ontinuity of c a r e M a n a g e m e n t u l CR020303 CR 020302 CR 020305 CR 020301 T HE HOSPIT AL CR 020304 CASE INT E GRAT E D ME DICAL DAT A ARE E NSURE S RE GIST E RE D MANAGE ME NT USE S CARE PL AN IS APPROACH T O CONT INUIT Y OF COMPL E T E L Y, DE DIAGNOST IC PART OF CASE CARE IS CARE AF T E R CORRE CT AND IN AND T HE RAPY MANAGE ME NT CURRE NT RE AL T IME WIT HOUT INIT IAL PROCE DURE S RE DUNDANCE PRACT ICE E VAL UAT ION

CARE PL AN IS PART OF CASE MANAGE ME NT Cr 02.03.04 Staff ensures complete and personalized care of the patient 02.03.04.01 C 02.03.04.02 C Nurses elaborate the care plan according to the medical problems 02.03.04.03 C The care plan is adapted in correlation to patient’s evolution 02.03.04.04 C On discharge the care plan is transmitted to the patient, the family, the GP or the physician who sent the patient for addmittence 2.03.04.05 C The necessary number of stff is established in accordence with the needs of the patients

T he r e que st of standar d 02 03 04 NURSING PL AN IS PART OF T HE CASE MANAGE ME NT Re sponsible attitude Staff c ompe te nc ie s Staff numbe r is ade quate to the of the staff towar ds ar e ac c or ding to the patie nts’ c ar e ne e ds the patie nt patie nt’s c ar e ne e ds

T he implementatio n o f the c o mplete and individualised c are plan o f the patient is ensured thro ugh T he de sign of the c ar e plan for the involve d spe c iality Nur se e duc ation towar ds the use and imple me ntation of the c ar e plan Ide ntific ation of me dic al r isks r e late d to the patie nt’s c ar e

Case management The concordance between physician recommendations and the care plan • Ve r ifie s the c onc or danc e in r e al time be twe e n me dic al pr e sc r iptions, T he atte nding hygie nic and die tar y physic ian r e c omme ndations and the c ar e plan • Pe r iodic ally analyse s the c onte nt of c ar e plans e labor ate d by nur se s and T he he ad nur se e nsur e s that e r r or s ar e not r e pe ate d

Adaptation of the care plan to the patient’s evolution Verifies in the care plan in real time that objectives are adapted to the patient’s evolution The physician Verifies the concordance of the recommendations with the administred medication

Case manage me nt Car e plan is announc e d to the patie nt and c ar e give r s fr om the pr imar y me dic al assistanc e at hospital disc har ge ´ T he atte nding physic ian: ´ Patie nt’s disc har ge doc ume nts c ontain the c ar e plan and e nsur e s the c ontinuity of c ar e ´ Patie nt’s disc har ge doc ume nts c ontain the c ar e plan and e nsur e s the c ontinuity of c ar e

The necesary staff is established in concordance with the care needs Adapts the staff number to the care needs Establishes the number of staff depending on the care needs and the patients’ degree of dependence T he he ad Ensures the staffing according to the nur se assessment of patients’ needs

Conclusions ´ Holistic approach to the patient by the multidisciplinary team and caring according to needs is the guaranty of the quality and safety of the care ´ In Western countries the case manager is the nurse ´ The case manager ensures the continuity of care after discharge from hospital, in the primary assistance