A Model of Care for Today and Tomorrow

Healthcare has seen significant change in recent years. The ways clinicians care for patients is different, patient and caregiver expectations are higher and staffing shortages and turnover are more prevalent. For many organizations, nursing models of care, which define how nurses and support staff deliver care, no longer align with the current environment.

“The world has changed around us and the way that healthcare is practiced has changed,” said Karen Kuehn, MSN, RN, NEA-BC, director of nursing for emergency and surgical services at Cleveland Clinic Avon Hospital. “To surmount the challenges and adapt to the changes, organizations need updated models of care.”

At the direction of Executive Chief Nursing Officer (ECNO) Meredith Foxx, MSN, MBA, APRN, NEA-BC, Kuehn and 20 of her colleagues spent nearly one year exploring a potential model of care redesign for acute inpatient care at Cleveland Clinic. They were fellows in Cleveland Clinic’s 2021 Executive Nurse Fellowship and their culminating project was to evaluate the health system’s current model of care and provide recommendations for a new one.

From October 2021 to September 2022, the fellows partnered with Cleveland Clinic’s continuous improvement (CI), nursing informatics, nursing executive teams and others to complete the project. They followed a detailed timeline inclusive of CI training and exercises, literature review, data collection and analysis, new model development, transition planning and more. They presented their work at the annual Nursing Leadership Summit, which is attended by all Cleveland Clinic nurse leaders — from assistant nurse managers to the ECNO.

A new model for a new world

When the fellows began the project, they found that other hospitals and health systems were facing similar obstacles and challenges.

“We spent a lot of time looking at how other hospitals were determining how to best care for patients and support nurses with a dwindling workforce,” said fellow Samantha Connelly, MSN, RN NE-BC, Cleveland Clinic’s director of caregiver well-being.

Before the pandemic, Cleveland Clinic’s model of care, known as Colleagues in Care, was fundamentally influential in transforming and transitioning inpatient care delivery practices from primary nursing to relationship-based care. Aligning with the organization’s professional practice model (PPM), it empowered nurses to collaborate with an interdisciplinary team and facilitate patient care delivery processes that promoted best practices and optimal outcomes. But as the pandemic unfolded, it became clear that the model wasn’t meeting daily patient care needs.

“The nurses who designed and implemented the Colleagues in Care model were clearly dedicated to professional nursing practice, patient care and optimal outcomes,” Kuehn said. “For more than a decade, it was a highly successful model. However, despite its historical efficacy, challenges and barriers such as nursing shortages, increased turnover and an ever-changing healthcare landscape required model evaluation and change.”

Taking a deep dive

For several months, the fellows conducted extensive research and gathered data. They utilized CI methodologies including A3, a Gemba walk and 5 Whys to produce a root cause analysis. According to Connelly, the current model, which was developed in 2010, was no longer universally sustainable across the enterprise.

It didn’t allow for staff flexibility, innovative role development or integration of resources or technology, and it lacked standardization. A gap analysis helped determine how to make the model more robust and address today’s dynamic healthcare needs.

“Role definition, technology and standardization were the themes that emerged as necessary to close the gaps, so our recommendations revolved around those,” Connelly said.

Recommendations either enhanced current model components or added new components to the model. The fellows’ primary recommendations, in operational order, were:

1. Review all unit tasks to better identify those for nurses versus support staff.
2. Develop innovative roles and job descriptions and assign tasks based on skill and certification.
3. Determine the best use of technology for all units.
4. Standardize technology across the health system.
5. Review existing nursing policies and procedures and define best practices per the current state.

Secondarily, the fellows suggested creating new shift structures, re-evaluating documentation requirements, improving ease of floating for sites and departments, establishing enhanced accountability and more.

“Our team felt that an effective and sustainable nursing care model should continue to align with our PPM and organizational mission, vision, values, priorities and goals,” Kuehn added. “For ongoing success and longevity, it needs be flexible, innovative in role development, optimize technology and standardize best practices.”

The fellows’ work and recommendations currently sit with Cleveland Clinic’s executive nurse leaders who are further advancing the project.

“Our hope is that our work will improve turnover and caregiver and patient satisfaction,” Connelly added. “When we developed our recommendations those were the greatest areas of impact and aligned with Cleveland Clinic’s enterprise and nursing goals.”

The model framework has already influenced work that is being done by other internal groups, including a Caregiver Office workforce taskforce and Nursing Informatics electronic health record (EHR) excellence team that is exploring automation workstreams to alleviate technology challenges for nurses.

Revamped considerations

When revamping nursing models of care, the main objective is to determine the best way to continue providing safe, quality care, according to Kuehn and Connelly.

They first suggest ensuring an understanding of the current state and organizational short- and long-term goals. Align models with these priorities as well as the organization’s mission, vision and values. Consider current staffing models and capitalize on technology, standardization practices, flexibility and caregiver scope of practice so all caregivers practice to the top of their license.

“Think outside of the box,” Kuehn says. “Whether it’s technology or additional support, caregivers need to be satisfied, engaged and prepared with tools and resources to effectively perform in their roles. You want nurses to continue to practice nursing in ways that promote the essence and purpose of the profession.”

Listening to and engaging other caregivers is important. Seek interdisciplinary input from both clinical and operational employees and build collaborative relationships with them. Obtaining feedback from bedside staff members is imperative before making any changes.

“Even though we are talking about a nursing model of care, success depends on all caregivers,” Connelly says. “A team of teams approach is necessary. Nurses can do a lot, but we can’t do it alone. Think bigger, expand your lens, lean on each other, and share best practices so all caregivers deliver high quality, safe care.”

Kuehn agrees. “Involve applicable stakeholders in the process because knowing and understanding what caregivers and patients want or need is integral to continued success and sustainability,” she says. “Models that promote nursing partnership with the entire care delivery team are quality-driven, safe, accountable, innovative, efficient, adaptable and flexible.”

Healthcare will always be in a state of flux and nurses will always be at the vanguard of patient advocacy and care delivery. Continually assess and evaluate models of care for efficacy as healthcare changes and time ensues.