Improving Teamwork, Morale and Outcomes with Plan-of-Care Visits

Asking questions, translating medical jargon and helping patients communicate their concerns are informal work responsibilities that most clinical nurses do every day. With the implementation of plan-of-care visits, conversations have become a formalized, integral part of hospital patient care at Cleveland Clinic.

Also known as collaborative medical rounds, plan-of-care visits are designed to ensure that a patient’s clinical nurse and primary physician or advanced care provider are actively engaged in medical rounds at the patient’s bedside. The approach, which relies heavily on the unique expertise of nurses, has been found to improve staff teamwork and patient satisfaction while reducing patient length of stay, readmissions and adverse events.

“These visits are intended to be three-way collaborations in which the patient, nurse and provider play critical roles in the decision-making process,” explains Shannon Kunberger, DNP, RN, NEA-BC, Chief Nursing Officer at Cleveland Clinic Euclid Hospital. “There is great value in the different perspectives each individual brings to the conversation, and these daily visits enable us to compile those ideas and convey a unified message to everyone involved.”

Empowering nurses

When developing a plan of care, nurses are encouraged to flag medical issues and report overnight concerns or changes in the patient’s condition. “Because we spend so much time with patients, we may be aware of subtle changes that other providers might overlook,” she says. “For example, the doctor might think a patient is ready to go home, but the nurse knows the patient still cannot ambulate independently. In a case like this, a plan-of-care visit would give the nurse an opportunity to suggest physical therapy. Multidisciplinary collaboration allows nurses to simultaneously advocate for both patients and providers.”

During these meetings, nurses are also called upon to report on medication use; the status of lines, drains or airways; nutritional concerns; and other clinical or safety issues. Stephanie Braun, BSN, RN, Assistant Nurse Manager at Euclid Hospital, has seen the benefits of plan-of-care visits firsthand. “Simply put, they work,” she says. “It’s an efficient team approach that allows us to care for the whole patient by ensuring that everybody’s on the same page.”

In a literature review of 25 studies with adult patients conducted by the Office of Patient Experience at Cleveland Clinic, researchers found that plan-of-care visits reduced hospital length of stay, readmission, mortality, adverse events and inpatient costs and enhanced the patient experience. Patients reported an increase in shared decision-making, staff teamwork and consistent communication by doctors and nurses. For nursing caregivers, plan-of-care visits appear to improve teamwork, interprofessional communication, and job satisfaction and to reduce inefficiencies (including calls to physicians) and burnout.

Importantly, Braun says that plan-of-care visits reinforce the role of nurses as valued members of the caregiving team and increase their confidence when sharing ideas or concerns that may be important to the case. She recalls one situation in which she spoke up during a plan-of-care visit about an issue that she believed the surgeon had overlooked. “We brought everyone together and changed our approach,” Braun explains. “As a direct result of that collaboration, the patient had a better outcome and was able to leave the hospital earlier than previously anticipated.”

Quick, scripted interactions

Plan-of-care visits are intended to be brief, focused daily meetings that last no more than 10 minutes. The process involves the following steps:

• Providers notify the health unit coordinator or clinical nurse when they are on their way and/or when they have arrived on the unit.

• Once in the patient’s room, the plan-of-care discussion begins.

• The provider opens the conversation, sets an agenda and asks questions regarding the patient’s perspective, status and concerns.

• The nursing team discusses their clinical observations, updates the patient and addresses any questions or concerns.

• The clinical team and patient develop a treatment plan together, including a tentative discharge date.

• The provider confirms that the patient understands and agrees to the proposed plan.

• The team documents in Epic that a plan-of-care visit occurred.

Another key component in these visits is the use of scripted language to ensure clear, effective communication that the patient will understand. Strategies to reduce confusion include eliminating medical jargon, using plain layperson terminology and encouraging all providers to use the same keywords and phrases consistently.

“All too often, patients express confusion about their condition or the care they’re receiving, but we’ve found that we can avoid a lot of uncertainty by standardizing the vocabulary we use,” says Kunberger. “Plan-of-care visits are excellent opportunities to recenter the care team. We can’t go wrong when we lead with empathy and put ourselves in patients’ shoes.”

Adapting to challenges

Kunberger explains that demanding workloads sometimes make it difficult for nurses and physicians to convene at the patient’s bedside, so different units developed systems for handling scheduling conflicts.

“We can’t let perfection get in the way of progress, so we’ve had to remain flexible and open to new approaches,” she says. “Plan-of-care visits for surgical patients are relatively straightforward, but things become more complicated when managing patients whose hospitalizations were unplanned. In these cases, we’ve had to get creative by relying on whiteboards and other tools, developing additional verbal scripts, and conducting more frequent visits. Even in the rare instance that a patient’s caregivers can’t be together in person, we’ve found communication strategies that can help us overcome physical distance.”

Despite the occasional challenge, Braun says plan-of-care visits are well worth the extra effort. “These interactions create an added layer of support for caregivers, patients and their families by enabling nurses to express and reiterate the goals of care throughout the course of their shift,” she adds.