Clinical Workflow Observations to Identify Opportunities for Nurse, Physicians and Patients to Share a Patient-centered Plan of Care

Abstract

Patient- and Family-Centered Care (PFCC) is essential for high quality care in the critical and acute-specialty care hospital setting. Effective PFCC requires clinicians to form an integrated interprofessional team to collaboratively engage with the patient/family and contribute to a shared patient-centered plan of care. We conducted observations on a critical care and specialty unit to understand the plan of care activities and workflow documentation requirements for nurses and physicians to inform the development of a shared patient-centered plan of care to support patient engagement. We identified siloed plan of care documentation, with workflow opportunities to converge the nurses plan of care with the physician planned To-do lists and quality and safety checklists. Integration of nurses and physicians plan of care activities into a shared plan of care is a feasible and valuable step toward interprofessional teams that effectively engage patients in plan of care activities.

Introduction

Patient- and Family-Centered Care (PFCC) is associated with better clinical outcomes in the critical care setting, improved decision-making for patient-centered goals of care, increased family satisfaction, decreased length of stay, and increased care-giving ability by family members post-discharge.^1–5 Effective PFCC in the acute and critical care setting requires the coordinated assessment and active consideration of the psychosocial needs and preferences of patients and families by the interprofessional care team through continuous engagement and involvement in discussions and decision-making.^2,6 Critical care patients are often too ill to advocate for themselves, making engagement of patients’ families in decision-making discussions especially important; yet, few specific strategies to operationalize and sustain family-centered care in adult patients have been published.¹ We believe that a valuable and novel strategy is to provide hospitalized patients and families with a means of viewing their plan and providing feedback about their plan to providers in real-time.

Unfortunately, within the high technology and high acuity critical and specialty care environment, patient and family needs related to care planning and transitions of care, such as increased family care-giving or end-of-life decisions, are often overlooked.² Without appropriate support and information, family members experience undue burden associated with the increased anxiety, ineffective coping, spiritual distress, and impaired decision-making ability related to their family member’s critical illness and end of life care. Likewise, patients in acute and critical care, when well enough to engage, seek information about their care and care team.^7,8 Engagement of patients and families occurs through the process of shared decision-making, which is a method to support patients and families with healthcare provider expertise while incorporating patient’s preferences to reach patient-centered decisions for goals of care.⁹ A multidisciplinary effort in 2007, spearheaded by the American College of Critical Care Medicine (ACCM), developed the clinical practice guidelines for support of the family in the patient-centered intensive care unit.² This guideline, consistent with other literature, specifically recommends: shared decision-making, early and repeated discussions with the patient and family at the first sign of ineffective coping, improved consistency in communication from the interprofessional care team, and staff education for PFCC.^2,10–12 Nurses and physicians, as the clinicians that interact most frequently and consistently with critical care patients and their families, are in an ideal position to engage patient/family members in shared plan of care discussions. However, first, nurses and physicians must share their plans of care with each other to establish a common plan for effective exchange and engagement with patients and their families. Critical and specialty care (e.g., oncology) are a highly collaborative environments where clinicians seek out knowledge from other clinical professions and specialties, but there is a lack of tools for interprofessional exchange of plans of care. Failure for the care team to effectively communicate is associated with patient/family stress, nurse stress, patient safety errors, inefficiencies, and excessive lengths of stay.^1–5

Ensuring that family members receive consistent and timely information from clinicians on the interprofessional care team is one of the greatest evidence-based practice (EBP) gaps within the model of family-centered care.¹³ Poor team communication is associated with mismatched patient care goals.^14–16 For effective shared decision making conversations to occur between the patient/family dyad and the interprofessional care team, nurses and physicians must first establish common ground.² In prior work, we found that clinicians, including nurses and physicians, sought to understand care interventions delivered by other professions.¹⁷ Active alignment of profession-specific care priorities with patient-centered priorities is a critical part of integrated care and the degree of knowledge sharing between professions increases as care becomes more patient-centered.^18,19 Currently, as a healthcare system we do a poor job at asking patients to provide their feedback with regard to their plan of care, particularly their problems, preferences, goals, schedule, and evaluation of their status. There are few use cases and even fewer evaluation studies in the literature of patient-centered knowledge sharing tools among patients, nurses, and physicians.^20,21 Sustainable and feasible patient-centered team behavioral interventions remain a challenge, but recent work points to active knowledge sharing as a critical component in effective models of patient-centered care.^19,22 This study is part of a large multi-year and multi-aim project that will provide hospitalized patients and their families with an iPad-based patient-centered toolkit (PCTK) to engage with their health data and plan of care as well as access information resources and communicate with their care team. The development of an electronic patient-centered toolkit (PCTK) for sharing the plan of care presents a ripe opportunity to: 1) understand the processes and plan of care activities that exist for patients, nurses, and physicians in critical and specialty care, 2) define opportunities for patient-centered engagement and alignment of plan of care activities, 3) define requirements for patient-centered plans that seize opportunities for clinician and patient engagement and avoids increasing clinician documentation requirements by considering existing processes and activities, and 4) provide patients with a novel mechanism to communicate real-time feedback and participate in the development of their plan of care.

The aims of this study are to: 1) Describe current clinical plan of care activities and workflow,2) Identify opportunities to integrate the care teams’ plan of care activities and workflow for care team engagement with patients and families, and 3) define workflow requirements for a plan of care that is integrated across the care team and shared with patients. This shared patient centered plan of care was deployed on the study units in May 2014.

Methods

This study took place at a large academic medical center in the Northeastern United States. We conducted observations on a Medical Intensive Care Unit (MICU) and Oncology Acute Care Unit (Oncology Unit) to understand the distinct and shared workflows of nurses and physicians and opportunities to engage with patients in development of the shared patient centered plan of care. The focus of this study was on nurses’ and physicians’ engagement with plan of care activities for the purpose of sharing an integrated team-based plan of care with the patient and family, to form a patient-centered plan of care. The study was reviewed and approved by the Partners HealthCare Human Research Committee.

Seven observations were conducted, 4 observations on the MICU and 3 observations on the Oncology Unit. Observations lasted between 2 and 4 hours. Each observation was conducted by 2–5 study investigators consisting of 2 nurse researchers, 1 physician, and 3 research assistants. The participants observed included nurses, residents and physicians assistants (PAs), attending physicians, fellows, charge nurses, staff nurses, pharmacists, patients and families. PAs managed patients in the Oncology Unit, but not in the MICU.

Study investigators took field notes during the observations; field notes were specifically targeted at activities and communication related to plan of care. Observational findings were validated using member checks during individual and group semi-structured interviews with clinicians. These interviews were conducted with 1–7 clinicians. During the interviews, clinicians were presented with 1) observational findings describing the current clinical plan of care activities and workflow, 2) Visio diagrams to confirm opportunities to integrate PCTK into plan of care workflow for patient and clinician engagement, and 3) user interface prototypes (paper-based screen shot mock-ups) to confirm workflow and documentation requirements for a shared patient centered plan of care. After each observation and interview session, the investigators met for peer debriefings to review field notes, reflect on past observations, iteratively identify emergent themes, and collectively add to, form consensus on, and refine requirements.

RE-AIM Conceptual Framework

The RE-AIM (Reach Effectiveness, Adoption, Implementation, and Maintenance) framework was used to understand existing processes and workflow related to plan of care activities, identify opportunities for patient-centered engagement, and avoid potential unintended consequences and poor adoption.²³ RE-AIM was developed specifically to direct the design and conduct of rigorous studies of real world implementations of efficacious interventions to facilitate their translation of research into practice and has been specifically applied to informatics implementations.²³ We used the RE-AIM framework to formulate the following targeted questions to consider during our observations and interview data collection:

• Reach: What are the documentation and workflow opportunities for nurses and physicians on the MICU and Oncology Units to engage with patients in a shared patient-centered plan of care?

• Effectiveness: What are the required plan of care activities and documentation for nurses and physicians?

• Adoption: What are the current clinical workflow processes related to plan of care that nurses and physicians engage in and must be considered for user acceptance and workflow fit?

• Implementation: What are the technical requirements for integrating nurses and physicians plan of care activities?

• Maintenance: Is the intervention sustainable overtime? [Will be evaluated after ‘go-live’ implementation].

Results

Care Unit Process Categories for Plan of Care Activity Workflow and Opportunities for Engagement

We found that plan of care activities were distributed among a number of clinical care unit process categories. To facilitate identification of opportunities to engage nurses and physicians with patients in plan of care activities, we used the clinical care unit process categories that emerged from the data to categorize the observational data. We identified six high-level clinical care unit process categories: Intake/Admission, 24 hours post-admission, Daily Rounds, Family Meetings, Discharge, Handoff/End-of-Shift Documentation.

Patient admission to a critical or specialty care unit is a busy time during which a patient is stabilized (if needed), assessed, and evaluated to determine their immediate needs/goal of care and a plan that meets those needs. Interview data confirmed that the plan of care may not be established immediately when a patient is admitted to the unit, but is established within the first 24 hours of admission. The first 24 hours after a patient is admitted was a critical opportunity for holding an initial plan of care discussion with patients and family so that the patient’s goals of care could be established. The nurses interviewed conveyed that during an initial family meeting the patient and family are typically focused on critical medical issues, patient acuity, and seek information regarding the patient’s treatments and logistics of the hospital stay.

After the initial 24 hours, Daily Rounds was the critical process used to evaluate plan of care progression over the past 24 hours and to revise the plan for the next 24 hours. Rounds were typically held outside patients’ rooms and patients and families were not actively engaged in the rounds discussion on the two study units. Rather this time was afforded to the interprofessional care team to facilitate common ground and a shared understanding of the plan of care amongst the team members. Some clinicians noted that this workflow excludes the patient and family in a manner that was inconsistent with patient-centered care. Benefits cited by the clinicians of reserving a time for only clinicians to discuss the patient included the ability for the care team to efficiently and openly confirm, dispute, and ask questions about the patient’s condition, diagnoses, therapeutic options, and share individual insights and communications that each clinician may have had with the patient and family or other clinicians.

Daily rounds on the MICU and the Oncology Unit have overlapping and distinct characteristics. Rounds on both units follow a consistent structure, which validated our prior work.^15,16,24 We observed and confirmed in interviews that the objective of rounds was to establish and discuss medically focused problems and goals for the next 24 hours. The documentation output from rounds included progress notes and to-do lists which were distributed and documented individually among care team members. In the MICU, the nurse was responsible for summarizing the team goals that were established during rounds and documenting those daily goals on a sheet that was posted outside the patient’s door. Overall, the discussion was well-structured, but allowed for dynamic engagement of outstanding issues highlighted by any team member. During rounds, the team referred to checklists to ensure certain items were discussed, including the patient’s code status. However, discussions of other patient preferences beyond code status was rarely observed, but was validated as important when brought up by team members. When patient preferences were discussed, the attending physician and nurse were most frequently observed to initiate those discussions. In the MICU, there was a focus on daily checklists, sometimes referred to as “bundles,” to ensure the patient’s plan was aligned with known safety goals, evidence-based care, and quality metrics. Examples of the checklists (“bundles”) include: the Ventilator Management Bundle, Catheter-associated Urinary Tract Infection (CAUTI) bundle, and the Central Line Bundle. The Quality and Safety Checklists used at MICU rounds also related to: restraints, nutrition, blood glucose checking, implementation of early physical therapy, deep vein thrombosis prevention, gastrointestinal ulcer prevention, communication with family, and code status.

The MICU nurses’ summarization of the team goals was viewed as valuable for coordinated team-based care, yet the daily goals sheet that reflected this summarization was not part of the patient’s formal medical chart and was discarded every 24 hours. For this reason, we conclude that there was no formal and permanent documentation that served as a central source of decisions or plan for reference and evaluation over time. When interviewed about the possibility of making the daily goals sheet computer-based for sharing among the interprofessional team and patient during and after rounds the nurses disagreed with the proposed workflow. The nurses stated that they use this daily goals sheet to quickly document the high level outcomes of rounds and quickly note tasks and To-Do’s to complete that day. The nurses were not opposed to sharing the daily goals sheet with the team, as it was already available for others to view (posted outside the patient’s room). Rather, the nurses were hesitant to make it computer-based; they referred to it as their “scut” sheet and felt that they needed a piece of paper to quickly take notes about the team’s goals for the patient, tasks and To-Do’s to refer to throughout the day. The nurses stated that all of the information on this daily goals sheet is formally documented after rounds, typically by the night shift nurse, in the nurses’ plan of care. While the daily goals sheet is not recognized as a formal part of the patient’s chart, the nurses’ plan of care is a formal part of the patient’s chart and may be a useful mechanism of communicating information that is meaningful to other members of the care team and patient.

Rounds on the oncology unit differed from the MICU in several ways. Only one team rounded in the MICU and the nurse cared for one to two patients per shift, facilitating the nurse’s ability to participate as an integral part of the team during rounds. On the oncology units, several teams rounded simultaneously making it more difficult for the nurse to be present for each team’s rounds. As a result, the PA or intern conducted a pre-rounding check with the nurse to identify important information to be shared on rounds. The oncology unit did not share a common checklist or “bundles,” however, on the oncology unit many patients are admitted for specific treatment protocols that have a relatively well defined course, and our observations and interviews indicated that the team typically had a common understanding of the patient’s anticipated progression. Informal handwritten notes were taken by PAs and interns during rounds, which were then entered into the online patient record and printed to be physically stored in the patient chart after rounds.

Family meetings are formal meetings scheduled with the family to discuss the patient’s condition, reach common understanding about the goals of care, and agree on a plan. These meetings are held in the clinical unit’s conference room and at a minimum include the attending physician or fellow, a nurse, the patient or health care agent, and family. The meetings are typically highly emotional, particularly meetings that are held “as needed” due to a patient’s worsening condition. An attempt is made to hold a family meeting within the first 24 hours of admission and every couple of days after, although this is not always practical or achieved. Documentation of what was discussed is completed on a structured Patient/Family Communication Note that is part of the chart and may be completed by the social worker or attending physician. Our observations and interviews indicated that the Patient/Family Communication Note is often not completed and instead the attending physician may write a physician progress/daily note. A point of concern noted by a charge nurse is that these notes include variable and often insufficient levels of detail. For example, the charge nurse pointed out a family meeting note that stated: “DNR/DNI but will continue aggressive therapy” and explained that this plan is not clear because it does not specify which type of therapy, for what purpose, and the plan and schedule to reevaluate the patient. In addition to formal scheduled family meetings, informal meetings and updates are conducted with the family on a daily basis. These updates may be shorter, less formal discussions between the patient and/or family and the physician and/or nurse and they may occur over the phone, in the patient’s room, or in the hallway of the clinical unit. The oncology unit has no specified plan for family meetings, using them only on an ad hoc basis. The PA teams return to the units in the afternoon to follow up with patients and families regarding changes or progress in the plan of care. Additionally, as most acute care oncology patients are able to engage in their care, informal meetings with other providers (nurses, social workers, etc.) are regularly held at the bedside as needed.

During daily rounds, patients are deemed “cleared for discharge” if their condition permits. Patients on the MICU that are cleared for discharge typically wait about 6 to 24 hours for a bed to be available on step-down/acute care unit or a long term care facility. On the Oncology Unit a Patient Progression Model with Interprofessional Huddles was recently piloted due to delays in discharge and to facilitate team-based coordination and communication. The Patient Progression Model is a clinical process model that engages the team in actively and collaboratively identifying the expected date of discharge, location of discharge and any barriers to discharge, such as medications that need prior approval for oncology patients or physical therapy referrals. The hospital had determined that patient discharge was often delayed due to insufficient coordination of logistical reasons and dependencies, not medical reasons, and the Patient Progression Model is an organizational effort aimed at increasing the transparency of discharge dependencies through Interprofessional Huddles – frequent and short team-based discussions that may leverage a care coordinator and other members of the care team to coordinate and manage dependencies earlier during the patient’s hospital stay. The Patient Progression Model with Interprofessional Huddles are promising workflows to engage the care team in a shared patient-centered plan of care. Yet, at this time, as a newly implemented pilot program, our ability to conclude how these workflows will be adopted and can be leveraged is limited.

In both the MICU and Oncology units, nurses document a plan of care on paper at the end of each shift. This is a continuous plan of care for the patient’s stay on the unit as it is shared among each nurse caring for the patient and includes multiples shifts and days on the same paper. The nurses’ plan of care includes a nursing problem list, relevant assessment data, goals, and interventions. The residents in the MICU update the “To-Do” list on a whiteboard every day after rounds in physician break-room. In addition to the To-Do list, physicians complete a computer-based semi-structured medical problem list using an internally developed clinical information system. The medical problem list is refined during rounds and documented on each physician’s daily note and used to inform the To-Do List. The “To-Do” list is shared by all members of the medical team, and primarily edited by the residents. The To-Do list is focused on items such as medications or procedures to order, laboratory results to review, consults to request, and family meetings to schedule. In our data collection, we observed that handoff at the end of a shift was used to convey the plan, any issues that arose during the past shift related to the plan, and outstanding issues that still needed to be addressed in the plan. These updates are incorporated into the nursing plan of care documentation and the physician “To-Do” list documentation.

Requirements for Nurse, Physician, and Patient Engagement with a Shared Patient Centered Plan of Care

Our observational and interview data indicated two existing documentation workflows that are feasible for data capture into a shared patient centered plan of care: 1) Nursing Shared Plan of Care documentation and 2) Physician Shared “To-Do” Lists and Safety and Quality Checklists (see Table 1). Both of these documentation workflows were paper- or whiteboard-based. The documentation was already shared among each profession, which eased some anticipated sociotechnical barriers to the development of a shared Patient-Centered Plan of Care. For example, we did not need to introduce the need for nurses to negotiate who is responsible for documenting the nursing plan of care and when the nursing plan of care documented should be completed. Likewise, the residents’ and interns’ responsibility for the Shared “To-Do” Lists and Safety and Quality Checklists had also already been negotiated. Therefore, the development of a shared patient centered plan of care that pulled from the nursing plan of care and physician checklists and “To-Do” Lists was seen as feasible and useful to the clinicians.

Table 1.

Care Unit Process Categories and Associated Opportunities for Engagement

Care Unit Process Categories	Ripe Opportunities for Clinician-Patient/Family Engagement with Shared Patient Centered Plan of Care
Admission	Introduction of a shared patient-centered plan of care approach to patient/family
24hrs post admission	Teaching by nurse with patient/family related to initial plan, medications, and procedures Identification of ○ Problems, preferences, and goals by patient/family ○ Problems, goals, initial plan by care team
Daily Rounds	Data display to care team during rounds captured from patient ○ Patient identified problems, preferences, and goals ○ Home/out-patient medications/therapy regimen Data capture from care team during rounds to push to patient ○ Leverage existing workflow to summarize goals and plan at end of rounds ■ Output to Nursing Shared Plan of Care ■ Output to Physician Shared “To-do” Lists and Safety and Quality Checklists Promote discussion of ○ Patient preferences among care team ○ “Big picture” to consider if goals of care are aligned with patient condition and preferences ○ Shared plan of care with patient/family in follow-up discussion after rounds
Family Meetings	Formalize patient preferences and goals of care in context of treatment option Clarify patient preferences and patient/family degree of certainty in decision-making Confirm shared understanding of “big picture” of patient’s condition Align problems and specific plan with patient’s goals of care and preferences Seek patient/family decision logic and “if/then” plan (e.g., if patient does not respond to therapy after X time then re-examine goals of care) Provide families with shared plan of care and sufficient time to consider plan Communicate outcome of family meeting to care team that was not present
Discharge	Implement patient progression framework prior to day of discharge
Handoff	Communicate shared patient centered plan of care to next shift

In the MICU, the residents and interns required the ability to document their “To-Do” List and Safety and Quality Checklists during rounds. The “To-Do” Lists include frequently documented tasks, such as the need to communicate with the surgical team or hold a family meeting. These frequently documented “To-Dos” could be structured and made available for selection, with the ability to add more detail or more “To-Dos” in free-text. The Safety and Quality Checklists required the ability to check off items daily during rounds and when appropriate provide a rationale for why an item was not completed. An analysis was required for checklist items that also existed on the nursing Plan of Care to determine the “source of truth” and level of sharing between each computer-based checklist. A core requirement for the To-Do list and Safety and Quality Checklists was the ability for the resident/interns to select “To-Do” and Checklist items to “push” to patient for viewing and that were Infobutton enabled.

During observations, Oncology clinicians identified rounds as a source of information exchange inefficiency, partially due to the informal process with which they recorded tasks. Thus, although a formal checklist and “To-Do” List was not part of the existing Oncology workflow; providers were willing to pilot a computer-based checklist during rounds that is being developed by the study team.

It is important to note that the physician/PA documentation related to the plan of care includes documentation of the medical problem list as well as the To-Do and Checklists. Based on clinical and technical stakeholder engagement, it was determined that it is currently not feasible to structure the medical problems entered by the physician/PA into the interprofessional and shared patient-centered plan of care due to hospital-wide clinical care dependencies on the existing applications used for problem list documentation. Modifying those existing applications was out of scope of this study. Hence, Figure 1 describes our initial model for working toward patient-centered care planning and conveys the documentation workflows that are feasible for integration in their current state. The Plan of Care and Daily Goals Sheet are included under “RN” in the figure to denote those are conducted by the nurse. The To-Do’s and Checklists and Medical Problem List are included under the MD to indicate those are conducted by the Physician. While the Physician To-Do list is informed by the medical problem list and the Nurses Plan of Care is informed by the Daily Goals Sheet we acknowledge that the exclusion of the medical problem list and daily goals for feasibility reasons is not ideal. We envision an ideal future version of a shared patient-centered plan of care that fully integrates the medical problem list and daily goals documentation.

Figure 1.

Toward Patient-Centered Care Planning Through Integration of Siloed Plan of Care Documenation

The nurses required the ability to view the plan of care from previous days and carry-over the problem list from shift-to-shift and revise as needed. The nurses shared plan of care documentation included a problem list and a separate system-based structure for the nurse to identifying goals and interventions that addressed each body system. The problem list used nursing terminology consistent with the Clinical Care Classification system, which facilitated the development of structured problems for selection with the ability to include free-text problems. There were a lack of linkages between the problems and daily goals/interventions which posed a challenge to pushing information from the nursing plan of care to the patient. The nursing plan of care was restructured as a problem-based plan of care to facilitate alignment with the Patient-Centered Shared Plan of Care. Additional requirements included the ability to select the status of goals (Improved, Stabilized, or Deteriorated). Both the residents’ To-Do list and Checklists and the nurses’ Plan of Care required the ability to save new versions without overwriting old versions, compare past days to current day on the same screen, and print.

Our data indicated that a patient-facing care plan requires the ability for patients and families to identify problems, preferences for care, goals, and provide a summary of feedback about the status of care toward those goals. We coined the term for these requirements as the Patient’s “PRGS: Problems, Respect for Preferences, Goals, and Summary/Status”. As part of their plan, patients and family want to know the logistics for any planned procedures, such as the need to go to a different location in the hospital for a procedure, particularly in the context of coordinating family visits. This finding validated prior work that found patients wanted to view their daily schedule.⁷ Finally, to ensure continuity of their plan, including information about their home and out-patient medications was important to patients. Including their out-patient therapy regimen was particularly important for oncology patients.

We also focused on the role of the attending and fellow physician and the charge nurse in the MICU and Oncology Unit. These roles were observed to actively drive the plan of care forward by focusing care team discussions and activities on the “big picture” (what are the care goals and are they aligned with current interventions and the patients’ condition), long term goal clarification, care coordination, patient preferences, and the need for and outcomes of family meetings.

Discussion

This study confirms prior work that nurses and physicians document in silos (paper and electronic), despite engaging in shared and formal conversations at rounds.^15,16,25,26 While it is not possible to conclude that the clinicians interviewed are a representative sample, confirmation of findings with prior work lends confidence that the sample and data obtained are similar to other groups of clinicians in the acute and critical care setting. This study extends beyond describing the silos to a unique workflow analysis of how those silos can be integrated for shared planning. However, with critical clinician input we identified existing plan of care activity and workflow processes that provide feasible opportunities for nurses and physicians to contribute to a shared patient-centered plan of care without significant burden. In this study the distinct differences in documentation structure and concepts completed by nurses and physicians serve as a facilitator to integrate each professions’ plan of care documentation into a unified view. The nurses’ problem list and goal identification using standard nursing terminology is seen as a patient-friendly method of communicating important risks, clinical states, and conditions to the patient/family. The resident/PA “To-Do’s” provide a mechanism of communicating concrete daily action items. The safety and quality checklists could leverage Infobuttons to educate patients about safety and quality care activities that they should be aware of and could help monitor.²⁷

The option to develop a shared patient centered plan of care that pulled from the nursing plan of care and physician checklists and To-Do lists is seen as ideal because it does not require redundant documentation by the clinicians and fit with their current responsibilities for documenting plan of care activities. Converting the nursing shared Plan of Care documentation and physician shared “To-Do” Lists and Safety and Quality Checklists to a computer-based version was a requirement, but is endorsed by the clinicians and technically feasible. Converting the clinicians’ plan of care activities’ documentation to a computer-based format would provide an infrastructure to push structured and semi-structured plan of care concepts from the nurses’ and physicians’ documentation to the patient and receive structured and semi-structured plan of care documentation from the patient. Future work will focus on the feasibility of integrating the physicians’ medical problem list and the daily goals sheet used by individual nurses’ to take quick and informal notes of tasks and To-dos.

In our observations, patients and families were not actively engaged in rounds discussions. We also rarely observed the discussion of patient preferences (except for code status), confirming our team’s prior work demonstrating the low frequency in which patient preferences are discussed during cardiac critical care and acute care rounds.²⁴ These practices are opposed to the principals of patient-centered care. However, our interviews confirmed that clinicians aimed to provide patient-centered care, yet believed rounds should be reserved for the clinical care team to discuss the patient case without the patient and family present. This observation raises critical questions: Within a PFCC model and a care setting that requires collaborative and coordinated team-based care for critical care and specialty patients is there a need for clinicians to preserve formal time for discussion without the patient and family present? Does the acuity of the patient, level of uncertainly of diagnosis and prognosis, and role of teaching rounds influence the need for clinicians to preserve formal time for discussion without the patient and family present? PFCC supports the full inclusion of the patient and family. Further research is needed to understand the clinical process requirements for the interprofessional care team to achieve a shared understanding of the patient’s state, plan, and preference if the patient and family continue to be excluded from the rounds discussion. It should be evaluated if the clinical workflow process change to include the patient and family in all shared discussions prevents open and efficient communication and disclosure of clinical issues, questions, and clarifications among members of the clinical care team.

Importantly, the attending physician and charge nurse were observed to function in critical roles for engaging the care team and patient in the plan of care, though this may not be reflected in any documentation. The attending physician and charge nurse focused on the “big picture” by challenging the care team to clarify long-term goals of care and validate that those goals were aligned with current interventions, the patients’ condition, and patient preferences. Development of a shared patient centered plan of care based solely on the individuals that document plan of care activities will miss care team leaders that may serve as “silent” stewards of a patient-centered plan. It is critical that these roles are able to view and contribute to the shared Patient-Centered Plan of Care.

Limitations

This study is limited to two clinical settings, a MICU and an Oncology Unit in one tertiary care academic institution. Our findings require further validation to determine if they are generalizable to nursing and physician engagement with patients for shared patient-centered plans of care in other critical care and acute care environments. These two units were targeted due to some overlap in patient populations between the MICU and Oncology Unit, specifically for oncology patients that require critical care. This allowed for an analysis of two units with important differences but some known similarities to enable an analysis of standard versus distinct approaches to integrating plans of care based on unique workflows and needs of each unit. The clinical settings in this study did not have a fully integrated EHR. However, to our knowledge most EHRs currently do not have interprofessional plans of care that integrate nurses’ and physicians’ plans.Therefore, we see utility in our findings for care settings with and without fully integrated EHRs.Finally, our data is based on observations and interviews targeted at nurses, physicians, and patients and did not target all types of clinicians that are members of the care team. Certainly, other types of clinicians provide critical plan of care activities. Further studies should: 1) focus on the role of other members of the care team in planning care in the hospital setting, 2) evaluate opportunities for engagement with patients and families for patient-centered plans of care, and 3) assess the impact of a unified plan of care on the quality and efficiency of communication and ultimately on patient outcomes and quality of patient care.

Conclusion

We found that there are common Plan of Care concepts that should be shared among interprofessional care team members, but data entry requirements appear to require tailoring to fit with workflow, data reuse, and minimize duplication of current documentation. Plan of care activities are distributed among a variety of care processes and formal methods of clinical communication. This distributed nature of planning in the care setting and the distribution of plan of care identification among different members of the care team (professional and patient) require the ability to document plan of care components separately while preserving the ability to unify that data for an integrated shared patient centered plan of care.

Table 2.

Plan of Care Requirements based on Opportunities for Engagement and Current Documentation Artifacts

User	Residents/Physicians’ Assistant Shared Checklists and “To-Do” list	Nurses Shared Plan of Care	Patient/Family PRGS (Problems, Respect, Goals, Summary)
User specific Requirements	Documented during rounds Structured commonly used “To-Do’s” Ability to free-text To-Dos Structured checklists Ability to electronically check off “To-Do” list Ability to select To-Do’s and checklist items to “push” to patient Future state: integration of medical problem list	Problem based Structured problems Ability to free text problems Ability to select problems to “push” to patient Identification of problem-based goals and interventions and status selection for each Share common checklists with Residents/Physicians’ Assistant checklists Future state: integration of daily goals sheet	Data Entry of PRGS ○ Problems ○ Respect for Preferences ○ Goals ○ Summary and Status Schedule/planned procedures Home/out-patient medications/therapy regimen
Shared Requirements*	Ability to view and edit Shared Patient Centered Plan of Care Data pushed from ○ Nurses Shared Plan of Care ○ Residents/Physicians’ Assistant Shared Checklists and “To-Do” list Data pulled from Patient PRGS (Problems, Respect, Goals, Summary) Ability to print Ability to version Ability to compare days

^*Shared Requirements pertain to users outlined in table as well as additional care team members such as Attending Physician and Charge Nurse.