|The Accountability Based Practice Model|
ACCOUNTABILITY BASED PRACTICE MODEL
The Accountability‐Based Practice model articulates the process of nursing care at the Kennedy Health System. It facilitates the delivery of high quality patient care by enabling and empowering Registered Nurses to assume ultimate accountability for nursing care provided to patients and families. The Registered Nurse is responsible for assessing, planning, coordinating, and evaluating nursing care, and for addressing post‐hospitalization care needs through collaboration with patients, families, and other health care providers.
Components of the Accountability‐Based Practice Model
In many ways, continuity is the cornerstone of the model. Without continuity in the patient care assignment or follow through on patient needs, the nursing process and accountability for outcomes cannot be fully accomplished. Continuity is more easily described than defined. Continuity focuses on creating a patient care assignment in such a way that the patient is cared for by the fewest number of different staff members as possible through the hospitalization. Continuity involves consideration of the typical length of stay of the patients on a given unit and development of a staffing assignment that maximizes the opportunity for the same nurse to care for the same patient/s throughout their stay.
Continuity means making a commitment to the daily patient care assignment process that keeps a caregiver with the patient(s) they had the day before and will have tomorrow. As the cornerstone of the practice model, continuity ‘drives’ all other decisions related to care. Continuity means ensuring a smooth, seamless ‘hand off’ of care responsibilities for a patient from one person to another. This can be at the change of shift, transfer to another unit, or discharge to another facility or home. A critical element of this process is clear, accurate, and detailed communication – both verbal and written. In order for the nursing process to work, there must be a comprehensive knowledge of the patient’s needs, preferences, and goals based on the patient profile, assessment and plan of care.
The Nursing Process
The Accountability‐Based Practice Model incorporates an expanded version of the nursing process that includes assessing, planning, coordinating, providing, evaluating and communicating care. Within the framework of the accountability based practice model, each patient will be assigned to a Registered Nurse who has accountability for developing the plan of care and monitoring the patient’s progress towards goal attainment. All Registered Nurses who care for that patient share that responsibility by using the nursing process to make any necessary changes to the plan and to ensure that the changes are communicated. Registered nurses are accountable for coordinating the plan of care with Physicians and other members of the healthcare team.
The initial assessment of the patient forms the basis for the plan of care. It means completing the patient profile and review of each system. It means gathering an understanding of the patient’s likes and dislikes, habits and behaviors, cultural and religious preferences and desired outcomes of care. It involves an assessment of the family needs and consideration of discharge issues. In short, the initial assessment means gathering all the information required to develop a plan of care that will safely, smoothly, and competently shepherd the patient through the hospitalization, whether that results in a discharge to home, transfer to another facility or care provider, or in a dignified death.
From the assessment, a comprehensive, individualized plan of care is developed that clearly outlines the desired nursing outcomes. In many ways, developing a plan of care is the most difficult component of the nursing process because it requires critical thinking, experience and knowledge. As length of stay continues to decrease, available resources shrink, and patient acuity and complexity increase, developing a plan of care that can be realistically implemented and where goals are achieved is a challenge. For many patients, it will not be possible to meet all the care needs during the hospitalization. This does not mean the care needs should be ignored. Rather, it means prioritizing the goals of care according to those most critical to the continuum of care and to the patient. It also means tapping into resources both within and outside the hospital. Above all, the quality and success of the care plan will be correlated with how well it is communicated to other caregivers, the patient and the family.
Coordination of care is multi‐faceted and, as with continuity, more easily described than defined. It means orchestrating the members of the healthcare team in the care delivery process by ensuring communication and collaboration. It means organizing the scheduling of tests, procedures and therapies to the extent possible to facilitate rest and recuperation for the patient. Coordination of care involves ensuring that appropriate resources are made available to the patient such as Social Workers, Case Managers, Dieticians, and Home Care Providers and that pertinent patient information is shared with these team members. Coordination of care means that the patient and family needs are clearly communicated among Registered Nursing staff members , whether it be through delegation of patient care activities to the Certified Nursing Assistant (CNA), sign‐off to another Registered Nurse at the change of shift, or requests to the unit secretary to secure equipment or items needed by the patient.
Provision of care involves a clear understanding of the practice parameters for all roles involved in the care process. Within the Accountability‐Based Practice Model, the Registered Nurse has the responsibility and ownership for the assessment, planning, coordination, evaluation, and documentation of care and the care activities that require professional licensure. As such, the Accountability Based Practice model requires ongoing evaluation of roles and systems so Nursing Practice focuses on full implementation of the Nursing Process.
Evaluation of care simply stated, involves an appraisal of the effect of care interventions toward achieving stated goals. Implicit in the evaluation process is the assumption that, if the plan isn’t working, the necessary steps will be taken to revise and communicate the changes. Evaluation is a constant process and each activity should be assessed for its impact toward goals.
The communication of care is both a written and verbal process. How well the care needs of the patient are communicated often makes the difference between sub‐standard and high‐quality care. Yet, despite the importance of written and verbal communication, it is probably one of the areas of nursing practice that needs the greatest improvement. The Accountability Based Practice Model provides an opportunity for review of verbal and written communication practices and establishes guidelines for report at change of shift and patient transfer. In addition, the model provides a framework for revising documentation tools to support care delivery. Finally, the model will move the nursing service toward the implementation of an integrated medical record in which nurses document their care in the Progress Notes with their colleagues.
Accountability means ownership of one’s actions and responsibilities. When applied to professional nursing practice, accountability means accepting the responsibility of stewardship for the patient and family through the health care experience. Within the framework of the Accountability Based Practice Model, the ownership for assessing, planning, coordinating, evaluating, communicating, and achieving nursing care outcomes is with the Registered Nurse. In addition, the Registered Nurse is responsible for the care that s/he delegates to others to provide.
Accountability extends beyond patients and families. Accountability involves the acceptance of responsibility for conduct, behaviors, and interactions with all members of the healthcare team. Accountability means taking ownership for individual learning needs and participating fully in the work of the unit to improve patient care. Finally, Accountability means providing care that reflects the beliefs about nursing care and practice articulated in the “Philosophy of Nursing”.