Joining Forces

Patient Aligned Care Team (PACT)

Patient Aligned Care Team (PACT), formerly known as Patient-Centered Medical Home (PCMH), is a team-based model of care led by a personal provider who enables continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PACT practice is responsible for providing for all of a patient’s health care needs or appropriately coordinating care with other qualified professionals. It is a model of practice in which a team of health professionals, led by a provider, works collaboratively with the patient to plan their overall health. PACT is based on a set of seven principles (from the American Academy of Family Physicians - AAFP, American Academy of Pediatrics - AAP, American College of Physicians - ACP) and depends on a core and expanded team of healthcare personnel who work with the Veteran patient to plan for their overall health. These principles emphasize the personal relationships, team delivery of holistic care, care coordination across specialties and settings of care, quality and safety improvements, open access and affordable care.

While most VHA Primary Care practices have already adopted many of the features of patient centered care and the medical home, complete achievement will involve strategic assessment and redeployment of resources, realignment of priorities, and a major cultural change – an effort that will be truly transformative.  It will help align VA with national health care reform initiatives and enable VHA to continue to provide leadership in health care delivery while assuring that our Veterans’ health is managed with the utmost quality, safety and effectiveness.  With the Patient Aligned Care Team, our Veteran patient population will have superb access to high quality primary care that affords them a healthier lifestyle.

ONS is presently collaborating with multiple VHA program offices and staff in the field as this initiative continues towards its end goal. 

Clinical Practice Program

The Clinical Practice Program was developed by the Office of Nursing Services to support nursing clinical practice, develop policies in coordination with other VHA program offices and to disseminate communication to the field. The program is made up of seven field advisory committees (FACs) in the following specialties: Cardiovascular, Geriatrics and Extended Care, Mental Health, Metabolic Syndrome/Diabetes, Oncology, Perioperative and recently added Polytrauma Rehabilitation.

Each FAC consists of a clinical nurse advisor and a committee made up of field-based nurses who serve a two-year rotation on the committee. The FACs are charged to assist Clinical Nurse Advisors in:

1. Aligning work of assigned patient populations with National Nursing Strategic Goals/Objectives.
2. Identifying/developing recommendations for:
   1. best practice, practice guidelines, patient care standards, and policy guidance
   2. staff and patient/caregiver training and educational priorities
   3. support tools for documentation, references
   4. research agenda for clinical inquiries
   5. publications and appropriate mechanisms for dissemination of best practices
   6. potential oversight functions needed in the field in the area of focus

Structured Language for Nursing Documentation

The Structured Language for Nursing Documentation (SLND) transformative initiative was launched in February, 2009. Structured languages (SL) are standardized vocabularies used to describe the actions that nurses perform in the process of caring for patients that label the elements of nursing care and facilitates communication among nurses, in addition to that between nursing and other health care disciplines.

Nursing is an information-intensive profession, and nurses are experts in the diagnosis and treatment of human responses to illness, prevention of illness and health promotion. Therefore, this work must also be included in clinical information systems. However, the terms that nurses have traditionally used to describe the nursing process and the documentation of that care have not been consistent. Describing nursing care in a standardized way will make it possible to organize the information in the electronic patient record in order to support data driven decision-making (clinical and administrative) and facilitate patient care continuity.

Registered Nurse (RN) Residency Program for New Graduate Nurses

The Office of Nursing Services (ONS) conducted a preliminary review of the literature and found that the quick transition from classroom to clinical practice can prove difficult for newly licensed nurses, leading to turnover rates as high as 60 percent.

In January 2009 ONS launched a 12-month pilot of a Nurse Residency Program at eight VHA facilities of various complexities. The program’s curriculum focused on refinement of graduate nurse clinical competencies, and development of professional nursing roles and leadership characteristics. The program utilized a variety of educational strategies including classroom education, precepted clinical experiences, monthly meetings, group clinical debriefings, one-on-one mentoring, and an evidence-based practice project. The success of the pilot has resulted in a planned national implementation that will be rolled out soon.

Staffing Methodology for VA Nursing Personnel

The Office of Nursing Services (ONS) is leading an effort to implement a nationally standardized staffing methodology for VA nursing personnel. Experts both within and external to the VA have reviewed best practices and innovative approaches to staffing and concluded that an expert panel-based approach be adopted, combining the professional judgment of nurses with quantitative data analysis based on the many factors that contribute to patient care workload. The initiative began with a national nursing strategic planning meeting in July, 2007, whereby 2008-2012 National Nursing Strategic Goals incorporated the following objective: “Using system redesign principles, deploy an automated, data-driven, evidence-based staffing methodology that supports patient-driven care delivery models.” By 2012, the goal is to achieve a standardized, automated staffing methodology for nursing personnel that is simple, reliable, and evidence-based. A five-year plan has been developed with three primary objectives:

1. Publish a national directive with core data sets and outcome measures to analyze staffing effectiveness;
2. Implement mechanisms for automated data extraction;
3. Implement mechanisms for data collection across the system to analyze correlations between patient outcomes and staffing.

A standardized staffing methodology for nursing services will support a national process to systematically measure the impact of staff levels and staff mix on patient care outcomes. Accordingly, facilities will have the necessary tools and methods to aggregate, share, and compare data with one another, ultimately leading to system-wide comparative data analysis and national benchmarks. This, in turn, leads to continuous quality improvement and results in the provision of increasingly effective, efficient, and high quality health care for veterans. Moreover, this project will result in Office of Inspector General (OIG) compliance as stipulated in OIG Report 03-0079-183: “Develop and oversee the implementation of a national nurse staffing policy that applies a single staffing methodology to generate consistent facility staffing standards.”

A multi-phased pilot implementation strategy has been completed at each of the forty VA Medical Centers within VISN 1, 6, 15, 16, and 20. Currently, pilot evaluation and revisions are in process and will be competed by August, 2009. Coordination with the Deputy Under Secretary for Health for Operations and Management for national roll-out is scheduled for September 2009.

VA/DoD Patient Transfer Electronic Summary Solution

Electronic medical information from the Department of Defense (DoD) about severely wounded troops is now being transferred to four VA special treatment centers. The VA-funded project is the result of collaboration among VA and DoD nurses and information technology professionals. The patient information to be shared between DoD and VA involves electronic notes based on the S-BAR communication framework:
S=Situation (includes patient demographic, diagnoses, allergies, vital signs, etc.);
B=Background (includes mental and physical status at the time of transfer);
A=Assessment (identifying needs and issues to be addressed; key nursing diagnoses); and
R=Recommendation (plan of care, documentation, fields required by joint commission, etc.)

A successful pilot project was completed, sharing patient information between Walter Reed Army Medical Center and the James A. Haley VAMC’s Polytrauma Unit in Tampa, FL, in September 2008. Walter Reed now shares enhanced data with VA’s four Polytrauma Centers in Tampa, FL; Richmond, VA; Minneapolis, MN; and Palo Alto, CA.

The note is now being sent from both Walter Reed and National Naval Medical Center- Bethesda to the VA Polytrauma Centers. In a collaborative effort between ARMY and NAVY nursing, this initiative is also being looked at to facilitate the flow of information in the same manner for communication between Landstuhl Regional Medical Center, Walter Reed and National Naval Medical Center. Landstuhl’s approval to fully implement the note is pending LRMC command approval. In May 2009, the handoff template was shared with the National Trauma Nurse Coordinator, Canadian Forces Health Services Group Headquarters. This uniform, standard method of communicating patient information will ensure that veterans receive high-quality care immediately after being transferred, and that this information is readily available and accessible to health care providers.

VA Nurse Scientist Toolkit

The purpose of the VA Nurse Scientist Toolkit is to assist in the orientation of nurse scientists to the VA focusing on resources for research and for building a program of research.

Let's Get Certified!  Campaign

The Let's Get Certified!  Campaign offers guidance and resources to support facility efforts in increasing the number of nurses with certification. Materials are made available for facilities to participate in VA Nursing's Let's Get Certified!  Campaign. (VA staff can find campaign materials on the intranet website: http://vaww.va.gov/nursing/certcampaign.asp) 
Campaign Awards 

Let's Get Certified: An Innovative National Campaign; Mary Seaman, Alan Bernstein; Nurse Leader November 2010 (Vol. 8, Issue 6, Pages 31-36)

Clinical Nurse Leader (CNL)

The Clinical Nurse Leader (CNL) role is designed to deliver clinical leadership in all health care settings and to respond to individuals and families within a micro-system of care. As of August 2007, over 80 VA Medical Centers (VAMC) sites have requested to participate in the CNL Initiative. The CNL is expected to address and improve the following:

• Cost/financial outcomes such as length of stay, patient flow, readmission rate and registered nurse (RN) turnover
• Patient satisfaction, staff satisfaction and retention
• Quality/internal process outcomes such as medication management, patient safety, and prevention of nosocomial infections
• Practice Model Transformation such as evidence-based and collaborative, interdisciplinary practice

This initiative is targeted towards RNs with a Master’s Degree in Nursing who desire to stay in the direct care setting but practice in an advanced generalist role with a broad scope of practice and more complex level of responsibility for a specific patient care unit.

More information: VA Clinical Nurse Leader Program 
American Association of Colleges of Nursing CNL site   

VA Nursing Academy

The Department of Veterans Affairs is establishing a VA Nursing Academy that will address the nursing shortage within the VA, as well as the Nation. The VA Nursing Academy Program is intended to address the nursing shortage in VA and the Nation in the following ways:

• Expanding teaching faculty in VA facilities and affiliated nursing schools
• Increasing VA recruitment and retention by enhancing clinical experiences for nursing students and expanding teaching and research opportunities for VA nurses
• Establishing scholarship programs for nursing students

The five-year, $59 million program has established a total of 15 VA/Nursing School partnership supported by this program. The 2009—2010 academic year recently selected partnerships are:

MRSA Virtual Simulation

On January 22, 2007, the Veterans Health Administration (VHA) launched a National Prevention Initiative to reduce the number of healthcare acquired Methicillin Resistant Staphylococcus aureus. In support of this initiative, the Office of Nursing Services took the lead on partnering with the Employee Education System and the Pittsburgh staff to develop and implement virtual reality simulation technology to support staff education. Through virtual simulation, the user receives in-depth training by way of an interactive 3-D environment that role models behavior to support adult learning. This multi-sensory, self-directed method of staff training improves knowledge retention and fosters changes in the behavior of the trainee. Alpha testing for the web-based virtual simulation training has been completed. National rollout is scheduled for Winter 2009 with an overall goal to create an interactive training video set in a virtual reality environment to enhance awareness and demonstrate proper protocols for controlling the spread of MRSA infection. The main components of the simulation (MRSA Bundle) include:

• Active Surveillance
• Hand Hygiene
• Contact Precautions
• Contact Precautions

Travel Nurse Corps (TNC) Program

www.travelnurse.va.gov 
The TNC program provides VA facilities with VA-experienced supplemental staffing for short/long-term assignments. Further details of this program are described within the Executive Decision Memorandum. VHA National Leadership Board granted conceptual approval for the TNC pilot in October 2006.