Howell DNP -- PODIUM Nashville 3dnpconferenceaudio.s3.amazonaws.com/2014/1PODIUM Presentatio… ·...
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Transcript of Howell DNP -- PODIUM Nashville 3dnpconferenceaudio.s3.amazonaws.com/2014/1PODIUM Presentatio… ·...
Memorial Hospital
• Belleville, Illinois • 20 Miles east of St. Louis • 316 Bed Community Hospital • Employs over 2300 employees • Memorial Care Center
• 108-bed skilled nursing and rehabilitative facility
Memorial Hospital Accreditations
– HFAP Accreditation – ANCC Magnet Re-designated in August 2013 – Distinguished Hospital for Clinical Excellence by Healthgrades for 3 consecutive years Top 5% of hospitals nationwide
Memorial Hospital
– Chest Pain Center with PCI re-accreditation by Society of Chest Pain Centers March 2014
• Memorial Care Center
– Five-star rated facility by CMS – 5th consecutive year as one of America’s Best Nursing Homes by U.S. News and World Report
Opportunities
Unit Specific Opportunity for Improvement Organizational Opportunity for Improvement
Current Workflow Methodology
Presented with rapidly changing healthcare environment Two conflicting paradigms: Bureaucratic and Relational expectations Increase in workload Reimbursement to hospitals Competition of hospitals Magnet Designation Chaotic Environment
Reason for Change
Significance and goals of an innovative workflow methodology • Decrease redundancy of tasks • Improve HCAHPS scores, core measures, and staff
satisfaction • Improve patient outcomes • Decrease LOS • Decrease 30 day readmission rate • Provide more time for nurses at the bedside • Improve interdisciplinary communication
Aims of Project
Assess caring behaviors of the nursing staff (CBI-24) pre and post intervention Use pre-intervention assessment data
to identify the specific issues that could be impacted by a new innovative workflow methodology
Aims of Project
Develop and implement a new innovative workflow methodology by incorporating RBC Determine if the implementation of a new innovative workflow methodology improves the designated measures: CBI-24 survey, NDNQI, HCAHPS, and core measures
PICO Question
Would instituting a nursing care delivery model based on RBC on a 24-bed telemetry unit improve staff and patient satisfaction and patient outcomes?
Project Inquiry
Many conversations with the Vice President of Nursing • Need for an innovative workflow methodology • Stakeholders • Pilot Unit – 2 North (24-bed Telemetry Unit) • Envision a one-year pilot • Steering Committee Members
Project Steering Committee
Development Phase
Development of Job Description • First Draft – Patient Care Facilitator
• Second Draft – Clinical Nurse Leader
• Final Draft – Clinical Leader
2N - Nurse Manager
Barriers to the Clinical Leader Role • Change – Long term nurses set in ways • Nurses think Clinical Leader will be controlling and
taking over what they do with their patients • Blurred professional role boundaries (CN, Staff RN) • Administrative duties that could take the Clinical
Leader away from the patient
CBI - 24
Assess attitudes and actions of caring behaviors of staff
Distributed to RNs, PCTs, & Care Manager of 2-North (Wu, Larrabee, & Putman, 2006)
Data Analysis
Analysis of CBI-24 Results: • 38.7% (12/31) RN response rate • 38% (8/21) PCT response rate • 25% - Associate’s Degree • 10% - Diploma • 30% - BSN
Data Analysis
Demographics • 30% - 0-5 yrs experience • 60% - > 10 yrs experience • 10% - > 25 yrs experience
Data Analysis
CBI-24 Outcomes Summarization: • 100% answered that they always or almost always
attentively listen to patient, treat the patient as an individual, treat patient confidentially, encourage the patient to call if there are problems, and show concern for the patient.
Data Analysis
CBI-24 Outcomes Summarization: • Staff do not feel that they can administer treatments/
medications in a timely manner, answer patient’s call lights in a timely manner, talk with the patient and include them in the care, be patient or tireless with the patient, or spend time with the patient.
Practice Pattern Observation Analysis
Practice Pattern Questions: If you could remove one barrier (at the unit level) to performing your job what would it be and why? Do you believe that your normal work day flows well? Describe interruptions that break up the
flow of your work or interfere with your time spent with patients.
Practice Pattern Observation Analysis
Describe things that facilitate your daily work flow on your unit. If you believe that your work day does
not flow well, what do you believe could be done to improve it? What is a barrier (if any) to your patient
having a functional individualized care plan?
Observation Analysis CM, CN, Staff RN, & UR Nurse
Demographics Analysis of Observation • Redundancy of tasks • Barriers to work flow • Barriers to D/C Process • Other Tasks • Barrier to functional individualized plan of care
Theory Development
In-depth literature review Reading and understanding of various theories How to incorporate Relationship-Based Care Developing foundation for building of innovative workflow methodology
Integration Theory
Integration Theory
Relationship- Based Care
Complexity Science Theory
Human Factor Theory
Diffusion of Innovation
Theory
Relationship-Based Care
Jean Watson’s Theory of Human Caring focuses on the interpersonal relationship between the patient and the nurse It is only through the understanding of
patient’s needs, history, and life experiences that the nurse can see the patient as a unique human being RBC – philosophical foundation of the
model Healthcare provided through relationships Activities of care organized around needs
and priorities of patients and families
Relationship Based Care
Theory
Relationship-Based Care
Elements of the model • Caring and healing environment • Leadership • Teamwork • Professional Nursing Practice • Patient Care Delivery • Resource Driven Practice • Outcomes Measurement
Relationship Based Care
Theory
Relationship-Based Care at Memorial Hospital
Complexity Science Theory
Complexity Science Theory • Study of complex adaptive systems • Consider patterns of relationships
in the system, how they are sustained, how they self regulate, self organize, and how outcomes emerge
Make Calm Out of Chaos
Complexity Science Theory
Complexity Science Theory
Complex System—group of two or more parts which interact to function as a whole (Health Care Team/Nursing Units) Pays attention to the interconnections among the group and not simply the individual (Need to understand building blocks of 2-N, type of staff, UPC, etc.) Encourages health care workers to work with rather than against overwhelming complexity
Complexity Science Theory
Diffusion Of Innovation Theory
Instilling change-know your audience/population who will be adopting the idea Four elements to consider: • Innovation • Communication Channels • Time • Social System
Diffusion of Innovation
Theory
Innovation
Why some innovations spread more than others • Relative advantage • Compatibility • Complexity • Trialability – Pilot • Observability – Post Outcomes
Diffusion of Innovation
Theory
Diffusion Of Innovation Theory
Communications Channels
How information is communicated (introduction of innovation, roll out, process changes, outcomes)
Diffusion of Innovation
Theory
Diffusion Of Innovation Theory
Time
Involved in decision process Five stages of innovation
Rate of adoption
Diffusion of Innovation
Theory
Diffusion Of Innovation Theory
Social System Set of interrelated units that are involved in group problem solving to accomplish a common goal
Diffusion of Innovation
Theory
Diffusion Of Innovation Theory
Human Factor Theory
1971-How humans and systems interact Three factors lead to human error, accidents, and an unsafe environment • Environmental Factors • Internal Factors • Situational Factors
Human Factor Theory
Integration Theory
Integration Theory
Relationship- Based Care
Complexity Science Theory
Human Factor Theory
Diffusion of Innovation
Theory
• Complex system-health care team/2N nursing unit • Interconnection-understand building blocks of 2N, UPC
• New equipment, technology, supply issues
• Inappropriate response-workaround/shortcuts
• Instill change-know your audience (2N) • Some innovation spread more d/t trialability (pilot) • Observability/post outcomes • Communication-UPC, Staff Meetings, Roll out
• Relationship between patient & nurse • Understanding patient’s needs • Setting goals w/patient • Care activities organized around pt/family needs • Mind/Body/Spirit • Leadership=vision; remove barriers to quality • Teamwork-Multidisciplinary • Professional Nursing Practice-compassion care throughout lifespan, • Resource driven practice-equipment/supplies
Clinical Leader Introduction to Practice
Evaluate the current workflow and roles on the pilot unit
Develop staffing plan of new workflow methodology
Clinical Leader Introduction Role Delineation
Clinical Leader Staff Nurse Care Manager Social Worker Charge Nurse U9liza9on/Cert Nurse
Clinical Documenta9on
Specialist General introduc.on to pa.ent and family.
Perform admission and discharge.
Assesses discharge needs.
Staffing, schedules Assess level of care and appropriateness for that day (How sick is the pa.ent and how are they being treated)
Coding
Based on diagnosis develops plan for pa.ent which consists of short and long term goals with outcomes.
Administer medica.ons, dressing changes, assuring blood glucoses are completed.
Coordinates with the CL to establish discharge needs and ensures discharge needs are met (DME, Home care, rehab, PT, OT)
Obtain report from staff nurses and CL.
U.lizes Interqual which states criteria for specific level of care (EBC)
Reviews documenta.on of severity of illness in pa.ent record
Progression of Care – LOS, throughput, finances, family mee.ngs, interdisciplinary rounds,
Based on diagnosis assesses core measures and how to successfully meet. Discharge Planner
Review CL’s goals for pa.ent and work together to achieve.
Appropriate placement of pa.ents unable to go home.
ATends bed mee.ng, assists with procedures, Assists with resolving conflict
If inappropriate treatment for level of care then communicates with EHR physician who communicates with insurance or BMH physician
Clinical Leader Introduction Role Delineation
Assures appropriate consults are no.fied and have seen pa.ent.
Incorporate HCAHPS in the daily care of pa.ents.
Physician advisor – con.nued stay reviews
Assess safety of pa.ent at home and interject appropriately.
Appropriate bed placement of pa.ents
Reviews observa.on pa.ents and current loca.on
Updates goals and changes goals as pa.ent condi.on changes.
U.lize white board for communica.on with pa.ents regarding goals for the day
Outlier Mee.ng Works closely with pa.ents and families.
Coordinates and assists with phone calls and physicians.
Communicates with payors
Works closely with pa.ents and families.
Works closely with pa.ents and families.
Coordinates discharge appeals – chart copied, take to HIM, Fax to QIO
Coordinates pa.ent movement and throughput of pa.ents.
Tracks denials
Assists physicians with procedures as able.
Assists physicians with procedures as able.
Contacts community agency for D/C needs
Works with nurse manager regarding staff issues.
Reviews quality of care ie. inappropriate orders in ER
Incorporates HCAHPS in the daily care of pa.ents.
U.liza.on of resources/LOS
Assists with giving staff evalua.ons.
Communicates with CL regarding goals of pa.ent
Discharge phone calls Touch base with resource staff to see who needs IM leTer
Midas Reports
Team of 12 pa9ents: 3 staff RN’s and a Clinical Leader collabora9vely working together to promote an efficient, produc9ve, high quality stay for the pa9ent.
Clinical Leader Staff Nurse Care Manager Social Worker Charge Nurse U9liza9on/Cert Nurse
Clinical Documenta9on
Specialist
Staffing Plan Utilizing the Clinical Leader
1 Roaming PCT 1 Charge Nurse on day shift 1 Social Worker 1 Utilization Review/Cert Nurse (M-F) 1 Unit Secretary (0645-2300) 1 Nurse Clinician (M-F)
Block B Rooms 268-2 thru 274, 295 1 Clinical Leader 3 Staff RN’s 1 PCT
Block A Rooms 264-268-1, 294 1 Clinical Leader 3 Staff RN’s 1 PCT
Alternative Staffing Plan
To only have charge nurses on weekends to follow through on the Clinical Leader plan for the patients Nurse Manager would be responsible for staffing and patient throughput during the week Assure that the patient goals and core measures are met
Clinical Leader Responsibilities
Collaboration with patient and family - Goals Assessment of core measures associated with the diagnoses Coordination of plan of care Adjustment of plan of care as needed Assuring consults are appropriate and completed Discharge follow-up phone calls Lead multidisciplinary team in achieving outcomes
Financial Impact
Budget Neutral – blending of the current charge nurse and care manager role Reassign the roles so there will be no reduction of labor Value-based purchasing goals may be met and reimbursement incentives obtained when a decrease in LOS occurs due to improved patient care planning or improved clinical oversight Hospitalization cost avoidance if decrease in readmissions (as a result of an improved comprehensive discharge planning process)
Limitations
No control over: Staff participation in the CBI-24 survey
observation, and interview process Staff acceptance or adoption to change Steering committee member’s schedules Fall 2012, the hospital changed from
utilizing the NDNQI staff satisfaction survey to utilizing the Advisory Board staff engagement survey
Project Implementation
Staff placed in Clinical Leader positions Educational program development Keeping staff and physicians informed Worked with Clinical Informatics to develop documentation Project go live was October 6, 2013
Evaluation of Project
Ongoing progress and outcomes of the pilot project were made available for staff HCAHPS and Core Measure scores were posted monthly with quarterly comparison A post CBI-24 survey will be redistributed in October 2014 one year after implementation for comparison with the pre-survey
Length of Stay
Data Collection & Analysis
Project Outcomes
0
1
2
3
4
5
6
Total Medicare
3rd Qtr 2013
4th Qtr 2014
1st Qtr 2014
2nd Qtr 2014
HCAHPS Patient Satisfaction
Project Outcomes
0
10
20
30
40
50
60
70
80
90
Rate This Hospital Recommend This Hospital Communication with Nurses
Pain Management
3rd Qtr 2013
4th Qtr 2013
1st Qtr 2014
2nd Qtr 2014
Core Measures
Project Outcomes
94
95
96
97
98
99
100
101
ASA at DC HF DC Inst ACE/ARB Beta Bl DC
3rd Qtr 2013
4th Qtr 2013
1st Qtr 2014
2nd Qtr 2014
Contact Information
Kim Howell, DNP, PhD, RN, CCRN
Director of Emergency, Cardiovascular and Obstetrical Services Memorial Hospital
[email protected] 618-257-5880
Questions?
