T RANSLATING C ARING T HEORY A CROSS T HE C ONTINUUM F ROM I NPATIENT TO A MBULATORY C ARE

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TRANSLATING CARING THEORY ACROSS THE CONTINUUM FROM INPATIENT TO

AMBULATORY CARE

Meghan McCann MSN, RN, NE-BCDirector Oncology Services

University of North Carolina Health Care

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• The Ambulatory Care Environment

• Translating Caring Theory to Ambulatory Care

• Translating Caring Theory to the

Emergency Department

• Sustaining the Carolina Care Culture at

UNC Health Care

Across the Continuum to Ambulatory Care

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• Times with patients are shorter

• Repetitive over time

• Span the length of treatment

• May be interrupted by inpatient stays

The Ambulatory Care Environment

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Translating Caring Theory to Outpatient Oncology

North Carolina Cancer Hospital

• Flagship site for UNC Cancer Care with 150,000 visits/year

• Clinical home of UNC Lineberger Comprehensive Cancer Center

• Multidisciplinary adult and pediatric space including 101 examination,

treatment, consultation, and procedure rooms

• 72 infusion stations for adults (48), children (14), and clinical trials (10)

• 3 Linear Accelerators for Radiation Therapy

• 50 inpatient beds for medical oncology and bone marrow transplant

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SCT and the Oncology Patient

• Maintaining Belief in patients ability to come through illness with

meaningful life/dignified death

• Understanding what is most important to patients/families

• Supporting patients/families through difficulty

• Assisting patients who cannot do for themselves

• Enabling patients to progress to highest level during

• Treatment

• Survivorship

• End of life

Tenets resonate for patients treated for a chronic illness over time

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Dissemination in Outpatient Oncology

• Replication of Inpatient Success

• Effort led by Oncology Carolina Care Committee

• Multidisciplinary membership of staff and leaders

• Guidebook rewritten to accommodate ambulatory

arena

• New behavior each month

• High patient volume with different providers

across diagnoses and clinical environments

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• Few minutes of uninterrupted time to

connect and convey concern during visit

• Recognize feeling of patient

• Establish connection

• Convey concern

• Goal – Each team member spend 3

uninterrupted minutes with at least one

patient

• Registration

• Scheduling

• Waiting room

Moment of

Caring:

Knowing

and

Being With

Carolina Care and Outpatient Oncology Patients

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Multi-level

Rounding:

Being With

and

Doing For

Hourly Patient

Rounding

Schedulers and

Registration

Director

Interdisciplinary

NurseManager


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Hourly

Patient

Rounds:

Being With

and

Doing For

ARe you comfortable?

Other/the care providers accompanying patients to their visits are acknowledged

Use the bathroom? Does patient need assistance/directions?

Need anything?

Door/curtain open or closed for privacy in clinic rooms?

Safety assessment/call bell in reach?

R

O

U

N

D

S


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• Allows Board members to

connect with patient over

shared experiences

• Offer insight and ease fears

Patient/Family

Advisory Board

Rounding:

Being With

and

Doing For


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• Patients become active participants

and decision makers in care• Guide interactions to ensure caring and

concern are consistently communicated

• Helps set and manage expectations

• Greet patients

• Correctly identify patients

• Perform hand hygiene

• Transition patient to next caregiver

Words

and

Ways

that Work:

Being With

and

Enabling


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• Entails careful listening to complaint, owning problem,

and working quickly to resolve issue

• Listen with care

• Provide blameless apology

• Thank patient/family for sharing concern

• Fix the problem

• Consider provision of service recovery item

• Follow up with patient/family to let them know how problem has

been addressed


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• By actively listening, showing empathy, apologizing

without blame, and fixing the problem, satisfaction

can be increased

• Creates opportunity for follow-up to improve systems


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• Team proactively discusses specific

patient needs, is attentive to safety, and

ensures needs are met during visit.

• Multidisciplinary daily team meeting in clinical

area to encourage information sharing

• Promotes care team partnership

• Enhances patient care

• Creates forum to address safety concerns

• Fosters teamwork

Clinic

Huddle:

Knowing


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• During huddle• Review of clinic schedule

• Discuss care needs that require focused

attention/support

• Identify opportunities to improve clinic flow

• Kudos are shared

Clinic

Huddle:

Knowing

Carolina Care andOutpatient Oncology Patients

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Evaluation and Sustainment in Outpatient Oncology

• Sustained scores highest in clinics across system

• 19 percentile increase for overall

• 4 percentile increase for nursing

• Consistent Top 5 Clinics of eligible clinic locations (Meg’s

graph?)

• Review of PG data on monthly basis

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Evaluation and Sustainment in Outpatient Oncology

• Coordination of improvement efforts with Oncology Operations Team

• Participation of Oncology leadership in organization wide CCIOC

• Repeat of roll out 2 years post initial implementation

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Translating Caring Theory to the Emergency Department (ED)

UNCH Emergency Department

• Annual visit volumes of approximately 72,000 adults and 10,000 pediatric patients

• One of the largest referral centers in North Carolina

• Admit rate near 30%

• Certified Level I Trauma Center for adult and pediatrics

• State Burn Center

• Joint Commission Stroke Center

• Chest Pain Center

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Caring Theory and the ED Patient

Tenets resonate for patients treated in an ED

• Stressors compounded

• High Acuity

• Mixed patient population

• High patient volumes

• Entry point for 50% of inpatient admissions

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Dissemination in the ED

• Replication of Inpatient Success

• Effort led by CNO and ED Director

• Multidisciplinary membership of staff and leaders

• Multiple week roll out

• Each behavior introduced across shifts

• High patient volume with different providers

across diagnoses and clinical environments

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• Convey presence and empathy despite

pressures of busy/changing environment

• Pat on shoulder

• Kind words

• Talking with patient during assessment

• Sitting down to connect while starting an

intravenous line

Moment of

Caring:

Knowing

and

Being With

Carolina Care and ED Patients

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C A R E S Y S T E M

Multi-level

Rounding:

Being With

and

Doing For

Hourly Patient

Rounding

Health Unit Coordinator

(HUC)

Director

Interdisciplinary

NurseManager


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C A R E S Y S T E M

• Hourly Comfort Rounds by Nurses

and Nursing Assistants

• Focus on personal needs• Offers of food and drink when permissible

• Pain management

• Helping patient and family understand wait time

• Communication of Plan of Care

Hourly

Patient

Rounds:

Being With

and

Doing For


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• Time compression makes 1st

impression essential

• Wait times and the unexpected are key

drivers of dissatisfaction

• AIDET organizes all major components

into one tool• Acknowledge• Introduce• Duration• Explanation• Thank you

Words

and

Ways

that Work:

Being With

and

Enabling


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• Other important Carolina Care

behaviors and messages

• Closing curtains for privacy

• Washing hands for safety

• Stepping out to document care

• Posting important info on the white board

in each room

Words

and

Ways

that Work:

Being With

and

Enabling


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C A R E S Y S T E M

• Entails careful listening to complaint, owning

the problem, and working quickly to resolve

issue

• Listen with care

• Provide blameless apology

• Thank patient/family for sharing concern

• Fix the problem

• Consider provision of service recovery item

• Follow up with patient/family to let them know how

problem has been addressed

Blameless

Apology:

Being With

and

Enabling


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Evaluation and Sustainment in the ED

• Increase from 15th percentile and sustain at 65th despite

volume/capacity constraints

• Current focus

• Improving patient throughput

• Increasing survey returns through discharge calls

• Introduction of Bivaris

• Sends discharged patients text or email with link to electronic survey

• Has increased response rate from 5% to 30%

• Patients respond within 24 hours versus 30 days

• Provides more detailed comments yielding more actionable format

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Sustaining the Carolina Care Culture at UNC Health Care

• Accountability

• Sustaining Carolina Care in Changing Environment

• Carolina Care 2014

• Evaluation and Sustainment of Carolina Care 2014

• Sustaining Excellence – The New Frontier

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Accountability

• Multidisciplinary Monday Morning Carolina Care

• Carolina Care Implementation Oversight Committee

• Big 5

• Geriatrics

• Pulmonary/Infectious Disease

• Family Medicine/Nephrology

• General Medicine

• GI Surgery

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• Inclusion in Performance Evaluation

• Inclusion in Nursing Professional Expectations

• Weekly Updates and High 5

Accountability

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Unit FY 15 Proposed Goal

3 AD 87.5CTSU 89.15 AD 88.5

3 WST 856 BT 868 BT 84

6 WST 85

4 AD-N 895 BT 88.2

5 EST 915 WST 917 NSH 916 NSH 87.56 EST 87.5

6 WH 88.15 WH 88.13 WH 89

7 CH 916 CH 875 CH 89

4 ONC 90BMTU 91

Annual goals: mean goals for each unit

Accountability

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Key Outcomes from Big 5

• GI Prep with Gatorade

• Care of floors

• Temperature control

• Development of unit brochures

• HUC initiated rounding

• Warm afternoon washcloths

• EVS on Demand

• New food tray activators to keep food warm

• Nutrition Food Service leadership rounding

Accountability

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Sustaining Carolina Care in Changing Environment

New challenges

• Organization adopted integrated Press Ganey Hospital Consumer

Assessment of Healthcare Providers and Systems (HCAHPS) patient

satisfaction survey in July 2013

• Implementation of new Electronic Medical Record

Goal - Increase UNCH overall patient satisfaction scores

during implementation of new electronic medical record and

adjust focus to align with HCAHPS

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Carolina Care 2014

Created Carolina Care 2014 Interprofessional Taskforce

• Nursing

• Pharmacy

• Pastoral Care

• Nutrition and Food Services

• Environmental Services

• Supply Chain Services

• Patient and Family Advisors

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Carolina Care 2014

Taskforce divided into eight working groups, with each

group assigned an area of focus• Patient engaged report

• Nurse-physician rounding

• Communication through care boards

• Narrating care

• Active listening

• Positivity

• Communication in an electronic environment

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Carolina Care 2014

Creating Carolina Care 2014

• Taskforce met for an all-day off-site work session

• During session, team members

• Reviewed goals of the initiative

• Created educational materials for staff

• Devised a rollout plan to ensure implementation prior to the

transition to the EMR

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Implementing Carolina Care 2014

• Carolina Care 2014 content was introduced in weekly segments

• Information was reviewed during weekly Carolina Care Huddles

• Managers utilized standardized template that included a weekly topic of

focus with

• Set goals and tasks

• Tools to educate staff members and weekly metrics to determine success

• Electronic access Carolina Care tools on a shared network drive

Carolina Care 2014

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Carolina Care 2014 Implementation Tools

• Weekly Huddle Guides

• Words and Ways that Work

• Evidence-based literature to support interventions

• Pocket cards with key weekly topic information

Managers also shared information and tools with staff members during

monthly staff meetings and through weekly email messages

Carolina Care 2014

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Evaluation and Sustainment of Carolina Care 2014

• Following implementation, scores improved to 76th percentile in March 2014 and reached high of 95th percentile week of March 16, 2014

• Post-intervention metrics: outperformed FY14 organizational goal (75th percentile) for patient satisfaction. These improvements were sustained in May 2014 (82nd percentile) and June 2014 (83rd percentile)

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Sustaining Excellence – The New Frontier

• Ambulatory Improvements across Medical Center and Physician led clinics

• Physician Engagement

• Carolina Care across affiliate hospitals within UNC Health Care System

• Annual Competency for all Nursing staff

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Tonges Translational Model for Theory-Driven Practice

T RANSLATING C ARING T HEORY A CROSS T HE C ONTINUUM F ROM I NPATIENT TO A MBULATORY C ARE

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