Post on 30-Apr-2020
Enterprise-Wide, Evidence-
Based Interdisciplinary Plan
of Care Content Validation:
Guiding Principles and
Lessons Learned
Mary Swenson, RN, MBA
Naomi Mercier, MSN, RN-BC
2
Objectives
Describe Partners eCare initiative and implementation timeline
Process Redesign decision for enterprise evidence based Plan
of Care development
Describe Plan of Care Strategy, Definitions and Guiding
Principles
Zynx Lead Content Review Bootcamp
Bootcamp Debrief and Gap Analysis of Developed Content
Strategic Plan to complete development
Lessons Learned
Next Steps
4/30/2015
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4/30/2015 4
Partners eCare Process Redesign
4/30/2015 5
The Decision:
Nurses and Health Professionals will document on the Partners eCare
Plan of Care activity
• Interprofessional tool for documentation of patient and family
centered plans of care
• Place to share and communicate your clinical judgments and
clinical decisions
The Challenge:
• Lack of consistency in care plans across the enterprise
• 9,100 nurses and 4,250 Health Professionals
• Lack of adoption for an integrated tool
• 2 year timeline for Group 1 Go Live
• Lack of consensus on standard terminology
Plan of Care : Strategy
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Unique
Services Specialty Care,
High Acuity,
Mental Health,
Rehabilitation
Vulnerable
Patients Medicaid & Medicare
High Quality/
Technology Information Systems
Clinical Care
Community
Programs Health Centers,
Wellness Programs
1. Vendor solution for Plan of Care
• Enable consistency across the Enterprise
• Evidenced-based
• Provides ongoing process for updates and maintenance
• Delivers a robust library of content
2. Assemble a Nursing Informatics Leadership Advisory Council
• Representation from each Partners entity
• Empowered to make decisions
• Respected influencers and thought leaders
3. Include Health Professional leadership early in the process.
4. Develop definitions and guiding principles
5. Engage staff nursing and allied health staff in the content review
process
6. Inclusive terminology
Provide a deliverable of 60-70 Plans of Care in 3 months!
Plan of Care Definitions
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Flowsheets
• Assessments
• Interventions
performed
Treatment
Plan
• Medical
problem list
• Orders
Notes
• Evaluation of
patient status
Patient
Education
Care Plan = Patient Chart
Plan of Care
Plan of Care Definitions
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Flowsheets
• Assessments
• Interventions
performed
Treatment
Plan
• Medical
problem list
• Orders
Notes
• Evaluation of
patient status
Patient
Education
Care Plan = Patient Chart
Patient
Problems
Associated
Goals
Interventions
Plan of Care
Plan of Care Definitions
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Patient
Problems
Associated
Goals
Interventions
Plan of Care A problem (whether physiological, behavioral, functional,
psycho/social, educational, or otherwise) is a barrier to the
patient achieving his/her goals or reaching his/her next level of
care.
A barrier is a high priority, active problem - it is unique to your
patient and relevant to the care you are delivering.
The problem is resolved sufficiently when the patient has
achieved his/her stated goals, the patient has reached the next
level of care, or the patient has progressed to a satisfactory
level based on his/her personal baseline functional status.
PHS Care Planning Process
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Assessment
Evaluation Clinical judgment
Resolution of
problems
Problems
Unique
and
relevant
Goals
Assessment
Interventions
Patient
Goals
Patient
Family
Centered
Guiding Principles
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• Shared, Inter-professional
• Active, patient and family centered problems, goals
• Discipline specific only if approach to care is different
• Simple
• Include only problems that are barriers to a transition
to a lower level of care or preventing the patient from
meeting goals
• No standards of care
• Minimal “at risk for”
• Active and relevant interventions
• Update Goals and interventions with changes in patient
condition
• Patient education will be documented in the patient
education activity
Zynx Led Content Review Bootcamp
by the Numbers
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3
Day offsite
content
review
24
Total
sessions
184
Single
patient
problems
4
Concurrent
sessions
56
Condition
Templates
14
Nursing and
HP
leadership
340
SME’s
30
PeC and
Accenture
Staff
354 SME’s, Nursing leaders and HP Leaders
274 Tasks completed in 50 working days
PeC Bootcamp Follow Up
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The work had just begun………….
Bootcamp Debriefing and Gap Analysis
of Developed Content
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Guiding Principles not applied consistently to all plans
developed during sessions
Variability in plan modifications for a variety of reasons
Focus on Interdisciplinary workflow slowed down
tailoring process
Lack of style guide resulted in differing terminologies,
inclusion/exclusion of assessments and education
topics
Strategic Plan Post Bootcamp
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A crosswalk of all problems created during Bootcamp
Combined multiple versions of same problem into one inclusive of
all terms for review
Established a 6 week timeline for NIAC (Nursing Informatics
Advisory Counsel) review 46** single problem templates
Utilized Viewspace as our collaborative tool for review, comments
and voting
Weekly meetings to finalize problems after Viewspace suggestions
added
Development of style guide “rules”
Gap Analysis and Needs Assessment for Plan of Care templates
Develop a Master Schedule for Content Review Sessions
**The 46 problems used as the starting point for all multi-problem condition specific
templates
Style Guide Development
Goals, assessments, treatments and procedures and education topics will
all be listed alphabetically throughout the plans
No Diagnosis or discipline used in in problem or template titles
" Knowledge of" goals should be sparingly as knowledge can be
documented in Patient Education Activity . Knowledge of should only be
used for problems where knowledge is necessary to resolve the problem or
move to the next level of care
Assessments are limited in the Plan of Care as most are documented in the
flowsheets and only included if it is essential to the goal(s)
Order related interventions are not included in the Plan of Care
Every problem will have a "patient specific / tailored intervention" to unable
the user to create a unique intervention
No referrals or consults to team or outside agencies used in the Plan of
Care as they are documented elsewhere in the chart
Education topics are added to each problem there is no "Knowledge Deficit"
problem
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Content Gap Analysis and Needs
Assessment
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Templates Needed that Align with Top 25 DRGs:
• Well Baby Nursery
• NICU / Special Care Nursery- Pediatric
• Antepartum Patient (Gap)
• Intrapartum Patient
• Postpartum Patient (Gap)
• Total Joint Surgery - Adult
• NICU / Special Care Nursery- Pediatric
• Psychosocial / Behavioral Health Conditions – Adult/Pediatric
• Substance Abuse / Withdrawal - Adult
• Sepsis - Adult and Pediatric (Gap)
• Integumentary Conditions - Adult (Gap)
• Respiratory Conditions - Adult and Pediatric
• Cardiovascular Condition - Adult
• Cardiovascular/Thoracic Surgery – Adult (Gap)
• Eating Disorders - Adult / Pediatric
• Hem / Immuno / Oncology Conditions - Adult and Pediatric
(Gap)
• Abdominal /GI Surgery /Condition - Adult and Pediatric
• Bariatric Surgery - Adult
• Renal Failure, Acute / Chronic Condition - Adult (Gap)
• Neurological Condition – Adult
• Diabetic Condition - Adult
Additional Titles Needed:
Individual Problem Templates:
Developmental Milestone Achievement Impaired, Risk or Actual (Gap)
Diaper / Incontinence Dermatitis – Pediatric (Gap)
Parenting, Altered – Pediatric (Gap)
Seizure, Risk or Actual – Adult and Pediatric (Gap)
Multi-Problem Templates:
Medical / Surgery Condition – Adult and Pediatric (generic) (Gap)
Cardiac/Thoracic/Vascular Surgery – Adult (Gap)
Skilled Nursing Facility Patient – Adult
Perioperative Care / Procedural Sedation Patient – Adult/Pediatric (Gap)
Transplant Surgery- Adult (Gap)
Palliative Care – Adult / Pediatric (Gap)
Nutrition Conditions – Adult / Pediatric (Gap)
Occupational Performance Conditions – Adult / Pediatric (Gap)
Functional Mobility Conditions – Adult / Pediatric (Gap)
Speech / Communication / Swallowing – Adult / Pediatric
Ophthalmology Condition – Adult /Pediatric (Gap)
Otolaryngology Condition – Adult/Pediatric (Gap)
Therapeutic Recreation – Adult (Gap)
Total Templates Needed
60 Individual Problems (Adult and
Pediatric)
26 Adult Multi-Problem Templates
11 Pediatric Multi-Problem Templates 3 OB Templates
100 Total Templates
Plan of Care Content Review Schedule
– Jan through May 2014
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January 2014-
• NIAC Weekly Review of Adult Individual Problems (Jan 13 – Feb 12)
• Pediatric Individual Problems Review
February 2014-
• PT/OT Workflow Discussions
• Antepartum, Intrapartum and Postpartum OB plans
March 2014-
• 9 SME Sessions Scheduled for Pediatric and Adult Templates
April 2014-
• 10 SME Content Sessions for Pediatric and Adult Templates
May 2014 (build deadline for plan 5/5/14)
•100 templates completed by deadline
•Average SME Content Session size: 12 participants
•More Plan of Care Development planned for Group 2 using the same Guiding Principles and Style Guide
Lessons Learned
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An aggressive timeline (3 day Bootcamp) is not an end point; it
is a starting point
Develop a Style Guide in conjunction with Guiding Principles
Cultivate Interdisciplinary buy in early in the process
Interdisciplinary care plan templates including Therapies is a
nirvana
Bigger is not better, (SME reviewers). Rightsizing is an optimal
strategy
Take the time to develop a small group of experts for review
and validation
Next Steps
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Group 2 Plan of Care Development (completed)
Plan Clinical Informatics and Patient Safety research
projects:
Fall Risk Plan of Care
Aim: To developing and test a Patient Centered Infrastructure,
inclusive of Care Planning and Safety Tools that engage patients as
active participants in their Care Plan and Safety and integrate with
components of the inpatient EHR, including the Nurses’ Plan of Care.
Funding: AHRQ, Making Acute Care More Patient Centered, 1P30HS0235335 (PI:Bates)
Gordon and Betty Moore Foundation, Transforming the Acute Care Environment:
BWH PROPSECT Framework, 3914 (PI:Bates)
PCORI/NIA, STRIDE (STrategies to Reduce Injuries and Develop confidence in
Elders), U01AG048270 (PI, Bhasin PHS Site PI, Dykes)
Development of reports for tracking usage and compliance
APPENDIX
Examples of Plan of Care Templates and Style Guide
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Goals with Timeframes
Evidence based
interventions
Assessments captured in Flowsheets
Each template has a patient
specific tailored intervention
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Flowsheet rows were attached in the
Plan of Care to allow OT/PT and SLP to
document the specific detail needed for
their goals
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Example of Multi-Problem
Condition Template
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Thank you for attending the Partners Healthcare Plan of Care Webinar!