School of Nursing

Applying Evidence to Improve Quality

Linda A Dudjak PhD RN

Associate Professor

‘University of Pittsburgh School of Nursing

Compare Two

Alternatives

Implement a Test of Change

(Experiment) to Fix a Broken

Process

Persuade Others of the Value

of a New Approach

Measure the Impact

of a Controversial

Change

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Steps in the Process Collect Evidence (what does the literature say that supports your idea; reveals a gap in what is known; or supports the need for additional study)

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Steps in the Process Develop a Concise Objective/Purpose Measurable terms Correlate with what you are able/plan to evaluate

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Steps in the Process Develop an Implementation Plan (Methods) • Who will be involved

• Where will it occur

• Over what time period will it occur

• Who needs to approve your plan

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Steps in the Process Evaluate the Outcome • How will you measure

success

• Do you need a tool to assist with measurement

• What information (data) do you need

• Are the data available; who will collect it; for how long

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Steps in the Process

Determine the “So What” Factor • What can you conclude?

• What can’t you conclude (limitations)?

• How will you apply the results?

• Are the findings generalizable?

• Where will you publish/present?

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How Does this Work - Really

• Implementation of an Acuity Adaptable Care Model

• Initiation of Bedside Report to Improve Shift Handoff

• Use of Guidelines and Scripting to Support Acute Care Nurses’ Recognition, Reporting & Treatment of Sepsis

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Implementing an Acuity- Adaptable Care Model in a Rural Hospital Setting

• Rural community hospital in Eastern PA

• Unit redesign to increase capacity by adding 6 beds between ICU and medsurg unit (the “annex”)

• Goal: increase flexibility of patient assignment and reduce need to staff for empty beds by sharing resources

Ramson, KP. et al.(2013). Implementing an Acuity-Adaptable Care Model in a Rural Hospital Setting. JONA. 43(9): 455-60.

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Evaluation of a Care Delivery Model

Ramson, KP. et al.(2013). Implementing an Acuity-Adaptable Care Model in a Rural Hospital Setting. JONA. 43(9): 455-60.

Key Element

Evidence

Experience of other institutions demonstrated positive clinical and financial outcomes; had not been evaluated in a rural hospital setting

Objective(s)

Evaluate the effect of the new model on: • nurse and patient satisfaction • LOS • HPPD • Adverse events

Implementation

• LOS, HPPD and adverse events measured Oct-Jan, 1 year apart • Nurse and patient satisfaction measured pre –implementation and 4

months post-implementation

Evaluation Tools LOS, HPPD and adverse events already tracked internally HCA HPS – selected 4 relevant items Designed 9-item nurse survey based on concerns expressed about staffing, low census, handoff time, etc

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Findings: Patient Satisfaction

Variable

Pre Implementation

Post Implementation

Rate hospital (Score 9-10) 62% 79.7% p < .00006**

Recommend hospital (always) 58.8% 75.5%

p < 0.003**

Communication with Nurses (always) • Courtesy/respect • Listen • Explain

78.2% 81.1% p < 0.52

Responsiveness (always) 59% 65% p < 0.26

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Findings: Nurse Satisfaction

Variable

Pre Implementation Post Implementation

Float weekly

15%

5%

Cancelled for low census

14% weekly 6% weekly

Time giving shift to shift report

81% < 30 minutes 78% < 30 minutes

Effective nurse communication during shift handoff

86% Agree/strongly agree

94% Agree/strongly agree

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Findings: Patient Quality

Variable

Pre Implementation

Post Implementation

Adverse events 16.21 20.12

Falls 4.17 3.66

Med errors 4.17 4.39

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Findings: LOS & HPPD

Variable

Pre Implementation

Post Implementation

Average Patient LOS

3.71

3.73

Total Case Mix Index (CMI)

1.26

1.21

WHPPD (RN) 6.9 6.1 7665days @

$30/hr = $212k

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Implications (So What) Implementation of the acuity-adaptable care model has the potential to:

• positively impact factors associated with nurse satisfaction which can affect turnover and overall engagement in the workplace

• favorably influence patients’ perceptions of the hospital experience

• improve efficiencies in care delivery that leads to salary expense reductions

Further study with larger units and varying types of patients is required

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Implementation of Bedside Shift Report to Improve the Effectiveness of Shift Handoff in an Acute Care Hospital

Cairns L et al. (2013). Utilizing bedside shift report to improve the effectiveness of shift handoff. JONA. 43(3): 160-65.

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Bedside Shift Report to Increase Handoff Effectiveness

Key Element

Evidence

Regulatory and quality organization recommendations e.g. TJC, IOM advocated value of patient centered care; professional accountability; patient safety Failed attempts/resistance/lack of standardization posed risk to quality

Objective(s) Demonstrate the positive outcomes associated with bedside shift report (nurse and patient satisfaction; reduced call light usage; reduced end of shift OT

Implementation

Education sessions with role plays and case studies highlighting concerns that has been a barrier e.g. interruptions, excessive time, sensitive family issues, lack of pertinent information Letter from UD to newly admitted patients

Evaluation Tools

Data pre and 3 months post intervention • OT and call light data from administrative data base • HCAHPS scores: kept you informed; included you in

decisions • 7 item nurse satisfaction survey

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Findings: Call Light Usage

Pre-Implementation (7/1/11 to 9/30/11)

Post- Implementation (10/1/11 to 12/31/11)

Percent Change

Call light usage 1591 1075 33%

7am-8am 809 501 38%

7pm-8pm 782 574 27%

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Findings: End of Shift Overtime Pre-Implementation (7/1/11 to 9/30/11)

Post- Implementation (10/1/11 to 12/31/11)

Percent Change

End of shift overtime

6194 minutes (103 hours )

5281 minutes (88 hours)

15% (10min/day)

Potential Cost Reduction: •10minutes/day at an hourly rate of $26-$39 results in a cost savings of $24,000 to $ 36,000 per quarter •Annually, reduction of $96,000 to $144,000 in salary expense!

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Findings: Patient Satisfaction

Mean Score Pre-Implementation (7/1/11 to 9/30/11)

Post- Implementation (10/1/11 to 12/31/11)

Nurses kept you informed

76.0

(N=65)

84.5 (N= 49)

Staff included you in decisions about your treatment

75.0 (N=61)

80.0 (N=46)

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Findings: Nurse Satisfaction Agreed or Strongly Agreed

Pre-Implementation

N=29

Post- Implementation

N=18

Report is concise; contained only pertinent information

38.0% 77.8%

Information contained in report consistent with initial assessment

72.4% 83.4%

Nurses available after report for questions 75.9% 88.9%

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Findings: Nurse Satisfaction Agreed or Strongly Agreed

Pre-Implementation

N=29

Post-Implementation

N=18 Time required for report is excessive

48.2% 38.9%

Time required for report interfered with ability to complete work within shift

41.4%

27.8%

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Implications (So What) • Involve direct care nurses in developing a

standardized report tool to increase buy-in and hardwire practices

• Expand use of bedside shift report to other units in the organization

• Replicate for longer period of time to accrue a larger volume of patients and determine trends in patient satisfaction

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Use of Evidence-based Guidelines and Scripting to Support Acute Care Nurses in Sepsis Recognition, Reporting, and Treatment

Drahnak D. ( 2014) DNP Capstone Project, University of Pittsburgh School of Nursing, Conemaugh Memorial Medical Center

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Change in Standard of Care to Improve Patient Outcomes

Drahnak D. ( 2014) DNP Capstone Project, University of Pittsburgh School of Nursing, Conemaugh Memorial Medical Center

Key Element Evidence

Internal Problem Identification: Sepsis among top 10 DRGs; Current SSC guidelines not followed; lack of sepsis screening policy Evidence: Surviving Sepsis Campaign; IHI Severe Sepsis Bundle; Sepsis screening tool available through EHR platform

Objective(s)

• Nurse education • Implement commercially available sepsis screening tool • Assess nurses’ knowledge and attitudes • Assess institutional compliance

Implementation

Developed voice over PPT education session about sepsis and bundle Retrospective chart audit pre and post education

Evaluation Tools Nurse assessment (knowledge and attitudes) Audit tool; established criteria for 3 levels of compliance

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Findings

Variable

Pre Implementation

Post Implementation

Nurse Perceptions & Attitude • Awareness (self and

peers) • definition • Confidence detecting • Confidence reporting

Statistically significant increase (p < 0.0001)

Nurses Knowledge (10 items) Statistically significant increase (p < 0.0001)

Compliance with documentation of sepsis bundles

Non: 40.6 Non: 8.9

Partial: 40.6 Partial: 69.1

Full: 18.5 Full: 21.9

School of Nursing

Implications (So What)

• Education, communication scripting, nursing policy, and EHR prompts can improve adoption of the IHI bundles and SSC 2012 guidelines for sepsis care

• Continued vigilance and support from administration on this initiative will be needed to support compliance and ensure success