Constructing a Team in 2012 What I’ve been telling the ...€¦ · –Workshop #3: Meeting the...
Transcript of Constructing a Team in 2012 What I’ve been telling the ...€¦ · –Workshop #3: Meeting the...
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Constructing a Team in 2012 What I’ve been telling the other doctors…
Joshua Koch, MD
Assistant Professor of Pediatrics
Medical Director, CICU
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Outline
• ACGME regulations and work hours
• Increasing medical complexity and “hybrid” models of care
• Training and educational needs for APNs and PAs
• Care and feeding of a growing program
• Tracking quality and efficiency
• Financial implications (now and in the future)
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Alphabet Soup
• APN = Advanced Practice Nurse
• PA = Physician Assistant
• APP = Advanced Practice Practitioner = APNs + PAs
• DEEP CRAP = What we’re going to be in if we don’t figure out how to care for patients safely, effectively, and efficiently in the very near future
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Reduced Resident/Fellow Work Hours
Nuckols and Escarce, JGIM, 2011
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Reduced Resident/Fellow Work Hours
Baldwin et al, JGME, 2010
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Expanding Patient Populations
• Increasing complexity leads to increased subspecialty care• Technology and expertise are increasing
– Command over “new knowledge” is limited to subspecialists– Specialty care can be targeted with focused education
• Traditional Models (Attending/Fellow/Resident) are becoming outdated
• Leads to “hybrid models of care”– Attending + Resident + APP– Attending + Fellow + APP– Attending + Fellow + APP + Hospitalist– Attending + APP
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What is a hybrid and why should I care?
Is it possible that we will all drive electric cars in the future?
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A Hybrid Model of Care
Traditional Model
• Attending physician
• Fellow
• Senior Resident
• 2 interns
Hybrid Model
• Attending physician
• Resident x 2
• APP x 2
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What is the ideal patient for an APP?
Traditional (clinic setting)
Low acuity
Low Intensity
High Complexity / Specialty Unit
NICU
Newer ModelsPICUCICUOncology Inpatient
Newer ModelsERStem Cell Transplant
Newer ModelsGI InpatientCardiology Inpatient
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Where are they now?
• Over 13,000 PNPs practice currently in the United States*– 59% work in primary care
– 64% do not provide care in inpatient settings
• Established settings are not “set”– For every newly graduated NNP, there are up to
80 open positions**
*Freed et al, Pediatrics, 2010**Freed et al, Pediatrics, 2010
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What are physicians planning?
• Survey of 498 pediatric generalists and 1696 subspecialists
Freed et al, Pediatrics, 2011
43% of subspecialists plan to increase thenumber of NPs they use in the next 5 years
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What is the supply?
Freed et al, Journal of Pediatrics, 2010
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How are NPs and PAs trained?
Nurse Practitioners**
• Undergraduate degree (4)
• Clinical time as an RN (?)– Critical thinking
– Targeted experience
• NP Training (2)*– Primary vs. Acute Care
– Practicum times spent in selected specialty
Physician Assistants**
• PA School (2)*– Broad education
– Adult and OR experience
– Limited pediatrics• 6 weeks with primary care
pediatrician
• 4 weeks elective/selective
*Program X ≠ Program Yand
**Graduate X ≠ Graduate Y
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The Ocean of Experience
NP
PA
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How should we educate APPs?
• Role Transition Program– Workshop #1: Laying the Foundation– Workshop #2: Launching– Workshop #3: Meeting the Challenge– Workshop #4: Broadening the Perspective
• Acknowledge that teaching model is different– Probing for knowledge gaps not the norm– Reluctance to ask for help may be even greater than
residents/fellows • Set clear expectations
• Understand your learner’s limitations– Depth and breadth are different– Don’t lose faith in competence
NP
PA
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How should we educate APPs?
• Involve them in research
• Involve them in journal club
• Involve them in the lecture series (give them a turn)
• Involve them…
Show that you want to be involvedWhen an opportunity presents itself,
grab the bull by the horns!
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How do we educate APPs and housestaff?
We may want electric cars, but a model of patient care is probably best as a hybrid…This is a new concept for many physicians you are working with!
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The Ocean of Experience
NP
PA
PGY-2
PGY-1
PGY-3
PGY-6PGY-5PGY-4
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Teamwork – where can we go wrong?
• Attending – APP • Fellow – APP• Resident – APP• Primary Goal = Quality Patient Care
– Avoid Us vs. Them– Encourage ownership– Build Trust
• Ok to acknowledge that there are different backgrounds and frames of reference
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Leadership and Communication
• Medical leadership is needed– Keep the ship on target towards ultimate goal
– Right the ship when needed
– Keep people from jumping ship
• Communication is essential– Goals will change, new hurdles arise
– Growth is expected and expectations will change
Reach out to your medical leadership, be specific in your needs, don’t be discouarged by initial hiccups
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What are we doing in the CICU?
• Teamwork
• Communication
• Leadership
• Focus on Education and Career
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CICU Clinical Discussion
• Weekly meeting
• Includes attendings, fellows, and NPs
• Led by attendings going off service– Who were the most challenging patients?
– What did we learn?
– What can we do differently next time?
– Should we be doing this differently as a group…
If they don’t want to organize this, do it yourself! Learn from each other. It’s less painful to learn from other people’s mistakes.
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CVICU Research Group
• Meets monthly• Goals
– Discuss ideas for research– Develop consensus for protocols– Engage in public humiliation model for
non-production (Alan Nugent, lead protagonist)
• Open to ideas, participation, guests• Engage the community in research
– Fellows, Residents, RNs, NPs, PAs, RTs
This is a great opportunity to make inroads with your physician group and build relationships
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Augmenting education
• Each APP has a faculty mentor– Resource for challenging situations– Educational liaison – Career guidance
• APPs lead journal club– Monthly, occurs outside of work (+ morale)– Mentorship by faculty member
• APPs lead simulation sessions– Critical events– Critical thinking
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Don’t forget about nursing!
• Development of consistent front-line safety net
• Education focused on specialty population– Quarterly education sessions led by medical and
nursing leadership
– Multidisciplinary simulation sessions
• Development of talent– Education, quality, and leadership
Demonstrate how to “bridge the gap”
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2008 2009 2010 2011
Unplanned Extubations
# Ex
tub
atio
ns
/ 10
0 ve
nt
day
s
2007 2008 2009 2010 2011 2007 2008 2009 2010 2011
Blood Stream InfectionsCardiopulmonary Arrests
# In
fect
ion
s /
1000
CL
day
s
# C
od
es /
100
pat
ien
t d
ays
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What are the next steps?
• Diagnosis Related Groups (DRG)– Classification system developed to replace “cost
based reimbursement”
– Used in the U.S. since 1982 for Medicare payments
• All Patient Refined DRG (APR-DRG)– Designed to encompass severity as well as
components of pediatric patient (birth weight, specific pediatric mortality distinctions)
Hospitals are going to start caring a lot about efficient care (LOS, etc.)
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Clinical Pathways: Effects on Professional Practice, Patient Outcomes, Length of Stay, and Hospital Costs
▶ A structured multidisciplinary plan of care.
▶ Used to channel the translation of guidelines or evidence into local structures.
▶ Detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other "inventory of actions".
▶ Possess time-frames or criteria-based progression (ie. steps were taken if designated criteria were met).
▶ Aimed to standardize care for a specific clinical problem, procedure or episode of care.
Rotter et al, Cochrane Database Syst Rev, 2010
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How does a clinical pathway help?• Defines a pathway in a chaotic environment• Improves clinical efficiency and communication• Identifies outliers to the clinical team
– Why is this patient different?– Differences must be documented!
• A well-designed protocol does not constrain decision-making
• Protocol-driven care does not replace clinical judgment
• Continual appraisal can be used to modify protocols and adapt new strategies
This may help NPs everywhere to stay sane!Get involved with design and implementation!
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Summary
• There will be continued need for hybrid models of care as resident and fellows hours are restricted
• Training and educational needs are different amongst APNs, PAs, residents, and fellows
• Leadership and communication are essential to retention and satisfaction
• Importance of tracking quality cannot be overstated– Patient Care– Financial Implications
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Acknowledgements
Joshua Wolovits
Joe Don Cavender
Lisa Milonovich
Jean Storey
Jeff McKinney