Designing a Toolkit to Navigate a Large Health Care System ...€¦ · Transforming Practice Team...
Transcript of Designing a Toolkit to Navigate a Large Health Care System ...€¦ · Transforming Practice Team...
Designing a Toolkit to Navigate a Large Health Care
System in Relationship-Based Care Adoption
Paula Thomas, RN, DNP
Chief Nursing Officer and Vice President, Patient Care Services, UPMC Bedford
Michelle Luffey, RN, MSN, NE-BC
Clinical Director of Neurosciences, UPMC Presbyterian
Melissa Kolin, DNP, CRNP
Chief Nursing Officer and Vice President, Patient Care Services, UPMC Horizon
No Disclosures
Learning Objectives
• Describe Relationship-Based Care model
implementation and spread at the business unit utilizing
electronic technologies.
• Describe assessment of business unit readiness to
transform practice in care delivery.
• Describe components of the comprehensive toolkit with
the Structure, Processes and Outcomes to implement
Relationship-Based Care.
UPMC
Western Pennsylvania 29 Counties and UPMC Hospital Facilities
UPMC Hospital Facilities
Relationship-Based Care Model
• As a healthcare system that spans western
Pennsylvania, it was important to have a common
language to deliver care.
• In 2007 a multidisciplinary team was formed with the
challenge - In concert with creating the best patient care
experience, build the conceptual framework (philosophy)
and delivery model for patient care that supports
consistent, innovative, and effective care that fully
integrates the patient and family as partners in care.
Relationship-Based Care Model
This team accomplished:
• Exploration of contemporary philosophies of patient care
• Made a recommendation for Relationship-based care; UPMC Care
• Clarified and crystallized the behaviors essential of all health care
providers to actualize the philosophy of care
• Identified patient and family requirements and clarified expectations
essential to leveraging partnership in care
• Integrated innovations in care delivery into existing systems of care
• Started building the requirements of this system into the
performance management infrastructure, including education,
orientation and job evaluations.
RBC Implementation Challenges
Relationship-based care was not adopted throughout the health
system
• Business units were at various levels of development and
adoption.
• Nurses were not clear on model and base in nursing theory.
• Business units were represented by various departments and
levels of personnel and education and spread were not
consistent.
Transforming Practice Team
• A second multidisciplinary team, with key nursing
representation from all hospitals, was established in 2009 to
examine care delivery models and transform practice.
• The work of the first group was morphed into this new group.
• Several team members also joined the Transforming Practice
Team.
• Both teams had representation from all system hospitals.
Transforming Practice Team
The Transforming Practice Team goals included:
1. Assess Business Unit readiness
2. Continue Relationship-based Care model implementation and spread at
the BU level
3. Develop a comprehensive toolkit with the Structure, Processes and
Outcomes to implement RBC
4. Mentor hospitals will form a team and utilize these tools and the “How to
Guide”
5. Serve as an expert group to assist members to lead their hospital team.
Relationship-Based Care Model
• The system readiness survey revealed the existence of a
shared vision for relationship-based care
• AONE Guiding Principles on Patient Care Delivery and
the Pathway to Excellence Program form a basis for our
toolkit
• Various tools were devised around the principles of
structure, process and outcome.
Relationship-Based Care Model Spread
• Transforming Practice Teams were developed at
all Business Units
• Tools to assist in training and spread were
introduced
– System Nursing Grand Rounds
– Newsletter articles
– Electronic technologies
– Shared access website
Nursing Grand Rounds
• Live monthly presentations
• Archived via electronic education modality for review at
any time
• Contact hours provided
• Forum to:
– Educate on Relationship Based Care
– Educate on Nursing Theorists and Caring Theories
– Present best practices
– Share work accomplished at Business Units.
Learning Management System
• Internal online electronic education tool
• Nurses can view Nursing Grand Rounds at their
convenience on any computer that has internet access
and at any time.
• Eliminated the need to repeat the learning activities all
across the system to ensure the message remained
consistent
Shared Access Website
SharePoint
• Web based enterprise information portal, that is
configured to run on the UPMC internal server.
• This site is accessed by all the members of the TPT and
it stores all the supporting documents, presentation,
templates, meeting agenda and minutes, links to
relevant web sites and resources.
Shared Access Website
• Provides online discussions option
• Access to relevant documents
• Eliminated need for shared papers and cumbersome emails
• One stop resource
• Many BUs have created their own local SharePoint to
replicate the model within their facility
Shared Access Website
Transforming Practice Team
• Our overarching goal is the spread of a patient centered
care delivery model across our health system and
weaved into our culture.
• To ensure sustainability, this team continues to meet,
share best practices, and add electronic resources.
• Each BU will re-evaluate its readiness survey annually
and report back to this steering committee.
Relationship Based Care
Readiness Survey
Michelle Luffey, RN, MSN, NE-BC
Clinical Director of Neurosciences, UPMC Presbyterian
In the early stages of our group development we
determined a list of questions that we felt could
help us to assess our readiness for
Implementation of Relationship Based Care.
These questions were formatted into a Survey
using Survey Monkey and sent out to all of the
Chief Nursing Officers of our 12 hospitals.
We asked if the hospital had participated in the
original Relationship Based Care project, had RBC
been spread to other units from the initial pilot unit(s)?
• We found that only 1 of our 12 hospitals had been
able to spread throughout their nursing division,
while the rest of the hospitals that had
participated had not moved beyond the initial unit
or 2 that they had piloted on.
• This led to a discussion of creating a “toolkit” that
could be used by the Business Units to assist in
implementation and spread.
We asked if your nursing department utilized a
nursing theorist or theory and if yes was it one of
the Caring Theories?
• 5 of 12 replied yes and all indicated the use of Jean Watson’s Caring Theory as their framework.
• One of the first “tools” added to the kit was a presentation on Caring Theories. The nurses at the table could barely speak to Jean Watson or any other caring theory, as well as, we had many non-nursing disciplines represented in the group.
We asked if they were following the AONE
Guiding Principles for Patient Care Delivery?
• 8 of our 12 facilities indicated yes to this
question, but since there were some who
were not, this also was added to the
“toolkit” for reference.
We asked if they had a Shared Governance
Model in place at the Organizational Level?
• Most of our facilities indicated they had a
Shared Governance Model in place at the
system level.
• Approximately 50% of them were still in
the developmental stages but were
progressing.
We asked if they had a Shared Governance
Model in place at the Unit level?
• This was where there again was more
opportunity as not all of our organizations
had unit based Shared Governance and of
those that did, again only 50% were well
developed.
• A detailed Step by Step guide to creating a
unit based council called “A Journey to
Developing a high Performance Team”
was added to the toolkit.
We asked if they had implemented any of
the Forces of Magnetism?
• Most of the hospitals in the system were
somewhere on the journey to Magnet and
therefore were implementing the forces.
• 2 of our facilities have achieved Magnet
Status.
• Several of our smaller facilities are
exploring the Pathway to Excellence
Program which is less resource intensive.
We asked if they belonged to NDNQI to
benchmark nurse sensitive indicators of quality?
• Since one of the outcome measures we
chose was to look at nursing sensitive
indicators, it made sense to have all of our
facilities belong to NDNQI that would allow
us to benchmark against ourselves as well
as other facilities.
• As of July of 2010 all of our facilities are
members.
We asked what Care Delivery Models they used
in ICU, Step-down/Telemetry, Medical/Surgical
and Rehab?
• The choices included
– Primary - Total Patient Care
– Modified Primary - Team
– Innovative - Functional
• We only found one unit in one hospital still
using functional nursing, which we felt was
good as RBC can easily be integrated into all
of the other models
We asked how RNs were scheduled in ICU,
Step-down/Telemetry, Medical/Surgical and
Rehab units?
• The majority of the nurses in all of our
departments were working either 8 & 12
hour combinations or straight 12 hour
shifts.
• This was one of the challenges that we all
face in trying to create continuity of care
while balancing staff satisfaction.
We asked what Scheduling Practices were Employed in
their ICUs, Step-down/Telemetry, Medical/Surgical and
Rehab units?
• Most of our units used some type of self scheduling or modified self scheduling.
• Given the concerns over the continuity of care issues raised by the 12 hour shifts there was recognition that some education related to trying to at least get 2 days back to back to promote continuity of care would need to be provided to the staff who were self scheduling.
We asked what was the PRIMARY focus in
Completing Patient Assignments in their ICUs, Step-
down/Telemetry, Medical/Surgical and Rehab units?
• There was far more emphasis on Acuity and
Geography than on continuity of care.
• This again presented an opportunity to
recognize the potential need for education as a
Business Unit was rolling out RBC in refocusing
some of the patient assignment practices on
providing continuity of care to help build the
caregiver – patient relationship.
We asked what was the PRIMARY focus in
Completing Patient Assignments in their ICUs, Step-
down/Telemetry, Medical/Surgical and Rehab units?
• There was far more emphasis on Acuity and
Geography than on continuity of care.
• This again presented an opportunity to
recognize the potential need for education as a
Business Unit was rolling out RBC in refocusing
some of the patient assignment practices on
providing continuity of care to help build the
caregiver – patient relationship.
We asked if there was any type of
Interdisciplinary Rounding occurring in their
facility?
• 11 of the 12 hospitals had some type of interdisciplinary rounding although for some it was in small pocketed areas.
• As we rolled out RBC we wanted to insure this was not just a nursing measure but rather encompassing all disciplines that touch the patient.
• Continued spread of Interdisciplinary rounding was one way of pulling other disciplines into Relationship Based Care.
Tools were added to the “Tool Kit” based on the
survey responses, but additional tools were added
as work continued and needs were identified.
• An example of this was a discussion
related to culture change versus hiring the
right people with the right skills in the first
place which led to the creation of a
Behavioral Based Interview guide that is
now used throughout the system during
the nursing interview process.
Relationship Based Care Toolkit
Melissa Kolin, DNP, CRNP
Chief Nursing Officer and Vice President, Patient Care Services, UPMC Horizon
How To Get Started: The RBC Toolkit
• Recommended multidisciplinary membership at
the business unit level
• Utilize Readiness Survey for first meeting to
assess
• Utilize Share Point and How To Get Started
Guide
• Utilize Structure/Process/ Outcome model
Structure
Structure categories components of
content that are included in the Toolkit:
• Shared governance
• Relationship Based Care
• AONE Care Delivery Principles
• Caring Theories-Sharon Dingman’s
The Caring Model™
• Journey to Excellence
• Healthy Work Environments
Process
Process categories/components of content
that are included in the Toolkit:
• Hiring/Employment
• Education
• Communication
• Schedule/Assignment
Hiring/Employment
• Behavioral Interview Tool Developed for Toolkit
What led you into nursing as a career?
We all go into nursing with preconceived ideas of
what it is. Tell me about something that has pleasantly
surprised you/disappointed you/ something you didn’t
expect or realize about the nursing profession.
• Competency Defined
Displays a positive attitude and disposition to patients
and family members through both verbal and non-
verbal cues.
Hiring/Employment: Competency Criteria
Acknowledges patients by name
Introduces him/herself by identifying name and title and
explaining role
Smiles and provides eye contact, especially when
greeting patients and family members
• Sample Interview Questions to Assess Friendliness
Tell me about a time when you built rapport quickly with a
patient or family member under difficult conditions.
It is important to maintain a positive attitude at work when
you have other things on your mind. Give a specific
example of when you were able to do that.
Education
Determined target audiences for additional
educational session beyond information
presented in Nursing Grand Rounds
• Teaching delegation skills
• Interdisciplinary staff education
• Patient education
• Role clarification
Components drive what educational content needs to
be provided
Communication• Communication Standards
Quality Rounds
Interdisciplinary Rounds
Whiteboards
• Communication Standards: based upon Dingman’s work
Care-giver: Patient/Family Communication
Introduce Self
Call patient by preferred name
Appropriate touch and non-verbals
Be engaged with patient (eye contact, sit with patient)
Review plan/tests/desired outcomes with patient
Interdisciplinary Communication
Use SBAR as framework
Communication: Interdisciplinary Rounds
Definition/Goal Establishment: Provide interaction
and collaborative care delivery focused on optimal
patient outcomes
Quality Rounds
To assess and monitor the care delivery model(s) impact
on achieving patient outcomes
Members: quality/performance improvement department,
physician, nursing, and other disciplines as appropriate
based upon patient population and topic
Frequency
Scheduling/Assignments
• Scheduling practices/Structure of Care
HPPD, RN/Patient ratios,
Staff continuity of care (8 hr, 12 hr, 2/more days in a
row)
• Assignments/Process of Care
Models of Care: Four care delivery models from RWJ
website
Continuity of Care/acuity based vs. geographically
based
Assessment and implementation of patient care,
patient education, discharge planning, patient safety
The UPMC
Relationship-Based Care Delivery ModelOutcome Measurements
• Based on American Nurses Credentialing Center (ANCC),
ANCC Magnet Recognition Program and the National
Center for Nursing Quality (NCNQ), Institute of Medicine
(IOM) and the Joint Commission.
Three Outcomes tools will be utilized in the Toolkit;
• National Database for Nursing Quality Indicators (NDNQI)
• Press Ganey patient satisfaction
• Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAPHS)
NDNQI: Definition and Value
The National Database of Nursing Quality
Indicators® was established in 1998 by the American Nurses
Association in response to ANA’s Safety and Quality Initiative.
ANA’s goals in developing the NDNQI were:
1. To provide member hospitals with unit level comparative data for
quality improvement activities.
2. To establish a national data resource for investigating the relationship
between nursing and patient outcomes.
NDNQI has over 1,700 participating U.S. hospitals that use NDNQI data to
improve patient safety and quality of patient care.
“Transforming Data Into Quality Care” National Database of Nursing Quality Indicators ®
NDNQI: Outcomes Data AvailableIndicators Available:• Patient falls and Patient falls with injury
• Pressure ulcers: – Community acquired, Hospital acquired and Unit acquired
• Unit Skill mix
• Nursing care hours per patient day
• RN education & certification
• Pediatric pain assessment cycle
• Pediatric IV infiltration rate
• Psychiatric patient assault rate
• Restraints prevalence
• Nurse turnover
• Healthcare-associated infections:
– Ventilator-associated pneumonia (VAP)
– Central line-associated blood stream infection
(CLABSI)
– Catheter-associated urinary tract infections
(CAUTI)
• RN Survey Includes evaluation of:
– Job Satisfaction
– Practice Environment
Comparisons:
• NDNQI provides a quarterly information stream that
includes national comparison data.
• The NDNQI data allow staff nurses and nursing
leadership the opportunity to review their data and
evaluate nursing performance relative to patient
outcomes.
• This information can be used to establish
organizational goals for improvement at the unit level.
• Progress in both improving the care of patient and the
work environment of nurses can be monitored.
• The RN Survey assists facilities in their your efforts to address staff needs, improve their work environment and focus initiatives towards staff retention and recruitment.
• RN job satisfaction is measured at the unit level, just as all other indicators included in the NDNQI®.
NDNDI and Relationship-Based Care
• NDNQI measures the structure, process and outcomes of
patient care delivery and the healthcare environment
through its various indicators.
• The focus of Relationship-Based Care is the
establishment of caring relationships with ourselves, our
colleagues and our patients and families.
• These relationships support optimal structure in our work
environment, promote the development of evidence-based
processes for patient care to deliver the best possible
patient outcomes.
NDNQI: Nursing Sensitive Measures
Nursing-sensitive measures reflect the
structure, process and outcomes of nursing
care.
• Structure of Care - The characteristics of the environment
in which the care is provided.
• Process of Care – The methods of providing care or what
is actually done to or for the patient.
• Patient Outcomes Indicators – The direct result of
receiving the care or performing a particular action. They
improve if there is a greater quantity or quality of nursing
care.
UPMC Horizon
RN Educational Level
UPMC Horizon Falls with Injury
UPMC Horizon HAIs
UPMC Outcomes Measurement
Corporate CNO Nursing Report Card
Benchmarking Business Units within the
UPMC Health System
• Structure of Care – HPPD, ratios, staff continuity of care
(staff scheduling 8 hr, 12 hr, days in a row), turnover
• Process of Care – Assessment and implementation of
patient care, patient education, discharge planning,
patient safety
• Outcome Indicators - Nurse sensitive indicators,
patient/family satisfaction
UPMC CNO Nursing Report Card
Patient Satisfaction
8G Unit at UPMC Presbyterian
• STANDARD: Q1 hour rounds completed effectively
• ISSUE: Q1 hour rounds were not being completed effectively and RNs were not getting an uninterrupted break.
• VISION: Increase patient satisfaction and deliver competent, compassionate care during the patient’s entire stay on 8G. All Staff to get an uninterrupted lunch.
• Strategic Goal: Consistently increase the Press Ganey
Scores and keep the scores at 95% or higher
Action Plan
• Decision made to adopt a Buddy system. Teams of two RNS would be established
• It was decided that each RN would give a mini report to their partner RN at the beginning of the shift
• Charge Nurse would make assignments and there would be
no changes by the oncoming shift or calling the unit to make
requests.
• PCTS assignments would change to be assigned to two
RNS.
• There would need to be effective communication with the
team members throughout the day to ensure everyone was
aware of any changes.
Patient Satisfaction Results
Nurses Section Overall Score
75.0
80.0
85.0
90.0
95.0
Sep
200
9
Oct
200
9
Nov
200
9
Dec
200
9
Jan
2010
Feb
2010
Mar
201
0
Apr
201
0
May
201
0
Jun
2010
Jul 2
010
Aug
201
0
Sep
201
0
Oct
201
0
Nov
201
0
Dec
201
0
Jan
2011
Patient Satisfaction Score
Patient Satisfaction
2W Unit at UPMC Horizon
• 2 West, a 32 bed medical-surgical unit in a rural
community hospital
• Leadership transition, poor patient satisfaction,
multiple patient complaints related to nursing
care, communication and attitude
• Implementation RBC with consistent 1 hour
rounding with scripting; use consistency among
rounders; daily leadership rounding
2W Unit Patient Satisfaction Dashboard
UPMC Horizon Inpatient Patient Satisfaction
Post-Implementation of RBC
83.9
82.2
83.082.8
84.0 84.1 84.0 84.084.3
85.686.0
86.7
79.0
80.0
81.0
82.0
83.0
84.0
85.0
86.0
87.0
88.0
Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Fe b-11
Inpatient Horizon
Inpatient Horizon
Linear (Inpatient Horizon)
HCAHPS
• Survey is designed to produce data about patients’ perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Public reporting serves to enhance accountability in health
care by increasing transparency of the quality of hospital care provided in return for the public investment.
There are 27 total questions pertaining to the recent hospital stay.
HCAHPS
HCAHPS results are publicly reported on the
Hospital Compare website, found at
www.hospitalcompare.hhs.gov.
• Increasingly technologically savvy patients and families
utilize this web site when choosing where to have care
provided
• Center for Medicare and Medicaid (CMS) use HCAHPS
scores to impact the facility under Pay for Performance
initiative
HCAHPS Survey
Survey: Communication/Care from Nurses
During this hospital stay, how often did nurses treat you
with courtesy and respect?
During this hospital stay, how often did nurses listen
carefully to you?
During this hospital stay, how often did nurses explain
things in a way you could understand?
During this hospital stay, after you pressed the call
button, how often did you get help as soon as you
wanted it?
HCAHPS Survey
The survey also includes many questions
related indirectly to nursing care:
• During this hospital stay, how often was the area
around your room quiet at night?
• How often did you get help in getting to the bathroom
or in using a bedpan as soon as you wanted?
• During this hospital stay, how often was your pain well
controlled?
Overall Rating of Care/Hospital
• Using a number from 0 to 10, where 0 is the
worst hospital possible and 10 is the best
hospital possible, what number would you
use to rate this hospital during your stay?
• Would you recommend this hospital to your
friends and family?
HCAHPS Report
UPMC Horizon
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
n=222 n=225 n=230 n=196 n=192 n=181 n=203 n=206
Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11
Overall rating of hospital equal to 9 or 10 (best hospital) % of HCAHPS respondents who rated UPMC Horizon as 9 or 10 (out of possible 10) UPMC ≥65%
Recommend this hospital -Definitely Yes % of HCAHPS respondents who answered "definitely yes" to recommending UPMC Horizon UPMC ≥62%
Linear (Overall rating of hospital equal to 9 or 10 (best hospital) % of HCAHPS respondents who rated UPMC Horizon as 9 or 10 (out of possible 10) UPMC ≥65%)
UPMC Shadyside 4 Main
Improved Outcomes Through RBC
Patient
Fall Rate
Fall Prevention Education
Hourly
“Purposeful”
Rounding
Decrease in
Patient Falls
“Rounding with Purpose“The premise of this project is that by
rounding on patients with the "Purpose" and focus of a comprehensive assessment of
patient needs, comfort issues, and potential safety concerns, on can improve
patient/nurse communication, patient/family
satisfaction, patient safety and reduce patient stress and anxiety during the hospital
experience ...
HCAPS Results: UPMC Shadyside 4 Main
Timeliness
of Pain Medication
Delivery
Spectralink phones for
staff
Phone number
on white board
Improved Pain Management and Communication
HCAHPS 2008 2009 2010
Communication w/ Nurses 66.0 67.5 73.0
Response of Hospital Staff 40.6 45.7 51.4
Pain Management 67.4 68.3 73.8
Questions???