NICHE Benchmarking & Evaluation: GIAP · Type of unit: (same) Unit 1 Unit 2 Unit 3 Subscale Age...

nicheprogram.org • 2015 Annual NICHE Conference • Innovation Through Leadership 1

NICHE Benchmarking & Evaluation: GIAP

Sue Nickoley, MS, RN, GCNS-BC Geriatric Clinical Nurse Specialist

RGH NICHE Coordinator

[email protected]

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Understanding & Using the GIAP Survey to Make a Difference: NICHE Stories & Numbers…

BACKGROUND & CONTEXT

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Create a NICHE Program of Care and Evaluation*

IRB approved* 3

mailto:[email protected]


(University of Wisconsin-Extension, 2007)

NICHE… a “Complex Intervention”

Select your evaluation method…

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Program Evaluation Research Logic Model

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Use a Framework

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RGH NICHE Program Mission Apply NICHE & Magnet evidence-based standards & resources to

build, evaluate & sustain a healthsystem culture of geriatric excellence that improves outcomes

NICHE Magnet Alignment

Identify your Program Strategies

1. Conduct program evaluation studies on building & evaluating geriatric evidence-based best practice standards.

2. Build & sustain the GRN model of care to improve geriatric nursing expertise, competencies & facilitate certification.

3. Facilitate Age matters! awareness, GRN visibility, voice in decision-making, identity & role as a geriatric nursing leader & achievement & documentation of outcomes.

4. Implement geriatric evidence-based best practices to improve patient/family outcomes.

5. Build an effective & supportive work environment that delivers age sensitive geriatric care.

6. Facilitate clinical integration of the NICHE model across Rochester Regional Health System.

7. Collaborate with national NICHE program & other NICHE hospitals to improve the community standard of geriatric nursing excellence. 6


• Increased # GRNs, # units, # completing GRN Core Course, role activities, outcome documentation, # certified, positive program evaluations

• Increased number of practice improvements

• Increased NICHE program implementation

• Magnet narratives reflect NICHE standards embedded

• Improved GIAP survey results

• Improved patient & family experience & outcomes

Define your evaluation criteria

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Outcomes:

What difference does your NICHE program make?

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“Align & Embed” your NICHE Program

Professional Practice Model

PREPARE FOR THE SURVEY

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The voice of the bedside nurse matters!

“Your answers provide an accurate picture of what bedside nurses know & believe about the care of our older adult patients & how the RGH practice

environment helps or hinders you in providing the best geriatric care possible.”

Using evidence to build & evaluate geriatric best practices

Identify who you want to take the survey & why

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Identify your survey purpose & timeline

Nov

2006

Nov

2007

Nov

2008 Mar

2011

Nov

2012

Nov

2013

Pre Intervention • Establish

baseline

Pre & Post Intervention • Compare to national benchmarks

• Explore open ended question responses

• Triangulate data

• Identify issues & opportunities for improvement

Post intervention

• Document the impact of by trending

Nov

2014

Nov

2016

Nov

2015

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Communicate to increase awareness

& buy in

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Make survey process decisions

• Link Structure-Process-Outcome

• Define level of excellence: outperform the mean of

the national benchmark used* • For Magnet reporting, RGH benchmarks NDNQI data

by hospital size

• Link evidence to Action Planning

• Trending: At least 3 post intervention data points*

*http://www.nursecredentialing.org/2014-MagnetManualUpdates

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Involve GRNs & Others

“Ownership-Engagement-Accountability”

From the RGH RN role description

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Participates in the RGH GIAP survey process: Facilitates • Unit participation • Results dissemination • Action planning & implementation

Communicate key messages

in writing

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Facilitate easy access

to the survey

“Print screen images” 16

ADMINISTER THE SURVEY

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Send a direct invitation & access link

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Geriatric CNS Rounding • Chocolate rounds- ”visibility” & “thank you” • Survey trouble-shooting

GRN or champion(s) on units CNO emails to support Tips on actions to take to improve response rates Raffle drawings

Survey response “facilitators”

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MONITOR RESPONSE RATES

• Obtain unit denominators • Seek representativeness • Rounding & problem-solving • Ongoing emails:

“How are we/you doing?” Tips to improve rates

• Use of challenges/competition

Consider what might help?

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UNDERSTAND, SUMMARIZE & COMMUNICATE YOUR GIAP EVIDENCE

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GAP ANALYSIS: HOW ARE YOU DOING?

What are we doing well (strengths)?

How do we compare to best practices & others who are doing it better (benchmark)?

How can we raise the bar beyond the highest benchmark (“getting to zero”)?

Where is our variation…what do we need to improve (gaps/weaknesses)?

How do we know that our NICHE practice changes are resulting in improvements (trending)?

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Review your demographics

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Review your demographics

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HOSPITAL LEVEL EVIDENCE

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Knowledge Area

2006 n=504

2007 n=410

2008 n=401

2011 n=516

Pressure Ulcers ** ** **

Sleep ** ** ** **

Incontinence * ** ** **

Restraints ** ** **

Outperforms mean national benchmark

* Statistically significant

RGH Knowledge-Benchmarking

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Knowledge Area

2006 n=504

2007 n=410

2008 n=401

2011 n=516

Pressure Ulcers

Sleep

Incontinence

Restraints

Improving score

Declining score

RGH Knowledge-Trending

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AN ACTION PLAN STORY:

“BEYOND KNOWLEDGE” & “MORE THAN A COMMITTEE”

Building & evaluating the RGH GRN Model of Care

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Identify & describe what’s in your NICHE “black box”… transparency to benchmark processes and outcomes

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Conducted an evidence review to identify best practices

Nickoley, S. (2010) Resource nurse models of care: An organizational strategy to improve nurse expertise and patient outcomes. ANCC National Magnet Conference, Phoenix, Arizona 30


Define & describe the components of your GRN model

GCNS provides leadership, facilitation, mentored learning & ongoing support

Education with standardized curriculum (national) Certification preparation/facilitation Identified competencies with skill validation Formal role description Ongoing professional development Ongoing meeting forum Access to external resources & learning community Organizational commitment & support

Dedicated time for role development/ activities Access to resources, removal of barriers Recognition & incentives

Model linked to other hospital initiatives in the specialty Steering group Nickoley, S. (2010) Resource nurse models of care: An organizational strategy to improve nurse expertise and patient outcomes. ANCC

National Magnet Conference, Phoenix, Arizona 31

Build & sustain the RGH GRN model of care to • Improve geriatric nursing

expertise & competencies & facilitate certification

Implement & evaluate strategies

Facilitate • Age matters! awareness • GRN

• Visibility • Voice in decision-making • Identity & role as a geriatric

nursing leader • Achievement &

documentation of outcomes 32

Define GRN role & expectations

Obtain Nurse Manager support

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Build & evaluate GRN education & outcomes

More discussion available at poster session tonight

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Knowledge Area

2006 n=504

2007 n=410

2008 n=401

2011 n=516

2012 n=605

2013 n=700

Pressure Ulcers

Sleep

Incontinence

Restraints

Improving score

Declining score

RGH Knowledge-Trending Post Intervention

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RGH Knowledge-Benchmarking Post Intervention

2014 (new survey)

Knowledge Area RGH n=578

Teaching Size

Pressure Ulcers

Meds/ Sleep/Pain

Restraints/Falls

Functional decline/ Incontinence

Dementia/Delirium *

Nutrition/Hydration * *


Below the mean national benchmark * Statistically significant 36


RGH Geriatric Attitudes Post Intervention

2014 (new survey) Attitudes RGH

n=578 Teaching

Size

Total attitudes

Evidence-based approaches

Restrictive approaches


Below the mean national benchmark

* Statistically significant 37

RGH Professional Issues-Benchmarking 2014

Professional Issues RGH N=578

Teaching

Size

Disagreements among staff * *

Disagreements between staff & patient /family

*

Limited access to geriatric services

*

Perceived legal vulnerability * *

Intensity behavioral problems

Burden behavioral problems * *


Below the mean national benchmark *Statistically significant 38

AN ACTION PLAN STORY:

Delirium/Dementia/

Cognitive Impairment/Understanding Behavior

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RGH Professional Issues-Behavior-Trending

2006 n=504

2007 n=410

2008 n=401

2011 n=516

2012 n=605

2013 n=700

2014 n=578

Intensity

Burden

Improving score

Declining score

Behavioral

problems

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Delirium

Evidence-based Practice Review & Protocol

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Understand & link to your EMR build

Delirium Risk Screen CAM Provider alert High risk medications Plan of Care Interventions

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HEARING AMPLIFIERS

LOCATED HERE

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Conducted an evidence review to understand care through a patient family centered lens

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Created a patient family centered care framework

45 Quote sources: Bridges, J. et. al.,(2010); Boltz, M. et.al. (2010); Schmidt, L. (2010)


Family & Staff Education

Interventions

46

GRN & Volunteer Interventions

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RGH Knowledge-Benchmarking 2014 (new survey)

Knowledge Area RGH n=578

Teaching Size

Meds/Sleep/Pain(sedative-hypnotic)

Restraints/Falls (risk factor delirium)

Dementia/Delirium *


Below the mean national benchmark * Statistically significant 48


RGH Professional Issues-Behavior-Benchmarking

Behavior Subscale

2006 n=504

2007 n=410

2008 n=401

2011 n=516

2012 n=605

2013 n=700

2014 n=578

Intensity of behavioral problems

** ** TS

Burden of behavioral problems

** * ** ** ** **


Below the mean national benchmark 49

T= teaching S=Size *Statistically significant

Type of unit: Unit 1 Unit 2 Unit 3

PROFESSIONAL ISSUES 2014 2014 2014

Intensity Behavior 7.5 6.8 8.2

Burden Behavior 3.3 3.8 3.4

RGH Professional Issues 2014 Unit-level comparison

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A lower score is better

COMPARE BY UNITS

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Benchmark Worksheet Type of Unit: (same) Unit 1 Unit 2 Unit 3 Benchmark Benchmark

KNOWLEDGE (2014) Size Teaching

Total Knowledge

Pressure ulcers

Medications/Sleep/Pain

Restraints & Falls

Functional decline & Incontinence

Dementia & Delirium

Nutrition & Hydration

KNOWLEDGE (2013)

Pressure Ulcers *

Sleep *

Incontinence * *

Restraints * *

*Statistically significant Below mean national benchmark Outperforms the mean national benchmark 52

Type of unit: (same) Unit

1 Unit 1

Unit 2

Unit 2

Unit 3

Unit 3

PROFESSIONAL ISSUES 2013 2014 2013 2014 2013 2014

Disagreement Among Staff Disagreement Patient Family Staff

Limited Access Services

Legal Vulnerability

Intensity Behavior

Burden Behavior

RGH Professional Issues-Unit Trending

53 Improving score Declining score

Type of unit: (same) Unit 1 Unit 2 Unit 3

Subscale Age Sensitive Care Delivery 22.7 24.8 29.7 Institutional Values 17.2 18 19.6 Resource Availability 14.9 18.7 17.1 Capacity for Collaboration 7.6 8.2 8.4 Total GCE 62.4 69.6 74.8

2014 RGH Geriatric Care Environment (GCE) Same Type of Unit Comparison Scores

Best score within same type of unit


COMPARE ALL GIAP QUESTIONS ON TOPIC

Pressure Ulcers & CAUTI

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Pressure Ulcers & CAUTI related GIAP questions

Knowledge (5)

• Donut shaped cushions/Braden score/skin color

• Securing catheters/Periurethral area cleaning

Attitudes (2)

• Organization values time spent

– preventing pressure ulcers

– managing urinary incontinence

Professional Issues (3)

• Staff disagreement about treatments

• Staff/Family/Patient disagreement about treatments

• Perceived legal vulnerability

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Open Ended Question Themes- Skin/Incontinence

• Skin/pressure ulcers (14) • Taping/placement & removal of multiple EKG patches

(3)/need smaller EKG patches (2) • MD & staff education on use of catheters (2) &

recognizing CAPU • Incontinence management with floors busy (3) • Insufficient rounding (staffing)/assessments of skin • Adequate hygiene (3) • Not enough staff/PCT/Education/Time • Mobility/turn & position/Turn & position teams (4) • New mattresses cumbersome/absence of bladder

scanner/more chairs/raised toilet seats • Lack of space to accommodate equipment-

commode/bigger rooms/wider bathroom doors 57


Facilitate a stakeholder meeting

Review Patient Clinical Indicators • Pressure ulcers • CAUTI

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DRILL DOWN TO UNDERSTAND CHANGE

Age Sensitive Care Delivery

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GERIATRIC CARE ENVIRONMENT RGH AGE SENSITIVE CARE DELIVERY (ASCD) SCORES

ASCD 2006 2007 2008

2011 2012

2013 2014

T=Teaching S=Size * Statistically significant

Below mean national benchmark

Outperforms the mean national benchmark

Trending ASCD 2006 2007

2008

2011 2012

2013 2014

Improving score Declining score

Benchmarking ** * ** ** ** T* S


RGH Aging Sensitive Care Delivery Differences by Individual Question 2013 2014 Difference

Staff individualize care 0.30566398

Older adults receive the medical care they need 0.35998352

Staff address issues about geriatric care 0.30531973

Staff are familiar with how aging affects response to treatment

0.35353729

Aging is considered a factor in planning/evaluation 0.34597802

Older adults receive the information they need to make decisions about their care

0.32163346

Families receive the information and support they need to help their older family members

0.329142164

Staff obtain information about older adults' pre-hospitalized baseline

0.314768287

Adequate continuity of care across settings 0.23909872

Adequate continuity of care across hospital units 0.24704177 61

RGH Aging Sensitive Care Delivery Question Grouping by Score

• Older adults receive the medical care they need

• Staff are familiar with how aging affects response to treatment

• Aging care is considered a factor in planning and evaluation

• Families receive the information and support they need to help their older family members

• Older adults receive the information they need to make decisions about their care

• Staff obtain information about older adults' pre-hospitalized baseline

• Staff individualize care

• Staff address issues about geriatric care

• There is adequate continuity of care across hospital units

• There is adequate continuity of care across settings 62

EXPLORE OPEN ENDED RESPONSES

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2014 RGH Open Ended Questions (OEQ) Number of Responses

GIAP Sample size 578

Responded to OEQ (usable information) 368 (64%)

Q1 What are the most pressing issues you currently face in caring for older adults?

337 (92%)

Q2 Do you have any reactions to a particular issue raised by this questionnaire?

93 (25%)

Q3 What would help improve care for older adults?

293 (80%)

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GIAP Open Ended Questions Worksheet

Themes (2014) Number (%) of Responses

Staffing/Time issues 251 (68%)

Delirium/Dementia/Behavior 132 (36%)

Survey process/content

Education

Falls Environment/equipment

Family/Decision making

Transitions

Insurance/financial

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Unit Level Survey

NICHE Program Evaluation Survey

CAN YOU TRIANGULATE YOUR GIAP RESULTS WITH OTHER EVIDENCE?

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Patient Clinical Indicators

Nurse Satisfaction

Patient Experience


NICHE Program Evaluation Survey Criteria

46. Evaluates alignment…through a GIAP & one additional measure

Patient clinical (NDNQI Outcomes)-Financial (Readmissions, Never Events)-Organizational (Staff Turnover)

47. Shares results and supports follow-up activity of program evaluation with stakeholders

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COMMUNICATING & SENSE MAKING

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Using evidence from the voice of bedside nurses

to improve geriatric care & outcomes

Identify your sense makers & stakeholders

• Bedside nurses (“survey voices”)/Units

• NICHE Steering Committee

• Nursing management-CNO, DON, NM

• Nursing shared governance

• Geriatric Resource Nurses

• Nurse Council

• Education Council/CNS Council

• SWAT team

• Patient Family Advisory Council

• Others

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Assess current reality through the

voices & experiences of bedside nurses

Sense making…the process by which people give meaning to & interpret experience

– Develop a deeper understanding of evidence & themes

– Identify geriatric strengths/challenges/unmet needs

– Explore solutions/opportunities for improvement

70 Liedtka & Ogilvie* (2011), Kumar (2013)

What is?*

Facilitate sense making conversations

Why do you think nurses answered the question(s) that way? Can you give us an example to illustrate-verify-clarify-amplify? What can WE do to improve care & outcomes? It takes a village: ownership-engagement-accountability Did we miss anything or is there something new you would like to add?

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Listen twice: A “GIAP” voice & a “sense making” voice

This is what our nurses told us about what they know and believe about care of older adults and the

practice environment in which they deliver care.

OUTCOME UNDERSTANDING & USING THE GIAP

SURVEY TO MAKE A DIFFERENCE…

What do your hospital’s GIAP stories & numbers tell you?

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NICHE Benchmarking & Evaluation: GIAP · Type of unit: (same) Unit 1 Unit 2 Unit 3 Subscale Age...

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