Leveraging Evidence-based Plans of
Care in Interdisciplinary Rounding to
Optimize Outcomes
October 24, 2013
Kathy S. Menefee DNP, RN, NEA-BC, CPHQ
Administrative Director for Patient Care Operations
Riverside Health System
Moderator:
Michele Norton MS, RN
Director Product Marketing and Strategy
Zynx Health
Patient Engagement, Process and
Technology Unite to Create Positive
Outcomes
Kathy S. Menefee DNP, RN - Administrative Director
Riverside Health System
Dr. Menefee does not have any conflicts of interest.
At the conclusion of this presentation participants should be able to:
Describe basic process steps in an optimization effort around
interdisciplinary plans of care.
Understand the importance of a defined process for patient-focused
interdisciplinary collaboration.
Appreciate the positive patient, organization and team impact that can
result from such an approach.
Objectives
Outline
About Us
The Problem
The Innovation
Technology
Process
Results
End Notes
“To care for others as we would care for those we love –
to enhance well-being and improve health”
Riverside by the Numbers
People Physicians = 1000+ (392 Employed by the Riverside Medical Group) Employees = 9000+
Hospitals Hospital Beds = 984 Acute Care, Community Hospitals = 5 Behavioral Health/Substance Abuse - Children, Adolescent, Adult (1) Physical Rehabilitation (1) LTACH (1) Discharges = 27,136 Patient Days = 141,858 4 ED/Trauma Centers = 118,976 Visits Births = 2,941
Outpatient Visits = 107,000 (excludes diagnostics)
PACE Centers = 6
Long Term Care Centers = 10 Resident Days = 303,405 Beds = 978
Retirement Communities = 3 Assisted Living Units = 306 Independent Living Units = 350
Total Post Acute Beds = 2,306
2012 Data
Where We Live
Our Locations
Who is Riverside? We are.
The Problem
A Plan of Care (POC)
A communication and documentation tool
Promotes communication between team members
Meets documentation needs and requirements
Contains
Patient problems
Plans to address those problems
Interventions to be implemented in patient care
Patient response to interventions
The Plan of Care
2012 Goal: Implement
POC in eHR
IPOC = 7 + Pages of
Paper
Inconsistent Use &
Process
Little to No Patient/Family
Involvement
TJC and MU
But it was much more
than just paper….
The Problem
<30%
The Importance
Value Based Purchasing (VBP) =
Reimbursement model where
hospitals are paid based upon
performance criteria
Affordable Care Act (2010) =
A law that puts in place
comprehensive health
insurance reforms that will roll
out over four years and
beyond
Pay for Performance (P4P)=
Financial incentives to health care
providers to meet defined targets.
VBP
P4P
The Innovation
The Evidence
Studies have shown that an interdisciplinary approach to care can assist in reducing readmissions, mortality, costs and length of stay while simultaneously increasing communication, collaboration and satisfaction of care providers and patients (Preen et al., 2005) (Vazirani, Hays, Shapiro, & Cowan, 2005).
Preen, D. B., Bailey, B. E., Wright, A., Kendall, P., Phillips, M., Hung, J.,…Williams, E. (2005). Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. International Journal for Quality in Health Care, 17(1), 43-51.
Vazirani, S., Hays, R. D., Shapiro, M. F., & Cowan, M. (2005, January). Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. American Journal of Critical Care, 14(1), 71-77.
The Framework
The Plan of Care
Interdisciplinary (IPOC) = Care Managers, Nurses,
Physicians, Rehab Services, Respiratory Therapy,
Nutrition, Pharmacy & others
The Patient is Engaged = Inclusion of Patient’s Daily Goal
Evidence-Based = Zynx Health & Mosby
Includes Transition Goal = Setting of Care
Process as Important as Documentation = Rounding &
Conferencing
Guided Rounding
Project Elements
Steering Council
Clinical Leaders
End Users
Support – IT, Project Management, Process Improvement
Workgroup
End Users
Nurses
Physicians
Ancillary
Mission
Goals – Steering Council
Guiding Principles – Workgroup
Key Concepts
Collaboration vs. Communication
Transition vs. Discharge
Process, process, process
Nurse as Integrator
Guiding Principles - Workgroup
Subject Matter Experts
(SMEs) must be open to the
ideas/suggestions of other
facilities represented.
“This is the way we have
always done it ” is not what
we need.
Keep in mind what is
important when caring for
YOUR patients in your
experience.
This will be a collaborative
effort of our facilities.
Subject Matter Experts for
your area and facility, you
are representing the
viewpoint of your entire
clinical discipline throughout
the design process.
In the event of a discussion
where two or more
members cannot come to an
agreement, the evidence will
prevail.
Getting It Done
Development Process Similar to Order Sets
Use of Zynx Health Evidence (ZynxCare) & Mosby Consult
Workgroup Sessions (chose “live” as preferred venue)
Seek input and expertise of team members in ‘local’ area
Start with “problems”, then diagnosis-based plans
Zynx AuthorSpace off-line review and comment
Approval –
Workgroup
Core Team
Ancillary Advisory Group
Nurse Executive IT Group
Physician Advisory Council (PAC)
Technology
Patient/Family Goals
Anticipated Transition Date
Anticipated Transition Date
07/25/12
IPOC Rounding Participation
IPOC Rounding Prompters
Use of Triggers in the IPOC
Tied to Assessment Findings & Order Sets
Result = Care Gets to Patient Faster
EXAMPLE:
Respiratory Care Screening Trigger
Assessment Finding:
SaO2 </= 93% with or without O2
General Respiratory Care Screen
Identify Problem R/O Problem & Dismiss
Establish POC with Care Team
Implement Interventions
Resolve Problem
Process
Role of Entire Care Team
Assess & Screen
Communicate & Collaborate
Identify IPOC Problems & Interventions
Screen & Intervene
Educate
Revise IPOC and Chart
Advocate
Anticipate
The Difference…….
Communication
The imparting or
interchange of thoughts,
opinions, or information by
speech, writing or signs.
Collaboration
Individuals assuming
complementary roles and
cooperatively working
together, sharing
responsibility for problem
solving, and making
decisions to formulate and
carry out plans.
IPOC Rounding Script (Prompts)
Cadence – IPOC Rounds
1. Begin with the current patient/family goal
2. Review patient status (use Rounding Tool*)
3. Review all current patient problems, interventions
and goals
4. Adjust ATD as needed
5. Revise IPOC adjusting goals, interventions, etc.
6. End with the patient/family goal – verify
consistency with IPOC
Results
Measures
Baseline Data – Ongoing Monitoring
IPOC Presence, Use, Individualization (eHR Audit)
Length of Stay (ALOS, All)
Readmission Rate (30-Day All Dx, All Payer)
Patient/Family Satisfaction
Staff Satisfaction
Physician Satisfaction
Transition Setting (Referrals to Home Health)
Key Clinical Quality Indicators (NDNQI – Falls)
Adverse Events (Midas – patient/procedural)
Average Cost Per Patient Day/Stay
Pilot Hospital: Has the IPOC
been reviewed at least daily?
75%
Pilot Hospital: Readmissions
30-Day, All Cause Readmissions
Pilot Hospital: Patient Satisfaction –
Patient Included in Treatment Decisions
Data Source: Press Ganey Online
Pilot Hospital - Readmissions
0
10
20
30
40
50
60
2012 Number
2012 Rate
2013 Number
2013 Rate
30-Day, All Cause Readmissions
Source: Riverside DSS
Pilot Hospital : Patient Satisfaction
Patient Included in Treatment Decisions
10 3
31
6 14
6
18
3
42 47
92 92 90
41
98
23
41
12
25
8
0
20
40
60
80
100
120
Score
AHA Region 3 Rank
AHA Region 3 Mean: 85.4
Data Source: Press Ganey Online
52.1
35.6
45.7 46.5
33.3
39.5 41.9
48.9
40.9
51.2 50 50.9 48.1
60.5 62.5
54
65.7
57.6
42.4
60.6
0
10
20
30
40
50
60
70
Pilot Hospital HCAHPS Survey Question: "Would you recommend this hospital to your friends and family?"
Desired
Trend:
Outcomes & Results:
Qualitative
Theme Exemplar Theme Exemplar
Improved
communication
“I not only feel free,
but obligated to
state my opinion
and ideas” (RT)
Consideration of
multiple viewpoints
“The team helps me
consider options” (MD)
Strength and
equality of the
team
“All of us are greater
than any one of us”
(RD)
Identification of
care gaps
“We make discoveries
that make a
difference” (RPh)
Team focus on
the patient
“Our patients
deserve this- all of us
together on the same
page” (PT)
Streamlined care “I don’t have to hunt
everyone down
anymore” (RN)
Proactive,
anticipatory
model
“Things don’t come
to a head anymore
– we are more
proactive” (MD)
Holistic approach “Aligns us with the
patient & family’s
wishes” (CM)
Identification of social and
support needs – air conditioning,
meals on wheels, caregivers
Screenings ordered and
completed earlier in stay (as much
as 1-2 days earlier)
Correcting conflicts between
patient-team goals and plans
Just a Few of the “Catches”…
Summer on the Shore (Outside
Temp = 102) patient with COPD,
almost returned patient home to
trailer with no fan or A/C…..
Pediatric patient not eating, team
determined he was grieving over
the loss of his mother…..
Patient “noncompliant” with home
respiratory treatment while
“compliant” in hospital – needed
different mask at home…..
Patient needed information on
losing weight in preparation for
surgery, team focused on
admission diagnosis…..
Maturity & Evolution
Screenings ordered and done earlier in stay (as much as 1-2 days earlier)
Clarification of end of life care wishes
Correcting conflicts in patient-team goals and plans
When “gut” assessment findings/feelings are shared “something’s just not right”
Staff time savings– “entire team is together to share information and make decisions right there”
“In the interdisciplinary team’s
care planning process, all
team members are not only
expected to, but obligated
to, cross over disciplines and
ask questions of each other,
while adding the perspective
of the patient.”
~Kyle Allen, DO,
Medical Director for Geriatrics
and Lifelong Health, RHS
End Notes
Senior Leadership support
invaluable
Champion (CNO)
Kick Off (CEO)
IPOC Rounding (COO)
Discipline of Measurement
Strong Project Management
Find the Champions
Constantly Learn and
Respond
Other Good Things will Follow
IPOC “Coach”
Patient Goal Dialogue
Nurse as Integrator
Patient Advocate
Information Source
Information Giver
Coordinator of care
Coordinator of care team
“Pulls it all together for the
patient”
IPOC Facilitator or Coach
Enforces mandatory attendance
Ensures timely, efficient meetings
Suggests when to take discussion “offline”
Elicits all patient information from team
Uses eHR to reference and update information
Eliminates sidebar conversations
Delegates responsibility for follow-up
Ensures information on Rounding Tool is covered
What does this really mean?
Patient/Family Goal = “I want to go home”
Care Team Goal = “I want them to go home”
What does the patient need to be able to DO before they
can go home (or transition to the next level of care)?
When do they want or need to be home?
How do they want to feel when they go home?
What can we do as a care team to help them get home?
In the patient’s own words…. “ wife’s birthday”, “pain in
my right knee”, “use the bathroom by myself”, “go
dancing”, “breathe”
Future
Bring patient (physically) into rounds
Give patient daily IPOC
Involve patient in developing IPOC
Diagnosis-specific IPOCs
Continue to update and enhance existing problems, add triggers
Continue to revise plans and process based on measurement results
LIPOC =
Longitudinal Plan of Care
Summary
Implementation of electronic plans of
care is an opportunity to improve
patient and organizational outcomes.
The process component is perhaps
more important than the technology or
documentation component.
Foundational elements must be in
place in order for this effort to be
successful.
Outcomes important to the patient,
interdisciplinary team and facility can
be positively impacted through the
IPOC process.
• Medical care is care provided by an individual physician or provider.
• Multidisciplinary care is provided by multiple care providers who all chart in
the same place.
• Interdisciplinary care is provided by multiple providers who actually talk to
each other and know what the other is doing.
~ Shared by a Riverside Dietician (Source Unknown)
Questions ?
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