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.


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.


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.


• 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.


• 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


• 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 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???

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