Enterprise-Wide, Evidence-

Based Interdisciplinary Plan

of Care Content Validation:

Guiding Principles and

Lessons Learned

Mary Swenson, RN, MBA

Naomi Mercier, MSN, RN-BC

2

Objectives

Describe Partners eCare initiative and implementation timeline

Process Redesign decision for enterprise evidence based Plan

of Care development

Describe Plan of Care Strategy, Definitions and Guiding

Principles

Zynx Lead Content Review Bootcamp

Bootcamp Debrief and Gap Analysis of Developed Content

Strategic Plan to complete development

Lessons Learned

Next Steps

4/30/2015

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4/30/2015 4

Partners eCare Process Redesign

4/30/2015 5

The Decision:

Nurses and Health Professionals will document on the Partners eCare

Plan of Care activity

• Interprofessional tool for documentation of patient and family

centered plans of care

• Place to share and communicate your clinical judgments and

clinical decisions

The Challenge:

• Lack of consistency in care plans across the enterprise

• 9,100 nurses and 4,250 Health Professionals

• Lack of adoption for an integrated tool

• 2 year timeline for Group 1 Go Live

• Lack of consensus on standard terminology

Plan of Care : Strategy

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Unique

Services Specialty Care,

High Acuity,

Mental Health,

Rehabilitation

Vulnerable

Patients Medicaid & Medicare

High Quality/

Technology Information Systems

Clinical Care

Community

Programs Health Centers,

Wellness Programs

1. Vendor solution for Plan of Care

• Enable consistency across the Enterprise

• Evidenced-based

• Provides ongoing process for updates and maintenance

• Delivers a robust library of content

2. Assemble a Nursing Informatics Leadership Advisory Council

• Representation from each Partners entity

• Empowered to make decisions

• Respected influencers and thought leaders

3. Include Health Professional leadership early in the process.

4. Develop definitions and guiding principles

5. Engage staff nursing and allied health staff in the content review

process

6. Inclusive terminology

Provide a deliverable of 60-70 Plans of Care in 3 months!

Plan of Care Definitions

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Flowsheets

• Assessments

• Interventions

performed

Treatment

Plan

• Medical

problem list

• Orders

Notes

• Evaluation of

patient status

Patient

Education

Care Plan = Patient Chart

Plan of Care

Plan of Care Definitions

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Flowsheets

• Assessments

• Interventions

performed

Treatment

Plan

• Medical

problem list

• Orders

Notes

• Evaluation of

patient status

Patient

Education

Care Plan = Patient Chart

Patient

Problems

Associated

Goals

Interventions

Plan of Care

Plan of Care Definitions

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Patient

Problems

Associated

Goals

Interventions

Plan of Care A problem (whether physiological, behavioral, functional,

psycho/social, educational, or otherwise) is a barrier to the

patient achieving his/her goals or reaching his/her next level of

care.

A barrier is a high priority, active problem - it is unique to your

patient and relevant to the care you are delivering.

The problem is resolved sufficiently when the patient has

achieved his/her stated goals, the patient has reached the next

level of care, or the patient has progressed to a satisfactory

level based on his/her personal baseline functional status.

PHS Care Planning Process

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Assessment

Evaluation Clinical judgment

Resolution of

problems

Problems

Unique

and

relevant

Goals

Assessment

Interventions

Patient

Goals

Patient

Family

Centered

Guiding Principles

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• Shared, Inter-professional

• Active, patient and family centered problems, goals

• Discipline specific only if approach to care is different

• Simple

• Include only problems that are barriers to a transition

to a lower level of care or preventing the patient from

meeting goals

• No standards of care

• Minimal “at risk for”

• Active and relevant interventions

• Update Goals and interventions with changes in patient

condition

• Patient education will be documented in the patient

education activity

Zynx Led Content Review Bootcamp

by the Numbers

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3

Day offsite

content

review

24

Total

sessions

184

Single

patient

problems

4

Concurrent

sessions

56

Condition

Templates

14

Nursing and

HP

leadership

340

SME’s

30

PeC and

Accenture

Staff

354 SME’s, Nursing leaders and HP Leaders

274 Tasks completed in 50 working days

PeC Bootcamp Follow Up

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The work had just begun………….

Bootcamp Debriefing and Gap Analysis

of Developed Content

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Guiding Principles not applied consistently to all plans

developed during sessions

Variability in plan modifications for a variety of reasons

Focus on Interdisciplinary workflow slowed down

tailoring process

Lack of style guide resulted in differing terminologies,

inclusion/exclusion of assessments and education

topics

Strategic Plan Post Bootcamp

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A crosswalk of all problems created during Bootcamp

Combined multiple versions of same problem into one inclusive of

all terms for review

Established a 6 week timeline for NIAC (Nursing Informatics

Advisory Counsel) review 46** single problem templates

Utilized Viewspace as our collaborative tool for review, comments

and voting

Weekly meetings to finalize problems after Viewspace suggestions

added

Development of style guide “rules”

Gap Analysis and Needs Assessment for Plan of Care templates

Develop a Master Schedule for Content Review Sessions

**The 46 problems used as the starting point for all multi-problem condition specific

templates

Style Guide Development

Goals, assessments, treatments and procedures and education topics will

all be listed alphabetically throughout the plans

No Diagnosis or discipline used in in problem or template titles

" Knowledge of" goals should be sparingly as knowledge can be

documented in Patient Education Activity . Knowledge of should only be

used for problems where knowledge is necessary to resolve the problem or

move to the next level of care

Assessments are limited in the Plan of Care as most are documented in the

flowsheets and only included if it is essential to the goal(s)

Order related interventions are not included in the Plan of Care

Every problem will have a "patient specific / tailored intervention" to unable

the user to create a unique intervention

No referrals or consults to team or outside agencies used in the Plan of

Care as they are documented elsewhere in the chart

Education topics are added to each problem there is no "Knowledge Deficit"

problem

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Content Gap Analysis and Needs

Assessment

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Templates Needed that Align with Top 25 DRGs:

• Well Baby Nursery

• NICU / Special Care Nursery- Pediatric

• Antepartum Patient (Gap)

• Intrapartum Patient

• Postpartum Patient (Gap)

• Total Joint Surgery - Adult

• NICU / Special Care Nursery- Pediatric

• Psychosocial / Behavioral Health Conditions – Adult/Pediatric

• Substance Abuse / Withdrawal - Adult

• Sepsis - Adult and Pediatric (Gap)

• Integumentary Conditions - Adult (Gap)

• Respiratory Conditions - Adult and Pediatric

• Cardiovascular Condition - Adult

• Cardiovascular/Thoracic Surgery – Adult (Gap)

• Eating Disorders - Adult / Pediatric

• Hem / Immuno / Oncology Conditions - Adult and Pediatric

(Gap)

• Abdominal /GI Surgery /Condition - Adult and Pediatric

• Bariatric Surgery - Adult

• Renal Failure, Acute / Chronic Condition - Adult (Gap)

• Neurological Condition – Adult

• Diabetic Condition - Adult

Additional Titles Needed:

Individual Problem Templates:

Developmental Milestone Achievement Impaired, Risk or Actual (Gap)

Diaper / Incontinence Dermatitis – Pediatric (Gap)

Parenting, Altered – Pediatric (Gap)

Seizure, Risk or Actual – Adult and Pediatric (Gap)

Multi-Problem Templates:

Medical / Surgery Condition – Adult and Pediatric (generic) (Gap)

Cardiac/Thoracic/Vascular Surgery – Adult (Gap)

Skilled Nursing Facility Patient – Adult

Perioperative Care / Procedural Sedation Patient – Adult/Pediatric (Gap)

Transplant Surgery- Adult (Gap)

Palliative Care – Adult / Pediatric (Gap)

Nutrition Conditions – Adult / Pediatric (Gap)

Occupational Performance Conditions – Adult / Pediatric (Gap)

Functional Mobility Conditions – Adult / Pediatric (Gap)

Speech / Communication / Swallowing – Adult / Pediatric

Ophthalmology Condition – Adult /Pediatric (Gap)

Otolaryngology Condition – Adult/Pediatric (Gap)

Therapeutic Recreation – Adult (Gap)

Total Templates Needed

60 Individual Problems (Adult and

Pediatric)

26 Adult Multi-Problem Templates

11 Pediatric Multi-Problem Templates 3 OB Templates

100 Total Templates

Plan of Care Content Review Schedule

– Jan through May 2014

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January 2014-

• NIAC Weekly Review of Adult Individual Problems (Jan 13 – Feb 12)

• Pediatric Individual Problems Review

February 2014-

• PT/OT Workflow Discussions

• Antepartum, Intrapartum and Postpartum OB plans

March 2014-

• 9 SME Sessions Scheduled for Pediatric and Adult Templates

April 2014-

• 10 SME Content Sessions for Pediatric and Adult Templates

May 2014 (build deadline for plan 5/5/14)

•100 templates completed by deadline

•Average SME Content Session size: 12 participants

•More Plan of Care Development planned for Group 2 using the same Guiding Principles and Style Guide

Lessons Learned

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An aggressive timeline (3 day Bootcamp) is not an end point; it

is a starting point

Develop a Style Guide in conjunction with Guiding Principles

Cultivate Interdisciplinary buy in early in the process

Interdisciplinary care plan templates including Therapies is a

nirvana

Bigger is not better, (SME reviewers). Rightsizing is an optimal

strategy

Take the time to develop a small group of experts for review

and validation

Next Steps

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Group 2 Plan of Care Development (completed)

Plan Clinical Informatics and Patient Safety research

projects:

Fall Risk Plan of Care

Aim: To developing and test a Patient Centered Infrastructure,

inclusive of Care Planning and Safety Tools that engage patients as

active participants in their Care Plan and Safety and integrate with

components of the inpatient EHR, including the Nurses’ Plan of Care.

Funding: AHRQ, Making Acute Care More Patient Centered, 1P30HS0235335 (PI:Bates)

Gordon and Betty Moore Foundation, Transforming the Acute Care Environment:

BWH PROPSECT Framework, 3914 (PI:Bates)

PCORI/NIA, STRIDE (STrategies to Reduce Injuries and Develop confidence in

Elders), U01AG048270 (PI, Bhasin PHS Site PI, Dykes)

Development of reports for tracking usage and compliance

APPENDIX

Examples of Plan of Care Templates and Style Guide

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Goals with Timeframes

Evidence based

interventions

Assessments captured in Flowsheets

Each template has a patient

specific tailored intervention

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Flowsheet rows were attached in the

Plan of Care to allow OT/PT and SLP to

document the specific detail needed for

their goals

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Example of Multi-Problem

Condition Template

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Thank you for attending the Partners Healthcare Plan of Care Webinar!