Goals for the session: Have beginning understanding of Saba CCC Model Commit to need for change Support introduction of Priority Problems as initial step of

Documentation Framework change Be able to verbalize the vision statement Have begun a unit-specific implementation plan Have seen a proposed rollout schedule Knowledge of resources available to support this work

CNO◦ We have a track record of successfully changing

nursing documentation – HED, AdminRx, and OPC implementations – but we keep adding to the documentation burden without taking anything away.

◦ We have adopted a new Documentation Framework that we are starting now to implement.

◦ Less of a technical change, more of a practice change.

◦ Cultural change bigger than the cultural change required to implement AdminRx

Karen Hughart – logistics:◦ Sit in teams by unit; CAPS or Systems Support Services

Rep. will sit with you

◦ We will be working in groups to begin to craft a unit-specific Implementation Plan

◦ We ask that you honor timeframes

◦ Jot down questions and “ah-ha’s” as you go so you don’t lose them. If there are any issues we are not able to address today, we will put on Parking Lot for follow up after the session.

Break into unit groups Use the CWS to complete the task You will have 7 minutes

Be prepared to answer these questions:◦ Were you able to find the information ? ◦ Were you satisfied with the quality of the

information ?ne sentence

Kotter’s Step Two: Form a Powerful

Coalition

As the Nursing Leaders of VUMC, we must actively LEAD this transformation of practice & documentation

Requires strong leadership & visible support

We cannot “manage” change from the sidelines

◦ Nursing Leaders & Nursing Educators

◦ Staff Nurses (novice to expert)

◦ SuperUser Champions

◦ SSS Liaisons

◦ Informatics Liaison

◦ Key Stakeholders: Medical Director, Physicians, Nurse practitioners

◦ Engage Opinion Leaders early & engage as Champions

Work as a TEAM

Build ongoing urgency & momentum for the need for change

Choose the pathway that most closely reflects the expected patient progression. Usually the reason for admission.

Medical Pathway – Heart Failure◦ Admission – Orders & interventions are aimed at

achieving stabilization ( improving pump action through diuresis, O2, hemodynamic stability, . . .)

◦ Stabilization - achieving a controlled symptoms (fluid excess control, med mgmt

◦ Discharge – Ready for self-care; or care by another caregiver.

Surgical Pathway - Knee Replacement◦ Pre-op Pre; Post-op Stabilization; Discharge

1 Pathway & Phase◦ Sets timed objectives to meet discharge goals based on

predominant medical or surgical plan2 Provider Plan

◦ Orders & planned procedures3 Other Disciplines Plans

◦ Reflects provider orders◦ Contributes specialty focusContributes specialty focus

4 Reflects patient goals

Population Based:• EVP > Mosby’s …

Unique Patient based on:◦ Nurse’s Skill in Nursing Process

Assess Dx Problems Plan Interventions Evaluate Outcomes

- 2 4 6 8

Extended LOS (under-reimbursed)

Expected LOS

Days

Phase

Pathway ProgressionMedical/Surgical Phases

I: Admission/Pre-Op

II: Stabilization/Post-op

Problem: Infection/Fall

III: Discharge

Problem: Discharge Delay

Managing/preventing problems can help reduce length of stay and improve the quality and cost bottom line

Adverse patient effects hospital acquired conditions (infections, injuries)dissatisfaction (unhappy, lost wages) . . .

Adverse VUMC effects lost revenue from under-reimbursed care dayslosing patients due to having no available beds . . .

Using the Clinical Care Classification- an evidence based Nursing terminology

in the patient’s plan of care

Physiological◦ Cardiac◦ Bowel/Gastric◦ Life cycle (pregnancy)◦ Metabolic (glucose)◦ Physical Regulation (infection)◦ Respiratory◦ Skin Integrity◦ Tissue Perfusion◦ Urinary◦ Medication

Psych/Behavioral◦ Cognitive◦ Coping◦ Health Behavior◦ Role Relationship◦ Self Care◦ Self Concept

Functional◦ Activity◦ Fluid Volume◦ Nutrition◦ Safety◦ Sensory/Pain

21 Categories: Skin Integrity182 Problems (Dx): Oral Mucous Membranes Impairment 3 Expected Outcomes: Improve, Stabilize,

Support decline198 Interventions: Mouth Care4 Actions: Assess, Care, Teach, Manage3 Actual Outcome: Improved, Stabilized, Decline

supported

____________________Plan of Care Summary________________________Pathway: CHF (chart once) Phase: Admission (update prn)Nsg Summary: Pt admitted via ambulance in respiratory distress…Plan Priorities: IV diuretics, fluid restrictions, I&O, reduce anxiety….____________________Initial Problem______________________________Priority Problem: Fluid Volume ExcessMay be related to: CHF, fluid intake, hi Na dietExp Outcome: Stabilize______________________q shift plan and outcomes__________________Exp Outcome Detail: diurese .5L this shiftExp Outcome Status: Not MetInterventions: chart as usual

Florence Nightingale◦ Notes on Nursing (1860)

Norma Lang◦ If you can’t name it, you

can’t control it, finance it, research it, teach it or put it into public policy (Clark & Lang, 1992)

Swan, Lang, & McGinley (2004)◦ Make the work of nurses

visible and show its value

Assess Problem Problem

IdentificationIdentification Plan/Goal Setting Care Interventions Outcome Evaluation

Building an Outcomes Oriented

Documentation Framework

A Home for Evidence Based Nursing Care

AAssess * CCare * TTeach * MManage Priority Problems

Priority problems will simplify and standardize how nurses:

document and communicate the patient’s top priority

problems identify plans and goals assess actual outcomes

This will improve patient care and clearly define nursing’s contributions to patient care and the team.

According to Albert Mehrabian’s research study in 1968 how much of the message is the actual words used?

◦ 38%◦ 7%◦ 55%

Email Group meetings One-on-one communication Company publications High level and executive storytelling

delivered company-wide

One-on-one face to face discussions that are honest and straight forward and that offer details of the change on a personal level

Cascading small group meetings to share information, brainstorm solutions and implement new processes

Baby Boomers born 1945 – 60

Traditionalists born before 1945

Generation X – children of boomers

Millenials – grandchildren of boomers

Traditionalists

Baby Boomers

Generation X

Millenials

 Make decisions based on what has worked in the past

Consistency is important

Show Me generation--Body language is very important

Favor top-down decisions

Value respect

Will fight for a cause

Highly Collaborative

Optimistic

Prefer messages presented from positive standpoint

Value work and life balance

Shaped by a culture of instant results

Multi-taskers

Avoid unnecessary meetings

Baby Boomers

Blog

Face to Face communication

Email

PowerPoint Presentation

Generation X

Millenials

Traditionalists

Branding Web Site Nursing News articles

From Marilyn Monthly updates for

leadership to communicate to staff

Articles in the reporter Blog Video of 8th floor staff

commenting re: priority problem documentation

In your unit groups, for the next 10 minutes discuss:

Who should be included in your unit’s coalition for change? List names and/or titles

Begin to identify your unit-specific communication plan – be specific and include timeframes

Obstacles are generally in 3 categoriesPeople

ProcessesStructure

1. Leadership: Commit to change & voice consistent message

2. Educators & Super Users: Communicate advantages of new process

3. Curmudgeons: Listen to their feedback but don’t leave true resisters in leadership positions

4. 5 positive encounters to overcome 1 negative5. All Leaders demonstrate their belief that the

change will improve patient care & continuity of care

o Can’t be too complicated o Must be fairly easy to learno Must fit into workflow o CQI: Looping process…education,

implementation, evaluation, reeducate or change, reevaluate, reeducate/change

o Commit to overtime pay: for SuperUsers to be available during implementation

o Change takes time: adapting to new processes can take up to 4 weeks

o Adequate Education: Educators, Superusers, Staff o Identify competing projects: safety, policy,

product… Anything that will require extra timeo Watch out for staff and Manager overload!

In your groups take 10 minutes to:

Identify obstacles to success & develop action plans to address

Include prior commitments that might influence timelines for Priority Problem rollout on your unit

8 South experience

1. What were improvements experienced with use of Priority Problem approach?

2. How did you hard wire the change?

3. What were the challenges to adoption?

Group to identify 2-3 successful changes they have experienced in VUH over the past 2-3 years

◦ During any of these changes, did you identify short-term wins during the change process?

◦ How did you celebrate these wins?

◦ What techniques did you use to hardwire the change?

Priority problems will simplify and standardize how nurses:

document and communicate the patient’s top priority

problems identify plans and goals assess actual outcomes

This will improve patient care and clearly define nursing’s contributions to patient care and the team.

Team completes Implementation Worksheet in 1 week and sends copy to Administrative Director

Educator Training and Practice sessions available

SSS revises implementation timeline by 1 week from today incorporating input re: obstacles

We will share your input with NAB/ QERI group

Utilize your support person and watch for communication updates