Disclosures. Learning Objectives 2/11/2015. Improving Patient Outcomes in Pediatric Primary and Acute Care. IOM Changing the Healthcare Environment

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1 Improving Patient Outcomes in Pediatric Primary and Acute Care Bonnie Gance-Cleveland, PhD, RNC, PNP-BC Jennifer Disabato, DNP, CPNP-PC, AC University of Colorado College of Nursing Anschutz Medical Campus Aurora, Colorado Disclosures Bonnie Gance-Cleveland This presentation is supported by grant number 1R18HSO A1 from the Agency for Healthcare Research and Quality (AHRQ), an agency of the U.S. Department of Health and Human Services. The content expressed in this module is solely the responsibility of the author(s) and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Jennifer Disabato No disclosures related to the content of this presentation Learning Objectives Review the call for practitioners to engage in efforts to improve patient outcomes in their practice Discuss the frameworks to guide quality improvement efforts in acute and primary care Provide strategies that participants can use to provide leadership for implementing current guidelines to improve patient outcomes Present examples of successful efforts in implementing practice change to improve patient outcomes in primary and acute settings Institute of Medicine (IOM) Crossing the Quality Chasm IOM Six Aims for Improvement Safe: avoiding injuries to patients from care that is intended to help them Effective: providing services based on scientific knowledge Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values Timely: reducing waits and harmful delays Efficient: avoiding waste (equipment, supplies, ideas, and energy Equitable: providing care that does not vary in quality because of personal characteristics (gender, ethnicity, geographic location, and socioeconomic status IOM Changing the Healthcare Environment Evidence-based care Using information technology Aligning payment with quality improvement Preparing the workforce Institute of Medicine (IOM) Report on the Future of Nursing Recommendation 2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts With physicians and other members of the health care team Conduct research and to redesign and improve practice environments and health systems Provide opportunities for nurses to diffuse successful practices. Recommendation 7:Prepare and enable nurses to lead change to advance health Assume leadership positions Health care organizations should ensure that leadership positions are available to and filled by nurses. 1

2 Barriers to Using Evidence for Practice Increase Access Insurance expansion Workforce expansion Reduce Costs Improve Quality Improved healthcare to individuals Improved population health outcomes Primary Care Acute Care Lack of patient motivation Fragmented, episodic care Lack of parent involvement Parental anxiety and uncertainty Lack of clinician time Lack of clinician time Lack of reimbursement Limited patient stay Lack of clinician knowledge Lack of clinician knowledge Lack of treatment skills Lack of coordination of treatment modalities Lack of support services Limited perspective of pt./family daily QOL Treatment futility Lack of attention to overall picture Lack of treatment referral resources Lack of coordination with PCP/community Lack of process/system to support EBP Lack of process/system to support EBP Barriers to Using Evidence - Asthma Barriers Pediatricians Face When Using Asthma Practice Guidelines Barriers in Primary Care for Obesity Arch Pediatr Adolesc Med. 2000;154(7): doi: /archpedi Evidence Based Practice EBP Integrates: - Best research evidence - Sound methodology - Focus on effectiveness and safety of interventions - Hierarchy of study designs to consider - Clinical expertise - Patient/Family values Better Clinical Decision Making Improved Outcomes EBP = Research Utilization Research Utilization Using results of a research study in an aspect of your nursing practice Essential understanding of how to critique a study to determine it s utility to the clinical issue in your practice you would like to change / improve EBP encompasses a broader approach Incorporates research intoother aspects of clinical decision making: expertise within the specialty, or specific care delivery setting patient and family preferences available resources 2

3 YES Clinical Practice Evaluation Does evidence support current practice? YES EBP in Use Is Evidence Available? NO Performance Improvement Project EBP in Use Muller, B. Evidence, Research and Quality Improvement in Practice; Children s Hospital Central California, Nursing Excellence, e-edition, Issue 10 NO Conduct Research Are Results Clinically Applicable? YES Performance Improvement Project EBP in Use NO Further Research First Step in EBP Asking the Right Question Easier said than done Most important step in achieving results Ask the clinical question in P-I-C-O format Patient population Intervention Comparison intervention Outcome Sackett, 1997; Melnyk & Fineout-Overholt, 2004 Hierarchy of Evidence Critically Evaluate the Evidence Are the results true? (as close to the truth as possible) Was random assignment used? Was follow up long enough to study the effects of the intervention? Were all subjects accounted for at the end of the study? Was the control group appropriate? Were the instruments used valid and reliable? System for Rating the Evidence Melnyk & Fineout-Overholt, 2005 RATING Level I Level II Level III Level IV Level V Level VI Level VII EVIDENCE TYPE Systematic review or meta-analysis of all RCTs or clinical practice guidelines Al least one RCT Controlled trial without randomization Case control or cohort study Systematic review of descriptive and qualitative studies Single descriptive or qualitative study Expert panel or authority opinion Another System for Grading the Evidence (American Association of Critical-Care Nurses, 2009) GRADE Level A Level B Level C LevelD Level E TYPE OF STUDY Meta-analysis of multiple controlled studies or meta-synthesis of qualitative studies with results that consistently support a specific action, intervention or treatment Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results Peer-reviewed professional organizational standards, with clinical studies to support recommendations Theory-based evidence from expert opinion or multiple case reports Level M Manufacturers recommendations only 3

4 Health Disparities Framework Frameworks for Putting Evidence into Practice. Health Disparities Framework Chronic Care Model Improve care to at-risk populations Implementation of EBP Innovative, data driven Public health partnership Use of chronic care model Computer information systems System redesign Iowa Model for EBP Problem / Knowledge Focused Triggers Priority for the Organization?? Sufficient Research Base?? Pilot the Change in Practice Is it appropriate to Adopt?? Resources to Support EBP Sources for current research evidence online databases / search engines Clinical Practice Guidelines (AHRQ) ANA Research Toolkit Joanna Briggs Institute Institute for Healthcare Improvement (IHI) Breakthrough Collaborative Learning Series 4

5 Resources for Evidence National Guidelines Clearinghouse Agency for Health Care Research and Quality Worldviews on Evidence-Based Nursing Centers for Disease Control and Prevention Institute for Healthcare Improvement Specialty organizations Databases ( Cochrane Reviews EBSCO CINAHL OVID Medline EBM (evidence based medicine reviews) Joanna Briggs Institute (JBI) Provide the best available evidence to inform clinical decision-making at the point of care International not-for-profit, research and development arm of the School of Translational Science based at the University of Adelaide, South Australia Collaborates with over 70 entities across the world. Promote and support: Translational Science Synthesis Science Implementation Science Promoting evidence-based practice Identifying feasible, appropriate, meaningful and effective practices to assist in the improvement of healthcare outcomes Evidence Based Practice Resources American Nurses Association ANA Research Toolkit Offers an introduction to research and evidence-based practice. It provides access to numerous resources to translate evidence into practice and to support nurse researchers Helps you provide evidence-based care that promotes quality health outcomes for individuals, families, communities and health care systems Assists you in shaping health policy at the bedside, within an organization, and at the local, state and national level ANA Nursing World Toolkit Institute for Healthcare Improvement (IHI) Founded in 1991 Committed to redesigning health care into a system without errors, waste, delay, and unsustainable costs. Grew from a collection of grant-supported programs to a self-sustaining organization First decade: identification and subsequent spread of best practices to reduce errors in microsystems such as the ED or ICU Second decade: established a defining focus on innovation, R&D; lead to the 100,000 Lives & 5 Million Lives Campaigns, spreading best practice changes to thousands of US hospitals Third decade: Created the Triple Aim, a framework for optimizing health system performance by simultaneously focusing on health of a population the experience of care for individuals within that population per capita cost of providing that care. IHI Science of Improvement 5

6 IHI Breakthrough Series: Learning Collaborative Improvement Science What are you trying to improve? How will you know that a change has been accomplished? What changes can be made that will result in improvement? Plan Do Study Act (PDSA) Specify Goals and Objectives Using the worksheet for PDSA cycle state What change are we going to make? What is the intended goal/outcome of this change? Make SMART objectives PDSA Worksheet for Testing Change (Institute for Healthcare Improvement) Tracking Progress for QI Over Time Lean Six Sigma Industry Approach Adapted to Healthcare Focus on reducing waste, improving throughput, improving efficiency and cost recovery Viewed from the lens of the customer experience and cost savings / streamlining May be perceived as a way for organizations to cut expenses by reducing staff or changing existing positions Example from Putnam County Memorial Hospital, Indiana Preventable Readmissions Goal:To increase patient compliance with posthospitalization appointments Outcome: Over 2 months there were no reports of errors or variances in medication or omissions in therapy for patients recovering at home. Zero readmissions in the month following the change saved the hospital $105,000 6

7 Institute for Healthcare Improvement 2013 Initiative ALWAYS EVENTS Always Events refer to aspects of the patient experience that are so important to patients and families that health care providers must perform them consistently for every patient, every time. Always Events Meet the Following Four Criteria 1) Important Patients and families have identified the experience as fundamental to their care This specification is designed to ensure that any event that is successfully implemented will have a meaningful impact on improving the patient experience 2) Evidence-based The experience is known to be related to the optimal care of and respect for the patient Always Events 3) Measurable The experience is specific enough that it is possible to accurately and reliably determine whether or not it occurred This specification is necessary to ensure that Always Events are not merely general aspirations but are translated effectively into operations 4) Affordable and Sustainable The experience can be achieved and consistently sustained by any organization without substantial renovations, capital expenditures or the purchase of new equipment or technology Always Events Examples University of Pittsburgh Medical Center s Transplant Guardian Angelsprovide patients and families in the organ transplant program with accurate, real-time updates clinical information reducing anxiety increasing effective communication between care delivery teams. Anne Arundel Medical Center, Annapolis, MD SMARTDischarge to ensure these key areas are always addressed with pts/families during hospitalization and at d/c Symptoms Medications Appointments Results Talk With Me Are there Always Events for Your Patient / Family Population? Primary Care Exemplar Providing improved patient/family communication: - Important -Reminder about return to clinic for 2 nd and 3 rd doses of HPV vaccine - Evidence-Based Studies have been done to examine the utility of text message reminders. Search and choose appropriate articles to review and meet as team to discuss - Measurable-Discrete documentation in the record of text messages/calls; and return rates/times before and after intervention - Affordable / Sustainable Staff already in place to communicate with patients and families; system in place can be adapted with staff input to effect change Think about your practice and daily challenges Take a moment to write down what you would like to change 7

8 Examples from Primary, Acute, & Chronic Care Pediatric Populations Pediatric Acute Care Setting Complex Chronic Population Transition to Adult Care for Pediatric Neurology Patients Focus on Epilepsy Patients Minimum 6-12 month wait for an adult epilepsy clinic appt. Adult clinic not getting health records; lack of useful information Lack of pro-active support for patients/families through transition Expanded to all Neurology Patients (institutional small grant program) Refined focus on successful aspects of original project Selected feasible national Best Practices incorporated Pediatric Acute Care Setting Complex Chronic Population Initial QI Project Question Will process improvements in the pediatric epilepsy clinic decrease the time to transition to adult care for AYA with refractory epilepsy? Process Improvements - Enhanced access /specificity of Release of Information forms - Transition Summary Letter populating from EMR with the addition of smart text to allow a broad overview of care history with a focus on important health summary information - Enhanced communication between providers, patients/families and the neurology social worker using Clinical Decision Support in the EMR (Best Practice Advisory) Pediatric Acute Care Setting Complex Chronic Population Transition Summary Letters - Care Team Input to Develop Letter flow & inclusions for pre-populated EMR data Smart Text and Phrases Process for initiation: provider request to clinic RN, template initiated, letter shared in EMR Provider returns to RN for completion/sending Transition Summary Letters Tracking from Phase I Epilepsy Patients Transition to Adult Care Pediatric Neurology Clinical Decision Support : EMR Best Practice Advisory Phase 2 All Neurology Patients Pop-up Reminder Triggers for >17 y/o in neurology f/u appt. Results: Increase in number of letters Increase in patients transitioned Use of new letter templates confirming spread of intervention If order accepted, smart text appears 8

9 # of Patients BPA Social Work Orders for Transition Consultation PATIENTS ELIGIBLE BPA OPENED & SEEN SW ORDERS PLACED Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q Transition to Adult Care for Pediatric Neurology Patients Summary of Key Points Interdisciplinary approach with multiple PDSA cycles to implement and revise changes with continual ongoing refinement Buy in from stakeholder groups within department took face time and patience (small steps, respecting dissent) Building to scale across other groups will require greater resources from within the organization Expanded to Network of Care Primary Care Exemplar Addressing Obesity Disparities Virtual Collaborative with & without technology 24 SBHC from six states (AZ, CO, MI, NC, NM, NY) Measures at baseline, post-training, and 6 mos post-training 1. Providers self report survey of knowledge, attitudes, and behaviors in managing overweight 2. Providers conduct chart audit on 32 charts 3. Parents complete a satisfaction survey (n=32) independent sample after well child visit at same intervals. 4. Elements of the Chronic Care Model 5. Focus groups of tech and non-tech groups at the end Using the health disparities collaborative approach to training Use of chronic care model PDSA cycles Web-based training on guidelines With or without technology support (HeartSmartKids) Primary Care Exemplar Virtual Collaborative with Training Videos Video Vignettes Training modules Web-based Learning Community Training videos, resources Facilitated synchronous events 9

10 Primary Care Exemplar Primary Care Exemplar Translation Research: Collaborative Findings Providers High satisfaction with training (µ= /4) Knowledge, behaviors, attitudes improved after training (p values range ) Proficiency in counseling improved (µ= /3; p=0.0005) Improvement in use of elements of chronic care model registry and follow-up visits Barriers unchanged Question Type b Mean Std Dev Learning Objectives Met Interesting Speaker Use Information in Practice Knowledgeable Speaker Useful Audiovisual/Handout Content Area b Guidelines Health Disparities Chronic Care Model Motivational Interviewing Advocacy Culturally-Sensitive Care

11 Translation Research: Collaborative Findings Chart audits Improvements with training Improvements with technology T1 T2 Parents Confidence in changing child s eating improved with technology (p=.04) BMI percentile documentation, by time and technology group. 100% 80% 60% 40% 20% 0% T1 T2 T3 Technology Non-Technology What would your first PDSA cycle look like? Anticipating Roadblocks & Moving Forward CHALLENGE POSSIBLE REASON STRATEGY Fewteam members interested in the problem Lackof a clear and specific question you want to answer Unsure of how to measure change and determine its impact Concerns about change Think problem is unsolvable Don t know where to start Too close to the issue/ can t see the forest for the trees Lack of knowledge Concern for punitive implications Lack of support resources Targeted invitations to generate a discussion; include naysayers Consider patient perspective on issue first Use PICO formatto narrow down on specific group, time, issue, and outcome Include leadershipfrom the start Focus on gradual, small changes Be willing to walk the path Summary & Moving Forward Advanced Practice Nurses have in-depth knowledge and sound ideas about how to improve care for children and families Evidence Based Practice plays a significant role in our education and daily practice Many tools and frameworks exist to support moving improvement ideas forward in your practice Teamwork and sustainability are foundations of Improving care in primary, acute and chronic settings Questions?? Thanks for your attention! 11