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.
Relationship-Based Care Model 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.
Transforming Practice Team 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.
Relationship-Based Care Model 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.
Shared Access Website 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
Shared Access Website
Transforming Practice Team 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, Stepdown/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 what was the PRIMARY focus in Completing Patient Assignments in their ICUs, Stepdown/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 nonverbal 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 Model Outcome 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 Available Indicators 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.
Sep 2009 Oct 2009 Nov 2009 Dec 2009 Jan 2010 Feb 2010 Mar 2010 Apr 2010 May 2010 Jun 2010 Jul 2010 Aug 2010 Sep 2010 Oct 2010 Nov 2010 Dec 2010 Jan 2011 Patient Satisfaction Results Nurses Section Overall Score 95.0 90.0 85.0 80.0 75.0 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 88.0 Inpatient Horizon 87.0 86.7 86.0 85.0 85.6 86.0 84.0 83.0 83.9 83.0 82.8 84.0 84.1 84.0 84.0 84.3 Inpatient Horizon Linear (Inpatient Horizon) 82.0 82.2 81.0 80.0 79.0 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
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 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% n=222 n=225 n=230 n=196 n=192 n=181 n=203 n=206 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%) 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
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
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