evaluating change and tracking improvement
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Evaluating Innovation:Moving Toward the New Paradigm
of Care Delivery
Jeffrey M. Adams, PhD, RNDirector, Center for Innovations in Care
DeliveryConnell Nursing Research Scholar
October 2013
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Gaurdia Banister Marianne Ditomassi Rick Evans Brian French Amy Giuliano Dorothy Jones
EVALUATION STEERING COMMITTEE
Annie Kingsley Linda Lacke Bret O’Flaherty Robin Lipkis-Orlando Colleen Snydeman Jeff Adams
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Innovation is…?????
HaircutsSoda
Airlines Automobiles
Hardwood Flooring Laundry Detergent
Garden Utensils
Source: Adams JM. (in press) Guest Editorial: How do we know if we’re innovating? A strategy for innovation evaluation in a practice setting. Journal of Nursing Administration.
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“History of Healthcare Innovating”
• Add photos of Healthcare Innovation Products
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A New Context for Innovation
• CMS
“Patient Journey” Framework
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Before During Post
Where Are There Opportunities to Reduce Costs Across These Processes of Care?
Admission Process: ED,
Direct Admits,
Transfers
Patient Stay; Direct Patient Care, Tests, Treatments, Procedures,
Clinical Support, Operational Support
Discharge Process
Post Discharge Care
Preadmission Care
Support Functions: Finance, Information Systems, HR
Goal: High-performing interdisciplinary teams that deliver safe, effective, timely, efficient and equitable care that is patient and family centered.
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INNOVATION UNIT EXPERIENCES SURVEY
“The MGH Innovation Units Program was developed as a frontline initiative to address the gaps in the continuum of care and utilize the expertise of all clinical disciplines to improve the patient experience, quality of care, staff satisfaction and empowerment while decreasing redundancy, costs, length of stay and readmission rates.”
Source: Ives Erickson J, Ditomassi M, Adams JM. (2012) Innovations in Care Delivery: A Blueprint for the Future. Nursing Economic$ 30(5): 282-287.
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Innovation Cluster Focus Areas *
Communication
Patient Engagement
Roles & Structures
Interventions ** Throughout Admission
Relationship-Based CareAttending Nurse Handover Rounding Checklist
Pre-AdmissionPre-Admit Data CollectionWelcome Packet
During AdmissionDomains of Practice Interdisciplinary RoundsBusiness CardsQuiet HoursHourly RoundingElectronic White BoardsIn Room White BoardsSmart PhonesHand Held/ Tablets
Post-DischargeDischarge Follow-up Phone Calls
Others as identified
Ed
uc
ation
Evaluation(Pre, During, Post)
Quantitative Qualitative•HCAHPS
•Leadership Influence over Professional Practice Environments (LIPPES)
•LOS
•Quality Indicators
•Patients Perceptions of Feeling Known (PPFKN)
•Readmissions
•Revised Perceptions of Practice Environment Scale (RPPE)
•Cost per Case Mix
•Staff Retention
•Focus Groups (Staff, Patients, Families, etc)
•Observations
•Survey of the Innovation Unit Expectations (SIUE-pre)
•Survey of the Innovation Unit Experiences (SIUE-post)
* The clusters are a lens with which we gain perspective on any particular intervention.
** May apply to any or all 3 of the cluster focus areas June 2013
Other measures as identifiedOther measures as identified
MGH PCS’s Approach
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It is in there
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Data, Data, Everywhere
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Why is this Innovation Unit Evaluation complex?
• Aimed at understanding successes & challenges of structures processes and outcomes of care delivery AND the evaluation process itself.
• Telling the story in context of the immediate, while tracking longitudinally to optimize sustainability.
• All while the ship is sailing…
• Different than research
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The Process
Innovation Evaluation (90-Day Cycle)
Day 1-30 Day 31-60 Day 61-90
Source: Institute for Healthcare Improvement (2013)
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So what are we finding?
• Three examples of how and what we’re finding…
– Idea Books
– Innovation Unit Experiences Survey
– Innovation Unit Interventions Sustainability Checklist
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Idea Books
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INNOVATION UNIT EXPERIENCES SURVEY
What is it like to work on an innovation unit?
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Analysis of the data yielded five interrelated themes:
1. Feeling prepared: “There was ample support and pre-education.”
2. Innovation: “A complete change of culture.”
3. Managing Challenges and Concerns: “It has been very challenging.”
4. The Attending RN: “The glue for nursing care.”
5. Benefits to patients and families: “The impact on patient care is worth it all.”
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INNOVATION UNIT EXPERIENCES SURVEY
Are the efforts being sustained?
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Innovation Unit Observation Checklist Phase 1 & 2
PATIENT/ FAMILY INTERVIEW Phase I Only Phase II Only Phase I & II
Do you have an Attending Nurse? Yes 59% 57% 58%
No 41% 43% 42%
If YES, was patient/family able to provide a name? Yes 85% 57% 66% *
No 15% 43% 34%
Did you receive an ARN Business Card? Yes 36% 47% 43%
No 64% 53% 57%
Do the nurses, doctors, and other staff make you feel like you are part of the team? Yes 100% 94% 96% *
No 0% 6% 4%
Do you have a Discharge Envelope/Checklist? Yes 47% 49% 48%
No 53% 51% 52%
If YES, is there a discharge date noted in the space provided? Yes 0% 21% 14%
No 100% 79% 86% *
Do you have a copy of the Patient & Family Notebook? Yes 55% 53% 54%
No 45% 47% 46%
If YES, has it been helpful to you? Yes 27% 73% 58% *
No 73% 27% 42% *
PATIENT/ FAMILY INTERVIEW Phase I Only Phase II Only Phase I & II
When someone comes in to check on you: Do they ask about your pain? Yes 96% 92% 93% *
No 4% 8% 7%
When someone comes in to check on you: Do they ask you whether you need to go to the bathroom? Yes 54% 58% 57% *
No 46% 42% 43%
When someone comes in to check on you: Do they ask you if you need to change position and if you are comfortable? Yes 71% 84% 80%
No 29% 16% 20%
When someone comes in to check on you: Do they ask you if you need anything else before they leave the room? Yes 96% 96% 96% *
No 4% 4% 4%
Has your call bell been answered promptly? Yes 92% 86% 88% *
No 8% 14% 12%
STAFF INTERVIEW OR OBSERVATION Phase I Only Phase II Only Phase I & II
Can you tell me the purpose of the Attending Nurse role? Yes 100% 100% 100% *
No 0% 0% 0%
Can you share an example of Relationship-based Care that has occurred on the unit? Yes 96% 90% 92% *
No 4% 10% 8%
Do Interdisciplinary Rounds occur at a regular scheduled time on your unit? Yes 83% 98% 93% *
No 17% 2% 7%
The Electronic White Board is utilized on the unit. (Phase I and Lunder only). Yes 92% 93% 92% *
No 8% 7% 8%
Voaltés are utilized on the unit. Yes 100% 100% 100% *
No 0% 0% 0%
Hourly Rounding (Safety Rounds) occur on the unit. Yes 100% 90% 93% *
No 0% 10% 7%
OBSERVATION - IN-ROOM WHITE BOARDPhase I
Only Phase II
OnlyPhase
I & II
Patient Name Complete & Accurate 100% 89% 93% *
Complete / Not Accurate 0% 0% 0%
Not Complete 0% 11% 7%
Date Complete & Accurate 92% 79% 83% *
Complete / Not Accurate 4% 19% 14%
Not Complete 4% 2% 3%
Nurse Name Complete & Accurate 92% 82% 85% *
Complete / Not Accurate 4% 16% 12%
Not Complete 4% 2% 3%
Physician Name Complete & Accurate 65% 30% 43% *
Complete / Not Accurate 4% 2% 3%
Not Complete 31% 68% 54%
Other Members of the Care Team (s) Complete & Accurate 50% 76% 68% *
Complete / Not Accurate 0% 0% 0%
Not Complete 50% 24% 32%
Estimated Discharge Date Complete & Accurate 17% 13% 14% *
Complete / Not Accurate 0% 2% 2%
Not Complete 83% 85% 84%
Goals for the Day Complete & Accurate 68% 48% 54% *
Complete / Not Accurate 0% 2% 2%
Not Complete 32% 50% 44%
OBSERVATION - PATIENT FACE SHEET Phase I Only Phase II Only Phase I & II
Pre-Admission Estimated Length of Stay was identified Yes 20% 26% 24% *
No 80% 74% 76%
Estimated Discharge Date was identified Yes 15% 0% 4% err *
No 85% 100% 96%
Discharge Disposition was identified Yes 9% 0% 3% *
No 91% 100% 97%
OBSERVATION/STAFF REPORT – QUIET HOURS Phase I Only Phase II Only Phase I & II
Do Quiet Hours occur on the unit? Yes 97% 92% 100% *
No 3% 8% 0%
Quiet Hours signage is visible on the unit? Yes 89% 92% 88% *
No 11% 8% 12%
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Positive: Patient Do nurse, doctors and others make you feel part of the team? When someone comes in to check on you do they ask about – your pain? When someone comes in to check on you do they ask if your are
comfortable and want to change position? When someone comes in to check on you do they ask if you need anything else before they leave the room? Has your call bell been answered promptly?
Staff Can you tell me the purpose of ARN role? Can you share an example of Relationship Based Care? Do interdisciplinary rounds occur at a regularly scheduled time?
Observation Electronic White Boards utilized on unit (Phase 1 and Lunder only)? Voaltés are utilized on the unit? In Room White Board – Patient Name Complete? Quiet Hours signage is visible?
Observed or Reported Quiet Hours occur on the unit? Hourly Rounding occurs on the unit?
Aggregate data for Phase 1 and Phase 2
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Opportunities: Observation D/C Envelope – if yes is a D/C date noted? In Room White Board – Physician Name? In Room White Board – Care Team Members Names? In Room White Board – Estimated Discharge Date? In Room White Board – Goals for the Day? Face Sheet – Pre-admit expected LOS? Face Sheet – EDD? Face Sheet – Discharge disposition?
Aggregate data for Phase 1 and Phase 2
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What is our evaluation telling us?
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Next Steps for Evaluation Continued evaluation in the 90-Day Cycle
Inclusion of Phase 3 and Phase 4 Units
Adjustment of measures based on Evaluation Steering Committee Recommendations (i.e., deep dive: Estimated D/C Date, White Boards, Face Sheet)
Increased evaluation of ARN role
Increased transdisciplinary team input (regular meetings/groups soliciting insights)
Coordinate longitudinal data management (research)
Developing an Innovation Evaluation Manual
Publish, present, publish, present, repeat
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MASSACHUSETTS GENERAL HOSPITALPATIENT CARE SERVI CES
IncludingMechanisms of EvaluationsData ElementsInstrumentsQuestionsTimelinesDashboard examplesObservation ChecklistNumber of Resources Needed
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To identify the new paradigm
• Evaluate trends
• Build for research
• Utilize evidence to make decisions
• Adopt, Adapt & Abandon
• Disseminate work
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Nursing Director Survey Quote:
“Managing the new [innovation] processes is time consuming. Communication to other staff is ongoing. I feel I’ve answered the question, ‘What is this all about?’ too many times.
But…the impact on patient care is worth it all.”