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DebraJ.Drew,MS,ACNSBC,RNBCDebraTopham,PhD,JD,RN

ImplementationoftheCAPA(ClinicallyAlignedPain

Assessment)Tool:PainisMorethanJustaNumber

ConflictofInterestDisclosure

AuthorsConflictofInterest DebraDrew,NoConflictsofInterest

DebraTopham,NoConflictsofInterest

UniversityofMinnesotaHealthbrandrepresentsacollaborationbetweenUniversityofMinnesotaPhysiciansandUniversityofMinnesotaMedicalCenter.

LackofConfidenceofOnesImpact

Nobodymakesagreatermistakethanhewhodidnothingbecausehecoulddoonlyalittle.

EdmundBurke

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ThePowerofManyDrops

Objectives

UniversityofMinnesotaHealthbrandrepresentsacollaborationbetweenUniversityofMinnesotaPhysiciansandUniversityofMinnesotaMedicalCenter.

Learnerswillbeableto:1. Discusstheconceptofpainassessmentasasocialtransactionbetweenpatientandclinician.

2. SummarizetheoutcomesofUniversityofMinnesotaHealthsimplementationofCAPA.

3. Describethelessonslearnedfromimplementingacomplexandculturechangingproject.

Objective1

1.Discusstheconceptofpainassessmentasasocialtransactionbetweenpatientandclinician.

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Selfreport=goldstandard Majordisconnectbetweenwhatisadvocatedandwhatcliniciansactuallydo

Painassessmentbestdescribedasadynamicprocess,atransaction Verbalandnonverbalinteractionbetweenpatientandclinicianismodifiedbythephysiologicandsocialcontext

Schiavenato,M&CraigKD.(2010).PainassessmentasasocialtransactionbeyondtheGoldStandard.ClinicalJournalofPain,26(8):667676.

PainAssessmentasaSocialTransactionBeyondtheGoldStandard

PainAssessmentasaSocialTransactionSchiavenato,M&CraigKD.(2010)ClinJPain.26(8);667676.

Problemwithselfreportusingaunidimensionalscale Painisamultidimensionalcomplexexperience Numericscaledifficultforsometouse Requireslinguisticandsocialskills:problematicwithsomeofmostvulnerablepopulations

Patientsmodulatepainbehaviorsandselfreportbasedontheirperceptionofwhatsintheirbestinterest

PatientsModulatePain

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PainAssessmentasaSocialTransactionSchiavenato,M&CraigKD.(2010)ClinJPain.26(8);667676.

BiologicalSociocultural

Developmental/PsychologicalExperience/EmpathyContextual/Situational

Experience(PatientMeaning)

Expression AssessmentJudgment(ClinicianMeaning)

ContributingFactors

AssessmentProcess Patient Clinician

PainStimulus

Intervention

ExamplesofContributingFactorsinPainAssessment

Biologic Sociocultural DevelopmentalPsychological

Experience/Empathy

Contextual/Situational

Patient Disease,clinicalcondition,druginfluences

Ethnicity, sex,accesstohealthcare,culturalorigin

Age,stress,drugaddiction,interpersonalskills,fear

Previousexperienceofpain

Language,fear/stress,Similarity toclinician,socioeconomicstatus

Clinician Biologicdisposition,stressreactivity

Pt.preferencesorbiases,age,sex,education,ethnicbackground

Viewsonpain,trust/suspicion,Interpersonalskills,criticalevaluation ofpainreport

Knowledge,clinicalcompetence,empathy,institutionalinsensitivity

Workload,interdisciplinarycommunication,facilityresources

Schiavenato,M&CraigKD.(2010)ClinJPain.26(8);667676

SummaryoftheSocialTransactionofPainAssessment

Painiswhatthepatientsaysitisacknowledgessubjectivityofpain,butignorescomplexpatient/clinicianrelationship

Painas5th VitalSignhighlightssignificanceofpain,butcanbemechanistic

Painassessment=intersubjectiveexchangeofmeaningbetweenpatientandclinician

Processdependentoninternal/externalfactorstobothpartiesandenvironment

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UniversityofUtah 2012PilotProject

CAPA developedtoreplaceconventionalnumericratingscale(NRS;010scale)

PressGaney scoresincreasedfrom18th to95th percentile

55%patientspreferredCAPA

NursespreferredCAPA 3:1overNRS

From,Donaldson&Chapman,2013.

ClinicallyAlignedPainAssessment(CAPA)PainisMoreThanJustaNumber

Evaluates intensityofpain effectofpainon

functionality effectofpainonsleep efficacyoftherapy progresstowardcomfort

Engagespatientandclinicianinabriefconversation aboutpainresultingincodedevaluation

From,Donaldson&Chapman,2013.

CAPA Tool(modified;originalinblue)Theconversationleadstodocumentation nottheotherwayaround.

Question Response

Comfort IntolerableTolerablewithdiscomfortComfortablymanageableNegligiblepain

ChangeinPain Getting worseAboutthesameGettingbetter

PainControl InadequatepaincontrolInadequate paincontrolPartially effectiveEffective,justaboutrightFullyeffectiveWouldliketoreducemedication(why?)

Functioning CantdoanythingbecauseofpainPainkeepsmefromdoingmostofwhatIneedtodoCandomost things,butpaingetsinthewayofsomeCandoeverythingIneedto

Sleep AwakewithpainmostofnightAwakewithoccasionalpainNormalSleep

From,Donaldson&Chapman,2013.

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ChangeorTransformation?

Changeisthefixingofpasttofuture: Better,cheaper,faster,leaner,etc.

Transformationisthejobofleaders: Buildingavision Startwiththefutureandworkback Helppeoplefallinlovewiththefuture

Transformation

ThebutterflyisNOTabetter,fastercaterpillar.

ItisaNEWsystem.

StepsofImplementation

1.Definethescopeandteam2.Identifyandmanagetherisks3.Breakdownthework4.Schedulethework5.Communicate6.Measureprogress

From,Verzuh(2008).

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UniversityofMinnesotaMedicalCenter ARiverRunsThroughIt

1.Definingthescopeandteam Phase1

Scope(AdultInpatient) MedicalUnits SurgicalUnits BehavioralUnits ObstetricsUnits AcuteRehabilitation TransitionalCare EmergencyDepartments PerioperativeServices

Team Champion:ChiefNursing

Executive QualityandPerformance

ImprovementConsultants DataAnalysts ElectronicHealthRecord

Consultant NurseManagers StaffNurseLeaders NurseEducators CommunicationsDepartment

1.Definingthescopeandteam Phase2

InfusionCentersClinicsProceduralAreas

Scope(AdultOutpatient)

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1.Definingthescopeandteam Phase3

Processbeginswithvalidationoftoolinpediatricpopulation

Scope(Pediatrics)

2.Identifyandmanagetherisks

Potentialfailures/risks Failuretogaincooperation

ofnursesandphysicians Concernsofresearchers

usingthenumericscale Failuretoincreasepatient

satisfactionorimprovepainmanagement

ManagingRisks Buyinfromkeyleaders ContactedIRBtonotify

researchersofchange Weeklymonitoringof

processwithmonthlymonitoringofoutcomes

3&4.BreakdownandscheduletheworkAug 13 Sept Oct Nov Dec Jan 14 Feb Mar April May June July

Take to Leadership groups

Develop content of presentations

Establish plan for data collection

Build doc and reports to support

Form House wide Group and unit based group

Engage Stakeholders

Assess current state of practice, research (

Communicate/educate all disciplines

Implement: Inpatient

Monitor, evaluate, tweak, sustain

Implement: Outpatient

,

Month

Determine & Establish Accountability desired outcomes, Structure /roles at all levels

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5.Communicate Who

Specialinterestgroups:NurseManagers/Directors,nursingstaff,physiciangroups,APRNs,nursingpracticecommittees,socialworkers,therapists,champions

When Before,frequentlythroughout

What Purpose,expectedbehaviors,expectedoutcomes,patient/familyfeedback,processandoutcomemeasures

How Viameetings,newsletters,intranet,patientstories,staffstories,email

6.Measureprogress

Processmeasures: Weeklycompliancereportperunit Identificationofindividualsstillusingnumericscale:canbecoachedandcounseled

Outcomemeasures: MonthlyCAPA outcomes PressGaney painsatisfactionscores

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Objective2

SummarizetheoutcomesofUniversityofMinnesotaHealthsimplementationofCAPA.

ElectronicDataAbstraction

ProcessMeasures CAPACompliance

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OutcomeMeasures CAPA

6.41%

27.01%

22.67% 22.67%21.82%

18.96%

16.67%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

January February March April May June July

EffectivenessofPainControl(byMonth)

OutcomeMeasures CAPA

50.50%

51.48%50.95% 50.95% 51.23% 50.75% 51.04%

44.00%

46.00%

48.00%

50.00%

52.00%

54.00%

56.00%

58.00%

60.00%

January February March April May June July

DegreeofComfortbyMonth

OutcomeMeasures PressGaney

OverallPainManagement StaffDidEverythingTheyCouldtoHelpWithPain PainWellControlled

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PressGaney OverallPainManagement(byQuarter)

67.866.7

60.862.6

64.6

68.0

63.7

65.9

69.067.1

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

Q112 Q212 Q312 Q412 Q113 Q213 Q313 Q413 Q114 Q214 Q314 Q414

PressGaney OverallPainManagement(bymonth)

50

55

60

65

70

75

80

% Average 3STD 2STD

PressGaney HowWellPainControlled(byQuarter)

61.6

59.3

52.353.4

55.9

59.2

55.256.7

61.0

57.7

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

Q112 Q212 Q312 Q412 Q113 Q213 Q313 Q413 Q114 Q214 Q314 Q414

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PressGaney HowWellPainControlled(byQuarter)

40

45

50

55

60

65

70

75

Jan12

Feb12

Mar12

Apr12

May12

Jun12

Jul1

2

Aug12

Sep12

Oct12

Nov

12

Dec12

Jan13

Feb13

Mar13

Apr13

May13

Jun13

Jul1

3

Aug13

Sep13

Oct13

Nov

13

Dec13

Jan14

Feb14

Mar14

Apr14

May14

Jun14

Jul1

4

% Average 3STD 2STD

PressGaney StaffDidEverythingtoControlPain(byQuarter)

74.0 74.1

69.4

71.773.2

76.7

72.1

75.277.1 76.4

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

Q112 Q212 Q312 Q412 Q113 Q213 Q313 Q413 Q114 Q214 Q314 Q414

PressGaney StaffDidEverythingtoControlPain(byMonth)

60

65

70

75

80

85

90

% Average 3STD 2STD 2STDEV 3STD

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Anecdotes

Patientperspective:Makesmefeellikethenursescaremoreaboutmypain.

Nursesperspective: Itmakessense. Manyfrustratedbynumericscale.Ihatedthat010scale.

NurseSurvey1medsurgunit(N=21,67%return)

80%satisfiedorverysatisfiedwithimplementation

80%feltcommunicationwithpatientsimprovedwithCAPA

71%satisfiedwithrationaleforchange

66%preferredCAPAoverNRS

47%believepatientshavesomewhatbetterpain

managementwithCAPA

ThankstoEmilyDrobinski,CarrieHallstrom,KellyPavlicek,MarySylvestre,HeatherWhite,ClareZielinski:Unit8A,UMMC

Objective3

Describethelessonslearnedfromimplementingacomplexandculturechangingproject.

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Learnings NumericscaleembeddedinmanydifferentplacesinEHR.

Painassessmentbymanydifferentpeople Students,faculty,therapists,technicians,etc.

Somestaffarenotskilledattalkingwithpatients;thispresentedachallenge.

Somepeopleresistchange! Staffcanbethebiggestchampions!

UnexpectedOccurrences

AdditionalLearnings

Staffneedtorecognizethisasculturechangeversusaproject

Glitcheshappeninspiteofbestplanning Rippleeffectsofchange Barriersalongtheway:people,processes,tools

Facilitators:people,processes,andtools

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Recommendations

Makeithardtodothewrongthing,andeasytodotherightthing.JoanneDisch,PhD,RN

Educateviapresentations,electroniclearning,writtenmaterials,interpersonalmeetings.Repeat,repeatagain.

Recommendations

Speaktofearsandconcerns: Fearofmakinganassessment:somemorecomfortablewithpatientsstatementofanumber

MDsfearthattheywontknowhowtorespondwhennursecallswithCAPAinformation

Engageexecutiveleadershipasnecessary

ATaleofTwoEmergencyDepartments

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URED2nd Quarter

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

3/24 3/31 4/7 4/14 4/21 4/28 5/5 5/12 5/19 5/26 6/2 6/9 6/16 6/23

3/24 3/31 4/7 4/14 4/21 4/28 5/5 5/12 5/19 5/26 6/2 6/9 6/16 6/23BothCAPAandNumeric 12% 7% 9% 7% 7% 5% 5% 2% 2% 2% 3% 1% 1% 0%CAPAOnly 84% 90% 87% 91% 90% 94% 94% 97% 98% 97% 96% 99% 98% 100%NumericOnly 4% 3% 3% 2% 3% 1% 2% 0% 0% 2% 1% 0% 1% 0%

BothCAPAandNumeric

CAPAOnly

NumericOnly

VPLettertoStaff

UUED3rd Quarter

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

6/30 7/7 7/14 7/21 7/28 8/4 8/11 8/18 8/25 9/1 9/8 9/15 9/22 9/29

6/30 7/7 7/14 7/21 7/28 8/4 8/11 8/18 8/25 9/1 9/8 9/15 9/22 9/29BothCAPAandNumeric 2% 1% 1% 2% 1% 0% 1% 1% 0% 0%CAPAOnly 98% 98% 99% 97% 97% 100% 99% 98% 100% 99%NumericOnly 0% 0% 0% 1% 1% 0% 0% 1% 0% 0%

BothCAPAandNumeric

CAPAOnly

NumericOnly

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URED3rd Quarter

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

6/30 7/7 7/14 7/21 7/28 8/4 8/11 8/18 8/25 9/1 9/8 9/15 9/22 9/29

6/30 7/7 7/14 7/21 7/28 8/4 8/11 8/18 8/25 9/1 9/8 9/15 9/22 9/29BothCAPAandNumeric 1% 1% 1% 1% 2% 1% 2% 1% 0% 2%CAPAOnly 98% 98% 99% 99% 98% 98% 98% 99% 100% 97%NumericOnly 1% 1% 0% 0% 0% 0% 0% 0% 0% 1%

BothCAPAandNumeric

CAPAOnly

NumericOnly

Summary

Painassessmentisnotmerelythesubjectivestatementofthepatient,nomorethanitisthesoleobjectivedecisionoftheclinician.

Rather,painassessmentistheintersubjectiveexchangeofmeaningbetweenthepatientandclinician.

Itisaprocess,whichisongoinganddependentonboththeinternalandexternalfactorsinherenttoboththepartiesandtheirenvironment.

Summary

CAPA isanexpandedwaytoassesspainusingatransactionalconversationbetweenpatientandclinician.

Findings:ChangingfromthenumericscaletotheCAPA toolisaculturalchangeforstaffandpatients.

Nextstepsatourinstitutioninclude: Expansiontomostcaresettingswithinhospitalsystem.

Validationoftoolinadolescents

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Questions?

ReferencesDonaldson,G.,&Chapman,C.R.(2013).Painmanagementismore

thanjustanumber.UniversityofUtahHealth/DepartmentofAnesthesiology.SaltLakeCity,Utah:DepartmentofAnesthesiology.

Schiavenato,M.,&Craig,K.D.(2010).Painassessmentasasocialtransaction:Beyondthegoldstandard.The ClinicalJournalofPain,26(8),667676.

UniversityofUtahHealthCare.(n.d.).Givingpatientsavoice,notanumber.Retrievedfrom:http://healthcare.utah.edu/nursinginnovation/10ideas/two.php

Verzuh,E.(2008).FastforwardMBAinprojectmanagement(3rd ed.).Hoboken,NJ:JohnWiley&Sons,Inc.