Nurses Leading EBP: The Imperative for Improving Care and Healthcare Systems

Centura EBP Conference – November 2, 2018

Gail Armstrong, PhD, DNP, ACNS-BC, CNE

Objectives

Objective 1: Describe updated thinking about competencies for nurses leading EBP in clinical settings

Objective 2: Distinguish the areas of overlap and differentiation between EBP and QI.

Objective 3: Identify elements of successful nurse-led projects that effectively translate current evidence into sustained microsystem practice norms.

• Step 0: Spirit of Inquiry

• Step 1: ?s in PICOT

• Step 2: Best Evidence

• Step 3: Critically Appraise

• Step 4: Clinic Exp & Pt Pref.

• Step 5: Evaluate Outcomes

• Step 6: Disseminate Results

• Inspiring and Inducing

• Intervening actively

• Educating & Role Modeling

• Monitoring & Giving Feedback

• Strategic Thinking

• Communicating

• Building and Sustaining EBP Culture

1. ?s practice

2. Describes clinical problems using evidence

3.Contributes to PICOT questions

4.Searches for extevidence

5.Critically appraises evid

6.Synthesizes evid

7.Collects practice data

8. Plans EBP changes

9.

QI is a systematic process •used by healthcare systems to analyze existing data and improve its processes or outcomes for a specific population

EBP is a problem• -solving approach to the delivery and improvement of healthcare that integrates the best evidence from rigorous research and combines it with a clinician’s expertise and patients’ preferences and values.

• Clinical practice guidelines, which should be routinely incorporated into EBP, are statements with recommendations for clinical practice that are rigorously developed based on systematic reviews of evidence and an evaluation of their benefits and harms.

Vision + Strategy/Execution +

. EBP Culture .

Success in Healthcare Quality & Outcomes

Level of Evidence +

Quality of that Evidence

____________________

Confidence to Act and Change Practice

Unprecedented Time in Healthcare

Clearer demand from our patients for cost• -effective, flexible, patient/family-centered care

Shift in our healthcare payment model from fee for •service to value-based payments models

Almost two decades since • To Err Is Human

More than • 10 years from the launch of the RWJ Quality and Safety Education for Nurses (QSEN) national initiative

Increasingly clear evidence about what high •functioning teams look like in healthcare

Preparing New Clinicians to Engage in Patient Safety (2017)

• How is the health system engaging clinicians in patient safety early in their career, to maintain these competencies throughout one’s practice career?

• Facilitate full engagement early in one’s career• What does a “culture of safety” look like in action?• Day to day reporting of safety concerns• Participate in analysis of safety events, so to eventually lead

to improvement in systems• How does leadership translate patient safety events to

system improvements?

Improving the work is not enough

• “….too often, hard-won improvements are lost as attention shifts to other priorities and staff revert to the 'old way' of doing things.”

• How can improvements in the safety, effectiveness and efficiency of patient care over time be sustained?

• IHI Why is Improvement So Hard to Sustain?

Sustaining improvement over time• Function of leadership

• Infrastructure• Human Resources• Processes

• Standardization: Processes exist to help define and disseminate standard work

• Accountability: A process is in place to review execution of standard work

• Visual Management: Process performance information is continuously available to synchronize staff attention and guide current activities.

• Problem Solving: Methods are available for surfacing and addressing problems that are solvable at the front line, and for developing improvement capability

• Escalation: Frontline staff scope issues and escalate those that require management action to resolve

Background & Structure of CTPProcess•

RFA every September •

Select ~• 16 teams/year (12 UCH, 4 CHCO)

Staff•8 • Faculty (UCH, CHCO, CON, SOM)

6 • physicians, 1 nurse

2 • Process Improvement Consultants

2 • Data Analysts

Method•22 • Biweekly Sessions (4 hours each)

• 2nd and 4th Tuesday of every month – 1pm to 5pm

22 • Biweekly Coaching Sessions (1-2 hours each)• 1st and 3rd week of the month

Initial Presentation of Most Teams

“Our People Are Unhappy”

Overlap of CTP with QSEN Competencies

• Patient –Centered Care:

• Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

• Safety:

• Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.

• Evidence Based Practice:

• Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

• Teamwork & Collaboration:

• Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.

• Quality Improvement:

• Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.

• Informatics

• Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.

CTP Curriculum Structure

1.Leadership & Change Mgmt

2.Social Intelligence & Teamwork

3.Communica-tion & Sense-making

4.Adaptive Thinking

5.Deploy QSE Methods Effectively

6.Innovation & Design Thinking

7. Computation Thinking & Data Mgmt

Competencies Teaching Topics

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Quality Improvement (9): Theory of Process Improvement | QI Data Management & Dashboards: Part I | Applying Process Improvement Locally | QI Data Management & Dashboards: Part II | RPO Method: Step 1 | RPO Method: Step 2 | RPO Method: Step 3 | RPO Method: Step 4 | RPO Method: Step 5 | Designing New Processes/Systems in Complex Environments | Advanced IT & Improvement: Part I | Advanced IT & Improvement: Part II | Improvement ROI Revisited

Prologue (2): Course Overview | Defining a Starting Point |

Policy & Business Drivers | Teambuilding | Health Systems

Performance | Systems Redesign 101 | QI & the IRB

Leadership Core (3): Change Management | Personality, Preference, & Communication | Power, Influence, & Negotiation | Negotiation Simulation | Building Effective Clinical Teams: TeamSTEPPS I & II

Culture & Safety (2): Safety Culture | Communication Workshop I & II: Transparency | Safety Methods

Healthcare Operations (2): Supply Chain Management | Healthcare Finance 101, 102, & 103

Capstone (4): Change Management & Diffusion of Innovation | Sustaining & Embedding Change | Dissemination I: Sharing Ideas Beyond the Local Environment | Dissemination II: Bringing Good Ideas Home | Balancing Efficiency & Safety | Integrating QSE Insights: Perspectives from Professional Disciplines | Revisiting QSE Drivers | Reflection & Evaluation| Project Presentations

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Practice

Learning Model: Beyond Skills “Boot camp”

CTP

Participants

Clinical Leadership Teams

(CTP Participants are Members)

Clinical Unit or Program

Rigorous Education

+

Intensive Coaching

+

Data and PI Support

➢ CTP participants learn via didactics

+ projects

➢ CTP participants help enhance the

broader Clinical Leadership Team

➢ Teamwork + Leadership -> Culture

➢ Mastery of CTP content -> Projects

➢ Projects + Culture -> Continuous &

Sustained Improvement

Every Team has a Process Improvement ExpertValue Stream Map: Return Patient ExperienceNon-Value Added Time: 23 minutes (53% of total visit)

07:49 08:32

08:07 - 08:17Resident

Encounter

08:00

08:00Scheduled

Appointment Time

07:57 - 08:01Patient wait

to be roomed

07:49 - 07:51

Check In

07:51 - 07:57

Paperwork

08:01 - 08:07Patient wait

for resident

08:17 - 08:22Patient wait

for physician

08:22 - 08:32Physician Encounter

Every Team has a Data Analyst

Enhance

Leadership Teams

Enhance Care

(QI Projects)

2014, 2015 & 2016 Combined Outcomes

• Business Drivers• 27% reported grasp of strategies to deal with

complex change

• Q&S / Cost Expertise• 23% reported ability to use QI/PI tools• 42% reported ability to use PS tools• 23% reported ability to reduce operational

waste

• Change Management• 26% reported confidence in ability to manage

change

• Teams• 68% reported ability to create & enhance high-

functioning teams

• Data• 43% reported ability to identify data needed

for systems improvement

• Business Drivers• 75% reported grasp of strategies to deal with

complex change

• Q&S / Cost Expertise• 81% reported ability to use QI/PI tools • 91% reported ability to use PS tools• 74% reported ability to reduce operational

waste

• Change Management• 82% reported ability to lead organizational

change

• Teams• 93% reported ability to create & enhance

high-functioning teams

• Data• 87% reported ability to identify & use data

needed for systems improvement

Intake Survey Exit Survey

IHQSE CTP Project Outcomes• Cancer Clinic:

• 13% reduction in time from referral to patient being seen

• Emergency Dept:

• 10% reduction in CT turnaround time

• 50% increase in % CP pts receiving EKG in 10 min.

• ENT Clinic:

• Provider engagement scores increase from lowest to highest tier in system

• Esophageal Surgery:

• 17% decrease in LOS

• ACE:

• 40% increase in % of pts discharged to sub-acute nsg facility before 2pm

• Infusion Center:

• 20% decrease in patient chair time (non-value added)

• Neonatal ICU:

• Reduction in readmissions from 3.3% to 0%

• OR:

• 43% improvement in urologic first case on-time starts

• Orthopedics:

• 33% reduction LOS for geriatric hip fracture pts.

• Palliative Care:

• 12% LOS reduction for pts receiving palliative care consultation

• Ped ABX Stewardship:

• 15% reduction in ABX days of therapy

• Ped BMT:

• 24% reduction in LOS

• Radiation Oncology:

• 24% reduction in time from referral to patient being seen

Pancreas Team - 2016

Pancreatic surgical patient volume at UCH increased by • 75% since 2012

length of stay (LOS) was on the rise. •

UCH pancreas cancer patient average LOS was ~• 12 days. National average LOS was 10 days.

Opportunities existed for the standardization of patient care •and improved communication among interdisciplinary teams.

Additionally, the second phase of the project focused, on •the standardization of patient education and the over utilization of the intensive care unit (ICU).

These inefficiencies led to delayed floor transfers, increased •charges and costs for the patient while in ICU, and inappropriate transfers to off service units.

Pancreas Team IHQSE Work• Phase 1

• Standardized Pancreas Pathway- Created a care progression pathway that was agreed upon by MDs, helpful for rotating residents to stay on track with (care progression, patient care pathway, orders and milestones before dc)

• Nurse Education: Specialized nursing course offered to all staff nurses regarding the specialized care of the pancreas population.

• Education Huddles: 15 minute focused education regarding specific key elements of pancreas patient care at the nurses’ statation.

• Daily RN/MD Rounds: Staff nurse lead. Created rounding tool and rounding process to stay up to date on patient care progressions and readiness for DC.

• Monthly Chief meetings: Nurse lead (charge nurse and educator) 10 minute meeting monthly gathering Chief residents and lower level residents on service to get on the same page with rounding expectations, pathway awareness and to build relationships and create a platform for additional collaboration.

Pancreas Team Ongoing Improvement Work

• Phase 2

• Care transitions: Bypassing ICU for targeted pancreas patient population

• ERAS (Enhanced Recovery after Surgery) included an extended stay from ~1 hour in PACU to 4 hours in PACU before direct transfer to the floor (bypassing ICU).

• Order set into EPIC- Educator lead: Created a standard order set for patients uploaded to EPIC for ERAS floor orders.

• Improved nurse/patient ratios: Nursing lead: Business plan created to adjust nurse rations from 4:1 to 3:1 with ERAS patients and to accommodate the increasing acuity of surgical patients.

• Patient Education: Professional pancreas booklet created by staff nurse, funded by a previous pancreas patient donation.

• Placeholder for Shannon’s video

How will your participation in the CTP impact your nursing practice?

Transformative•

The interdisciplinary •faculty were powerful role models

New perception of my •nursing practice

Given me a new sense •of my career

Increased confidence•

• Much more aware of cultural, leadership issues and how to help

• I will use this content forever

• In all ways, I am a better nurse

• Excitement for system transformation

What have I learned from six years of IHQSE?

• Teaching improvement can barely be done in twelve months

• Quality and Safety are not elective nursing content areas

• Systems are the context for everyone’s practice and must be taught in nursing programs

• Understanding and improving microsystem culture is an imperative need right now

• Nurses play the biggest role in developing healthy culture

• Nurses need to lead and be involved in EBP work, from start to finish to sustaining the work

Requisite Competency for Systems Leaders

The Financial Disconnect

Current payment models are problematic ▪ Fee for service (FFS) – no feedback loop to

promote higher value care (no skin-in-the-game)▪ The person providing the service gets paid

without regard to ▪ quality(outcome) or ▪ Value(whether the service was needed or not, or

the cost)

Traditional payment models do not support

delivery of higher value care

Value Based Payment (VBP) What is it?

HealthCare.Gov Definition

Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers.

“Some skin-in-the-game”

It’s not about trying harder…..

IOM Crossing the Quality Chasm

“…the effective remedy is • not to browbeat the health care workforce by asking them to try harder …. If we want safer, higher-quality care, we will need to have redesigned systems of care…[and]… ongoing tracking to assess progress…”

trans·formverb \tran(t)s-ˈform\ : to change (something) completely and usually in a good way

Value Based Payment Models and MACRA

• Medicare Access &CHIPs Reauthorization Act

• Passed by Congress April 2015 to replace the Sustainable Growth Rate (SGR)) with a plan to pay for higher Value/Quality and better coordinated care instead of classic fee-for-service volume based care

• 2020-2025: option for one of two payment tracks, based on data from 2019 services

MACRA affects most providersUnless you’re new to Medicare or bill very low Medicare volume, you can’t opt out.

Time is shortYou must report some data in 2017 to avoid penalties.

Expect an administrative burdenThe data collection and reporting can be extensive. Ensure you have an EHR that sets you up for success – and without extra work.

Meaningful Use (MU) is not going away

MACRA does not change hospital or Medicaid MU. Medicaid MU participants who also bill Medicare will need to participate in both Medicaid MU (through 2021) and MIPS.

MACRA is here to stayMACRA was passed with bipartisan support, and is separate from the ACA. A repeal of the ACA does not mean a repeal of MACRA, so providers should expect it to continue to move forward.

Proposed quality scoring is publicAll reporting performances will be publicly reported on Medicare’s Provider Compare site.

The Mechanics of How Culture Eats Strategy

Source: Beyond Lean.com

The Silent Treatment

• Mixed methods study• Traditional survey (quantitative measure)

• Completed by 4,235 RNs, 832 of those were managers

• Story Collector• Completed by 2,383 RNs, 169 of those were managers

• Concerns about dangerous shortcuts• 34% say dangerous shortcuts have led to concerns about

incompetence• 19% say incompetence has harmed patients

• Concerns about disrespect• 20% say that disrespect is making them seriously consider leaving

their job or profession.

• In 2010 21%-31% of nurses spoke up about their concerns

Emotional exhaustion and workload predict clinician-rated and objective patient safety.

Welp, A, Meier, LL, Manser, T. (2015) Frontiers in Psychology, 5: 1573

• This Swiss ICU study enrolled 1425 nurses and physicians on 54 ICU teams from 48 different hospitals, evaluated the effect of individual and unit-level burnout scores and clinician ratings of overall safety on standardized mortality ratios and length of stay.

• Importantly, the study controlled for unit workload and workload predictability.

• Higher individual burnout scores were related to poorer overall safety grades.

• When measured at the unit level, emotional exhaustion (a component of the overall burnout score) was an independent predictor of standardized mortality ratio.

What contributes to joy in work?

• Translating EBP so to improve Systems

• Healthy teams• Being important to the team• Knowing what to expect • Feeling seen/known/appreciated

• A healthy work environment• Respect, autonomy, mastery, purpose

• Meeting goals• Clear expectations

• Work/Life Balance• Minimal overtime, few unexpected/uncompensated hours

“Joy is a resource for excellence”Don Berwick

https://www.youtube.com/watch?v=3JTdHStR6KI

Thank You!!

Questions??

Gail.Armstrong@ucdenver.edu