Pat Comoss NO DISCLOSURES NO CONFLICTS OF INTEREST. Pat Comoss RN, BS, MAACVPR. Not New, Revisit WHAT WHY WHEN HOW

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1 Pat Comoss NO DISCLOSURES NO CONFLICTS OF INTEREST Pat Comoss RN, BS, MAACVPR To receive WNA nursing contact hours, participants need to complete the web presentation, submit a completed post-test with a minimum score of 66%, and submit the evaluation at the end of this program. Upon completion of this activity, participants will be able to: Discuss why an annual staff competency plan is important for rehab personnel Select criteria that are useful when choosing competency topics List acceptable methods for evaluating a staff member s competency Identify the program certification requirements for how many selected staff competencies must match AACVPR s published Core Competencies Select & use a performance checklist to document staff members competency Not New, Revisit WHAT WHY WHEN HOW WHY: Intrinsic Philosophy = desire for continuous learning to be the best rehab practitioner you can be WHY: Intrinsic Philosophy = desire for continuous learning to be the best rehab practitioner you can be Extrinsic Expectation: Hospital requirement Joint commission standard AACVPR Program Certification criteria

2 WHAT: The Joint Commission Competence assessment lets the hospital know whether its staff have the ability to use specific skills and to employ the knowledge necessary to perform their jobs. Human Resources chapter: 2014 Hospital Accreditation Standards Staff are competent to perform their responsibilities. The hospital Defines the competencies it requires of staff who provide patient care/treatment/services Uses assessment methods to determine competence in the skill being assessed Test taking, return demonstration, simulation/role play An individual with the educational background, experience, or knowledge related to the skills being reviewed assesses competence The hospital can utilize: An outside individual Competency guidelines from an appropriate professional organization Staff competence is assessed & documented once every 3 years or more often per hospital policy AACVPR Program Certification: CR & PR = Staff Competencies Individuals should possess a common core of professional & clinical competencies, regardless of academic discipline A program must provide evidence of annual assessment of clinical/professional staff competency (Underline added for emphasis) PULMONARY REHAB Program Certification: Four assessed competencies MUST be specific to the Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals 2007 Nici, Limberg, Hilling et al. CARDIAC REHAB Program Certification: Four assessed competencies MUST be specific to the Core Competencies for Cardiac Rehabilitation/ Secondary Prevention Professionals: 2010 Update Hamm, Sanderson, Ades et al

3 WHAT NOT: Discipline-specific hospital/department required competencies: Cardiology RNs = conscious sedation Respiratory RTs = precautions to prevent ventilator acquired pneumonia (VAP) WHAT NOT: Initial/Orientation checklist for new employees often emphasize mechanical functions within dept vs. clinical patient care Hospital-wide required competencies e.g. HIPAA rules, safety/security color-codes, etc. HOW: Choose skills that need to be learned, reviewed, or updated because they are: NEW HIGH RISK LOW VOLUME PROBLEMATIC Release of new PR Gdlns Review of CORE paper Competency: Determination of COPD Severity Using GOLD Classification PROBLEMATIC: denial of Medicare coverage for PR if patient s COPD severity is not confirmed as Moderate Severe Very severe TRIGGER 1. Find & read key values in PFT results: FEV1/FVC ratio, FEV1 2. Compare those values to GOLD criteria for COPD severity 3. Assign correct severity label KNOWLEDGE/SKILL Name Date Dept. PULMONARY REHAB Expectation: The pulmonary rehab staff member will use PFT results to identify the appropriate GOLD Stage of COPD by name & number. Essential Elements of Performance: Proficient Needs Review/ Inadequate Improvement ** 1 Define GOLD as the Global Initiative for Chronic Obstructive Lung Disease consisting of an international panel of COPD experts 2 Recognize the GOLD classification of disease severity as the preferred source for assigning extent of COPD 3 Retrieve the patient s latest PFT results 4 Have available the GOLD classification as a reference guide 5 Explain that the best PFT results for this purpose come from those taken after administration of a bronchodilator drug 6 Compare the patient s PFT results to the GOLD criteria as follows: 7 STEP 1 a Identify the patent s percent of FEV1/FVC from their PFT results b State that a value of less than 70% is necessary to confirm presence of COPD and that value must be confirmed when classifying for all stages of COPD 8 STEP 2 a Identify the patient s FEV1 percent of predicted value from their post bronchodilator PFT results b Outline which FEV1 values indicate which stage of COPD severity as follows: 9 FEV1 greater than or equal to 80% of predicted = stage I, mild COPD 10 FEV % of predicted = stage II, moderate COPD 11 FEV % of predicted = stage III, severe COPD 12 FEV1 less than 30% of predicted = stage IV, very severe COPD

4 Match to CORE Category: Emergency procedures Exercise Pathophysiology & comorbidity Patient education & training Professional communication Psychosocial GOLD Criteria Cross-reference: AACVPR s Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals. JCRP 2007; pg 356, Assessment B1 = Professional Communication: Personnel will obtain medical records and verify medical/health history to include diagnosis, therapeutic interventions, and comorbidities. Core Competency document has been updated! New edition is in press & will be introduced at AACVPR National Meeting: September 3-6, 2014 Denver, CO PROBLEMATIC: Denial of Medicare coverage for HF if patient does not meet criteria: 35% EF NYHA class II-IV On optimal medical therapy for 6 weeks No planned major CV procedures in next 6 months 1. Obtain medical records to document EF & NYHA class of HF 2. Confirm that rehab admission occurs at least 6 weeks after hospital discharge & that patient is stable Change in Medicare R/R KNOWLEDGE/SKILL TRIGGER KNOWLEDGE/SKILL Competency: Determination of CHF Patient Appropriateness for Cardiac Rehab Participation Using Medicare Criteria Name Date Dept. CARDIAC REHAB Expectation: The cardiac rehab staff member will use Medicare criteria to qualify CHF patients for cardiac rehab participation Essential Elements of Performance: Proficient Needs Review/ Inadequate Improvement ** 1 Recognize acceptable patients for CR as chronic Heart Failure (HF) 2 Identify potential sources of HF referrals to CR such as from inpatient discharge, HF clinical, home health, or MD office 3 Explain the basic pathophysiology of HF as ventricular dysfunction, impaired ability of the heart to contract sufficiently to eject a normal amount of blood into systemic circulation 4 Describe the most common symptoms of HF as shortness of breath, fatigue, & edema. 5 Define ejection fraction (EF) as percent of blood volume squeezed out of the heart with each ventricular contraction 6 State the normal left ventricular EF as 55-75% 7 Differentiate between HF with reduced ejection fraction (HFrEF) of < 40% & HF with preserved ejection fraction (HFpEF) of > 50% 8 Connect the older descriptors of systolic & diastolic HF to the cut-points for reduced & preserved EF 9 List the 3 main Medicare criteria that qualify CHF patients for cardiac rehab participation as follows: a Ejection Fraction (EF) of 35% or less confirmed by medical record, e.g. diagnostic test report (Echo, cath) or physician progress note stating the EF finding b New York Heart Association functional classification II - IV c Stable patient = on optimal HF therapy for at least 6 weeks + no planned cardiovascular procedures for next 6 months Match to CORE Category: Blood pressure management Diabetes management Exercise training Lipid management Nutritional counseling Patient assessment Physical activity counseling Psychosocial management Tobacco cessation Weight management CHF Criteria Cross-reference: AACVPR s Core Competencies for Cardiac Rehabilitation/ Secondary Prevention Professionals: 2010 Update. JCRP 2011; pg 4, Patient Assessment, Knowledge bullet 1 = Demonstrate an understanding of cardiovascular anatomy, physiology, and pathophysiology.

5 Core Competency document is basis for new CCRP certification! New professional certification exam will be introduced at AACVPR National Meeting: September 3-6, 2014 Denver, CO Examples NEW = BODE Index calculation (PR), MET-minutes calculation (CR) HIGH RISK = diabetic exercise management (blood sugar testing, high & low cut-offs) LOW VOLUME = tobacco cessation Sample checklists for the preceding examples are provided in handout materials HOW TO: Staff & Manager collaborate to choose WHAT = skill or topic WHEN = quarterly or annually WHO = staff member or outside expert Competency: Tobacco Cessation Counseling Name Date Dept. Cardiac Rehab Pulmonary Rehab Expectation: To provide effective counseling to help those patients who wish to quit smoking do so during the course of rehab. HOW TO: Staff & Manager collaborate to choose WHAT = skill or topic Review CORE COMPETENCY DOCUMENT Identify topic/function to be implemented or improved Essential Elements of Performance: Proficient Needs Review/ Improvement 1 Discuss the impact of continued smoking on cardiac/pulmonary disease & the benefits of quitting now. 2 Recognize smoking status as a routine outcome measure & point-out questions in both admission & discharge interviews that collect that information 3 At the beginning of rehab, assess each smoker for readiness to change their smoking behavior & reassess their stage every 30 days during rehab 4 Use appropriate counseling strategies & resources for each stage of readiness 5 List common medications used to assist smoking cessation, including nicotine replacement & psychotherapeutics, & provide related information about each to patients 6 Identify outside resources Hospital Tobacco Counselor Community cessation programs Help line by phone or internet that can be tapped for additional help during rehab or follow-up after rehab Inadequate ** Resources: For knowledge AACVPR PR Guidelines (new 4 th edition) section on Smoking Cessation, pgs US Dept. of Health, Treating Tobacco Use & Dependence Krames patient workbooks For skills Workshop with hospital Tobacco Counselor to emphasize: a. assessing readiness to change b. teaching prescribed medication use Reference to AACVPR Clinical Competency Guidelines: pg. 357, Assessment C4; pg. 357, Intervention B2. Evaluation: Signature Date ** any/all ratings of Inadequate require a corrective action plan tailored to the staff member involved

6 Competency: Assessment of Patient Readiness to Change Name Date Dept. Cardiac Rehab Pulmonary Rehab Smoking Cessation Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals: 2010 Update pg 7 Tobacco cessation, Knowledge 1-7, Skills 1-3. Pulmonary Clinical Competency Guidelines: pg. 357, Assessment C4; pg. 357, Intervention B2. Expectation: To provide effective strategies to assist patients in making behavior changes, cardiac/pulmonary rehab staff will identify a patient s stage of readiness to change & respond appropriately to that stage. Essential Elements of Performance: Proficient Needs Review/ Inadequate Improvement ** 1 Discuss the rationale for focusing patient education efforts on behavior change. 2 List the 5 stages in the Readiness to Change model, also known as the Trans-theoretical model (TTM) of behavior change: Precontemplation Contemplation Preparation Action Maintenance 3 As part of initial set-up of each patient s ITP, determine which stage the patient is in for each particular behavior in question. Ask: Are you planning to in the next month or so? 4 Give appropriate examples of: he s in Precontemplation 5 Give appropriate examples of: he s in Contemplation 6 Give appropriate examples of: he s in Preparation 7 Give appropriate examples of: he s in Action 8 Give appropriate examples of: he s in Maintenance 7 To help assure consistency among staff members, use the worksheet for assessing Readiness to Change to guide questions & answers 8 As part of 30-day ITP review/update, re-visit selected behaviors & re-ask the readiness question; note if the patient has moved further along the change continuum 9 As part of discharge evaluation, repeat the readiness question for behaviors still needing attention 10 Document movement along the change continuum as improvement, even when the behavior change is incomplete. Resources: 1. AACVPR. Collaborative Self Management Education. Chapter 3 in Guidelines for Pulmonary Rehabilitation Programs, 4 th ed. Champaign IL: Human Kinetics Publishers, AHA Prevention Committee of the Council on Cardiovascular Nursing. AHA Scientific Statement: Interventions to Promote Physical Activity & Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults. Circulation 2010;122: Hamm L, Sanderson BK, Ades PA, et al. Position Statement of the AACVPR: Core Competencies for Cardiac Rehabilitation/Secondary Prevention Professionals: 210 Update. Journal of Cardiopulmonary Rehabilitation & Prevention. January February 2011, pp Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society Statement on Pulmonary Rehabilitation. American Journal of Respiratory & Critical Care Medicine, vol. 173, pp , Cross-reference to CORE: Cardiac Rehab Pulmonary Rehab Page 5, Patient assessment. Knowledge Page 357, Intervention B. Patient bullet 13, Skills bullet 5&6 Education & Training: B1 Core Competencies for Cardiac Rehabilitation Page 5 Patient Assessment. Knowledge 13 Adult learning principles, theoretical models for behavior change, adherence, coping, disease management strategies Page 5 Patient Assessment. Skills 5 & 6 Obtain information on patent preferences & goals. Interactive communication & counseling with patient/family on treatment plan through shared decision making Evaluation: Signature Date ** any/all ratings of Inadequate require a corrective action plan tailored to the staff member involved Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals Page 357 Intervention. B Patient Education & Training, B1. Use basic educational principles, theories of learning, and methods of counseling, as well as knowledge of specific behavioral modification techniques, to promote healthy lifestyle changes. HOW TO: Staff & Manager collaborate to choose WHEN = schedule an in-service presentation and/or practice session WHO = find an experienced instructor e.g. behavior specialist, health coach, patient educator

7 GOOD PEOPLE HOSPITAL Outpatient Cardiac Rehab Program 2013 Staff Competency Plan Topic 1 Rationale 2 Schedule 3 FOCUS: Patient Outcome Assessment 1stQ 2ndQ 3rdQ 4thQ 6 Walk PROBLEMATIC: Test Functional status measurement is recommended to evaluate the effectiveness of exercise training in cardiac rehab The 6 walk test is increasingly used in cardiac rehab as a simple submaximal assessment of function To help assure test reproducibility, standardized methods & patient instructions have been developed by the American Thoracic Society (ATS) All staff members need to learn & follow the ATS recommendations Outcome NEW: Measure- Outcome measurement is essential to demonstrating program ment effectiveness Some important outcome information depends on patient selfreport Surveys on paper/pencil surveys Staff must be familiar with the survey tools to properly instruct & assist patients in their use Surveys must be administered in a timely & consistent manner among all staff members Waist NEW: Circumfer- Metabolic syndrome is recognized as an emerging cardiac risk ence Mea- factor Abdominal fat distribution is one important sign of metabolic surement syndrome Proper measurement of abdominal circumference is essential to useful outcome data A standardized procedure should be followed by all staff members Smoking LOW FREQUENCY: Cessation Smoking status is a required outcome measure at the beginning & Counseling end of cardiac rehab Most cardiac patients who were smokers have quit prior to arriving at cardiac rehab; however the few who continue to smoke present a challenge. Successful change of smoking habits requires staff to assess each smoker s readiness to change so that the most appropriate intervention strategies for cessation can be chosen Staff need to be aware of available cessation resources that can be tapped when needed Summary WHAT = documentation of staff knowledge, skill, & ability WHY = improve quality of program; requirement for TJC & AACVPR WHEN = each year for cert/recert HOW = learn, practice, demonstrate, document Notes: 1. Each topic requires a cognitive component (new knowledge) and a performance (new skill) component. Learning packets that include an article, sample policy, etc. and a skills checklist are developed for each topic and completed by each staff member. 2. Topics selected by the staff are important aspects of care that are: high risk, low frequency, problem-prone, or new. 3. Completion of each competency includes review/revision (or original development) of the corresponding program policy. Q & A??? Thank You! Good luck with planning & documenting your program s staff competencies!! patcomoss@comcast.net