Building Skills in Organizational and Systems Change: A DNP Curricular Thread NONPF 2014 Christine Hoyle, DNP, APRN, FNP cah@u.washington.edu Gail Johnson, DNP, APRN. FNP gailj@uwashington.edu Department of Psychosocial and Community Health University of Washington School of Nursing 1 Calls for APN leadership for redesign and transformation of health care system IOM call (2001) transform healthcare system 6 national quality aims IOM 2010 landmark report Practice to full extent of education Achieve higher levels of education FULL partners with others in redesigning healthcare in US AACN Essential Competency of organizational and system leadership for quality improvement and system thinking 2 The Triple Aim Developed by the Institute for Healthcare Improvement (IHI), Triple Aim includes: Improving the health of the defined population Enhancing the patient care experience (including quality, access and reliability) Reducing or controlling the per capita cost of care 3 1
Components Population Health Experience of Care Measures A decreasing trend in modifiable risk factors for chronic conditions Smoking, obesity, physical inactivity, unhealthy eating and alcohol consumption Increased uptake of strategies to prevent disease/illness Screening, vaccinations, infection prevention Decrease in heart attacks Fewer people hospitalized with conditions that could be cared for elsewhere Fewer unplanned return visits to the emergency department for a mental health or substance abuse condition An increase in the use of telemedicine for clinical patient consultations More adults who are able to see their doctor on the same or next day All residents access key health services More diabetic residents receive care that follows best practice Per Capita Cost A decrease in emergency department visits by people with diabetes, chronic obstructive pulmonary disease and heart disease A decrease in hospitalizations of people with diabetes, chronic obstructive pulmonary disease, stroke and heart disease 4 Building skills in systems change Goal: safe, effective, patient centered care, leading to improved health outcomes Use quality improvement strategies Identify and assess system issue/problem Facilitate change in practice delivery Evaluate and sustain change at the system level 5 Quality Improvement Strategies Process Map Fishbone Diagram PDSA Cycle 6 2
Current Clinic Process Poor delegation r/t provider involvement MA not involved in DM assessment MD w/ too many items to cover Factors Leading to Elevated A1C in Patients with Type II Diabetes Methods No standardized med review Unclear C/E of meds & outcomes Med recon b/w providers & facilities Delay in med changes No reporting of normal results Missed opportunity to validate pts making positive changes to sustain effort Communication among collaborating providers EHR limited SL Clinic and Valley MC Long time lag for outside docs to be scanned Very few pts referred to endocrinology, even w/ complex disease or mgmnt Erroneously not reporting results lead pts to believe results are normal Difficult to locate specific outside records in EHR Avoidance of med changes d/t safety concerns in unsure what meds pt is taking Communication No dedicated diabetes visits (only general f/u) Visit focus unclear Pts come w/o BG logs Clinical Logistics Time spent covering multiple issues Reliance on verbal instructions No written plan given to pt for reference Appointment availability Little availability for acute visits for DM related issues Not enough appt slots for routine f/u q3-6mo Poor pt understanding of glycemic goals Pts may be unsure of plan No written info to share among pt caregivers Patients don t report negative changes in glycemic control Lose time to correct before next f/u appt May fear provider response to poor BG control No QA process providing clinician feedback Other meds increasing BG (e.g. steroids) Minimal Technical Support BG Hx dependent on pt report Unable to download glucometer data No in-house support services Must refer out to nutrition, DM education Alternate living situations Pts w/o easy access to food limits flexibility of insulin regimen Co-morbidities Visual deficits & dexterity that challenge injectable therapies Unable to customize services to pt population Pts in AL or SNF have little control over meal content or knowledge of ingredients Mental health issues Dementia Therapeutics Clinician unaware of many local resources Patient Characteristics Low utilization of advanced diabetes therapy Financial Constraints Appts Medications Glucometer + Strips Low levels of physical activity Low health literacy Med noncompliance Inconsistent follow-up Clinician not familiar w/ adv therapies Poor understanding/ enactment of diabetic diet Poor insurance coverage of new agents/therapies Undertreated disease Safety concerns r/t hypoglyemic risk Relaxed A1C target r/t age, comorbidities, life expectancy Limited access Elevated A1C Poor education regarding modified activity options Belief that increasing or changing Tx not worth risk or of negligible benefit Applying PDSA Continuous Improvement Set Vision Set Vision Adjust Hypothesize Act Plan Evaluate Study Do Experiment 9 3
What is LEAN A philosophy, mindset and set of tools focused on delivering value to customers through the elimination of waste in the process of care delivery. Improving quality and efficiency while controlling costs in the provision of optimum patient care. 10 Curricular Thread through FNP Clinical Courses Awareness of systems issues in the context of individual patient care Introduction to quality improvement strategies and skills Systems approach to care and panel management Implementation of plan for systems practice change 11 Clinical Rotations Clinical Performance Evaluation (CPE) Tool Progression in leadership competencies each quarter Beginning understanding of DNP role and identifying potential leadership opportunities in clinical practice Identifying issues in mobilizing resources, coordinating care and advocating for equity at the systems level Recognizing clinical system level changes needed to insure higher quality care Identifying a clinical system level change needed to insure higher quality care and planning practice change 12 4
Clinical Performance Evaluation Tool CLINICAL PERFORMANCE EVALUATION (2nd Year Students - Winter), Page 3 13 Clinical Seminars Year 1 Primary focus on building clinical skills related to individual patient care Identify issues in mobilizing resources, coordinating care, and advocating for equity in clinical practice at the systems level. 14 Clinical Seminars Year 2 Identification of population issues in clinical case presentations Introduction to quality improvement strategies and skills Leadership case exploration of systems approach to chronic disease in the primary care setting 15 5
Clinical Seminar Year 3 Provide care that is patient or population centered, continuous, collaborative and coordinated over time. Evaluate dimensions of practice in terms of improving outcomes of care and enhancing effectiveness of care systems delivery. Panel management identify useful quality measures/indicators Function as an effective member of the health care team 16 Final Practicum Work with agency stakeholders to: Identify current practice/system/care delivery process needing improvement Systematically assess current practice/ system issue/care delivery process (process mapping) Evaluate the current process with the practice team (fishbone diagram) Plan new process based on evidence and needs assessment Begin implementation with consideration of first PDSA cycle 17 Evaluation Competency based (CPE tool) Peer/faculty/agency feedback Self reflection 18 6
Future Challenges DNP 2.0 Integrating thread into new clinical courses 19 Questions? 20 7