Grey Bruce Health Network Administrative Policies and Procedures Policy Covering: Evidence-Based Effective Date: June 2006 Prepared by: Evidence- Based Coordinator Category: Patient Administration Policy Number: 100 Supersedes Policy #/Dated: New Page 1 of 1 Issued by: Grey Bruce Health Network Contract Implementation Approved by: Grey Bruce Health Network Purpose: To ensure success of the Evidence-Based (EBCP) in the Grey Bruce Health Network. Policy: Appendix 100-A outlines the Evidence-Based Flowchart. All staff have a role in ensuring the success of this program, as is outlined in Appendix 100-B Development of EBCP Initiatives, 100-C Pilot of EBCP Initiatives, 100-D Implementation of EBCP Initiatives, and 100-E Evaluation of EBCP Initiatives. 1
Evidence-Based Flowchart (Development Pilot Implementation Evaluation & Maintenance) Grey Bruce Health Network Steering Evidence-Based One Corporate Professional Practice Representative Remains on Team throughout development Adhoc Members One Corporate Representative Diagnostic Imaging, Lab, Librarian, Physician, Nursing, Pharmacy, Physio, Utilization Mgmt, Unit Clerk (Called upon for input as needed) Site Champions Staff Using Pathway Patients On Pathway Last modified April 11/06
DEVELOPMENT OF EBCP INITIATIVES Grey Bruce Health Network (Evidence-Based CEO) Evidence-Based (Coordinator & Administrative Assistant) Steering (One Senior Management Representative Corporation and the EBC Program Coordinator) o Foster a culture for the provision of evidence-based care o Mandate & monitor initiatives to provide accessible rural healthcare through a patient focused delivery system that is well coordinated and cost effective o Advocate for the EBC Program o Facilitate use of EBCP Framework for Development o Coordinate and drive the process by gathering input o Advocate for the EBC Program o Aid in selection of initiatives o Support the culture of evidencebased care within their o Review monthly Evidence-Based Care Report successful development, implementation and evaluation of initiatives and the provisions of evidence-based care o Report to CIC on progress o Participate in CIC o Collect, evaluate and communicate evidence-based data o Assemble and coach team membership o Prepare resource evidence-based materials as needed for team members o Educate team members, include Framework for Development, Evidence- Based Practice and Clinical Pathways o Facilitate Development Team o Organize team, record minutes o Report monthly to Network Program CEO & Steering on progress o Participate in Professional Practice (PPC) at each Corporation to facilitate communications o Share information with staff by using existing communication tools, such as unit communication book, e-mails, memos to shared drives, newsletters and regularly scheduled staff to deliver information regarding EBCP o Participate in Steering o Review criteria for pathway selection o Review monthly Evidence-Based Care Reports successful development, implementation and evaluation of initiatives and the provisions of evidence-based care o Enlist Team memberships 11 Apr 2006 1 of 2
DEVELOPMENT OF EBCP INITIATIVES Corporate Professional Practice s (PPC) representative of the PPC Corporation in the Network) Adhoc Members representative discipline, including: Diagnostic Imaging, Lab, Physician, Library, Librarian, Nursing, Pharmacy, Physio, Utilization Mgmt, Unit Clerks) Site Champions o Liaison to the Evidence-Based Care Program Coordinator o Assist the EBC Program Coordinator in communications with the professional disciplines in their o Collaborate with EBC Program Coordinator in gathering corporate feedback o Communicate discipline specific evidence-based standards and/or current best practice to the Development Team o Collaborate with colleagues within their and the Network to standardize care o Participate in Development Team o Present the information of the professional disciplines of their at the of the Development Team o Participate in corporate PPC and communicate information needs of the Development Team to each of the respective disciplines and assist in gathering their corporate information from the respective disciplines o Use email to review and revise documents between Each health discipline is responsible for the following: o Collecting information through consultation and consensus from their professional discipline throughout their by attending existing discipline specific committee and using existing communication tools, such as unit communication books, e-mails, memos to shared drives o Communicating information gathered from their respective disciplines to their representative on their PPC in writing o Use email to review and revise documents between o Assist in gathering staff feedback at unit staff and sharing information with representative of PPC o Share information with their unit staff by using existing communication tools, such as unit communication book, e-mails, memos to shared drives and regularly scheduled staff to deliver information Staff Utilizing Pathways o Provide consistent quality evidencebased care to patients o Assist in gathering of information on current practice and evidence-based practice o Sharing information with their professional representative on the PPC 11 Apr 2006 2 of 2
1 PILOT OF EBCP INITIATIVES Grey Bruce Health Network (Evidence-Based CEO) Evidence-Based (Coordinator & Administrative Assistant) Steering (One Senior Management Representative Corporation and the EBC Program Coordinator) o Foster a culture for the provision of evidence-based care o Mandate & monitor initiatives to provide accessible rural healthcare through a patient focused delivery system that is well coordinated, efficient and cost effective o Advocate for the EBC Program o Facilitate use of EBCP Framework for Development o Coordinate and drive the process by gathering input o Support the provision of evidencebased care o Aid in evaluation o Review monthly Evidence-Based Care Report successful pilot of initiatives and the provisions of evidence-based care o Report to CIC on progress o Participate in CIC o Collect, evaluate and communicate evidence-based data o Collaborate with pilot site Professional Practice (PPC) to chose a pilot start date o Prepare supplies for pilot to take place at three sites o Update files on shared drive with materials to be used during pilot o Facilitate planning and implementation of pilot site staff education with corporate representatives from PPC o Report monthly to Network Program CEO & Steering on progress o Participate in PPC at each to facilitate communications o Select collective pilot sites based on recommendations of the Development Team o Review Evidence-Based Care monthly report o Participate in Steering successful evaluation and the provisions of evidence-based care April 11,2006 1 of 3
2 PILOT OF EBCP INITIATIVES Corporate Professional Practice (PPC) representative of the PPC Corporation in the Network) Adhoc Members representative discipline, including: Diagnostic Imaging, Lab, Physician, Library, Librarian, Nursing, Pharmacy, Physio, Utilization Mgmt, Unit Clerk) o Liaison to the Evidence-Based Care Program Coordinator o Assist the EBC Program Coordinator in communications with the professional disciplines in their o Collaborate with EBC Program Coordinator in gathering corporate feedback o Communicate discipline specific evidence-based standards to the Development Team o Participate in Development Team o Present the pilot information of the professional disciplines of their at the of the Development Team o Participate in corporate PPC and communicate pilot information needs of the Development Team to each of the respective disciplines o Use email to review and revise documents between as much as possible o Use existing communication tools, such as newsletters, memos to shared drives and regularly scheduled staff meeting to deliver information regarding pilot information to staff impacted by pilot Each health discipline is responsible for the following: o Assist in planning and implementation of pilot site staff education o Collecting information through consultation and consensus from their professional discipline throughout their by attending existing discipline specific committee o Communicating information gathered from their respective disciplines to the Development Team Member who is the corporate representative of the PPC o Use existing communication tools, such as e-mails, unit communication books and regularly scheduled staff meeting to deliver information regarding pilot to staff impacted by pilot April 11,2006 2 of 3
3 PILOT OF EBCP INITIATIVES Site Champions o Assist in planning and implementation of pilot site staff education o Weekly tracking forms completed and original Variance Records returned by inter-hospital mail to Evidence-Based Coordinator every Friday o Assist in gathering staff feedback, at unit staff and sharing written information with representative of PPC o Share information with their unit staff by use of existing communication tools, such as unit communication book, e-mails, memos to shared drives and regularly scheduled staff meeting to deliver information regarding the pilot to staff impacted by pilot Staff Utilizing Pathways Patient Pathway Users o Provide consistent quality evidencebased care to the patients o Provide information to Development Team on patient perspective and needs o Use pathway on all patients meeting pathway inclusion criteria o Review pathway at the start of every shift o On patient discharge, complete Pathway Variance Record and Discharge Summary and return to The Evidence- Based Coordinator o Pilot feedback to site champion or representative on PPC o Review Patient Pathway and education materials and participate in management of care April 11,2006 3 of 3
IMPLEMENTATION OF EBCP INITIATIVES Grey Bruce Health Network (Evidence-Based CEO) Evidence-Based (Coordinator & Administrative Assistant) o Foster a culture for the provision of evidence-based care o Mandate & monitor initiatives to provide accessible rural healthcare through a patient focused delivery system that is well coordinated and cost effective o Advocate for the EBC Program o Facilitate use of Framework for Development o Coordinate and drive the process by gathering input o Review monthly Evidence-Based Care Report successful development, implementation and evaluation and the provisions of evidence-based care o Report to CIC on progress o Participate in CIC o Collect, evaluate and communicate evidence-based data o Obtain Steering approval of initiatives o Determine full implementation date and implementation plan for all sites with the Professional Practice (PPC) o Prepare files for posting on shared drive o Prepare site full implementation materials o Collaborate with sites to provide staff education o Facilitate team o Organize team, record minutes o Report monthly to Network Program CEO & Steering on progress o Continue to gather feedback and prepare resources for annual review. o Participate in PPC at each to facilitate communications Steering (One Senior Management Representative Corporation and the EBC Program Coordinator) o Advocate for the EBC Program o Aid in selection, implementation and evaluation o Maintain the provision of evidencebased care o Participate in Steering o Review monthly Evidence-Based Care Report o Give approval for full implementation successful development, implementation and evaluation and the provisions of evidence-based care April 11,2006 Page 1 of 3
IMPLEMENTATION OF EBCP INITIATIVES Corporate Professional Practice (PPC) representative of the PPC Corporation in the Network) o Assist the EBC Program Coordinator in communications with the professional disciplines in their o Assist EBC Program Coordinator in gathering corporate feedback o Participate in Implementation o Assist in implementation staff education o Participate in corporate PPC and communicate information needs to each of the respective disciplines o Continue to forward any feedback during implementation to the EBC Program Coordinator o Assist in annual review by participating in Annual Review Team Meetings using the Framework for Development Adhoc Members representative discipline, including: Diagnostic Imaging, Lab, Physician, Library, Librarian, Nursing, Pharmacy, Physio, Utilization Mgmt, Unit Clerks) Site Champions o Communicate discipline specific evidence-based standards to the Development Team o Collecting information through consultation and consensus from their professional discipline throughout their by attending existing discipline specific committee o Continue communicating information from their respective disciplines to their representative on the PPC as needed during implementation and annual review o Assist in planning and implementation of staff education o Weekly tracking forms completed and original Variance Records returned by inter-hospital mail to EBC Program Coordinator every Friday o Assist in gathering staff feedback at unit staff and sharing written information with representative of PPC o Share information with their unit staff by use of existing communication tools, such as unit communication book, e-mails, memos to shared drives and regularly scheduled staff meeting to transfer information regarding updates and annual review April 11,2006 Page 2 of 3
IMPLEMENTATION OF EBCP INITIATIVES Staff Utilizing Pathways Patient Pathway Users o Provide consistent quality evidencebased care to the patients they are assigned o Provide information to Pathway Development Team on patient perspective and needs o Use pathway on all patients meeting inclusion criteria o Review pathway at the start of every shift o On patient discharge, complete Variance Record and Discharge Summary and return to the EBC Program Coordinator o Review Patient Pathway and education materials and participate in management of care April 11,2006 Page 3 of 3
EVALUATION AND MAINTENANCE OF EBCP INITIATIVES Grey Bruce Health Network (Evidence-Based CEO) o Foster a culture for the provision of evidence-based care o Mandate & monitor initiatives to provide accessible rural healthcare through a patient focused delivery system that is well coordinated, efficient and cost effective o Review monthly Evidence-Based Care Report o Eliminate barriers that impact on the successful evaluation of initiatives and provision of evidence-based care o Report to CIC on progress o Participate in CIC o Guide EBC Coordinator of program direction based on data and evaluation Evidence- Based Care Program (Coordinator & Administrative Assistant) Steering (One Senior Management Representative Corporation and the EBC Program Coordinator) o Advocate for the EBC Program o Facilitate use of EBCP Framework for Development o Coordinate and drive the process by gathering input o Support the provision of evidencebased care o Aid in evaluation of EBCP initiatives o Collect, evaluate and communicate evidence-based data o Organize and facilitate team for pilot and annual review, record minutes o Prepare data for team members. Include LOS, patients admitted with pathway diagnosis, # of patients on pathway, indicator data, education data, and other information collected on the Variance Records o Facilitate data verification through Evaluation Team chart audits o Share information with staff by using existing communication tools, such as unit communication book, e-mails, memos to shared drives, newsletters and regularly scheduled staff o Report monthly to Network Program CEO & Steering on progress o Participate in Professional Practice (PPC) at each to facilitate communications o Attend Steering successful evaluation of initiatives and the provisions of evidence-based care o Assess key outcomes o Review data reports o Senior Management representatives to communicate regularly with their corporate adhoc physician representative o Collaborate with EBC Program Coordinator in maintaining initiatives April 6, 2006 1 of 2
EVALUATION AND MAINTENANCE OF EBCP INITIATIVES Corporate Professional Practice (PPC) representative of the PPC Corporation in the Network) o Liaison to the EBC Program Coordinator o Assist the EBC Program Coordinator in communications with the professional disciplines in their o Collaborate with EBC Program Coordinator in gathering corporate feedback o Attend Evaluation Team o Assist in Evaluation Team chart audits o Provide the pilot feedback information of the professional disciplines of their at the of the Evaluation Team o Participate in corporate PPC and communicate information needs of the Evaluation Team to each of the respective disciplines o Use email to review and revise documents between as much as possible Adhoc Members representative discipline, including: Diagnostic Imaging, Lab, Physician, Library, Librarian, Nursing, Pharmacy, Physio, Utilization Mgmt, Unit Clerks) Site Champions o Communicate discipline specific evidence-based standards or current best practice to the Development Team Each health discipline is responsible for the following: o Collecting information through consultation and consensus from their professional discipline throughout their by attending existing discipline specific committee o Communicating information to their discipline representative on the corporate PPC o Assist in gathering staff feedback at unit staff and sharing written information with representative of PPC o Hand out and retrieve Evaluation Questionnaires to staff and forward to EBC Program Coordinator o Share evaluation information with their unit staff Staff Utilizing Pathways Patient Pathway Users o Provide consistent quality evidencebased care to patients o Provide information to Evaluation Team on patient perspective and needs o Provide information to their disciplines representative on the PPC o Complete Pilot and Annual Evaluation Questionnaire o Respond to patient questions regarding pathways on Evaluation Questionnaire. April 6, 2006 2 of 2
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