The High-Reliability Clinical Enterprise: Part 1

Nursing Executive Center The High-Reliability Clinical Enterprise: Part 1 Best Practices for Ensuring Every Patient Receives the Known Standard of Care Every Time Phoebe Draper Analyst draperp@advisory.com

The High-Reliability Clinical Enterprise: A Three-Part Series 2 1 The Ambition for High Reliability and How to Address Rapidly Changing Standards 2 How to Address More Diverse Care Settings and Broader Organizational Reach 3 How to Address Larger Care Teams and Slow Transition to Electronic Documentation Tuesday, July 26 3 PM ET Tuesday, August 2 3 PM ET Tuesday, August 9 3 PM ET Source: Nursing Executive Center.

3 We ve Come a Long Way Sample Quality and Safety Improvement Efforts Best Practices Staff Training Technology Joint bedside report Hourly rounding Safety huddles Time outs SBAR Clinical bundles Adverse event RCAs 1 TeamSTEPPS Simulation Culture of safety Zero defect Lean, Six Sigma Critical thinking Barcode scanning Biomedical device integration Smart IV pumps Bed alarms Clinical decision support Incident reporting systems 1) Root cause analyses. Source: Nursing Executive Center interviews and analysis.

4 Efforts Yielding Meaningful Results Sample National Quality Improvements, 2010-2013 17% Reduction in HAC 1 rate (i.e., fewer adverse drug events, surgical site infections, etc.) 1.3M Estimated reduction in HAC events, cumulative 50K Inpatient deaths avoided from HAC prevention, cumulative $12B Total estimated cost savings from avoided HACs 1) Hospital-acquired conditions. Source: 2014 National Healthcare Quality and Disparities Report, Agency for Healthcare Research and Quality, April 2015; Nursing Executive Center interviews and analysis.

5 Improvements in Quality Plateauing National HAC 1 Rates, 2010 to 2014 2 Rate per 1,000 Discharges 145 142 132 121 121 2010 2011 2012 2013 2014 2 1) Hospital-acquired conditions. 2) Interim rate for 2014 calculated by the Agency for Healthcare Research and Quality on November 19, 2015. Source: Saving Lives and Saving Money: Hospital-Acquired Conditions Update, Interim Data From National Efforts To Make Care Safer, 2010-2014, Agency for Healthcare Research and Quality, December 2015; Nursing Executive Center interviews and analysis.

6 The Bar for Quality Is Rising VBP 1 Performance Relative and Increasingly Outcomes-Focused Factors Determining Total Performance Score (TPS) for VBP Total Performance Domain Weights, By Year Factor Achievement Score Improvement Score Consistency Score Description Points allocated for performance compared to national performance standards Points gained for performing better than institution s own baseline performance Points lost if lowest scoring domain falls below 50 th percentile 5% 10% 20% 45% 25% 25% 25% 70% 30% 20% 25% 30% 40% 30% 25% 25% 30% 25% 20% 25% 25% 25% FY13 FY14 FY15 FY16 FY17 FY18 1) Value-Based Purchasing. Clinical Process Patient Experience Safety Outcomes of Care Efficiency Source: Centers for Medicaid and Medicare Services; Advisory Board analysis.

7 Nurse Executives Searching for a New Playbook Select CNO Remarks I have an approach [for care quality] that had been working inside the hospital, but my approach isn t working cross-continuum. CNO Health System in the East If I were a nurse at the bedside today, I m not sure how well I would be doing. Things are different today they have to deal with so much change. CNE Health System in the Midwest I feel like I ve pushed as far as I can go with my current playbook [for care quality]. What else can I do? CNO Hospital in the South I m facing so much pressure to improve quality. But I feel like I m hitting a brick wall and can t move the dial any further. Regional CNO Multi-State Health System Source: Nursing Executive Center interviews and analysis.

8 What s Making High Reliability Harder Today? Key Complicating Factors Rapidly Changing Standards More Diverse Care Settings Broader Organizational Reach Larger Care Teams Glacially Slow Transition to Electronic Documentation New standards add to staff workload when they already feel overwhelmed Harder to create system-wide standards that work for all sites Harder for senior leaders to rely on personal influence to achieve compliance Harder to coordinate care across more roles, professions, and settings Time-sensitive patient information gets buried in the EMR Source: Nursing Executive Center interviews and analysis.

9 Building a New Playbook Complicating Factor Why Is This Making It Harder? Solvable Challenge Executive Strategy Best Practices 1. Rapidly Changing Standards New standards add to staff workload when they already feel overwhelmed 2. More Diverse Care Settings Harder to create systemwide standards that work for all sites 3. Broader Organizational Reach Harder for senior leaders to rely on personal influence to achieve compliance 4. Larger Care Teams Harder to coordinate care across more roles, professions, and settings 5. Glacially Slow Transition to Electronic Documentation Time-sensitive patient information gets buried in the EMR Source: Nursing Executive Center interviews and analysis.

10 The High-Reliability Clinical Enterprise Complicating Factor Best Practices 1. Rapidly Changing Standards 2. More Diverse Care Settings 1. Front Line Standard Testing 2. Data-Driven Peer Coaching 3. Change Calendar 4. The Non-Negotiables for Standards 5. Variance Request Support Team 3. Broader Organizational Reach 4. Larger Care Teams 5. Glacially Slow Transition to Electronic Documentation 6. Executive E-visibility Bundle 7. Executive Stand-In 8. Single Owner for Frequently Missed Care 9. Specialized Support Staff Roles 10. Secure Clinician-to-Clinician Texting 11. Secure Video Handoff Source: Nursing Executive Center interviews and analysis.

11 Defining Our Ambition High Reliability When every patient receives the known standard of care, every time, in every setting Known Standard of Care The policies, procedures, and protocols for patient care set by a health care organization Source: Nursing Executive Center interviews and analysis.

12 1. Rapidly Changing Standards Complicating Factor Why Is This Making It Harder? Solvable Challenge Executive Strategy Best Practices Rapidly Changing Standards New standards add to staff workload when they already feel overwhelmed Staff default to workarounds or don t follow the standard at all Integrate Standards Into Frontline Workflow 1. Front Line Standard Testing 2. Data-Driven Peer Coaching Rationalize the Pace of Change at the Front Line 3. Change Calendar

13 Why Is This Making it Harder? New Standards Add to Staff Workload When They Already Feel Overwhelmed Representative Protocol Update Sample Initiatives Already Causing Staff to Feel Overwhelmed Updates to Catheter Removal Protocol The need for continued catheterization should be assessed at least daily and urinary catheter removed by a registered nurse. Use HOUDINI acronym to assess whether or not it is appropriate to remove catheter: Hematuria, gross Obstruction, urinary Education on new defibrillators Delirium assessment project New EMR wound documentation Updated sepsis protocol New standardized hourly rounding scripting Fall assessment screening New patient education resources Source: BJC Healthcare, St. Louis, MO; Nursing Executive Center interviews and analysis.

14 Number of Clinical Standards Continues to Grow 1,871 Number of AHRQ 1 clinical guideline updates between 2013 and 2015 2 1) Agency for Healthcare Research and Quality. 2) Through November 16, 2015. Source: Agency for Healthcare Research and Quality, National Guidelines Clearinghouse, New this week archive, http://www.guideline.gov/new-this-week/archive.aspx?pmissueid=2555; Nursing Executive Center interviews and analysis.

15 The Solvable Challenge Staff Default to Workarounds or Don t Follow the Standard at All Staff Workaround Jeopardizing Patient Safety Nurse places all barcodes for medication administration on single sheet of paper Nurse scans barcodes off of the paper instead of each medication to save time Source: Nursing Executive Center interviews and analysis.

16 Recommended Executive Strategies Integrate Standards Into Frontline Workflow Solvable Challenge Executive Strategies Integrate Standards Into Frontline Workflow Staff default to workarounds or don t follow the standards at all Rationalize the Pace of Change at the Front Line Source: Nursing Executive Center interviews and analysis.

Practice #1: Front Line Standard Testing 17 The Power of Pre-Implementation Testing Average Length of Stay for Patients in Banner ICUs Pre- and Post-Implementation of System-Wide Delirium Assessment 80 Hours 60 Hours Pre-Implementation Post-Implementation Source: Banner Health, Phoenix, AZ; Nursing Executive Center interviews and analysis.

18 The Power of Pre-Implementation Testing Case in Brief: Banner Health 29-hospital system headquartered in Phoenix, Arizona In early 2000s, leaders committed to system-wide clinical standardization as a means to improve quality and reduce unnecessary care utilization; to support this endeavor, leaders built Care Management, an infrastructure with strong clinical leadership committed to developing and implementing system-wide standards of care Three phases used by Care Management infrastructure to set system-wide standards are: Define, Design, and Implementation In Define phase, CCG 1 identifies organization s opportunities for standardization, and proposes a system-wide standard to be approved by the Care Management Council In Design phase, Design Workgroup decides which standards would benefit from simulation testing before being rolled out system-wide; simulation testing happens in dedicated simulation center; examples of standards that have been tested using the simulation center include: delirium assessment, post-partum hemorrhage, safe surgery process, and safe procedure process In Implementation phase, site-specific leaders use implementation toolkit created by Design Workgroup to implement new standard on system-wide go live date; Clinical Performance Assessment Specialists provide on-the-ground support for sites during rollout and assess performance after implementation On average there are 45 standard updates or changes rolled out per year; of these, between two to four will go to simulation center for testing; one recent standard tested via simulation is new delirium protocol in ICU; since implementation, length-of-stay for ICU patients decreased an average of 20 hours 1) Clinical Consensus Group. Source: Banner Health, Phoenix, AZ; Nursing Executive Center interviews and analysis.

Unrealistic to Do Frontline Testing for Every New Standard 19 Representative Standard Changes at One Organization Expansion of safety huddles to SNFs System-wide delirium assessment Updated urinary tract infection guidelines New electronic home health scheduling system New blood pressure cuffs System-wide post partum hemorrhage protocol Primary care clinic smoking cessation education Mandatory physician bridge orders from ED New joint bedside report template Revised NICU visiting policy System-wide safe procedure process Updated sepsis bundle System-wide medication bar code scanning Updated depression risk screening ICU early mobility bundle System-wide safe surgery process New patient boards on med/surg units System adoption of smart IV pumps Centralized patient follow-up phone calls Updated readmissions risk assessment New bed alarms for high fall-risk patients Source: Nursing Executive Center interviews and analysis.

20 Being Judicious About Which Standards to Test Number of New Standards Introduced at Banner 1 : 45 Criteria for Simulation Testing 1 Large-Scale Change 2 Substantial Impact on Staff Workflow 3 Significant Training Required to Learn Standard Number Tested in Simulation Center: 2 4 1) Across 12 month period. Source: Banner Health, Phoenix, AZ; Nursing Executive Center interviews and analysis.

21 Testing Standards Through Simulation Key Elements of Banner s Simulation Testing for Most Complex Clinical Standards Led by Design Workgroup Simulation exercise led by interprofessional team responsible for standard development Focused on Education and Workflow Tests material for teaching standard and integration into workflow Tested in Simulation Center Selected standards tested in 55,000 squarefoot simulation center 1 Tested by Frontline Staff Frontline staff from affected disciplines visit simulation center to test new standard 1) Simulation center also used for general training for new clinicians. Limited Time Commitment On average, participants attend one session lasting 3-4 hours Billed to Corporate Cost Center Staff time for testing covered by corporate cost center budget Source: Banner Health, Phoenix, AZ; Nursing Executive Center interviews and analysis.

22 Another Option for Input: Surveying the Front Line Representative Survey Questions on Vendor Options for Frontline Staff For each item please indicate the level to which you agree with each statement using the following scale: 1 = Strongly Disagree 2 = Disagree 3 = Tend to Disagree Vendor A 4 = Tend to Agree 5 = Agree 6 = Strongly Agree Use an even number scale to avoid ambivalence Vendor A is easy to use...1 2 3 4 5 6 Vendor A would fit well into my workflow...1 2 3 4 5 6 Please rank order Vendors A, B, and C in order of your preference for use at our hospital, with 1 being the vendor you most prefer. Vendor A 1 2 3 Vendor B 1 2 3 Vendor C 1 2 3 Use rank order to further differentiate staff preference Source: Nursing Executive Center interviews and analysis.

Practice #2: Data-Driven Peer Coaching 23 Acknowledging the Benefits of Peer Coaching Sample Articles Acknowledging Benefits of Peer Learning in Nursing Education The use of peer leadership to teach fundamental nursing skills. Journal of Nursing Education, 2008 Peer-coaching with health care professionals: What is the current status of the literature and what are the key components necessary in peer-coaching? A scoping review. Medical Teacher, 2013 Peer coaching: the next step in staff development. Journal of Continuing Education in Nursing, 2005 Source: Journal of Nursing Education, The Use of Peer Leadership to Teach Fundamental Nursing Skills, http://www.ncbi.nlm.nih.gov/pubmed/18600155; Medical Teacher, Peer-Coaching with Health Care Professionals: What is the Current Status of the Literature and What are the Key Components Necessary in Peer-Coaching? A Scoping Review, http://www.ncbi.nlm.nih.gov/pubmed/24094039; The Journal of Continuing Education in Nursing, Peer Coaching: the Next Step in Staff Development, http://www.ncbi.nlm.nih.gov/pubmed/15835584; Nursing Executive Center interviews and analysis.

24 Using Data to Identify High and Low Performers Representative Pain Assessment Protocol Compliance at Midland Memorial 90% Nurses documenting at least 90% of the time considered high performers 50% Nurses documenting consistently below 50% considered low performers Nurse A Nurse B Nurse C Nurse D Complete Pain Assessment Protocol Available Source: Midland Memorial Hospital, Midland, TX; Nursing Executive Center interviews and analysis.

25 Using Data to Identify High and Low Performers Case in Brief: Midland Memorial Hospital 470-bed community hospital located in Midland, Texas In 2011, nurse leaders established peer review committee to identify challenges with standards that weren t fitting into staff workflow; review committee includes eight frontline nurses, committee chair, and director When Midland rolled out updated pain assessment protocol for nurses in November 2012, peer review committee provided opportunity to help integrate the new standard into workflow, particularly for frontline staff having a difficult time hardwiring new protocol Nurse leaders identified frontline staff needing additional support by pulling individual data from EMR on staff compliance with pain assessment; nurses not meeting 90% completion target for three consecutive months must attend peer review committee High performers asked to join peer review committee to serve as peer support for low performers; high performers share their own personal tips for hardwiring the assessment by sharing real-life scenarios and personal experience Since December 2013, 51 nurses have attended peer review for support (out of approximately 600 staff nurses), and in three-year period from November 2012-October 2015, compliance with pain assessment protocol has increased by 52 percentage points from 2013 to 2015 (through October) Source: Midland Memorial Hospital, Midland, TX; Nursing Executive Center interviews and analysis.

26 Formalizing Peer Support for Low Performers Process for Formalizing Peer Support for Pain Management Assessment Low Performers First Month Second Month Third Month Notification from Manager After first month of compliance below 50%, nurse receives email from manager alerting nurse of low performance Face-to-Face Meeting with Manager After second consecutive month of compliance below 50%, nurse meets with manager to identify barriers to compliance and how to overcome them Peer Support Session After third consecutive month of compliance below 50%, nurse required to attend Peer Review Session Source: Midland Memorial Hospital, Midland, TX; Nursing Executive Center interviews and analysis.

27 Convening Peer Support Group to Boost Compliance Key Elements of Pain Assessment Protocol Peer Support Sessions Session Hosted by Peer Review Committee Peer review committee meets monthly Committee includes frontline nurses from across organization appointed by directors High and Low Performers Attend Session Nurses who have been low performers for three consecutive months required to attend session High performers invited to attend as peer mentors High Performers Share Tips from Experience High performers use real-life experiences to share personal tips for adhering to pain assessment protocol On rare occasions, high performers meet one-on-one with low performers for further assistance Source: Midland Memorial Hospital, Midland, TX; Nursing Executive Center interviews and analysis.

28 Improving Pain Assessment Protocol Compliance Percentage of Nurses with Excellent Compliance with Pain Assessment Protocol 1 at Midland Memorial Yearly Average 52 percentage point increase Often, the low-performing nurses attending Peer Support Sessions become some of our highest performers. Then, these same nurses come back as the peer mentors at the Peer Support Sessions. Bob Dent, SVP/COO Midland Memorial Hospital Pre-Implementation Post-Implementation 1) Rated on a five-point scale from poor to excellent. Source: Midland Memorial Hospital, Midland, TX; Nursing Executive Center interviews and analysis.

29 Recommended Executive Strategies Rationalize the Pace of Change at the Front Line Solvable Challenge Executive Strategies Integrate Standards Into Frontline Workflow Staff default to workarounds or don t follow the standards at all Rationalize the Pace of Change at the Front Line Source: Nursing Executive Center interviews and analysis.

Practice #3: Change Calendar 30 Assess All Changes Using a Single Calendar Excerpt of Froedtert s Change Calendar Activity Standardize Communication Boards Magnet Application for 3rd Designation AHRQ Culture of Safety Survey Lead 2014 Oct 2014 Nov M. West X 2014 Dec 2015 Jan J. Dark X X X C. Harris X Schedule all changes on one calendar Patient Monitors Education R. Wits X Crucial Conversations Education 1 Patient Defibrillators Education K. Mill X X X X R. Wits X X Resequence initiatives when too many changes fall at one time To access the full Change Calendar practice within The National Prescription for Nurse Engagement, visit advisory.com/nec/publications. Source: Nursing Executive Center, National Prescription for Nurse Engagement, Washington DC: The Advisory Board Company, 2013.

31 Assess All Changes Using a Single Calendar Case in Brief: Froedtert & the Medical College of Wisconsin Froedtert Hospital 500-bed academic medical center; part of three-hospital regional health system headquartered in Milwaukee, Wisconsin CNO and nursing director team meet on regular basis to discuss upcoming initiatives, changes, and change management needs; discuss impacts to staff nurses, nurse managers, magnitude of change, interdependencies and other requirements to be successful; adjust timing of changes and education as indicated CNO distributes finalized change calendar to directors, managers, and educators on a regular basis during leadership team meetings Unit managers use change calendars as reference tool while discussing rollout of new initiatives during unit huddles; managers transparent about rationale behind timing of change Details of changes posted on unit bulletin boards, education boards, and in unit newsletters Source: Nursing Executive Center, National Prescription for Nurse Engagement, Washington DC: The Advisory Board Company, 2013..

32 Dedicating a Vis Room to Organizational Changes Sutter Eden Hospital Keeping Its Change Calendar in Plain View Snapshot of Sutter Eden Hospital s Vis Room Full calendar permanently posted on wall of dedicated vis room for all leaders to see Green dots indicate change successfully rolled out; red dots indicate deadline missed, need to resequence Source: Sutter Eden Hospital, Castro Valley, CA; Nursing Executive Center interviews and analysis.

33 Dedicating a Vis Room to Organizational Changes Case in Brief: Sutter Eden Hospital 130-bed hospital located in Castro Valley, California; part of Sutter Health In fall 2014, senior leaders at Eden Hospital implemented a vis room (visualization room) to help better pace the rollout of organization-wide changes Eden s A-team (COO, CMO, CNO, quality director, and HR leader) meet weekly, and on a monthly basis use vis-room to plan and re-sequence changes for coming months Goal of vis room is to see changes in one place; one wall is dedicated to the change calendar (listing initiatives, updates, and new standards, by week); a second wall is dedicated as a work wall, which lists all proposed changes; items on the work wall are reviewed by the A-team and evaluated for potential inclusion on the schedule When a deadline is met or initiative completed, the A-team places a green dot on the wall next to the initiative; when a deadline isn t met, the A-team places a red dot on the wall next to the initiative; when several initiatives have red dots, the A-team resequences initiatives appropriately Source: Sutter Eden Hospital, Castro Valley, CA; Nursing Executive Center interviews and analysis.

34 Tactics for Rationalizing Change Communication Practice Capsule Description Change Communication Hierarchy Hospital limits organization-wide emails, instead directing staff to intranet to learn about non-urgent information Directive Email Color Coding Hospital creates a color coding system to indicate the priority level of email messages To access National Prescription for Nurse Engagement, visit advisory.com/nec/publications. Source: Nursing Executive Center, National Prescription for Nurse Engagement, Washington DC: The Advisory Board Company, 2013.

35 Key Takeaways 1 For large-scale standard changes with a deep impact on frontline workflow, don t wait until after implementing them to gather frontline feedback. Instead, have staff test them in advance, but be judicious about which standards to test. 2 Don t underestimate the potential impact of peer-to-peer coaching on even your lowest compliers. When given the right coaching, your lowest compliers may become your highest compliers. 3 As a nurse leader, you can t control external market forces driving the pace of change, but you can control how these changes impact frontline staff by carefully sequencing and thoughtfully communicating organizational changes. Source: Nursing Executive Center interviews and analysis.

The High-Reliability Clinical Enterprise: A Three-Part Series 36 1 The Ambition for High Reliability and How to Address Rapidly Changing Standards 2 How to Address More Diverse Care Settings and Broader Organizational Reach 3 How to Address Larger Care Teams and Slow Transition to Electronic Documentation Tuesday, July 26 3 PM ET Tuesday, August 2 3 PM ET Tuesday, August 9 3 PM ET Source: Nursing Executive Center.