Applying Evidence to Improve Quality Linda A Dudjak PhD RN Associate Professor University of Pittsburgh School of Nursing
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Implement a Test of Change (Experiment) to Fix a Broken Process
Persuade Others of the Value of a New Approach
Measure the Impact of a Controversial Change
Collect Evidence (what does the literature say that supports your idea; reveals a gap in what is known; or supports the need for additional study) Steps in the Process
Develop a Concise Objective/Purpose Measurable terms Correlate with what you are able/plan to evaluate Steps in the Process
Develop an Implementation Plan (Methods) Who will be involved Where will it occur Over what time period will it occur Who needs to approve your plan Steps in the Process
Evaluate the Outcome How will you measure success Do you need a tool to assist with measurement What information (data) do you need Are the data available; who will collect it; for how long Steps in the Process
Steps in the Process Determine the So What Factor What can you conclude? What can t you conclude (limitations)? How will you apply the results? Are the findings generalizable? Where will you publish/present?
How Does this Work - Really Implementation of an Acuity Adaptable Care Model Initiation of Bedside Report to Improve Shift Handoff Use of Guidelines and Scripting to Support Acute Care Nurses Recognition, Reporting & Treatment of Sepsis
Implementing an Acuity- Adaptable Care Model in a Rural Hospital Setting Rural community hospital in Eastern PA Unit redesign to increase capacity by adding 6 beds between ICU and medsurg unit (the annex ) Goal: increase flexibility of patient assignment and reduce need to staff for empty beds by sharing resources Ramson, KP. et al.(2013). Implementing an Acuity-Adaptable Care Model in a Rural Hospital Setting. JONA. 43(9): 455-60.
Evaluation of a Care Delivery Model Key Element Evidence Objective(s) Implementation Evaluation Tools Experience of other institutions demonstrated positive clinical and financial outcomes; had not been evaluated in a rural hospital setting Evaluate the effect of the new model on: nurse and patient satisfaction LOS HPPD Adverse events LOS, HPPD and adverse events measured Oct-Jan, 1 year apart Nurse and patient satisfaction measured pre implementation and 4 months post-implementation LOS, HPPD and adverse events already tracked internally HCA HPS selected 4 relevant items Designed 9-item nurse survey based on concerns expressed about staffing, low census, handoff time, etc Ramson, KP. et al.(2013). Implementing an Acuity-Adaptable Care Model in a Rural Hospital Setting. JONA. 43(9): 455-60.
Findings: Patient Satisfaction Variable Pre Implementation Post Implementation Rate hospital (Score 9-10) Recommend hospital (always) Communication with Nurses (always) Courtesy/respect Listen Explain Responsiveness (always) 62% 79.7% p <.00006** 58.8% 75.5% p < 0.003** 78.2% 81.1% p < 0.52 59% 65% p < 0.26
Findings: Nurse Satisfaction Variable Pre Implementation Post Implementation Float weekly 15% 5% Cancelled for low census 14% weekly 6% weekly Time giving shift to shift report 81% < 30 minutes 78% < 30 minutes Effective nurse communication during shift handoff 86% Agree/strongly agree 94% Agree/strongly agree
Findings: Patient Quality Variable Pre Implementation Post Implementation Adverse events 16.21 20.12 Falls 4.17 3.66 Med errors 4.17 4.39
Findings: LOS & HPPD Variable Pre Implementation Post Implementation 3.71 3.73 Average Patient LOS Total Case Mix Index (CMI) 1.26 1.21 WHPPD (RN) 6.9 6.1 7665days @ $30/hr = $212k
Implications (So What) Implementation of the acuity-adaptable care model has the potential to: positively impact factors associated with nurse satisfaction which can affect turnover and overall engagement in the workplace favorably influence patients perceptions of the hospital experience improve efficiencies in care delivery that leads to salary expense reductions Further study with larger units and varying types of patients is required
Implementation of Bedside Shift Report to Improve the Effectiveness of Shift Handoff in an Acute Care Hospital Cairns L et al. (2013). Utilizing bedside shift report to improve the effectiveness of shift handoff. JONA. 43(3): 160-65.
Bedside Shift Report to Increase Handoff Effectiveness Key Element Evidence Objective(s) Implementation Evaluation Tools Regulatory and quality organization recommendations e.g. TJC, IOM advocated value of patient centered care; professional accountability; patient safety Failed attempts/resistance/lack of standardization posed risk to quality Demonstrate the positive outcomes associated with bedside shift report (nurse and patient satisfaction; reduced call light usage; reduced end of shift OT Education sessions with role plays and case studies highlighting concerns that has been a barrier e.g. interruptions, excessive time, sensitive family issues, lack of pertinent information Letter from UD to newly admitted patients Data pre and 3 months post intervention OT and call light data from administrative data base HCAHPS scores: kept you informed; included you in decisions 7 item nurse satisfaction survey
Findings: Call Light Usage Pre-Implementation (7/1/11 to 9/30/11) Post- Implementation (10/1/11 to 12/31/11) Percent Change Call light usage 1591 1075 33% 7am-8am 809 501 38% 7pm-8pm 782 574 27%
Findings: End of Shift Overtime Pre-Implementation (7/1/11 to 9/30/11) Post- Implementation (10/1/11 to 12/31/11) Percent Change End of shift overtime 6194 minutes (103 hours ) 5281 minutes (88 hours) 15% (10min/day) Potential Cost Reduction: 10minutes/day at an hourly rate of $26-$39 results in a cost savings of $24,000 to $ 36,000 per quarter Annually, reduction of $96,000 to $144,000 in salary expense!
Findings: Patient Satisfaction Mean Score Pre-Implementation (7/1/11 to 9/30/11) Post- Implementation (10/1/11 to 12/31/11) Nurses kept you informed 76.0 (N=65) 84.5 (N= 49) Staff included you in decisions about your treatment 75.0 (N=61) 80.0 (N=46)
Findings: Nurse Satisfaction Agreed or Strongly Agreed Pre-Implementation Post- Implementation N=29 N=18 Report is concise; contained only pertinent information Information contained in report consistent with initial assessment 38.0% 77.8% 72.4% 83.4% Nurses available after report for questions 75.9% 88.9%
Findings: Nurse Satisfaction Agreed or Strongly Agreed Pre-Implementation Post-Implementation N=29 N=18 Time required for report is excessive 48.2% 38.9% Time required for report interfered with ability to complete work within shift 41.4% 27.8%
Implications (So What) Involve direct care nurses in developing a standardized report tool to increase buy-in and hardwire practices Expand use of bedside shift report to other units in the organization Replicate for longer period of time to accrue a larger volume of patients and determine trends in patient satisfaction
Use of Evidencebased Guidelines and Scripting to Support Acute Care Nurses in Sepsis Recognition, Reporting, and Treatment Drahnak D. ( 2014) DNP Capstone Project, University of Pittsburgh School of Nursing, Conemaugh Memorial Medical Center
Key Element School of Nursing Change in Standard of Care to Improve Patient Outcomes Evidence Objective(s) Implementation Internal Problem Identification: Sepsis among top 10 DRGs; Current SSC guidelines not followed; lack of sepsis screening policy Evidence: Surviving Sepsis Campaign; IHI Severe Sepsis Bundle; Sepsis screening tool available through EHR platform Nurse education Implement commercially available sepsis screening tool Assess nurses knowledge and attitudes Assess institutional compliance Developed voice over PPT education session about sepsis and bundle Retrospective chart audit pre and post education Evaluation Tools Nurse assessment (knowledge and attitudes) Audit tool; established criteria for 3 levels of compliance Drahnak D. ( 2014) DNP Capstone Project, University of Pittsburgh School of Nursing, Conemaugh Memorial Medical Center
Findings Variable Pre Implementation Post Implementation Nurse Perceptions & Attitude Awareness (self and peers) definition Confidence detecting Confidence reporting Nurses Knowledge (10 items) Compliance with documentation of sepsis bundles Non: 40.6 Non: 8.9 Statistically significant increase (p < 0.0001) Statistically significant increase (p < 0.0001) Partial: 40.6 Partial: 69.1 Full: 18.5 Full: 21.9
Implications (So What) Education, communication scripting, nursing policy, and EHR prompts can improve adoption of the IHI bundles and SSC 2012 guidelines for sepsis care Continued vigilance and support from administration on this initiative will be needed to support compliance and ensure success