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1 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Improving Patient Care Outcomes and Staff Satisfaction Using Evidence-Based Interdisciplinary Plans of Care
Romina Hipolito Elias, MSN, RN-BC
Clarissa Tojos, RN-BC
Grant Campbell, MSN, RN
2 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Today’s Objectives
• Define the need for evidence-based interdisciplinary plans of care (IPOCs)
• Describe the Zynx Health™ boot camp model that rapidly develops and implements evidence-based IPOCs
• Outline the challenges to develop and implement evidence-based IPOCs
• Discuss ways to gain consensus and overcome resistance to adoption of evidence-based IPOCs
3 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
About White Plains Hospital
• 292 beds
• 15,828 admissions
• 54,152 ED visits
• 1,933 births
• Magnet® Designation from the American Nurses Credentialing Center (ANCC)
• 11-time winner of the Consumer Choice Award
• Joint Commission Top Performer of Key Quality Measures (2012)
• Outstanding Achievement Award from the American College of Surgeons Commission on Cancer (2013)
• Get With The Guidelines®–Stroke Gold Plus Quality Achievement Award from the American Heart Association (2013)
• Beacon Award for Excellence for the Intensive Care Unit (ICU) from the American Association of Critical Care Nurses (2014)
4 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
About White Plains Hospital
• Clinical IT
• Nursing Informatics Council (Nursing representative from each unit)
• Ancillary department reps (PT, Respiratory, Dietary, Social Services)
• Nursing Management
• Quality Management
Interdisciplinary Plan of Care (IPOC) Team
5 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
White Plains Hospital Objectives
• Support quality and patient safety
• Achieve standardization in practice
• Implement and transition to evidence-based practice
• Provide clinical decision support for IPOCs at the point of care
6 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Background to Zynx Health™ IPOC Project
• CNO and nursing leadership recognized need for evidence-based IPOCs
• Need to improve compliance
– Chart reviews showed 60% compliance with care plans
• Need for meaningful care plans
– Evidence-based plans of care (v. just because/just protocol/non-specific to patient or care provider)
– Envisioned interdisciplinary plans of care v. just nursing care plans
• Disciplines functioned in silos
Defining the need for evidence-based IPOCs
7 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Zynx Health’s Approach to Evidence-based Practice
Grant Campbell, MSN, RN
Senior Director, Nursing Strategy and Informatics
8 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Plan of Care – Current State Challenges
Inconsistent development methodology
Limited scope
Irregular and/or non-existent updates and maintenance methodology
Nursing focused
Mixes standards of care, plan of care, and policy/procedure elements
Inconsistent integration of performance measure requirements
Inability to “tell the Patient Story”
9 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
ZynxCare – Future State Opportunities
Gold standard for content development methodology
Range and granularity of evidence – key clinical processes, evidence and
performance measure requirements (national, state, specialty)
Extensive content scope – by populations, acuity, and venue
Established updates and maintenance methodology
Interdisciplinary approach
Supports deployment of standards of care, plans of care, and
policy/procedure
Ability to “tell the Patient Story”
10 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
MEDITECH System
Organizational protocols,
procedures, and practices
Framework for Maximizing Clinical and Financial Performance
Improved Clinical and Financial Performance
CDS Content
Services
Clinical Expertise
11 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Plan of Care Model
• Plan of Care definition Philosophical
• Patient Problem definition
• Content use cases Conceptual
• Content utilization (initiate, monitor, resolve)
Operational
12 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Transitions across
the Care
Continuum
Continuous Optimization and Outcomes Improvement
Patient and Family Centered Care
Organizational Infrastructure
Dependent Orders
Inter & Independent Orders
Clinical Documentation
Education
13 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Standards of Care
• Defined by population and/or venue (acuity)
• Combination of assessments and interventions that every patient/family receives from admission to discharge regardless of reason for admission or diagnosis
• Mechanism to identify and monitor a patient problem
14 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Plan of Care
• Defined as:
An individualized approach to managing unique and relevant patient and/or ‘family’ problems
• Requires an organizational definition for a patient problem
15 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Defining the Patient Problem
When is a problem a problem?
“When a clinical, behavioral,
educational and/or social issue(s)
is preventing the patient and/or family
from getting to the next level of care.”
– Critical to general care
– Acute care to transitional care (Rehabilitation/LTAC)
– Acute or transitional care to community (home or other clinical setting)
16 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Plan of Care
–Includes use cases that provide organizational structure to the plan
–Requires a policy and procedure governing the: initiation
monitoring
and resolution of the patient problem(s)
17 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Use Case Content Application
A stand alone problem identified as a result of
use of a standardized risk assessment scoring
tool
Example:
Falls - Risk of
A stand alone problem identified as a result of a
clinical assessment finding
Example: Serum Glucose Level - Abnormal
when signs of hypo/hyperglycemia are present
A stand alone problem identified as a result of a
co-morbidity
Example: Serum Glucose Level - Abnormal for
patient with a history of diabetes (Type I or II)
A stand alone problem is used to inform,
improve, and/or standardize a clinical protocol,
practice and/or policy & procedure (P&P)
Example: Infection, risk of – Indwelling Urinary
Catheter
Patients with indwelling catheters are managed
according to the organizational policy, procedure
and protocol but the above problem would not be
activated on the plan of care
18 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Use Case Content Application
A problem set (condition/procedure plan) identified
based on admitting or a developing diagnosis.
Within the set problems are selected depending on
scoring tools and/or assessment findings.
Example:
Total Hip Replacement (procedure)
Stroke (condition)
Vaginal Delivery (process)
A problem set combined with additional problem
set(s) to create a broader problem set
Example:
Joint Replacement created by merging Total Hip
Replacement with Total Knee Replacement
A problem set is repurposed for use with another
similar clinical condition for which the evidence is
essentially the same
Example:
Hemorrhagic Stroke based on Ischemic stroke
For a clinical condition for which Zynx does not have
a problem set, a plan of care is created using patient
problems
Example:
Burn Trauma Adult
Anxiety
Breathing Pattern Ineffective
Fluid Volume Imbalance
Gas Exchange Impaired
Infection – Risk of
Mood Altered
Tissue Perfusion Altered
19 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Evidence Summaries
• Online library of clinical research, national guidelines, and quality measures designed to support the development of plans of care
• Transparent, rigorous, repeatable methodology
•Cochrane
•PubMed
•CINAHL
•US Based
Quality/Performance
Measures
Accumulate
Appraise/Synthesize Publish
20 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Evidence-based plans of care embedded into the
MEDITECH Patient Care System (PCS) application
Non-biased evidence summaries derived from robust
research methodology
106 Plans of Care
Annual Content Updates and Maintenance
program to ensure that content remains optimized
and current
Content Updates and Maintenance
Industry’s Deepest Possible Level of Evidence-based CDS Integration MEDITECH Client Server 5.54+
21 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
63 Medical condition/
procedure topics covered
53 Patient problem
topics addressed
300 Customizable plan
of care templates
7 Standards of Care
22 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
4 Transition of Care checklists:
• General (overall)
• Admission
• Pre-discharge
• Post-discharge
8 Rehabilitation modules:
• Cardiac
• Musculoskeletal Amputation
• Musculoskeletal Arthroplasty
• Musculoskeletal Spine Surgery
• Neurological Spine Cord Injury
• Neurological Brain Injury
• Cerebrovascular Disorders
• Pulmonary
Supporting the Care Continuum
Cardiac: Phase I, II, III; postdischarge
Musculoskeletal: preoperative; phase I, II, III; phase IV
amputation; postdischarge arthroplasty & spinal surgery
Neurological: Admission/discharge, outpatient,
postdischarge
Pulmonary: Admission/discharge, outpatient, postdischarge
Including…
23 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
ZynxCare® Content Format
Z icon = links you
to the Zynx
Health evidence
summary
Blue Ribbon
icon = quality &
performance
measure
Key icon =
intervention
directly impacts
clinical and
financial
outcomes
24 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Zynx’s Vital Interventions™ Focusing on Evidence-Based Interventions Proven to Impact Clinical and Financial Outcomes
All Evidence
Proven impact on clinical & financial
outcomes
Performance measures (eg,
core measures)
Mortality
Cost
Length of Stay
Admissions/
Readmissions
Hospital-Acquired
Conditions
25 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Zynx® Evidence – Key Clinical Processes
26 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Zynx’s Model for Support of Evidence-Based Practice At the Bedside and Organization Wide
Evidence-Based
Practice at the
Point of Care
Plan of Care
Templates Client
Approval
Customization and
Validation
106 IPOCs embedded
MEDITECH
Add’l IPOCs imported
MEDITECH
AuthorSpace
ViewSpace
Goal:
Standardization
27 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Onsite Clinical Content Review Options
• Sequential days (back to back)
• 2 or more Zynx clinicians (Regional Nursing Officers)
• Concurrent rooms (population based)
• Client SME participants:
– Content experts (point of care clinicians)
– Steering/project committee(s)
– Specialty SME (i.e. wound care clinicians)
– Clinical informatics
• Key benefit
– Critical mass of content customized rapidly
–
Multi-day intensive onsite
28 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Community-Acquired Pneumonia
29 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Community-Acquired Pneumonia
30 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
White Plains Hospital Plan of Care Experience
Romina Hipolito Elias, MSN, RN-BC Assistant Nurse Manager Clarissa Tojos, RN-BC Clinical Nurse Informaticist
31 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Things We Considered: Background
• Order set project began 2011 – saw the benefits from prior project
• Closely worked with Stellaris Network
• Because of the success of ZynxOrder®, we chose ZynxCare® with ZynxInside™
• Jan 2013: decision made for ZynxCare® with ZynxInside™ after inter-departmental conversations
Choosing ZynxCare®
32 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Things We Considered: Background
• Discussed options to implement into MEDITECH
– Had version 5.64 – ZynxInside™ compatible with 5.54+
– Upgrade to version 5.66 in October 2013
– timed implementation until the upgrade
– Began the IPOC process in January 2013
• Informatics council key player during the entire process from start to finish
– Coaches/educators
– Representatives from each unit
–Super users/champions for care plans
33 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Challenges to the IPOC Project
• Consideration of Stellaris network (additional 3 hospitals)
– Evaluated whether other facilities would take on IPOCs
– Our nursing leadership were champions of IPOCs
• Timing
– Very strict deadline for project (development to completion)
– Short time frame
• Educating interdisciplinary team
– Spreading accountability to measure outcomes and documentation of the IPOC in MEDITECH
34 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
White Plains Hospital Timeline Zynx Health™ IPOC implementation with go-live
Project Timeline set
Jan 2013
Assembled care plan team
Feb 2013
IPOC customization –
1.5 day bootcamp
implementation
June 3-4, 2013
Migrate add’l Zynx content
into MEDITECH:
customizing and testing
July-Aug 2013
Zynx IPOCs final MEDITECH
upload
October 8, 2013
MEDITECH and Zynx
IPOC
Go-live
October 8, 2013
35 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Boot Camp Planning • Held 1 plan of care boot camp
– 2 days
– 14 participants in 2 rooms
• Sent existing plans of care to Zynx in advance
– Zynx made recommendations on what problems to put in IPOCs (i.e., disease-specific)
• Working groups were created by specialty
– Critical care
– Hematology, oncology, palliative
– Maternal child health
– Pediatrics
– Med/Surg
• Healthy competition: winner received gift for customizing most number of plans of care
36 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Organizational Culture Shift
• Brand new paradigm and way of thinking to involve interdisciplinary teams
– Need to get team on same page and onboard
– Respiratory, case managers, etc.
• Shift in nursing care process
– Before: Including any and all problems into the care plans (pertinent or not)
– After: getting patient to next level of care
• Changed workflow of documenting care plans in MEDITECH
• Veteran nurses v. newer nurses
Site challenges
37 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Overcoming Resistance and Achieving Consensus
• Started from the top: support from nursing leadership
• Ongoing support for staff
• Formed an alliance between interdisciplinary team members
– Informatics council
– Clinical IT delivering education
– Nurses
– Ancillary care providers
38 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
White Plains Hospital Outcomes Rapid deployment and increased collaboration with ZynxCare®
Collaboration between disciplines
Clinician buy-in and consensus
Meaningful documentation of patient goals
Provider-provider communication
39 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
White Plains Hospital Outcomes Improved compliance and quality of care with ZynxCare®
Staff satisfaction
Staff compliance
Meeting Magnet® designation for EB practice
Evidence at the point of care
Standardization, quality of care, and patient safety
40 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
White Plains Hospital Outcomes Improved LOS and interdisciplinary documentation with ZynxCare®
Source: 2010 Zynx Health Conference | 2009 Zynx Health Conference
Length of Stay Rate
Documentation Time
41 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
White Plains Hospital Outcomes Achieving strategic goals with new cultural transformation
Nurse Informaticists influence strategic decisions
Cultural transformation
42 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Post Go-Live Activities and Ongoing Efforts
• Evidence updates
• Additional care plans and patient problems
• Definition of processes
• Future goal: Outpatient plan of care
43 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Lessons Learned
• Evidence-based IPOCs are a major project on its own
– Separate go-live and training sessions
– More training sessions
• Streamline assessments in MEDITECH
• Longer timeline to complete
44 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Summary
• Evidence-based practice needed not only in physician order sets, but also in plans of care
• Management support is crucial to the success of the project
• Collaboration and engagement from interdisciplinary team is key in achieving compliance
• Supportive team from Zynx Health
• Nurse informaticists have unique skills for strategic decision-making and program success
– help bridge gaps between care providers
– lead nurse satisfaction and patient care improvement programs
45 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
Contact Info
• Romina Hipolito Elias, MSN, RN-BC
rhipolito@wphospital.org
• Clarissa Tojos, RN-BC
ctojos@wphospital.org
• Grant Campbell, MSN, RN
gcampbell@zynx.com
46 © 2014 Zynx Health Incorporated | The information contained herein is confidential and proprietary to Zynx Health Incorporated and is intended for its authorized recipient.
Unauthorized review, use, disclosure or distribution is strictly prohibited. All rights reserved.
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