improving patient care outcomes and staff satisfaction ... · pdf file–envisioned...

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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



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



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)



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



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



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



Zynx Health’s Approach to Evidence-based Practice

Grant Campbell, MSN, RN

Senior Director, Nursing Strategy and Informatics



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”



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”



MEDITECH System

Organizational protocols,

procedures, and practices

Framework for Maximizing Clinical and Financial Performance

Improved Clinical and Financial Performance

CDS Content

Services

Clinical Expertise



Plan of Care Model

• Plan of Care definition Philosophical

• Patient Problem definition

• Content use cases Conceptual

• Content utilization (initiate, monitor, resolve)

Operational



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



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



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



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)



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)



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



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



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



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+



63 Medical condition/

procedure topics covered

53 Patient problem

topics addressed

300 Customizable plan

of care templates

7 Standards of Care



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…



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



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



Zynx® Evidence – Key Clinical Processes



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



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



Community-Acquired Pneumonia



White Plains Hospital Plan of Care Experience

Romina Hipolito Elias, MSN, RN-BC Assistant Nurse Manager Clarissa Tojos, RN-BC Clinical Nurse Informaticist



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®



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



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



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



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



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



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



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



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



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



White Plains Hospital Outcomes Achieving strategic goals with new cultural transformation

Nurse Informaticists influence strategic decisions

Cultural transformation



Post Go-Live Activities and Ongoing Efforts

• Evidence updates

• Additional care plans and patient problems

• Definition of processes

• Future goal: Outpatient plan of care



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



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



Contact Info

• Romina Hipolito Elias, MSN, RN-BC

[email protected]

• Clarissa Tojos, RN-BC

[email protected]

• Grant Campbell, MSN, RN

[email protected]

mailto:[email protected]



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