T RANSLATING C ARING T HEORY A CROSS T HE C ONTINUUM F ROM I NPATIENT TO A MBULATORY C ARE

1. TRANSLATINGCARING THEORYACROSSTHE CONTINUUM FROM INPATIENTTO AMBULATORY CARE MeghanMcCann MSN, RN, NE-BC Director Oncology Services University of North Carolina Health Care

2. Across the Continuum to Ambulatory Care • The Ambulatory Care Environment • Translating Caring Theory to Ambulatory Care • Translating Caring Theory to the Emergency Department • Sustaining the Carolina Care Culture at UNC Health Care

3. The Ambulatory Care Environment • Times with patients are shorter • Repetitive over time • Span the length of treatment • May be interrupted by inpatient stays

4. Translating Caring Theory to Outpatient Oncology • North Carolina Cancer Hospital • Flagship site for UNC Cancer Care with 150,000 visits/year • Clinical home of UNC Lineberger Comprehensive Cancer Center • Multidisciplinary adult and pediatric space including 101 examination, treatment, consultation, and procedure rooms • 72 infusion stations for adults (48), children (14), and clinical trials (10) • 3 Linear Accelerators for Radiation Therapy • 50 inpatient beds for medical oncology and bone marrow transplant

5. SCT and the Oncology Patient Tenets resonate for patients treated for a chronic illness over time • Maintaining Belief in patients ability to come through illness with meaningful life/dignified death • Understanding what is most important to patients/families • Supporting patients/families through difficulty • Assisting patients who cannot do for themselves • Enabling patients to progress to highest level during • Treatment • Survivorship • End of life

6. Dissemination in Outpatient Oncology • Replication of Inpatient Success • Effort led by Oncology Carolina Care Committee • Multidisciplinary membership of staff and leaders • Guidebook rewritten to accommodate ambulatory arena • New behavior each month • High patient volume with different providers across diagnoses and clinical environments

7. Carolina Care and Outpatient Oncology Patients • Few minutes of uninterrupted time to connect and convey concern during visit • Recognize feeling of patient • Establish connection • Convey concern • Goal – Each team member spend 3 uninterrupted minutes with at least one patient • Registration • Scheduling • Waiting room Moment of Caring: Knowing and Being With

8. Carolina Care and Outpatient Oncology Patients Nurse Manager Multi-level Rounding: Being With and Doing For Interdisciplinary Schedulers and Registration Director Hourly Patient Rounding

9. Carolina Care and Outpatient Oncology Patients ARe you comfortable? R Other/the care providers accompanying patients to their visits are acknowledged O Hourly Patient Rounds: Being With and Doing For Use the bathroom? Does patient need assistance/directions? U Need anything? N Door/curtain open or closed for privacy in clinic rooms? D Safetyassessment/call bell in reach? S

10. Carolina Care and Outpatient Oncology Patients • Allows Board members to connect with patient over shared experiences • Offer insight and ease fears Patient/Family Advisory Board Rounding: Being With and Doing For

11. Carolina Care and Outpatient Oncology Patients • Patients become active participants and decision makers in care • Guide interactions to ensure caring and concern are consistently communicated • Helps set and manage expectations • Greet patients • Correctly identify patients • Perform hand hygiene • Transition patient to next caregiver Words and Ways that Work: Being With and Enabling

12. Carolina Care and Outpatient Oncology Patients • Entails careful listening to complaint, owning problem, and working quickly to resolve issue • Listen with care • Provide blameless apology • Thank patient/family for sharing concern • Fix the problem • Consider provision of service recovery item • Follow up with patient/family to let them know how problem has been addressed

13. Carolina Care and Outpatient Oncology Patients • By actively listening, showing empathy, apologizing without blame, and fixing the problem, satisfaction can be increased • Creates opportunity for follow-up to improve systems

14. Carolina Care and Outpatient Oncology Patients • Team proactively discusses specific patient needs, is attentive to safety, and ensures needs are met during visit. • Multidisciplinary daily team meeting in clinical area to encourage information sharing • Promotes care team partnership • Enhances patient care • Creates forum to address safety concerns • Fosters teamwork Clinic Huddle: Knowing

15. Carolina Care andOutpatient Oncology Patients • During huddle • Review of clinic schedule • Discuss care needs that require focused attention/support • Identify opportunities to improve clinic flow • Kudos are shared Clinic Huddle: Knowing

16. Evaluation and Sustainment in Outpatient Oncology • Sustained scores highest in clinics across system • 19 percentile increase for overall • 4 percentile increase for nursing • Consistent Top 5 Clinics of eligible clinic locations (Meg’s graph?) • Review of PG data on monthly basis

17. Evaluation and Sustainment in Outpatient Oncology • Coordination of improvement efforts with Oncology Operations Team • Participation of Oncology leadership in organization wide CCIOC • Repeat of roll out 2 years post initial implementation

18. Translating Caring Theory to the Emergency Department (ED) • UNCH Emergency Department • Annual visit volumes of approximately 72,000 adults and 10,000 pediatric patients • One of the largest referral centers in North Carolina • Admit rate near 30% • Certified Level I Trauma Center for adult and pediatrics • State Burn Center • Joint Commission Stroke Center • Chest Pain Center

19. Caring Theory and the ED Patient • Tenets resonate for patients treated in an ED • Stressors compounded • High Acuity • Mixed patient population • High patient volumes • Entry point for 50% of inpatient admissions

20. Dissemination in the ED • Replication of Inpatient Success • Effort led by CNO and ED Director • Multidisciplinary membership of staff and leaders • Multiple week roll out • Each behavior introduced across shifts • High patient volume with different providers across diagnoses and clinical environments

21. Carolina Care and ED Patients • Convey presence and empathy despite pressures of busy/changing environment • Pat on shoulder • Kind words • Talking with patient during assessment • Sitting down to connect while starting an intravenous line Moment of Caring: Knowing and Being With

22. Carolina Care and ED Patients Nurse Manager Multi-level Rounding: Being With and Doing For Interdisciplinary Health Unit Coordinator (HUC) Director Hourly Patient Rounding

23. Carolina Care and ED Patients • Hourly Comfort Rounds by Nurses and Nursing Assistants • Focus on personal needs • Offers of food and drink when permissible • Pain management • Helping patient and family understand wait time • Communication of Plan of Care Hourly Patient Rounds: Being With and Doing For

24. Carolina Care and ED Patients • Time compression makes 1st impression essential • Wait times and the unexpected are key drivers of dissatisfaction • AIDET organizes all major components into one tool • Acknowledge • Introduce • Duration • Explanation • Thank you Words and Ways that Work: Being With and Enabling

25. Carolina Care and ED Patients • Other important Carolina Care behaviors and messages • Closing curtains for privacy • Washing hands for safety • Stepping out to document care • Posting important info on the white board in each room Words and Ways that Work: Being With and Enabling

26. Carolina Care and ED Patients • Entails careful listening to complaint, owning the problem, and working quickly to resolve issue • Listen with care • Provide blameless apology • Thank patient/family for sharing concern • Fix the problem • Consider provision of service recovery item • Follow up with patient/family to let them know how problem has been addressed Blameless Apology: Being With and Enabling

27. Evaluation and Sustainment in the ED • Increase from 15th percentile and sustain at 65th despite volume/capacity constraints • Current focus • Improving patient throughput • Increasing survey returns through discharge calls • Introduction of Bivaris • Sends discharged patients text or email with link to electronic survey • Has increased response rate from 5% to 30% • Patients respond within 24 hours versus 30 days • Provides more detailed comments yielding more actionable format

28. Sustaining the Carolina Care Culture at UNC Health Care • Accountability • Sustaining Carolina Care in Changing Environment • Carolina Care 2014 • Evaluation and Sustainment of Carolina Care 2014 • Sustaining Excellence – The New Frontier

29. Accountability • Multidisciplinary Monday Morning Carolina Care • Carolina Care Implementation Oversight Committee • Big 5 • Geriatrics • Pulmonary/Infectious Disease • Family Medicine/Nephrology • General Medicine • GI Surgery

30. Accountability • Inclusion in Performance Evaluation • Inclusion in Nursing Professional Expectations • Weekly Updates and High 5

31. Accountability Annual goals: mean goals for each unit

32. Accountability • Key Outcomes from Big 5 • GI Prep with Gatorade • Care of floors • Temperature control • Development of unit brochures • HUC initiated rounding • Warm afternoon washcloths • EVS on Demand • New food tray activators to keep food warm • Nutrition Food Service leadership rounding

33. Sustaining Carolina Care in Changing Environment • New challenges • Organization adopted integrated Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction survey in July 2013 • Implementation of new Electronic Medical Record • Goal - Increase UNCH overall patient satisfaction scores during implementation of new electronic medical record and adjust focus to align with HCAHPS

34. Carolina Care 2014 • Created Carolina Care 2014 Interprofessional Taskforce • Nursing • Pharmacy • Pastoral Care • Nutrition and Food Services • Environmental Services • Supply Chain Services • Patient and Family Advisors

35. Carolina Care 2014 • Taskforce divided into eight working groups, with each group assigned an area of focus • Patient engaged report • Nurse-physician rounding • Communication through care boards • Narrating care • Active listening • Positivity • Communication in an electronic environment

36. Carolina Care 2014 • Creating Carolina Care 2014 • Taskforce met for an all-day off-site work session • During session, team members • Reviewed goals of the initiative • Created educational materials for staff • Devised a rollout plan to ensure implementation prior to the transition to the EMR

37. Carolina Care 2014 • Implementing Carolina Care 2014 • Carolina Care 2014 content was introduced in weekly segments • Information was reviewed during weekly Carolina Care Huddles • Managers utilized standardized template that included a weekly topic of focus with • Set goals and tasks • Tools to educate staff members and weekly metrics to determine success • Electronic access Carolina Care tools on a shared network drive

38. Carolina Care 2014 • Carolina Care 2014 Implementation Tools • Weekly Huddle Guides • Words and Ways that Work • Evidence-based literature to support interventions • Pocket cards with key weekly topic information • Managers also shared information and tools with staff members during monthly staff meetings and through weekly email messages

39. Evaluation and Sustainment of Carolina Care 2014 • Following implementation, scores improved to 76th percentile in March 2014 and reached high of 95th percentile week of March 16, 2014 • Post-intervention metrics: outperformed FY14 organizational goal (75th percentile) for patient satisfaction. These improvements were sustained in May 2014 (82nd percentile) and June 2014 (83rd percentile)

40. Sustaining Excellence – The New Frontier • Ambulatory Improvements across Medical Center and Physician led clinics • Physician Engagement • Carolina Care across affiliate hospitals within UNC Health Care System • Annual Competency for all Nursing staff

41. Tonges Translational Model for Theory-Driven Practice