Data to inform change

1. Data to inform change • Pediatric Pain Resource Nurse Curriculum

2. Where can you focusyour first effort for the quickest win and biggest reward? • Who are key members of your team? • Do you have the resources you need to secure success? Understand data sources and the analytic process What do actionable data look like?

3. Performance Improvement Ideal Goals & Objectives Specific Measurable Achievable Relevant Time-bound Performance Measurement Ideal Metrics Sensitive: Can measure the difference that really happens Meaningful: The patients & the providers agree that what is measured is important Accurate: Valid and precise Reliable: Means the same with repeated measurement Timely: The data are on time for decisions SMART goals and metrics

4. Measures Example: procedural pain in children • Outcomes • 1. Start at the end and work back • What is the expected outcome of this change? ( procedural pain) • What are indicators of that outcome? (Pain ratings) • How can they be measured? (Documentation review) • 2. Look at the literature • What is currently measured? • How hard would new data be to collect? Engage clinical experts when needed • Processes • 1. Start at the end & work back • What is the expected change in practice? (Pain assessment, comfort plan, evidence-based interventions) • What are indicators of that change? (Documentation of pain assessments, comfort plan, intervention) • How can they be measured? • 2. Look at the literature • What is currently measured? • How hard would new data be to collect? • Engage clinical experts when needed

5. Process your thinking! Define your measure and identify how to get it. Why did you choose that answer?.

6. The Analytic Process • The analytic process is an uncertain and complex process you will need to steer through. It cannot be fully delegated. PROCESS OUTCOME • Assess the data • Are the data clean enough? • Are the data representative enough? • Begin statistical testing • Tend to outliers, inter-relationships, underlying patterns • Anything unexpected? • Final testing • Assess reproducibility • What makes you uneasy? • State the hypothesis or analytic question • It must be falsifiable • Define the path to answer it • Lit review (pay attention to methods sections) • Identify potential data sources • Develop comparison approach • Is this plan feasible? • Systematically collect & prepare data for analysis • Vast amount of time and resources involved

7. What is Nursing Informatics? • Nurse informatics specialists review clinical needs and documentation input, work flows & utilization. The goal is to use technology to gain wisdom. • Current nursing informatics standards are published in the Nursing Informatics: Scope and Standards of Practice, 2nd ed (2015). • Data, information, knowledge, and wisdom model • Nursing Informatics is a specialty that integrates nursing science with multiple information and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice

8. Implications for Informatics and Documentation of Pain Response • Informatics tools facilitate pain documentation. The PRN should contact nursing informatics or other organizational resources to ensure tools populate based on age and establish the workflow if the patient does not fit standard criteria. • “If you don't know where you are going, you will probably end up somewhere else”. ~Laurence Peter • “If you don't know where you are going, any road • will get you there.” ~ Lewis Carroll • Pain assessments and responses to treatments are usually documented in a flow sheet of the EHR. Ensure that this documentation is visible, so it can be acted upon by all relevant healthcare providers (HCPs). • Documentation should portray the patient’s pain experience, so HCPs can use this knowledge to continue or modify the treatment plan.

9. Measuring and Improving Outcomes • If interventions fail to achieve the expected outcome, it may be an implementation failure, rather than failure of the intervention. • If practice change is not implemented as intended (low fidelity), outcomes may fail to improve (e.g., if steps are skipped, pain scores or satisfaction may not improve). • Balancing measures determine risk associated with practice change. • Deciding if the outcome met the intended goal for improvement and understanding risks is key to making next steps decisions. • Although outcomes can be measured, they can only be managed through improvements in care processes. • Processes are steps for improvement (e.g. auditing pain assessment documentation) • Outcomes are goals for improvement (e.g. interventions given in response to pain) • Balancing measures monitor for systemic effects and unintended consequences from practice change (e.g. respiratory depression). In order to change outcomes, you need to change processes.

10. Implications of Informatics for the Pediatric PRN • Tools are available to the PRN to incorporate appropriate resources into patient electronic health records (EHR) to document care that meets unique cultural, ethnic, and religious values and beliefs. • As technology advances, the EHR will evolve to: • advance the patient story in the documentation of health care across the continuum of care. • focus on health • incorporate or download patient centric information to personalize the EHR. • Ideally, pain experiences, including all pain histories, assessments, treatments and evaluations of treatment efficacy, will flow into patients’ personalized plans of care. • Plans of care should focus on patient-generated goals.

11. Key Points A Pain Resource Nurse (PRN) is a registered nurse who interfaces with healthcare team members, patients, and families as a resource, change agent, and leader to disseminate information, facilitate optimal pain management, and systemize quality pain care. • Leadership commitment to PRN and PRN role is critical for success. • PRN responsibilities include: • Personal Professional Development • Clinical • Educator • Researcher • Change agent • Leader • Clinical standards • PRNs champion and facilitate quality, leadership, pain management and ethical standards • When implementing the PRN role… • Establish an interdisciplinary team to explore opportunities for improvement, identify barriers, develop an action plan, champion change, and monitor outcomes. • Use communication, trust-building and listening skills. Identify high-impact opportunities • Identify and implement change: Question, Evidence, Teamwork, Pilot, and Disseminate Your role as a Change Agent • Phase project implementation to create awareness and interest, build knowledge and commitment, promote action and change, and plan integration and sustained use. • Identify specific data sources and outcome measures. Leverage Informatics Advocate for patients and families • Tailor the pain-related information to the patient and family.

12. Checklist: Instituting Evidence-Based Practice • Define units, patient populations to extend evidence-based practice • Select opinion leaders • Select change champions • Select core group members • Outline responsibilities • Establish timelines • Keep them involved • Decide on initial education • Who? • Opinion leader • Change champion • Core group • Staff • Methods • When • Plan for education of new staff • Plan for annual competency review • Decide on written resources needed for implementation • Quick reference guides. • Patient/education forms. • Decision tree. • Plan for and make system changes as needed (e.g., documentation forms, etc.) • Plan baseline data collection • Process indicators • Outcome indicators • Frequency • Initial feedback to staff • Graphs • Who • When • Posting • Audit and feedback of data • Frequency • Where to post • Celebrate progress and success “The reason most people never reach their goals is that they don’t define them, or ever seriously consider them as believable or achievable. Winners can tell you where they are going, what they plan to do along the way, and who will be sharing the adventure with them.” ~Denis Watley

13. What’s your plan? • Review the characteristics for implementing the PRN role successfully. What do you still need? • Review the types of projects PRNs can take responsibility for. Which can immediately benefit your clinical unit or specialty? • Review the checklist for instituting evidence-based practice. Who needs to be on your interdisciplinary team? • Think about your own professional development. Who can be your mentor? Write your next steps here.