Priority Problems Implementation Planning Nursing Leadership October, 2010

1. Priority Problems Implementation PlanningNursing Leadership October, 2010 Goals for the session: • Have beginning understanding of Saba CCC Model • Commit to need for change • Support introduction of Priority Problems as initial step of Documentation Framework change • Be able to verbalize the vision statement • Have begun a unit-specific implementation plan • Have seen a proposed rollout schedule • Knowledge of resources available to support this work

2. Intro • CNO • We have a track record of successfully changing nursing documentation – HED, AdminRx, and OPC implementations – but we keep adding to the documentation burden without taking anything away. • We have adopted a new Documentation Framework that we are starting now to implement. • Less of a technical change, more of a practice change. • Cultural change bigger than the cultural change required to implement AdminRx

3. Intro • Karen Hughart – logistics: • Sit in teams by unit; CAPS or Systems Support Services Rep. will sit with you • We will be working in groups to begin to craft a unit-specific Implementation Plan • We ask that you honor timeframes • Jot down questions and “ah-ha’s” as you go so you don’t lose them. If there are any issues we are not able to address today, we will put on Parking Lot for follow up after the session.

4. Kotter’s 1st Step:Increasing the Sense of Urgency

5. Increasing the Sense of Urgency • Break into unit groups • Use the CWS to complete the task • You will have 7 minutes • Be prepared to answer these questions: • Were you able to find the information ? • Were you satisfied with the quality of the information ?ne sentence

6. Finding our way together…. Kotter’s Step Two: Form a Powerful Coalition

7. “Managing change isn’t enough – you have to lead it.” (Kotter, 1996) • As the Nursing Leaders of VUMC, we must actively LEAD this transformation of practice & documentation • Requires strong leadership & visible support • We cannot “manage” change from the sidelines

8. Managers create order & predictability, while leaders establish direction, vision, motivate & inspire people. (Weber & Joshi, 2000)

9. Building a Change Coalition • Nursing Leaders & Nursing Educators • Staff Nurses (novice to expert) • SuperUser Champions • SSS Liaisons • Informatics Liaison • Key Stakeholders: Medical Director, Physicians, Nurse practitioners • Engage Opinion Leaders early & engage as Champions

10. Change Coalition will… • Work as a TEAM • Build ongoing urgency & momentum for the need for change

11. Kotter’s Step 3: Create a Vision

12. If documentation is a reflection of our care – does it show that nurses make a difference?

13. Pathway & Phase • Choose the pathway that most closely reflects the expected patient progression. Usually the reason for admission. • Medical Pathway – Heart Failure • Admission – Orders & interventions are aimed at achieving stabilization ( improving pump action through diuresis, O2, hemodynamic stability, . . .) • Stabilization - achieving a controlled symptoms (fluid excess control, med mgmt • Discharge– Ready for self-care; or care by another caregiver. • Surgical Pathway - Knee Replacement • Pre-op Pre; Post-op Stabilization; Discharge

14. How do we document our plan of care and outcomes? • 1 Pathway & Phase • Sets timed objectives to meet discharge goals based on predominant medical or surgical plan • 2 Provider Plan • Orders & planned procedures • 3 Other Disciplines Plans • Reflects provider orders • Contributes specialty focus • 4 Reflects patient goals

15. Nursing Plan of Care • Population Based: • EVP > Mosby’s … • Unique Patient based on: • Nurse’s Skill in Nursing Process • Assess • Dx Problems • Plan • Interventions • Evaluate Outcomes

16. Managing/preventing problems can help reduce length of stay and improve the quality and cost bottom line • Adverse patient effects • hospital acquired conditions (infections, injuries) • dissatisfaction (unhappy, lost wages) . . . • Adverse VUMC effects • lost revenue from under-reimbursed care days • losing patients due to having no available beds . . .

17. Focus on PrioritizingThe NursingProblem List Using the Clinical Care Classification - an evidence based Nursing terminology in the patient’s plan of care

18. Physiological Cardiac Bowel/Gastric Life cycle (pregnancy) Metabolic (glucose) Physical Regulation (infection) Respiratory Skin Integrity Tissue Perfusion Urinary Medication Psych/Behavioral Cognitive Coping Health Behavior Role Relationship Self Care Self Concept Functional Activity Fluid Volume Nutrition Safety Sensory/Pain 21 CCC Categories

19. CCC Frameworkfor the Nursing Plan of Care • 21 Categories: Skin Integrity 182 Problems (Dx): Oral Mucous Membranes Impairment 3 Expected Outcomes:Improve, Stabilize, Support decline 198 Interventions: Mouth Care 4 Actions:Assess, Care, Teach, Manage 3 Actual Outcome:Improved, Stabilized, Decline supported

21. Assigning pathway in Starpanel

22. ____________________Plan of Care Summary________________________ Pathway: CHF (chart once) Phase: Admission (update prn) Nsg Summary: Pt admitted via ambulance in respiratory distress… Plan Priorities: IV diuretics, fluid restrictions, I&O, reduce anxiety…. ____________________Initial Problem______________________________ Priority Problem:Fluid Volume Excess May be related to: CHF, fluid intake, hi Na diet Exp Outcome: Stabilize ______________________q shift plan and outcomes__________________ Exp Outcome Detail: diurese .5L this shift Exp Outcome Status: Not Met Interventions: chart as usual Plan of Care admission documentation

23. Why – the Nursing Process? • Florence Nightingale • Notes on Nursing (1860) • Norma Lang • If you can’t name it, you can’t control it, finance it, research it, teach it or put it into public policy (Clark & Lang, 1992) • Swan, Lang, & McGinley (2004) • Make the work of nurses visible and show its value • Assess • Problem Identification • Plan/Goal Setting • Care Interventions • Outcome Evaluation

24. Assess * Care * Teach * Manage Priority Problems Building an Outcomes Oriented Documentation Framework A Home for Evidence Based Nursing Care

25. Vision Statement Priority problems will simplify and standardize how nurses: • document and communicate the patient’s top priority problems • identify plans and goals • assess actual outcomes This will improve patient care and clearly define nursing’s contributions to patient care and the team.

26. Kotter’s Step 4:Communicating the message • According to Albert Mehrabian’s research study in 1968 how much of the message is the actual words used? • 38% • 7% • 55%

28. Which of the following delivery methods is the most effective? • Email • Group meetings • One-on-one communication • Company publications • High level and executive storytelling delivered company-wide

29. According to the 2005 Change Management Best Practice Report…. • One-on-one face to face discussions that are honest and straight forward and that offer details of the change on a personal level • Cascading small group meetings to share information, brainstorm solutions and implement new processes

30. Communicating to Different Generations Traditionalists born before 1945 Baby Boomers born 1945 – 60 Millenials – grandchildren of boomers Generation X – children of boomers

31. Show Me generation--Body language is very important Favor top-down decisions Value respect Will fight for a cause Make decisions based on what has worked in the past Consistency is important Traditionalists Baby Boomers Generation X Millenials Value work and life balance Shaped by a culture of instant results Multi-taskers Avoid unnecessary meetings Highly Collaborative Optimistic Prefer messages presented from positive standpoint

32. Styles of CommunicationMatch the Generation to a Style Preferred by that Generation Baby Boomers • Blog • Face to Face communication • Email • PowerPoint Presentation Traditionalists Generation X Millenials

33. You can expect to see some/all of the following strategies used to communicate Documentation Framework Changes: • Articles in the reporter • Blog • Video of 8th floor staff commenting re: priority problem documentation • Branding • Web Site • Nursing News articles From Marilyn • Monthly updates for leadership to communicate to staff

34. Area Specific Coalition and Communication Plan In your unit groups, for the next 10 minutes discuss: • Who should be included in your unit’s coalition for change? List names and/or titles • Begin to identify your unit-specific communication plan – be specific and include timeframes

35. Kotter’s Step 5:Removing Obstacles & Empowering Action Obstacles are generally in 3 categories People Processes Structure

36. People • Leadership: Commit to change & voice consistent message • Educators & Super Users: Communicate advantages of new process • Curmudgeons: Listen to their feedback but don’t leave true resisters in leadership positions • 5 positive encounters to overcome 1 negative • All Leaders demonstrate their belief that the change will improve patient care & continuity of care

37. Process • Can’t be too complicated • Must be fairly easy to learn • Must fit into workflow • CQI: Looping process…education, implementation, evaluation, reeducate or change, reevaluate, reeducate/change

38. Structure • Commit to overtime pay: for SuperUsers to be available during implementation • Change takes time: adapting to new processes can take up to 4 weeks • Adequate Education: Educators, Superusers, Staff • Identify competing projects: safety, policy, product… Anything that will require extra time • Watch out for staff and Manager overload!

39. Removing Obstacles & Empowering Action In your groups take 10minutes to: • Identify obstacles to success & develop action plans to address • Include prior commitments that might influence timelines for Priority Problem rollout on your unit

40. Kotter’s Step 6: Create Short Term Wins • 8 South experience • What were improvements experienced with use of Priority Problem approach? • How did you hard wire the change? • What were the challenges to adoption?

41. Kotter’s Steps 7 & 8:Build on the Change & Anchor the Change in culture • Group to identify 2-3 successful changes they have experienced in VUH over the past 2-3 years • During any of these changes, did you identify short-term wins during the change process? • How did you celebrate these wins? • What techniques did you use to hardwire the change?

42. Vision Statement Priority problems will simplify and standardize how nurses: • document and communicate the patient’s top priority problems • identify plans and goals • assess actual outcomes This will improve patient care and clearly define nursing’s contributions to patient care and the team.

43. NEXT STEPS • Team completes Implementation Worksheet in 1 week and sends copy to Administrative Director • Educator Training and Practice sessions available • SSS revises implementation timeline by 1 week from today incorporating input re: obstacles • We will share your input with NAB/ QERI group • Utilize your support person and watch for communication updates