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How To Overcome Resistance to Your Good Ideas - AONE

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Presentation ID: CD2
March 13, 2014
Disclosure Slide
Today’s presenters do not have any relevant financial interests presenting a conflict of interest
to disclose.
Participants must attend the entire session(s) in order to earn contact hour credit. Continuing
Nursing Education credit can be earned by completing the online session evaluation.
The American Organization of Nurse Executives is accredited as a provider of continuing
nursing education by the American Nurses Credentialing Center’s Commission on
Accreditation.
AONE is authorized to award one hour of pre-approved ACHE Qualified Education credit (nonACHE) for this program toward advancement, or recertification in the American College of
Healthcare Executives.
Note: AONE will follow up directly with specific language for those speakers that disclosed a
conflict of interest
2
At the conclusion of the presentation
participants will be able to:
п‚— Identify the roles of nurse leaders and physicians in
redesigning the future care delivery system across the
continuum of care.
п‚— Describe an innovative clinical process entitled
Structured Interdisciplinary Bedside Rounds used to
achieve desired value-based metrics.
п‚— Delineate the role of the Clinical Nurse Leader as a
change agent in redesigning care delivery systems.
3
A Model Designed to Improve Patient and Hospital Outcomes
Program and Implementation Guide
Wellstar Kennestone Regional Medical Hospital
Laura Caramanica, RN PhD CENP FACHE, FAAN
VP & Chief Nursing Officer
Sonia Camphor, MD
Medical Director of Accountable Care Units
Carole Harman, BSN, MSA. RN
Executive Director of Nursing, Acute Care Service Line
Accountable Care is….
п‚— Having a reimbursement system that emphasizes
primary care, wellness and population health
management
п‚— Taking fiscal and clinical accountability for the
population
п‚— Actively engaging patients to take more responsibility for
their health
п‚— Building hospital-physician relationships and partnering
in a deeper way with patients, populations and payors
п‚— Improving the health of our communities and
decreasing health care costs by proactively managing
chronic care and patients’ health needs
6
Current State of Healthcare System Delivery
Care
delivered in
unorganized
silos
No integrated
comprehensive
health
information
No
orchestrated
care
pathways
Providers’ goals
& outcomes not
aligned
Network
may not be
high valuedriven
Payors not
partnered with
aligned &
incented
providers
7
ACO = a way to transition from volume to value
that is aligned with WellStar’s vision
Readmissions/HAC Penalties
Value-based purchasing:
HACs, quality, efficiency, cuts
Shared savings
Bundled payment
Capitation
FEE FOR SERVICE TO INTEGRATED CARE, NEW PAYMENT MODELS AND RISK
High-performing hospitals
and physician networks
• Best outcomes in quality,
safety
• Waste elimination
• Most efficient supply chain
• Satisfied patients
8
High-value
episodes
• DRG and
episode targeting
• Care models and
gainsharing
• Data analytics
• Cost
management
Population management
• Population analytics
• Care management
• Financial modeling and
management
• Legal
• Physician integration
The “ACO Movement” is growing
– 310 ACOs in 45 states and the District of Columbia
– First ACOs (10 organizations) part of the PGP Demonstration project beginning in 2006
– 32 CMMI “Pioneer” participants, program began January 2012
– Roughly 30% physician organization led
– Medicare Shared Savings Program
– 04/01 – 27 ACOs selected to participate.
– Majority of organizations physician organization led
– 07/01 – 89 ACOs selected to participate in this second cohort
9
Source: Center for Accountable Care Intelligence, “Growth and Dispersion of Accountable Care Organizations: June 2012 Update (06/2012)
CMS Shared Savings Program
п‚— Focus on the Triple Aim = Better
п‚—
п‚—
п‚—
п‚—
health, Better Quality, Lower
Costs
Current FFS payments to
providers continue
CMS establishes an ACO
benchmark for “bending the cost
curve”
Must achieve a “Minimum
Savings Rate” (MSR) +
performance on 33 Quality
metrics
50/50 cost savings sharing
between CMS and ACO
10
Why Are We Doing This?
ACO Future State
Create seamless coordinated world class care
п‚— Put beneficiary and family at the center
п‚— Proactively manage beneficiary care
п‚— Attend carefully to care transitions
п‚— Manage resources carefully and respectfully
п‚— Remember patients over time and place
п‚— Evaluate data to improve care and patient outcomes
п‚— Innovate around better health, better care and lower costs
п‚— Invest in team-based care
11
Background
п‚— How do you optimize clinical outcomes for patients
nurses and physicians
п‚— Properly Designed Hospital Units (ACU)
п‚— Institute Medicines STEEEP Dimensions of Care
Safe, Timely, Effective, Efficient, Equitable and Patient
Centered
п‚— Team Based Setting
12
Story of Harm
пЃЅ Mrs. BB is 80yo lady:
пЃЅ Admitted in January by urologist for nephrectomy пѓ stayed in Hospital 5
days (acute renal failure, hyperglycemia) пѓ went home with Cr=1.9/Hct=26
пѓ all previous medications continued (patient’s
Nephrologist/Cardiologist/PCP not aware of surgery)
пЃЅ 10 days after discharge Mrs. BB came to see Nephrologist complaining of
weakness, somnolence, “just not feeling well” пѓ hypoglycemic, Cr=2.9, Hct22 пѓ admitted by Nephrologist пѓ most medications discontinued
 Hospital Stay – one week
пЃЅ Seen by:
пЃЅ three different nephrology MDs and one AP
пЃЅ three different cardiologists
пЃЅ two different pulmonologists
пЃЅ two different GI MDs
пЃЅ Urologist
 On their way home (Friday @7pm) patient’s daughter called family memberMD asking what to do with her blood sugars/diabetes medications (prior to
discharge BG=200) and stating patient c/o urinary urgency.
13
Opportunities
п‚— No Lead Physician
п‚— Patient/Nurse do not know who is in charge
п‚— RN discussing POC with 30+ providers
п‚— Patients regularly discharged after 4pm
п‚— RN needing to paging multiple physicians leads to delayed
discharge
п‚— Patient satisfaction with discharge process very low
(HCAHPS)
 Patients’ understanding of the “next steps” very low
14
Solutions
п‚— Establish Accountable Care Unit (ACU)
with following attributes:
п‚— Unit-based Hospitalist-led teams
п‚— Structured Interdisciplinary Bedside Rounds
(SIBR) – MD, RN, CNL, Care Coordinator,
Pharm. D, (PT. Dietary)
п‚— Redesigned MD-RN collaborative partnership
п‚— Unit level performance data (HCAHPS, LOS,
discharges before 2pm, readmission rate, costper-case)
15
Building hospital-physician relationships and
partnering in a deeper way with patients, populations
and payors
Definition:
A geographic inpatient area consistently responsible
for clinical and cost outcomes it produces
16
Design Features of Team-Based Model
Patient-Centered Team-Based Work Flow
SIBR Roll Call
п‚—
п‚—
п‚—
п‚—
п‚—
п‚—
Patient/Family
Hospitalist
Nurse
Clinical Nurse Leader
Care Coordination
Clinical Pharmacist
17
п‚— Transition Coach
п‚— Charge Nurse
п‚— As Staffing/Pt needs
allow:
п‚— Physical Therapy
п‚— Respiratory Therapist
SIBR Ground Rules
п‚— All patients 5 days/week
п‚— All SIBR team members must be
present
п‚— Start and finish on time
 Rounds end only after patient’s planfor-the-day has been verbalized and
patient/family had an opportunity to
ask questions
18
The Structured Dialogue of SIBR
Emphasis on Role Clarity
п‚— Introduce All Team Members
п‚— Update Status: (45 sec)
п‚— Overnight events & Review
patients goal of the day
(On in room white board)
п‚— Vital Signs & Pain Control
п‚— Fluid and Food Intake
п‚— Urine and Bowel Output
Report
“abnormals”
п‚— Mental Status and ADLs
п‚— Physical Findings/Pathophysiology
19
The Structured Dialogue of SIBR
Emphasis on Role Clarity
п‚— Checklist for Quality and Safety (15 sec)
п‚— Foley Catheter
п‚— Central or Pic Line
п‚— VTE Prophylaxis
п‚— Pressure Ulcers/Stage
п‚— Plan of the Day and Assign Responsibilities
п‚— Discharge Planning Checklist (30 sec)
п‚— Discharge Needs
п‚— Discharge day and realistic time
п‚— Follow up Appointment
п‚— Patient Education (30 sec)
20
Clinical Nurse Leader (CNL)
MDs
RNs,
CCP’s, and
Students
п‚— Masters Prepared RN (University of West
Georgia)
п‚— CNL functions as clinical leader for
RNSs, Clinical Care Partner, &ancillary
staff
п‚— Comprehensive knowledge about each
patient in their unit
п‚— Provides continuity of care for patient in
the hospital to offset fragmentation
CNL
 Acts in the role of �traffic control’ in
coordinating rollout of the plan for care
п‚— Acts as the primary liaison for
physicians, other disciplines, and
families
Other
Disciplines
21
п‚— Monitors competency and provides
mentorship to team members
Families
and students
ACU and the CNL
• Leads interdisciplinary team, fosters collaborative in
SIBR Rounds
• Addresses gaps in care with Physicians and Nurses
• Develops complex plan of care
• Mentor for nursing staff
• Translates & integrates evidence into practice
• Emphasizes systems to accomplish health promotion,
risk reduction, & preventing readmission
• Facilitates quality & LEAN process improvements at the
bedside
• Conducts comprehensive unit-level assessment to
establish plan for improvement in efficiency, effectiveness
& outcomes
• Mentor Staff
22
23
Accountable Care Unit Outcomes
Average Length of Stay
ALOS 6S /7W
ALOS 6N /7N
BEFORE
JAN 2013
AFTER
JAN 2013
BEFORE
JAN 2013
AFTER
JAN 2013
4.00
3.89
4.21
4.01
ALOS 7W
BEFORE
JAN 2013
-
TOTAL LOS
AFTER
JAN 2013
BEFORE
JAN 2013
AFTER
JAN 2013
3.81
5.01
4.89
О”2.39%
% DISCHARGES PRIOR TO 2 PM
BEFORE
JAN 20
AFTER
JAN 20
24.20%
43.44%
*Implemented ACU Jan 20, 2013
24
Accountable Care Unit Outcomes
ACU 2PM Discharge Comparison
CURRENT ACU
50.00%
PRIOR TO ACU
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
25
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
Accountable Care Unit Outcomes
2 PM Discharge Compliance
2PM Discharges by Time
700
600
Cases
500
400
300
200
100
0
12 1
2
3
4
5
6
7
8
9 10 11 12 1
2
3
4
5
6
7
8
9 10 11
AM AM AM AM AM AM AM AM AM AM AM AM PM PM PM PM PM PM PM PM PM PM PM PM
BEFORE JAN 20
26
AFTER JAN 20
Accountable Care Unit Outcomes
Cost per Case Savings
Before January 20th 2013
$8,134
After January 20th 2013
$7,954
•364 patients/month X 8months X $180 = $524,160 (Annualized $786,240)
•HM at KRMC annual census 8,000 = potential savings ~$1,440,000/year
27
ACU HCAHPS Outcomes
28
29
Lessons Learned
п‚— Positive impact on Nursing staff
п‚— Potential for system-wide large-scale impact
п‚— Transformation is a process - not an event
п‚— Understanding the stages of change and common
pitfalls increases chances of successful transformation
п‚— Transformation requires investment of human and
financial capital
30
Clinical Nurse
Leader
Care
Coordinator
Pharmacist
Primary RN
Hospitalist
SIBR Process Map for Accountable Care Unit (ACU)
Greets Patients
/Introduces Team
Overnight Events
Vital Signs and Pain
I&O
ADLs
Addresses
Medication
Questions
Addresses
Discharge Plan
Supports Clinical
Aspects of Care
Hospitalist synthesizes all information inputs from SIBR
team and summarizes the patients care plan for the
day, updates anticipated discharge date and time.
Answers patient questions.
Active Problem list
Test results
Consult Findings
Family Inputs
Quality
Safety
Checklist
Med Red
Discharge
Assessment
Answers
Questions as to
Processes
Central
Line
Foley
Catheter
New or
Discontinued
Medication
Follow Up
Appts.
Addresses Issues that
Measure or Affect
Clinical Quality
DVTProphylaxis
SCD
Side Effects &
Complication
Home Health
Requirements
Pressure
Ulcers
Glycemic
Control
Discharge
Medications
Family Support
Issues
Addressed
Unit Charge Nurse
Remains Outside the Patient
Room during SIBR. Holds
Primary RN Phone,
Coordinates Additional
resources such as PT/OT, Acts
as Timekeeper.
STOP
3
Minutes
32
A Model Designed to Improve Patient and Hospital Outcomes
Program and Implementation Guide
Contact us at:
carole.harman@wellstar.org
Carole Harman, BSN, MSA. RN
Executive Director of Nursing, Acute Care Service Line
Wellstar Kennestone Regional Medical Hospital
Marietta, GA
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