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Published on October 6, 2007

Author: ShawnHoke

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Transformation in Healthcare Delivery: Essential Components Marita G. Titler, PhD, RN, FAAN Director of Research, Quality and Outcomes Management Department of Nursing Services and Patient University of Iowa Hospitals and Clinics Clinical Professor University of Iowa College of Nursing Senior Scientist – CRIISP VA HSR Center Iowa City, IA

Transformation Reform – process for trying to make the current pattern work. Transformation – developing a new and very different pattern. Revolution – new models of thought; paradigm shift.

Reform – process for trying to make the current pattern work.

Transformation – developing a new and very different pattern.

Revolution – new models of thought; paradigm shift.

Why the current system cannot be reformed Third party payer system Current system is profoundly misfocused in defining the doctor as the center of the system and acute care as its primary interest. Activities of healthcare are simply too complex to be reformed by a political process. The rejection of new ideas and new technologies are inherent in the current system (Gingrich, 2003)

Third party payer system

Current system is profoundly misfocused in defining the doctor as the center of the system and acute care as its primary interest.

Activities of healthcare are simply too complex to be reformed by a political process.

The rejection of new ideas and new technologies are inherent in the current system

Comparisons Binary, market mediated Triangular third-party-controlled market Electronic, information based Paper based Use genetic, outcomes-based knowledge to create a preventive, self-managed, and health-oriented system of continuous involvement using the nutrition-activity-attitude model Care is reactive, episodic, and disjointed Rapid innovation and speed of diffusion Slow diffusion of innovation Knowledge intense Knowledge disconnected Value Driven Price Driven Individual Centered Provider centered Transformed System Current System

Comparisons (Gingrich, 2003) Overall cost decrease Overall cost increase Fair, affordable system of health justice that protects individuals and encourages access to quality care Expensive, predatory trial lawyer-enriching system of dispute resolution Outcomes measured and improved Outcomes undermeasured and ignored Increased choice Limited choice Collaborative government manages by outcomes Adversarial government manages by process Transformed System Current System

 

Essential Elements to Transform Healthcare Leadership Collaboration and Community Partnerships Balance between regulation and creativity Health care Information systems Research Programs of Research Considerations when planning clinical studies – translation into practice Studying current transformations

Leadership

Collaboration and Community Partnerships

Balance between regulation and creativity

Health care Information systems

Research

Programs of Research

Considerations when planning clinical studies – translation into practice

Studying current transformations

Leadership Central function of leadership is to achieve a collective purpose. Transaction-based “you scratch my back, I’ll scratch yours” Mutual purposes are advanced only as long as both parties perceive their individual interests are furthered by the relationship Transformation-based When leaders engage with followers in pursuit of jointly held goals Relationship based

Central function of leadership is to achieve a collective purpose.

Transaction-based

“you scratch my back, I’ll scratch yours”

Mutual purposes are advanced only as long as both parties perceive their individual interests are furthered by the relationship

Transformation-based

When leaders engage with followers in pursuit of jointly held goals

Relationship based

Transformation-Based Leadership: Essentials Balancing the tension between efficiency and reliability – that is quality and safety with cost. Creating and sustaining trust Actively managing the process of change Involving workers in work design and work flow decision making Creating a learning organization (IOM, 2004; A rapid learning health system/Health Affairs S, 2007)

Balancing the tension between efficiency and reliability – that is quality and safety with cost.

Creating and sustaining trust

Actively managing the process of change

Involving workers in work design and work flow decision making

Creating a learning organization

Challenges in HCD: Leadership Role of CNE in organizational structures Development of nurse managers of micro-systems Education of CNE and NMs Dollars invested by healthcare systems in training of current and future nursing leaders Span of control and performance expectations of nurse managers Responsibility and accountability for staffing, quality and safety in patient care

Role of CNE in organizational structures

Development of nurse managers of micro-systems

Education of CNE and NMs

Dollars invested by healthcare systems in training of current and future nursing leaders

Span of control and performance expectations of nurse managers

Responsibility and accountability for staffing, quality and safety in patient care

Collaboration and Community Partnerships Nurse Physician collaboration Collaboration with consumers/individuals Creating acute care environments that promote self-care of individuals and their families (e.g. critical care; peri-op settings; medication management; patient/family education). Partnerships across acute care hospitals School settings – how are school nurses being utilized? Need to be engaged as interactive resources for wellness education

Nurse Physician collaboration

Collaboration with consumers/individuals

Creating acute care environments that promote self-care of individuals and their families (e.g. critical care; peri-op settings; medication management; patient/family education).

Partnerships across acute care hospitals

School settings – how are school nurses being utilized? Need to be engaged as interactive resources for wellness education

The National Nursing Practice Network for EBP and Translation Science NNPN represents a commitment to the promotion and implementation of evidence-based practices through a collaborative model designed to promote shared learning and participation.

Mission and Vision Statement The mission of the NNPN is to foster exceptional healthcare outcomes; advance professional nursing practice thru application of evidence; support nursing leadership development for EBP; increase understanding of mechanisms and strategies that fosters use of evidence. Vision – to be a national exemplar of nursing practice excellence, innovation, translation science, and promotion of EBPs

The mission of the NNPN is to foster exceptional healthcare outcomes; advance professional nursing practice thru application of evidence; support nursing leadership development for EBP; increase understanding of mechanisms and strategies that fosters use of evidence.

Vision – to be a national exemplar of nursing practice excellence, innovation, translation science, and promotion of EBPs

About Us: NNPN Represents 15 states

Regulation and Creativity: The Balance CMS core metrics October 2008 – payment for adverse events Emphasis placed on meeting regulatory requirements May detract from creative innovative ways to meet health and healthcare needs Self-care management for chronic illnesses Health education and wellness. Will/are health systems resourcing these federal expectations (Auerbach et al, 2007 NEJM; Shortell et al, 2007 JAMA)

CMS core metrics

October 2008 – payment for adverse events

Emphasis placed on meeting regulatory requirements

May detract from creative innovative ways to meet health and healthcare needs

Self-care management for chronic illnesses

Health education and wellness.

Will/are health systems resourcing these federal expectations

Information Systems: Challenges Need to be adequately piloted, tested and revised for usability in care prior to deployment Understand the work and workflow and then designed to support work Data warehouses and repositories – essential data elements Including nursing treatments – standardized language to capture the work of nursing (Doebbeling et al, 2006; Titler et al, 2004)

Need to be adequately piloted, tested and revised for usability in care prior to deployment

Understand the work and workflow and then designed to support work

Data warehouses and repositories – essential data elements

Including nursing treatments – standardized language to capture the work of nursing

Publications Dochterman J., et al. (2005). Describing nursing care using standardized language . Journal of Nursing Scholarship, 37 (1), 57-66. Titler, M., Dochterman, J., Pettit, D., Everett, L., Xie, X., Kanak, M., & Fei, Q. (2005). Cost of hospital care for elderly at risk of falling. Nursing Economics, 23 (6): 290-306 . Titler, M., Dochterman, J., & Reed, D. (2004). Guideline for conducting effectiveness research in nursing and other healthcare services. Iowa City, IA: The University of Iowa, College of Nursing, Center for Nursing Classification & Clinical Effectiveness. Titler, M., Dochterman, J., Xie, X. J., Kanak, M., Fei, Q., Picone, D. M., et al. (2006). Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures. Nursing Research, 55 (4), 231-242.

Dochterman J., et al. (2005). Describing nursing care using standardized language . Journal of Nursing Scholarship, 37 (1), 57-66.

Titler, M., Dochterman, J., Pettit, D., Everett, L., Xie, X., Kanak, M., & Fei, Q. (2005). Cost of hospital care for elderly at risk of falling. Nursing Economics, 23 (6): 290-306 .

Titler, M., Dochterman, J., & Reed, D. (2004). Guideline for conducting effectiveness research in nursing and other healthcare services. Iowa City, IA: The University of Iowa, College of Nursing, Center for Nursing Classification & Clinical Effectiveness.

Titler, M., Dochterman, J., Xie, X. J., Kanak, M., Fei, Q., Picone, D. M., et al. (2006). Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures. Nursing Research, 55 (4), 231-242.

Publications Shever, L., Titler, M., Dochterman, J., Fei, Q., & Picone, D.M. (2007). Patterns of nursing intervention use across six days for three older patient populations. International Journal of Nursing Terminologies and Classifications, 18 (1), 18-29 Titler, M., Dochterman, J., Kim, T., Kanak, M., Shever, L., Picone, D. M., et al. (2007). Cost of care for seniors hospitalized for hip fractures and related procedures. Nursing Outlook, 55, 5-14 . Titler, M., Jensen, G. A., McCloskey-Dochterman, J., Xie, X., Kanak, M., & Reed, D. (in press). Cost of hospital care for older adults with heart failure: Medical, pharmaceutical, and nursing costs. Health Services Research .

Shever, L., Titler, M., Dochterman, J., Fei, Q., & Picone, D.M. (2007). Patterns of nursing intervention use across six days for three older patient populations. International Journal of Nursing Terminologies and Classifications, 18 (1), 18-29

Titler, M., Dochterman, J., Kim, T., Kanak, M., Shever, L., Picone, D. M., et al. (2007). Cost of care for seniors hospitalized for hip fractures and related procedures. Nursing Outlook, 55, 5-14 .

Titler, M., Jensen, G. A., McCloskey-Dochterman, J., Xie, X., Kanak, M., & Reed, D. (in press). Cost of hospital care for older adults with heart failure: Medical, pharmaceutical, and nursing costs. Health Services Research .

Publications Picone, D. M., Titler, M., Dochterman, J., Shever, L., Kim, T., Abramowitz, P., & Kanak, M., (in press). Predictors of medication errors among elderly hospitalized patients. American Journal of Medical Quality Kanak, M., Titler, M., Shever, L., Fei, Q., Dochterman, J., & Picone, D. M. (in press). The effects of hospitalization on multiple units. Applied Nursing Research Reed, D., Titler, M., Dochterman, J., Shever, L., Kanak, M. & Picone, D. (in press). Measuring the dose of nursing interventions. International Journal of Nursing Terminologies and Classifications .

Picone, D. M., Titler, M., Dochterman, J., Shever, L., Kim, T., Abramowitz, P., & Kanak, M., (in press). Predictors of medication errors among elderly hospitalized patients. American Journal of Medical Quality

Kanak, M., Titler, M., Shever, L., Fei, Q., Dochterman, J., & Picone, D. M. (in press). The effects of hospitalization on multiple units. Applied Nursing Research

Reed, D., Titler, M., Dochterman, J., Shever, L., Kanak, M. & Picone, D. (in press). Measuring the dose of nursing interventions. International Journal of Nursing Terminologies and Classifications .

The wonder pill most frequently encountered currently is in fact the “wonder clinical information system,” despite the often glaring discrepancy between the promise of systems in showrooms and the way they perform in the real world. Shojania & Grimshaw (2006). Health Affairs , 24(1), p 149 Warning

The wonder pill most frequently encountered currently is in fact the “wonder clinical information system,” despite the often glaring discrepancy between the promise of systems in showrooms and the way they perform in the real world.

Essential Elements to Transform Healthcare Leadership Collaboration and Community Partnerships Balance between regulation and creativity Health care Information systems Research Programs of Research Considerations when planning clinical studies – translation into practice Studying current transformations

Leadership

Collaboration and Community Partnerships

Balance between regulation and creativity

Health care Information systems

Research

Programs of Research

Considerations when planning clinical studies – translation into practice

Studying current transformations

TRIP Intervention Saves Healthcare Dollars and Improves Quality of Care University of Iowa Iowa City, Iowa Principal Investigator Marita G. Titler, PhD, RN, FAAN Co-Principal Investigator Keela Herr, PhD, RN Project Director Gail Ardery, PhD, RN Investigators John Brooks, PhD Kathleen C. Buckwalter, PhD, RN, FAAN William Clarke, PhD Linda Everett, PhD, RN J. Lawrence Marsh, MD Margo Schilling, MD Bernard Sorofman, PhD Toni Tripp-Reimer, PhD, RN, FAAN Xianjin Xie, MS Funded by AHRQ RO1 HS10482

Aim 1 : To test the effect of the TRIP intervention on nurse and physician adoption of evidence-based acute pain management practices in elders . Aim 2 : To test the effect of the TRIP intervention on decreasing barriers to use of evidence-based acute pain management practices. Aim 3 : To determine the cost effectiveness of the TRIP intervention. Follow-up – sustainability Specific Aims RO1 HS10482

Aim 1 : To test the effect of the TRIP intervention on nurse and physician adoption of evidence-based acute pain management practices in elders .

Aim 2 : To test the effect of the TRIP intervention on decreasing barriers to use of evidence-based acute pain management practices.

Aim 3 : To determine the cost effectiveness of the TRIP intervention.

Follow-up – sustainability

Cost Findings (Aim 3) Total costs per patient were $1,495.89 less in the E group than the C group (p <0.0001) For each one-unit increase in the Summative Index, total costs decreased by $1,598.75 (p = 0.002) A net savings to the hospital of more than $131,000 per 100 patients, even after implementation costs are taken into account.

Total costs per patient were $1,495.89 less in the E group than the C group (p <0.0001)

For each one-unit increase in the Summative Index, total costs decreased by $1,598.75 (p = 0.002)

A net savings to the hospital of more than $131,000 per 100 patients, even after implementation costs are taken into account.

Cancer Pain in Elders: Promoting EBPs in Hospices Keela Herr PhD, RN, FAAN (PI) Marita Titler PhD, RN, FAAN (Co-PI) Other investigators: Perry Fine, M.D. John Swegle Pharm D Sara Sanders PhD Mary Ersek, PhD

Keela Herr PhD, RN, FAAN (PI)

Marita Titler PhD, RN, FAAN (Co-PI)

Other investigators:

Perry Fine, M.D.

John Swegle Pharm D

Sara Sanders PhD

Mary Ersek, PhD

Study Aims To test the effect of a multifaceted TRIP-Cancer Pain Intervention on promoting adoption, by health care providers, of evidence-based cancer pain management practices for elder hospice patients To test the effect of a multifaceted TRIP-Cancer Pain Intervention on pain severity in elder hospice patients with cancer pain.

To test the effect of a multifaceted TRIP-Cancer Pain Intervention on promoting adoption, by health care providers, of evidence-based cancer pain management practices for elder hospice patients

To test the effect of a multifaceted TRIP-Cancer Pain Intervention on pain severity in elder hospice patients with cancer pain.

Improving Continence and Pain Control in Nursing Homes: M-TRAIN Multi-level Translation Research Application in Nursing Homes Janet Specht, PhD, RN (PI) Paula Mobiliy, PhD, RN, (Co-PI) Other investigators Keela Herr Sara Sanders Gerald Jogerst

Multi-level Translation Research Application in Nursing Homes

Janet Specht, PhD, RN (PI)

Paula Mobiliy, PhD, RN, (Co-PI)

Other investigators

Keela Herr

Sara Sanders

Gerald Jogerst

Study Aims To test the effect of the M-TRAIN intervention on urinary continence and pain outcomes for elderly NH residents. To test the effect of the M-TRAIN intervention on NH quality outcomes, state survey violation citations, and staff turnover. To describe the relationship of facility characteristics with high and low adoption among NHs that receive the intervention.

To test the effect of the M-TRAIN intervention on urinary continence and pain outcomes for elderly NH residents.

To test the effect of the M-TRAIN intervention on NH quality outcomes, state survey violation citations, and staff turnover.

To describe the relationship of facility characteristics with high and low adoption among NHs that receive the intervention.

Use of Evidence-Based Practices in Schools Susan Adams – doctoral dissertation Purpose – descriptive study to explore factors that promote use of evidence-based practices by school nurses. Instrument and conceptual model to guide further research Variables that promote or impede use of EBPs to guide implementation intervention research

Susan Adams – doctoral dissertation

Purpose – descriptive study to explore factors that promote use of evidence-based practices by school nurses.

Instrument and conceptual model to guide further research

Variables that promote or impede use of EBPs to guide implementation intervention research

Impact of System-Centered Factors, and Processes of Nursing Care on Fall Prevalence and Injuries from Falls RWJ - INQRI (interdisciplinary quality research initiative) Purpose - investigate linkages among 2 NQF patient outcomes of falls and injury from falls, NQF system-centered measures such as skill mix, nursing care hours per patient day (HPPDS), and professionalism, and processes of care to prevent falls. Sites are 190 adult medical-surgical units from 45 hospitals in the U.S. that are members of the NNPN.

RWJ - INQRI (interdisciplinary quality research initiative)

Purpose - investigate linkages among 2 NQF patient outcomes of falls and injury from falls, NQF system-centered measures such as skill mix, nursing care hours per patient day (HPPDS), and professionalism, and processes of care to prevent falls.

Sites are 190 adult medical-surgical units from 45 hospitals in the U.S. that are members of the NNPN.

Center Grants

What factors should one consider in designing a research study to make it ready for translation, assuming efficacy and effectiveness are found? Nature of the intervention being tested Population Health care system Public Policy

Disseminate Knowledge Generate New Knowledge Quality Clinical Practice Apply Findings in Practice Conduct Research Identify Questions

Factor to Consider: Nature of the intervention Complexity of the intervention Intervention dose Frequency of delivery Who delivers the intervention How will this intervention get packaged for ease of use? How will you package the dependent variables from the study into metrics for use in busy HC settings

Complexity of the intervention

Intervention dose

Frequency of delivery

Who delivers the intervention

How will this intervention get packaged for ease of use?

How will you package the dependent variables from the study into metrics for use in busy HC settings

Factor to Consider: Nature of the intervention Clinically relevant alternative interventions Who delivers the intervention RA Knowledge and skills Multiple care givers Credentials Educational level Expertise (novice to expert) Family caregivers Lay persons Health literacy Training package

Clinically relevant alternative interventions

Who delivers the intervention

RA

Knowledge and skills

Multiple care givers

Credentials

Educational level

Expertise (novice to expert)

Family caregivers

Lay persons

Health literacy

Training package

Factor to Consider: Sample, Patient population, Consumer Population of interest Severity of illness/health status Primary medical diagnoses Co morbidities Heterogeneity; inclusion criteria Age/developmental level Where does this population have the greatest opportunity to receive this intervention

Population of interest

Severity of illness/health status

Primary medical diagnoses

Co morbidities

Heterogeneity; inclusion criteria

Age/developmental level

Where does this population have the greatest opportunity to receive this intervention

Factor To Consider: Healthcare System Setting Type Integration into work flow IT implications Population – high volume; high cost Leadership Data source in the HCS for effectiveness (process and outcome metrics) Packaging the intervention specific to the setting “ Context matters”

Setting Type

Integration into work flow

IT implications

Population – high volume; high cost

Leadership

Data source in the HCS for effectiveness (process and outcome metrics)

Packaging the intervention specific to the setting

“ Context matters”

Healthcare System Will this intervention work in settings like ours with staff resources and competing demands similar to those we have? Community based research networks

Will this intervention work in settings like ours with staff resources and competing demands similar to those we have?

Community based research networks

Factor to Consider: Public Policy If I do this study and the effect of the intervention is realized, what would the public policy headline look like? Why should policy makers care about your findings? (high volume issue; high cost?) Cost-effectiveness of the intervention What are the key messages for local, state and national public policy makers.

If I do this study and the effect of the intervention is realized, what would the public policy headline look like?

Why should policy makers care about your findings? (high volume issue; high cost?)

Cost-effectiveness of the intervention

What are the key messages for local, state and national public policy makers.

Institute for Healthcare Improvement This document is in the public domain and may be used and reprinted without permission provided appropriate reference is made to the Institute for Healthcare Improvement. Studying Current Transformations

Propensity Scoring Statistical method for determining the unique effect of a treatment; reduces the bias in studies in which groups are not randomized to a treatment. Attempts to recreate circumstances comparable to randomization. Propensity score is defined as “the conditional probability of being treated given the individual covariates” (D’Agostino, 1998, p.2265)

Statistical method for determining the unique effect of a treatment; reduces the bias in studies in which groups are not randomized to a treatment.

Attempts to recreate circumstances comparable to randomization.

Propensity score is defined as “the conditional probability of being treated given the individual covariates” (D’Agostino, 1998, p.2265)

Methods Propensity Scores Propensity scores are a useful method in observational studies where the researcher had no control on what subjects received the treatment variable of interest. It reduces the bias between the group that received the treatment and the group that did not receive the treatment by controlling for a number of confounders. Alternative to case control design – matching on variables is limited Researcher must first decide what the treatment variable of interest is. Propensity score analysis dictates that the treatment variable be dichotomous

Propensity Scores

Propensity scores are a useful method in observational studies where the researcher had no control on what subjects received the treatment variable of interest.

It reduces the bias between the group that received the treatment and the group that did not receive the treatment by controlling for a number of confounders.

Alternative to case control design – matching on variables is limited

Researcher must first decide what the treatment variable of interest is.

Propensity score analysis dictates that the treatment variable be dichotomous

Qualitative Research Example – Hysong et al 2006 Understanding knowledge use in acute care settings needs to be further informed by qualitative research that uncovers the relative effectiveness of implementation strategies ( ex- audit and feedback ). Although RCTs may be the gold standard, qualitative methods may add to our understanding of implementation interventions, and mechanisms by which they work We should invest in more qualitative studies of ongoing national efforts to improve care (100,000 lives campaign; patient safety practices)

Example – Hysong et al 2006

Understanding knowledge use in acute care settings needs to be further informed by qualitative research that uncovers the relative effectiveness of implementation strategies ( ex- audit and feedback ).

Although RCTs may be the gold standard, qualitative methods may add to our understanding of implementation interventions, and mechanisms by which they work

We should invest in more qualitative studies of ongoing national efforts to improve care (100,000 lives campaign; patient safety practices)

 

Closing thoughts When will we see transformation of healthcare? Acute care – who should be running hospitals or multi hospital systems? How will continuity of care and wellness be emphasized? Will we capture care delivered by nurses and other healthcare providers?

When will we see transformation of healthcare?

Acute care – who should be running hospitals or multi hospital systems?

How will continuity of care and wellness be emphasized?

Will we capture care delivered by nurses and other healthcare providers?

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