Proposed evidence based Change project Plan

Student Sample Project Plan

Project Plan

Plan

This change project will utilize tactics and strategies suitable for a

multigenerational nursing team. During the planning process, the author of this paper will

establish the knowledge baseline by offering a survey to the ED triage nurses regarding

SSC. Nurses will be selected by corresponding Sepsis Coordinators. This strategy will

assess the individual member’s level of awareness of the current knowledge base,

identify the barriers, and challenge the institutional benchmark of O/E. Appendix B offers

the questionnaire for the assessment the baseline and post- intervention.

The executive sponsor, Tamara Alvarez, will initiate the communications and

assist with removing the barriers for APN. This will be achieved through collaboration

with the Director of Education and members of the performance improvement

department. The APN will guide the teams in establishing missions, visions and goals.

Through this multidisciplinary approach, creative strategies will be formed and utilized to

fulfill the objective of having fewer deficiencies and create better quality of care for

patients at SJH hospitals. Theories and frameworks will be chosen, the proposal will be

formulated, outcome measures will be identified, and activities will be planned according

to Lean methodologies, including the analysis of root cause, process mapping, data

collection and direct observation.

Do

The APN will analyze the results from the above-mentioned survey and present

them to Mrs. Alvarez and regional sepsis coordinators during the monthly SJH system-

wide collaborative sepsis coordinator conference call. The APN will then propose the

change projects with the goal of meeting SJH goals in early sepsis recognition and

initiation of evidence-based treatments as suggested in SSC. During this meeting,

feedback would be solicited, the group will agree on the timeline of the change project,

the ER core performance improvement project team will be formed, and members will be

recruited from triage nurses to ensure compliance and continued quality improvement

throughout the duration of the project. “Creating and developing high-performance teams

is a critical process that today's health care leaders must master in order to be effective"

(Manion, 2005, p. 207). The message must be communicated that patient safety must be

consistent and sustained as it can take a long time for a culture to change.

APN will suggest that according to the lessons learned from the previous cycle,

the bi-weekly meetings be more beneficial to discuss results, celebrate successes, identify

barriers, and countermeasures/mitigation strategies. According to Alvarez, T., & Griffith,

K. (n.d.) “over-communication is not possible!” (Slide 22).

The communication about accountability will be placed on all members of the ED

nursing team. This will be done in lieu of adding that compliance with early identification

and early treatments initiation for sepsis to be a part of performance evaluations.

One of the contributing factors to this rapid change will be the availability of

educational information. Extensive training with scenario simulations and distribution of

printed and training materials (handouts) will be offered at all levels and to members of

all departments involved.

Study

Lean methodologies, including the analysis of the root cause, process mapping,

data collection and direct observation will be applied. Although Lean has its roots in the

manufacturing industry, its philosophy and methodology have been applied to service

industries and healthcare from the late 1980s. This is applied to redesign all patient

pathways and the processes that support those (Clark et al., 2013). It is a transformational

change and SJH has successfully integrated Lean methodologies in the past where staff

engagement was the key to success.

Data will be collected in two ways: by Screening Data Collection Tool (SDCT)

(See Appendix C for screening data collection tool) and the utilization of the Meditech

Daily Log (See Appendix D for a Meditech Daily Log example).

The ED Charge Nurse will be responsible for having the SDCT completed by the

end of each shift and submit it to the APN at the end of each shift. The Daily Report will

be generated from a Meditech platform and it will be captured daily by the ED Clinical

Director to assess compliance with utilization of MSS, bundle, and length of stay (LOS)

data using US Medicare Severity Diagnosis-Related Group sepsis codes (MSDRG 870,

871, 872). One of the clinical quality indicators that will be measured is “time when

assessment was done” and “time-to-treatment,” or how much time it takes for the patient

who meets sepsis and SIRS criteria or is found to be already septic to be placed on the

bundles protocol. This information will be made available to unit directors to share with

staff and will tie the results to staff performance evaluations. The results will be

presented monthly to the Department of Internal Medicine.

Act

This step is an integration of lessons learned. At this point, the team will

determine whether the method and proposal need to be adjusted. Plan modifications will

be made and adapted to the next cycle based on the conclusions from the previous period.

If the team achieves the desired results, then the strategies need to be developed to sustain

the improvements, and policies and procedures will be updated to include the utilization

of MSS 100% of all admitting patients and to become a standardized method to identify

and manage sepsis.

Change Project Timeline

Gantt Chart for Change Project Timeline

Figure 1. Gantt Chart for change project timeline.

Proposed Projects Budget

The estimated cost of the project has shown here is limited to two hours of

educational classes attended by 400 benefited RNs from the ED. The hospital would pay

the nurses while they attend the course, and the cost is projected to be $28,000. The

Sepsis Change Project: " Utilizing MSS" 1/15 4/15

Activities 4 1 2 3 4 1 2 3 4 1 Initiation

Proposal presentation to Executive Sponsor,regional and ministry leadership

Communication with stakeholder, developing timeline, soliciting feedback

Planning 14 days

Preparation for (kick-off) -Identify team sepsis team members -Logistics (meeting day/time, location, appointments, tools, resources, supplies) -Meeting planning (facilitator, agenda, Core Team roles/responsibilities,meeting packets).

Pre-implementation -Review of evidence and toolkit content -Adopt and adapt solution tools (e.g., algorithms, order sets, checklists) to local ministry population, resources, and infrastrucure. -Set Go Live date

Education and training the "go - to" staff

Education & training all staff

Implementation 30 days Go Live

Leadership, champion & subject matter experts presence

Audits; rounding Identify barriers; make rapid changes to mitigate Re-education as needed

Phase III Evaluaiton & Refinement 14 days

Convene Core Team & Champions -Review data -Refine process -Capture key learnings

2/15 3/15

budget for the cost of the educator who would work 14 sessions (30 attendees each), two

hours per session, plus the original preparation time of eight hours. Therefore, the

instructor would need to work a total of 36 hours. At an hourly rate of $50/hour, the cost

for the instructor would be $1,800. Meanwhile, office expenses (e.g., supplies) are

estimated at $1,000. In conclusion, the cost of two hours of nursing training is expected at

$30,800.

Item Cost per Unit Units Total Cost Education classes $70 per RN 400 RNs $28,000

Educator fees $50 per hour 36 hours $1,800 Office expenses $2.50 per RN 400 RNs $1,000

Total cost - - $30,800

At Midpoint

At the midpoint, the alignment of the project with the strategic aims of the

organization is evaluated; current literature review is presented to support the strategies

employed in this project. Challenges and opportunities are identified, and strategies to

improve the compliance via strengthening the evidenced-based education, incorporating

informatics, strengthening the interdisciplinary team, and improving multigenerational

communication strategies are offered.

Survey

With assistance from Tamara L. Alvarez, MSN, RN, CCRN, Executive Director

of Performance Improvement at SJH, the survey using the questionnaire was forwarded

to the Sepsis Team members in SJH (14 hospitals nationally), who selected five nurses

from ED to respond to the survey (n=54). The goal of the questionnaire was to assess the

needs, level of knowledge and seek input from the Sepsis Collaborative team, and they

chose participants for completion of the survey. The results were analyzed and placed in

the easy to view formats.

The survey yielded several important areas of opportunity for directors’ of

educational and emergency services departments. Three major barriers to success were

identified, including: the knowledge deficit, the lengthy assessment at triage and time

constraint associated with it, and the need to improve the communication within the

interdisciplinary team. According to the survey (see Appendix E, the ED Nurses

Questionnaire), around 30 % of nurses shared that they are not confident in the

identification of SIRS and sepsis. Anne Jahnsen, the data analyst for Performance

Improvement Department, shared the “sample report” for one of the hospitals (see

Appendix G for Monthly Sepsis Report). This report showed the patient’s arrival date

and time, diagnosis, sepsis screen completion, and antibiotics initiation day and time.

From this report, it was concluded during the “Monthly Sepsis Working Team Call” that

there are opportunities to improve the compliance with the screening (Anne Jansen,

personal communication, February 16, 2015). This concludes the validation of the

problem. The mortality and morbidity did not worsen, but they may be improved if the

screening is done during the triage. The author of this paper suggesting that the outcomes

may be improved by improving compliance with the procedures.

Monthly Sepsis Working Team Call

The survey results were discussed during the Monthly Sepsis Working Team Call

utilizing WebEx. Cisco WebEx meeting center is an application that creates an effective

online meeting space where screens may be shared to facilitate efficient collaboration,

eliminating the lengthy email review cycles (“Cisco WebEx Meeting Center - Products &

Services,” n.d.). A variety of issues were discussed on the team call, including the need to

remove any barriers to communication with the ED educators and directors, as well as

understanding the need for assistance from the author to propel the change project.

Tracking tools were finalized and time is added to the Daily Log to capture the time of

the sepsis screen completion and bundle initiation (See Appendix D for a Daily Report

example with the green arrow where the time will be placed).

Challenges and Opportunities

Modern health care institutions are monitored by government agencies to ensure

all laws are followed, by insurance companies to ensure that billing is correct, and by

professional organizations to confirm that the practice meets standards. There are several

competing priorities that create challenges for a successful implementation of this project,

such as the presence of on-site federal inspectors who check for compliance with the

Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs)

and current nursing union negotiations. The above mentioned constraints keep the SJH

nursing leaders challenged, since they are expected to be available for inspections (T.

Alvarez, personal communication, February 10, 2015).

CMS

Extraordinary government regulations, ever-changing insurance industry

requirements and constant uncertainty about federal compensation create a perplexing

time for hospitals’ operations, which are also pressed to improve quality and safety of

care (American Hospital Association, 2013). The SJH, with 14 acute hospitals, has

chosen to participate in Medicare and/or Medicaid federal surveys to assess compliance

with the CMS Conditions of Participation (CoPs). The healthcare industry must be in

compliance with CMS Hospital Inpatient Payment Regulation (CMS, 2015). This creates

an incredible pressure to obtain cost optimization while at the same time meeting the

needs of the communities by improving quality and striving for superior outcomes with

improved patient experiences (Minkin, 2014).

Union Negotiation Times

Registered nurses (RNs) play a central role in the health care system. Many RNs

believe that unionization elevates the profession and encourages more young people to

choose nursing as a career (Brengman, & Shields, 2000). There are other nurses who

believe that the presence of unions in the institution undermines the independent

authority of the nurse and puts the patient at risk for substandard care. During the union

negotiation, there is a discussion about professional practice issues and the positive and

negative aspects of the current healthcare environment.

Expected Project Outcomes and Timeline Adjustments

Expected Project Outcomes

When the team will adopt four methodologies such as: sepsis screening of all

patients, accelerating processes for timely diagnoses, streamlining the processes to

promote compliance with protocols, and ongoing patients’ monitoring the results will be

an early detection during the first encounter with the patients. This will be the case even

in the absence of laboratory results, with only understanding the vital signs and patient

history will decrease the risk of death from delaying the proper treatment (AHRQ, 2012;

Sepanski et al.,2014).

Time Adjustment

According to Hopkins, et al. (2007), there are benefits to working on a project in

an environment with other on-going projects, including increased learning opportunities

for prioritizing work in a busy environment. However, the author of this paper has

learned that this project was larger than anticipated and due institutional challenges, the

goal of the project shifted from implementation of the project to offering

recommendations to be executed in the near future.

Gantt Chart for Change Timeline Adjustment

Figure 2. Gantt Chart for change project timeline adjustment.

Recommendations

Today, the business of health care cannot be sustained without healthcare workers

being caring, safe, and compliant. These professionals need to be competent,

knowledgeable, and effectively communicate that they can provide excellent care.

Conrad and Sherrod (2011) stated that as modern health care improves and expands,

nursing knowledge acquisition, dissemination, generation, and processing will continue

to advance. The improved compliance is recommended to be achieved by increasing the

educational opportunities, after analyzing the survey results by the nursing staff, and

adding the Clinical Decision Support (CDS) tool to the integrated ED Management

Sepsis Change Project: " Utilizing MSS" 1/15 4/15 Activities 4 1 2 3 4 1 2 3 4 1 Initiation

Proposal presentation to Executive Sponsor, regional leadership

Sepsis Questionnaires to offer to all 14 acute hospitals

Communication with stakeholder, developing timeline, soliciting feedback

Planning 14 days Preparation for (kick-off) -Identify team sepsis team members -Logistics (meeting day/time, location, appointments, tools, resources, supplies) -Meeting planning (facilitator, agenda, Core Team roles/responsibilities, meeting packets) -Sepsis Collaborative Monthly Call -Review of education toolkit content

Implementation periodically -Survey results communicated to Sepsis Leadership -Communication with Vendor -Identify barriers; make rapid changes to mitigate

Evaluation & Refinement -Review data -Refine process -Capture key learnings

2/15 3/15

(EDM) component, as well as improving the communication within the ED department

personal (See Appendix F for the ED Nurses Questionnaire).

Proposed continued timeline for the facility based on the cycle of 4 weeks

presented in Table 3.

! What? By when? By whom?

" Go Live Week 1

(Week 8

following

regional/ministry

kick-off)

Ministry

Leadership

Core Team

Project

Manager

" Leadership, champion, and subject

matter expert presence

-Rounding

-Audits; review Daily Report

Weeks 1-4 Ministry

Leadership

Project

Manager

Core Team

Operational

Managers

" Daily/case debriefs

-Identify barriers/glitches; make rapid

changes to mitigate

-Record lessons learned

Weeks 1-4 Ministry

Leadership

Project

Manager

Core Team

Operational

Managers

" Re-education and/or additional

education on SSC and the effective

communication strategies

Weeks 1-4 Core Team

Education

work group

" Communication & messaging

-E-mail & posted announcements

-Unit-based councils & staff meetings

-Medical Staff & Nursing Leadership

meetings

Ongoing Ministry

Leadership

Core Team

" Report to SJH Sepsis Core Team and

subsequently system leadership team

Week 4 Ministry

Leadership

Project

Manager

Table 3. Proposed continued timeline

Education

SJH already has a useful and effective program for sepsis and SIRS training.

According to Jamie Roney, MSN, RN-BC, BSHCM, CCRN-K, the SJH Regional Sepsis

Coordinator, Nursing Professional Development Specialist IV, she utilizes the mandatory

sepsis education in the form of courses including case study reviews. The classes are

offered at shift change to facilitate attendance (J. Roney, personal communication,

March15, 2015). The recommendation will be to offer the centralized and standardized

two-hour class on sepsis system-wide utilizing the WebEx technology with a centralized

educator. In addition, the organization should offer additional computer training

opportunities for direct care staff, including triage nurses, and on-demand training for

those reviewing cases. The effective, high-quality and efficient outcome-based training

program will offer the measurable results and the long-term benefits of behavioral

changes that align with the goals of the institution. This training program for ED triage

nurses will facilitate growth and provide opportunities for skill-building, boast the

mindset of a competent clinician, and align personal and professional values with

institutional values.

To evaluate the learning outcome, several levels of evaluation will be used.

Learning level evaluation implements the post-program test where it provides an

immediate evaluation of the effectiveness of the training. The application evaluation will

be conducted after trainees go back to the department and have time to practice acquired

skills and knowledge. The expected outcome is increased compliance with the ED Adult

Triage Assessment Tool performed on all patients by the ED triage nurse, and the earlier

initiation of a clinical alert for the rest of the multidisciplinary team, so the patient will

receive high quality service that will improve his or her outcome.

Incorporating the Informatics

The other way to improve compliance is by integrating the pop-up message

(sometimes called a “soft stop”), where the software automatically flags patients at risk

for SIRS or sepsis. In accordance with Dan Seltzer, PCS Applications Analyst with

Medical Information Technology, Inc., the Meditech offers this option, and according to

him it will take a minimal rebuilding. He also stated that soft stop and so-called “hard

stop” are different. Soft stop allows the user to pass by the pop-up message and proceed

with filing his or her documentation (personal communication, February 10, 2015).

Seltzer shared in his email:

If a patient is flagged, the nurse must also document the name of the physician

contacted; if they do not, they get a hard stop (error message), which forces them

to return to the screen and complete this documentation before filing (personal

communication, February 10, 2015).

During the course of this project, it became known that the Meditech system is

expecting a new software update, and therefore, the potential change in software to

satisfy this need is not feasible at this time.

Baldwin (2011) explored the current and upcoming challenges regarding

incorporating the soft stops in the software and stated that sometimes the clinical side

believes that IS can improve the processes. However, he stressed that health information

technology (HIT) is just a tool, and it cannot fix the inefficient processes based on the

process flow, nor an inefficient communication that has been adopted by some healthcare

providers.

Effective Collaborative Communication

The health care providers’ interaction is a multifaceted communication process

that must be improved during this performance improvement change project. This

interaction involves an inter-professional, multigenerational collaborative practice team.

According to the American Association of Critical-Care Nurses (2005), the U.S. health

care system puts thousands of patients at risk of medical errors annually due to

ineffective interpersonal relationships and communication failures between members of

the healthcare team. The way to resolve this issue is through collaborative

communication education. In other words, there is a need to have an interdisciplinary

health care team that can acquire communications skills necessary to support effective

working conditions and to create a safe environment for patients. In fact, the ACCN

(2005) have identified effective communications skills to be just as important as nurses’

clinical skills, and naming communication skills as one of the six standards for

establishing and sustaining healthy work environments (“Essential Standards” section,

para.2).

Today’s healthcare provider populations are diverse, not only by cultural

backgrounds but also by generation. Johnson and Romanello (2005) suggested that the

most represented generations in the ED include the Generation X or Baby Busters (born

1965-1976) and Generation Y or Millennials (born 1976-1995). Therefore, the

implications of having such diversity are that educators need to be keenly aware of who

they are teaching, how they like to learn, and which teaching styles will be most effective

to help the group learn.

Baby Busters are active learners and are able to retain and best understand

information by practicing in the form of group case study discussions, especially when

they can explain the learned information to a colleague. Both Baby Busters and

Millennials have a difficult time sitting through long lectures without being physically

active (taking notes is not considered being active). As a result, Felder and Spurlin

(2005) recommend that lecture time be limited to 20 minutes. Such a limit would be

especially beneficial to the Millennials, who are more likely than Baby Busters to

disengage when exposed to uninteresting material for an extended period of time.

For Millennials, according to Royse and Newton (2007), the evidenced-based

strategy that works well is teaching in the form of gaming. Since this group prefers to

learn from real life experiences, games replicate those experiences, and this type of

activity keeps these students stimulated, enthusiastic and inspires critical thinking.

Collaborative Communication Lesson Plan

1. PPP: Overview on emotional intelligence and is usefulness for the profession 30 min

2. Role - Play in groups 30

min.

3. Activity: the “best communicator” and the “worst communicator” 10 min

4. Matching activities: “nice doctor” and “not too nice” 10 min

5. Effective communication with physicians. 20 min

6. Activity: group utilization effective communications techniques acquired during the

class.

40

min.

Specific learning outcomes. Participants will be able to:

1. Correlate that cognitive intelligence, emotional intelligence, technical

expertise, or ambition alone does not make people collaborative.

2. Describe the collaborative communications patterns with the members of the

interdisciplinary team.

3. Verbalize how to efficiently communicate with members of the

interdisciplinary team

4. Understand that behavior change requires practice over weeks and months; it

may take up to six months to develop a new competency. With extended

practice, reflection, reinforcement, and success, mastery is possible.

5. Indemnify the supplementary activities that will facilitate behavior change,

such as: reading and studying about leadership or emotional intelligence,

self-reflection journals, discussion, reflective learning groups, experiential,

learning exercises, and measurement feedback.