planning and cultivating nursing roles developing a five
TRANSCRIPT
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Strategic Planning and Cultivating Nursing RolesStrategic Planning and Cultivating Nursing Roles –
Developing a Five SEVEN Year Plan
The Norton Healthcare Experience
Tracy E Williams, DNP RNSenior Vice President and System Chief Nursing Officer
Kim Tharp – Barrie, DNP RN, SANESystem Vice President , NHC Institute for Nursing
Making the Case
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Health Care Reform
Government Health ReformFour components of Health Reform:
Coverage Reform puts everyone into the market for health care by mandating that everyone be covered by
insurance
Delivery System Reform. The proposed regulations issued by CMS on Accountable Care Organizations
and the Medicare Shared Savings program may prove unworkable – but all the buyers in this market (commercial health plans, state governments, employers and individuals) are demanding that providers address efficiency, cost and effectiveness deficits.
Payment Reform. In 2012, the Medicare Hospital Value Based Purchasing (VBP) program will cover all
acute care providers, and in future years the program will expand to cover outpatient care. CMS describes the VBP as the latest stage of the evolution of CMS from a “passive payer of claims based on volume to an active purchaser of care based on the quality of care beneficiaries receive.”
Quality Improvement. A hospital admissions reduction program for preventable Medicare inpatient
hospital admissions starting in FY 2013 which can reduce payments by one percent for targeted cases and up to 3% in 2015 and subsequent years.
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A Prescription for Patient ValueThe Value Proposition
• Achieving universal coverage and access to care are essential, but not enough
• The core issue in health care is the value of health care delivered
• Value: Patient health outcomes per dollar spent
• Value is the only goal that can unite the interests of all system participants– Patient / Physician / Provider / Payor
• How to construct a dynamic system that keeps rapidly improving
• The central goal in health care must be value for patients, not access, volume convenience or cost containmentvolume, convenience, or cost containment
Value = Health Costs / Cost of Delivering the Outcomes
Hospital ‐ ER services, OP services, IP stays
Value in the Future is…the Patient Care Continuum
Specialty Physician
Diagnostic Center
Skilled Nursing; LTAC; Rehab
Patient Home
HomeICC
Care Team Center
Wellness Center
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The Norton Healthcare Accountable Care Ecosystem
Population ManagementHumana – Brookings Dartmouth Partnership
Medicare AdvantageHealth Department Partnerships Coordinate Manage to
Components of Accountable Care
Effective Health Management
Employers PatientsHospitals Physicians Acute, sub‐acute and long‐term care providers
The Players
p pHealthy Start Flu VaccinationNeeds Assessment
N‐Good Health Employee Program Cost and
Efficiencies
Effective Health Management
Coordinate Items and Services
Manage to Quality
Standards
Manage Costs and Efficiencies
Manage to Quality Standards
Coordinate Items and Services
Clinical Effectiveness with Integration of:
Ambulatory care centers Pharmaceutical companiesMedical device manufacturers Care Givers (physicians, nurses, home health, clinical social worker, clinical psychologist, and other ancillary providers)
Payors Federal government
Care Management Service ExcellenceQuality
Quality Transparency ReportingData Management and Analytics
EpicAmalga
Norton Nursing Institute
Risk Management Finance and Accounting Integrated in Quality Prioritization
Disease management with Cost Data from External Partners (i.e. Humana, Anthem, United)
Measurement of Clinical, Operational and Financial Key Performance Indicators in Combined Dashboard
Norton Healthcare Center for Wellness and Prevention
Practice Health Navigators Telemedicine (Rural)UK Partnership for Outreach for a Healthier Commonwealth
Supply Chain MaximizationWomen and Children’s Agenda
Community Health Needs Assessment
• Patient Protection and Affordability Care Act
• Applies to all 501 3C Organizations
• Every three years
• Documented action plans
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Clinical Re‐Engineering…the Nursing Perspective
• Improved care coordination and communication
• Improved access – physician extenders – email – phone call etc.
• Prevention and early diagnosis
• ED and Immediate Care Center visits
• Increase generic medication utilization
• Hospital re-admissions and multiple ED visits
• Improved management of complex patients
– Care Coordination and High Resource Utilizers
Institute of Medicine Report
Six Aims for Improvement
•SafeSafe
•Effective
•Patient Centered
•Timely
•Efficient
•Equitable
Crossing the Quality Chasm: A New Health System for the 21st Century; National Academy Press, 1999
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IOM Report
Ten Rules for Redesign:1. Care is based in continuous
healing relationships.2 C i i d2. Care is customized
according to patient needs and values.
3. The patient is the source of control.
4. Knowledge is shared and information flows freely.
5. Decision making is evidence‐ based.
6. Safety is a system property.7. Transparency is necessary.8. Needs are anticipated.9. Waste is continuously
decreased.10. Cooperation among
clinicians is a priority.
Crossing the Quality Chasm: A New Health System for the 21st Century; National Academy Press, 1999
IOM report, Future of Nursing Key Messages
– Nurses should practice to the full extent of their education and training.
– Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
– Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the US.
– Effective workforce planning and policy making requireEffective workforce planning and policy making require better data collection and an improved information infrastructure.
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IOM report, Future of Nursing Recommendations
Remove scope of practice barriers.
Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.
Implement nurse residency programs.
Increase the proportion of nurses with a baccalaureate degree to 80% by 2020.
Double the nurses with a doctorate by 2020.
Ensure that nurses engage in lifelong learning.
Prepare and enable nurses to lead change to advance health.
Build an infrastructure for the collection and analysis of interpersonal health care workforce data.
• What are the framing questions we need to ask...and answer?
So How Do We Begin….
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• What is Nursing’s role?
Framing Questions
• If Nursing doesn’t manage Nursing, someone else will…
• What are we willing to change?
Framing Questions
• How can nursing drive care across continuum?
• How can nursing create
patient centered focus?
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• Are we willing to “diminish” inpatient hospital care?
Framing Questions
hospital care?
• If Nursing stays defined within the four walls of acute care, what is itsacute care, what is its future?
• How will we evaluate and VALUE Nursing’s
Framing Questions
Nursing’s contribution?
• What are the metrics tometrics to determine success and establish ROI?
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• Is this strictly a “MD” thing? A Hospital thing?
Framing Questions
• What is Nursing’s role to be in this new reform culture?
• How do we shift the roles within the
kf ?
Framing Questions
workforce?
• What are the implications and models for care delivery?for care delivery?
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• And finally…
• What are the
Framing Questions
implications for Nursing professionals?
• What are the implications for Nurse Executives?Executives?
Call to Action
IOM
Nursing Strategic Plan
Pt Protection &
Affordability Act
Health care Reform
ACO Transparency
Value Proposition
Workforce Needs
Meaningful Use
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Change Process vs. Grief Process
Evolution vs. Revolution
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Integrated Delivery Network of
Five Not‐for‐Profit Hospitals
15 Out‐patient Centers
Norton HealthcareNorton Healthcare
1.6 Million yearly patient encounters
$1.6 Billion yearly revenue
11,000 Employees
4800 Registered Nurses
600 Employed Providers
2,000 Physician Medical Staff
1,857 Licensed Beds
60 000 Admissions/year60,000 Admissions/year
46% market share
Validated Key Findings
• Functioning within silos; not working as a system• Everything is a priorityN d d f• No standard of care across system.
• Limited resources were not effectively used• Lack of education, understanding• Non‐hospital divisions view of value and reform as a “clinical” issue
• Scattergun and “flavor of the month”• System resources view of “ownership”• System resources view of ownership• No accountability structure• No incentives to “succeed” • Results not achieved and sustained
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Risk AnalysisRISK MITIGATION STRATEGY
Erosion of the bottom line financials and/or a reduced market share that may realign the organization’s priorities No margin = no mission
Align to mission, vision, values.Align to strategic plan in multiple areas.“Mission critical” to achievepriorities. No margin = no mission. Mission critical to achieve objectives.
Non achievement of significant results in a short time frame.
Set the right stretch achievable goals.Support owners with system resources.Visibility of success to BOT, Execs, etc.Celebrate!
Lack of alignment of incentives for key leadership
Connect to variable compensation (short term).Connect to perform appraisals (LT).Sr. leaders presentations to BOT, etc.
The program costs are too high for long term sustainability.
Use and retool existing resources.
Strategic Principles
• System Level Initiative
• Within all components of strategic plan• Within all components of strategic plan
• Drive Focused Measurable Approach– Quality– Safety– Service– Process OutcomesProcess Outcomes– Financial
• Engagement of the Entire System
– Key Distinction
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Internal Stakeholder Assessment
• BOT, Executive, Operations & System Leadership, Service Line, MD leaders
• Patient/ Family/Community focus groups
• Identification of Need & Validate – Issues, concerns, frustrations, suggestions
– 1:1 interviews (informal conversation supplemented with interview guide)
– Document review
– Feedback of findings & validation of accuracy
Integration and Alignment
• Prioritize efforts by facility/division
• Integrate Quality, Safety, Process, Service and Fi i lFinancial
• Align work across Norton Healthcare
– Balancing system vs. “local” needs
– Sharing information
– Replicating process and practice
– Aligned Incentives• Executive compensation
• Managers’ evaluations
• Staff evaluations
• Reward & Recognition
• Physician goals
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• Engagement of the broad stakeholder base in all phases of the project. S d b “ h i ” j d hi ( d
Internal marketing plan
• Structured to be “their” project and ownership (and accountability) resides with the operations leaders.
• Opportunities for the “owners” to visibly share their experiences, successes and difficulties are built into the process.
• All reinforce: the programs the programs, reinforce behavior, support cultural change, influences compensation (both variable and performance reviews)
and breed success.
Nursing 2020Creating Care that is Accountable to Patients & Families
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• Model of Care – Acute Care
– Patient and Caring Focused
Nursing 2020
– Differentiated Practice Model
– Credentialing and Privileging
– Family Care Partners
– LPN Acute Care
– Multidisciplinary Team PerformanceMultidisciplinary Team Performance
– Individual Accountability
• Model of Care – Acute Care– RN placement and transitions of patient based on care needs– Patient Cohort alignment based upon Nursing care needs
Nursing 2020
Patient Cohort alignment based upon Nursing care needs (clean/potentially contaminated; high flow/low flow; high RN intensity/low RN intensity)
– Nursing centralization of expertise• “EICU” (and use with regional “affiliates”)• Remote Central Monitoring• Central Order Management• Placement and Transition• Pt/Family education and support• Continuum Management• Nursing Hospitalist• CNS/NP/Educator Model• Acute Care and Critical Care NP model
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• Model of Care – Acute Care
– Program Development (chronic, elderly, specialty surgical high recidivism)
Nursing 2020
surgical, high recidivism)
– Enhanced communication tools for patient/family
– Enhanced Technology/Automation (equipment interface and auto population, remote monitoring, documentation
– Nursing Sensitive Indicators
• Unit based dashboards
• Individual measurement of performance
• Model of Care – Continuum Management– Multi specialty Nursing Practice at key locations matched with key physician partners and practices to leverage
Nursing 2020
with key physician partners and practices to leverage relationships
– Neighborhood “watch”
– Health ministries expansion and redefinition
– Alignment with Schools for provision of care and education
– Alignment with Community agencies for provision of care and education
– RN in physician practices to manage D/C, transitions, pt education and pt follow up – Practice Navigator
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• Nursing Systems– Credentialing and Privileging
Nursing 2020
– Clinical Advancement Programs (RN, LPN, PCA)
– Certification
– Nursing Sensitive Indicators
– NDNQI
– CERP and Prioritization
– Patient/Family Advisory Councils
– Clinical Design and Transformation
– Nursing Finance and Modeling
• Nursing Systems– Grants
• RWJ Kellogg IHI etc
Nursing 2020
RWJ, Kellogg, IHI, etc.
– Practice Governance• System Governance Launch
• Non hospital governance launch
• Expansion of acute care governance (care providers)
– Nurse Leader Development• Nurse Executive Initiative
• Nurse Executive Fellows
• Nurse Leadership Initiative
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• NHC Institute for Nursing– Workforce Preparation
• Preparation of “continuum care practitioners”• Specialty orientation extension programs (ED, OB, Children)
Nursing 2020
p y p g ( )• PCA development/upgrade/transition• Defined education/orientation units• “Personal/cultural “nursing orientation
– School of Nursing Affiliations• Joint Appointments• LPN Acute Care Models• CNS certification program• “Faculty practice” model• “Faculty practice” model• “Shared class” faculty
– Simulation• Mobile/Fixed• Development of Affiliation Relationships (SON, Rural Network)• Development of Learning Laboratory
Workforce
• RN credentialing and Privileging
• BSN
• Role requirements
• Differentiated Practice
• Advanced Practice
• Doctoral preparation
• Roles beyond hospitals (i.e. Navigators, “Neighbors”, etc.)
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Executive Nurse Leadership IntensiveGED
N‐CAPCredentialing/
Leadership Development
Norton A d
NHC Workforce Development
Career Development
School at Work
Credentialing/ Privileging
Harnessing Our
Learning Culture
Workforce Development
Norton University
Continuing Education
Academy
ShadowProgram
pProgram
at Work
College at Work
Partnerships
PCA Development Program Norton Scholars
& Educational Assistance
Institute for Nursing
ExternProgram
Lessons Learned
• Integration vs. Silo
• Pilot, adapt, adopt, system
• Local Constituencies vs. Standardization of System
• Hardwiring
• Accountability structure
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Lessons Learned
• Be Revolutionary in thought and Evolutionaryi tiin action.
• No is not a “forever” answer.
• Negotiation is not a one time thing.
• Be a good mother and let the child grow up and move on beyond youand move on beyond you.
NHC 30 day select chronic readmission pattern 5/1/08 – 10/31/09
47106
4003140068
47106
47172
4002640031
40068
HospitalICCPhysician Office
4 7 1 0 6
4 0 0 3 14 0 0 6 8
44 7 1 2 4
4 7 1 0 6
4 7 1 7 2
4 0 0 2 6
4 0 0 1 0
4 0 0 3 14 0 0 6 8
Hos pita lIC CP hys ic ian O ffic e
40217
40203
402
09
40211
40202
40241
40207
40219
40213
40291
40299
40023
40059
4022340245
40014
40023
40067
40022
40068
4006
447124
47117
47122
47136
47119
47150 47129
47172
47130
40258
40216
40212
40210
40215
40214
40208
40204
40206
40205
40218
40228
40220
40222
40242
40243
40056
40245
40010
40014
40068Physician Office
4 0 2 1 7
4 0 2 0 3
402
09
4 0 2 1 1
4 0 2 0 2
4 0 2 4 1
4 0 2 0 7
4 0 2 1 9
4 0 2 1 34 0 2 9 9
4 0 0 2 3
4 0 0 5 9
4 0 2 2 34 0 2 4 5
4 0 0 1 4
4 0 0 2 3
4 0 0 6 7
4 0 0 2 2
4 0 0 6
4 7 1 2 2
4 7 1 3 6
4 7 1 1 9
4 7 1 5 0 4 7 1 2 94 7 1 3 0
4 0 2 5 8
4 0 2 1 6
4 0 2 1 2
4 0 2 1 0
4 0 2 1 5
4 0 2 1 4
4 0 2 0 8
4 0 2 0 4
4 0 2 0 6
4 0 2 0 5
4 0 2 1 8
4 0 2 2 8
4 0 2 2 0
4 0 2 2 2
4 0 2 4 2
4 0 2 4 3
4 0 0 5 6
4 0 2 4 5
4 0 0 1 4
40291
4017740177
40071
40272
40118
40109
40165
40229
40047 40071
= 1 RN
= 1 Patient
4 0 2 1 9
4 0 2 9 1
4 0 1 7 74 0 1 7 7
4 0 0 7 1
4 7 1 1 7
4 0 2 7 2
4 0 1 1 8
4 0 1 0 9
4 0 1 6 5
4 0 2 2 9
4 0 2 2 8
4 0 0 4 7 4 0 0 7 1
= 1 R N
= 1 P atien t
44
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Defying Gravity
Questions