TAKEheart Training Module 2 Systems Change: …...2003/09/20 · Hearts®/AACVPR Cardiac Rehabilitation Change Package (CRCP). Access the Change Package at: TAKEheart Website Resource
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Systems Change: Laying the Foundation, Leadership and Action Plans Kim Newlin, RN, CNS, ANP-C Kathleen Traynor, RN, MS, FAACVPR February 27, 2020 Module 2
Systems Change: Laying the Foundation, Leadership and Action Plans
K i m N e w l i n , R N , C N S , A N P - C K a t h l e e n T r a y n o r , RN, MS, FAACVPR F e b r u a r y 2 7 , 2 0 2 0
Module 2
Presenter
Presentation Notes
Good afternoon everyone, welcome to TAKEheart Module 2: Systems change: Laying the foundation, leadership and action plans. My name is Therese Rodda, I am an associate with Abt associates, together with my colleague Lisa Leroy, we will be moderating today’s discussion.
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American Hospital Association (AHA)/Health Research and Education Trust (HRET): TAKEheart AHRQ’s Initiative to Increase Use of Cardiac Rehabilitation
TAKEheart Initiative Webinar Series: Systems Change: Laying the Foundation, Leadership and Action Plans: Module 2
February 27, 2020 The planners and faculty of TAKEheart Initiative Module 2 indicated no relevant financial relationships to disclose in
regard to the content of their presentations with the exception of: Kim Newlin, MSN, ANP, FPCNA reports that she received consulting fees from Boehringer-Ingelheim, Amgen, Kinetix Group, and PCNA. This presentation has been reviewed and is found to contain no bias. Ms. Newlin has no other relevant financial relationships to disclose regarding the content of this presentation. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) and American Hospital Association (AHA)/Health Research and Education Trust (HRET). ABQAURP is accredited by the ACCME to provide continuing medical education for physicians. The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hours through the Florida Board of Nursing, Provider # 50-94.
Presenter
Presentation Notes
This slide provides you with disclosure and CEU information
Reduces health care costs by reducing hospital readmissions
CR referrals, participation, and completion rates are low and should be increased
Automatic referral (AR) with care coordination is an evidence based intervention to increase CR
Presenter
Presentation Notes
Before we begin our presentation for today, we will start with a brief summary of the information presented in the first module. Module 1 created the case for Cardiac rehabilitation with automatic referral and care coordination and provided the scientific evidence to support implementation. Resources and references can be found in the Module 1 materials.
TAKEheart Training
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PURPOSE 1 3 2
Second of 10 training webinars to help Partner Hospitals implement automatic referral with care coordination
Bookmark the TAKEheart website (https:\\takeheart.ahrq.gov) Central hub for all program materials and resources,
including webinar recordings
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Presenter
Presentation Notes
Today’s presentation is the second in a series of 10 webinars designed to provide support and share best practices with you about implementing automatic referral with care coordination in a cardiac rehabilitation program. The purpose of Module 2 is to support interested hospitals in building the foundation to support this change. This module will describe the role of the CR champion, guide the formation of the cardiac rehabilitation quality improvement team, and provide you with a framework for developing an action plan. We want to remind you to bookmark The TAKEheart website: www.takeheart.ahrq.gov. This is the one-stop for all TAKEheart educational materials and resources, including training webinar recordings.
The training, educational resources and technical assistance offered by TAKEheart are designed to support the implementation of interventions contained in the Million Hearts®/AACVPR Cardiac Rehabilitation Change Package (CRCP).
Access the Change Package at: TAKEheart Website Resource Center
Presenter
Presentation Notes
Million Hearts ® 2022 is a national initiative to prevent 1 million heart attacks and strokes within 5 years. It focuses on implementing a small set of evidence-based priorities and targets that can improve cardiovascular health for all. The initiative seeks to keep people healthy, optimize care and improve outcomes for priority populations. One goal set within Million Hearts was to create a roadmap to increase the use of cardiac rehabilitation to 70% of eligible patients. One of the resources you will find on the TAKEheart website under the resource center tab is the Cardiac Rehabilitation Change Package (CRCP). You will hear it referenced several times today because it serves as the roadmap for all of our training modules.
100+ tools and resources: AACVPR strategies Case studies Program specific tools Organization specific tools: CDC, AHA, ACC
Expertise, tools, and resources from: 18 states 22 institutions 36 CR professionals and researchers
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Presentation Notes
The CRCP was created through a collaboration between CDC and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). The package includes evidence-based strategies, case studies and 100+ tools and resources from 18 states, 22 institutions and 36 CR professionals and researchers, just like yourselves – all aimed toward increasing participation in cardiac rehabilitation for/with eligible patients. As part of TAKEheart and using the CRCP developed by Million Hearts and the AACVPR, partner hospitals will implement a quality improvement program to adopt two evidence-based practices for increasing referral and enrollment: Automatic referral of patients and care coordination
Today’s Webinar Presenters
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PARTICIPANTS INTRODUCTIONS
Kim Newlin, RN, CNS, ANP-C Director Cardiovascular Services and Interventional Radiology Sutter Roseville Medical Center
Kathleen Traynor, RN, MS FAACVPR Director Cardiovascular Disease Prevention Center Massachusetts General Hospital
Presenter
Presentation Notes
Our speakers today, Kim Newlin and Kate Traynor were actively engaged in the development of the Million Hearts Cardiac Rehabilitation Change Package. Both speakers are leaders in cardiac rehabilitation and have implemented automatic referral to cardiac rehabilitation. Kim is the Director of Cardiovascular Services at Sutter Roseville Medical Center and President of the Preventive Cardiovascular Nurse Association’s Board of Directors. Since Kim assumed a leadership position in cardiac and pulmonary rehab four years ago, both programs have doubled in size and continue to grow. She also works on process improvement programs for the cardiovascular service line within the hospital and throughout the region. Kathleen Traynor, RN, MS, FAACVPR is the immediate past president of the American Association of Cardiovascular and Pulmonary Rehabilitation. and has received numerous awards for her work with cardiovascular prevention and rehabilitation. She has served as Director of Cardiovascular Disease Prevention at Massachusetts General Hospital since 1992 where her responsibilities include overall clinical, fiscal and administrative management of four clinical programs and Center personnel in the Heart Attack Prevention Program, Cardiac Rehabilitation Program, Metabolic Syndrome Program / Learn to be Lean Program, and the Women’s Heart Health Program.
Learning Goals
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PARTICIPANTS
Upon completion of this module, attendees will be able to:
1 Select a CR champion to advocate for automatic referral with care coordination and lead the team
2 Identify key members of a multidisciplinary CR QI team, e.g. representatives from key departments and patient advisors
3 Create an action plan for implementation of automatic referral with care coordination
Presenter
Presentation Notes
These are the learning goals for today’s webinar. We will explore what factors to take into account when selecting a CR champion who will advocate for automatic referral with care coordination in your hospital and be a team leader. What qualities do you need in that champion? We will discuss who you may want to include when developing your CR implementation team and why. We will also offer you a framework and template for creating an action plan to implement automatic referral with care coordination. Finally, we will conclude with a preview of the topics in Module 3. We have a lot to cover so without further delay, I welcome Kim Newlin.
Select a CR Champion
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PARTICIPANTS ROLE
Team Leader Engages and collaborates with hospital
leadership to obtain support for automatic referral with care coordination
Understands staff and patient needs, as well as management
Manages conflicting interests and scarce resources to get things done
Helps to build a culture to support the change
Assists the team in developing its Aim Statement and Action Plan
Presenter
Presentation Notes
Thank you Therese. Selecting a cardiac rehab champion is a vital first step in the implementation process. You need to consider who is the right person to serve as the champion in your hospital. The champion needs to be an individual who can disseminate the message about the value of both cardiac rehab and automatic referral with care coordination for increasing cardiac rehabilitation. This individual must have proven leadership skills, credibility in the hospital, someone who can help problem solve challenges as they arise. The champion motivates and provides momentum all the while advocating for the needs of the team.
Select a CR Champion (Cont.)
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PARTICIPANTS QUALITIES TO CONSIDER
Credibility with peers Passion and interest in improving CR Understanding of CR programs, structure
and regulations Action oriented Experience with change management and
improvement projects Communication skills
Presenter
Presentation Notes
The champion or leader is critical to the success of the project. Consider what qualities you need in that person. These qualities are also important to consider in choosing team members. It is possible that your champion and formal team leader might be different people. e.g. the champion might be a cardiologist capable of working with his/her peers and explaining the importance of the effort to top management but not available to make sure the whole change process moves forward. Resource on clinical champions. https://www.health.nsw.gov.au/wohp/Documents/mc3-clinical-champions-mcneil.pdf
Forming Your Multidisciplinary CR Implementation Team
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PARTICIPANTS
CHOOSING TEAM MEMBERS
Who will be involved in implementing automatic referral with care coordination?
Bring together individuals who represent all parts of the CR referral, enrollment and participation process; clinicians and managers
Plan for coordination across inpatient and outpatient settings by involving staff members from both
Include billing and insurance personnel
Include staff or patients (advisors) who can address the needs of patients
Presenter
Presentation Notes
The next step is forming your multidisciplinary improvement team. As you consider forming your implementation team, think broadly about staff members who will be needed to implement automatic referral with care coordination and who represent all aspects of the cardiac rehabilitation referral, enrollment and participation process. Physicians are key members because they care for eligible patients and drive referrals. Include nurses, hospital administrators and managers as you implement change. Some of you might have inpatient or outpatient cardiac rehabilitation programs that are part of your hospital you will need to plan for coordination across inpatient and outpatient programs. If your hospital doesn’t have a CR program or even if you do --you likely refer to other programs outside of your hospital. Consider how you will make that bridge between inpatient and outpatient services. You may want to include billing and insurance personnel to share insights about maximizing reimbursement. Finally, consider including staff or a patient advisor who can provide information about the needs of the patient.
Potential Multidisciplinary CR Team Members
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PARTICIPANTS
CR Champion: leads the team and advocates for the initiative
Cardiac care clinicians: cardiologists, cardiac surgeons, physician assistants, or nurse practitioners provide input on treatment and referral
Cardiac Rehabilitation clinicians: nurses, physical therapists, exercise physiologists, physicians provide valuable perspectives on enrollment and participation
Cardiac care manager: provides important information about current workflows and potential areas for improvement
Presenter
Presentation Notes
The list here and on the next slide is not meant to be exhaustive. These are suggestions of kinds of staff members to consider as you build your team. People involved in different parts of the CR process bring different perspectives to the table. You can start small and grow over time. You also might want to think about including someone who can bring a “fresh” perspective; for example someone who has tried to implement another change process in your hospital.
Potential Multidisciplinary CR Team Members(Cont.)
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PARTICIPANTS Information Technology (IT) staff: have the ability to enact the required changes for automatic referral and data collection. May include IT vendor representatives. Quality improvement leaders (QI): provide insight into best practices for implementing and measuring quality improvement. Patients: provide the end user perspective.
Presenter
Presentation Notes
You should examine your own environment and decide who needs to be involved. These suggestions are meant to stimulate your thinking about your own situation. Now I am going to turn the presentation over to Kate Traynor who is going to share her insights about selecting a CR champion based on implementing automatic referral at Mass General Hospitals cardiac rehabilitation program. Kate:
Clinical Champion Story
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PARTICIPANTS
Secrets to Success
Peer to Peer Strategy- MD Advocate
It Takes a Village
Communicate, Communicate, Communicate
Remain Vigilant
Presenter
Presentation Notes
Thank you Kim, “I will focus on the need to have an MD advocate for this automatic referral with peers( at a staff meeting or via email or whatever process internal to the setting would be most effective and include the evidence basis/research data for the referral) and in the same communication provide a real example( actual picture/screen shot) of the referral from the EMR. This is a peer-to-peer strategy that will add credibility to the process as well as practical information re the “how to” refer. In tandem with this, the cardiologists’ administrative assistants in their offices will need to understand how this works so they can respond to patient questions, issues etc. and they will need to know to know who the CR Champion for problem solving etc. In other words, there is no such thing as too much communication with key personnel when it comes to adding this new process! An additional point- the CR Champion needs to be familiar with the structure of the automatic referral to be certain each referral will be “worked” or handled by a staff member as we had one option for “refer to external CR Program” that was not directed to anyone and hence the referrals were not processed.
Resources for Selecting a CR Champion
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PARTICIPANTS TABLE 1 CRCP
Presenter
Presentation Notes
Kate will discuss the CRCP resources for CR champion. Back to you Kim.
Set the Stage for Change: Model for Improvement
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PARTICIPANTS MODEL FOR IMPROVEMENT
What are we trying to accomplish? How will we know that a change is an
improvement? What change can we make that will result in
improvement? TAKEheart change/improvement
= Automatic referral with care coordination
Presenter
Presentation Notes
Thank you Kate. Now we will turn to planning for change. How will you get started? One framework that has been used a lot in healthcare is the Model for Improvement developed by the Institute for Healthcare Quality. Many of you may be familiar with this framework. It starts with 3 fundamental questions. In our case, we know what the answer to the third question is – we have all agreed to implement an evidence based change which is automatic referral with care coordination. The Model for Improvement calls for developing an AIM statement and an Action plan. Today, we will walk you through how to develop them, then your coaches and facilitators for your Partner Hospital Peer Action Groups will provide additional support.
Develop an Action Plan
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PARTICIPANTS STEPS IN DEVELOPING AN ACTION PLAN
Step 1: Develop an Aim Statement Step 2: Determine how to assess or measure your progress Step 3: Identify the tasks required to achieve the aim, who is responsible for each task and the timeframe for completing each task
Presenter
Presentation Notes
These are the high level steps required to develop an Action Plan. We will walk through each of them. First, develop an aim statement Next, you need to determine how you will measure your progress so it can be communicated to stakeholders Finally, you need to identify the tasks that need to occur to achieve the aim, who is responsible for each task, and the timeframe for completing each task
Develop an Aim Statement
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PARTICIPANTS WHAT IS IT?
Why create an Aim statement? Acts as your beacon to guide and focus your team’s efforts An Aim state answers: What are we trying to accomplish? It is an explicit statement, crafted by the
team, of the desired outcome of your improvement project
Presenter
Presentation Notes
The first step is getting the team together to write a unifying statement, the aim statement. This is the team’s shared vision for the future, what the team hopes to achieve and serves as a beacon to guide the efforts of the team. This is the first question in the IHI model for improvement. What are you trying to accomplish? The statement should be clear and specific. The statement can be revised. You can have a statement for the first 6 months then rewrite for the next 6 months.
Develop an Aim Statement in TAKEheart
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PARTICIPANTS AIM STATEMENT
Q: What do you hope to accomplish? A: Increase cardiac rehabilitation referrals, enrollment, and participation Q: For whom? A: Patients with eligible diagnoses, e.g. MI, CABG, PCI Q: Why is it important? A: Improves health, saves lives and reduces hospital readmissions Q: What change will you implement? A: Automatic referral with care coordination
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Presentation Notes
The AIM statement answers many important questions that drive the future of the project.
A TAKEheart Aim Statement Example
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PARTICIPANTS EXAMPLE We aim to increase the number of patients with MI, PCI and CABG who are referred, enrolled and participate in cardiac rehabilitation by 30%. This is important because we want to improve patient care and outcomes and reduce hospital readmissions. We will accomplish this aim by implementing automatic referral with care coordination by December 31, 2020. We intend to see a 30% increase in current participation rates by December 31, 2021.
Presenter
Presentation Notes
This is an example of an aim statement. It provides clear direction for the project and can be used to spread the message about the importance of the project. You will note that the date to implement the change is December 2020 and the date by which participation rates are expected to reach their goal is a year later. Your aim statement may be similar to this but each hospital will have its own aim statement.
Determine How to Assess Your Progress
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PARTICIPANTS MEASUREMENT
Include both short term and long term assessments.
Develop specific outcome and process
measures.
Set specific goals that are numeric and measurable.
Presenter
Presentation Notes
How will you assess your progress? You need to know if the things you are doing are making a difference. You need to assess in the short term and the long term. Look at your process and consider outcomes and design a measures for each. Set goals for your measures that are numeric and measureable.
SMART Goals
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PARTICIPANTS GOALS Specific Description of a specific outcome or process
Measureable How is it going to be measured, e.g. rate, frequency?
Achievable Plan to stretch but make sure it is achievable
Relevant Need to link directly to the Aim statement
Time bound Need clear start and finish dates
Presenter
Presentation Notes
SMART is a popular acronym and structure to consider when designing and creating goals for your project.
Examples
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PARTICIPANTS SMART GOALS
The percentage of eligible patients referred to cardiac rehabilitation will increase by 10% from Q1 to Q3.
The percentage of referred patients who enroll in a CR
program will increase by 5% from Q1 to Q2. The percentage of enrolled patients who complete a CR
program will increase by 15% from Q2 to Q4.
Presenter
Presentation Notes
Examples: Increase referrals with a diagnosis of MI by 10% from Q1 to Q3. Increase CR enrollment by 5% from Q1 to Q2. Remember goals can be short term and long term Accomplishing short term can be used to spread the message of success and motivate continued efforts to improve.
Complete an Action Plan
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PARTICIPANTS IDENTIFY ACTION PLAN COMPONENTS
What tasks does your hospital need to undertake to implement automatic referral?
What tasks does your hospital need to
undertake to implement care coordination?
Who will lead each task? When will each task be completed? Consider resource needs and priorities
Presenter
Presentation Notes
The Model for Improvement calls for developing an AIM statement and an Action plan. Now that you have your Aim statement, it is time to operationalize the project. We will now guide you through a framework for developing an action plan. Each hospital needs to create an action plan based on their unique situation. In addition to working on the plans individually, you will receive support and feedback from your Partner Hospital Peer Action Groups. The action plan components include: tasks, responsibilities and target completion dates. This is where you need to decide the tasks you need to take for automatic referral and for care coordination. As you look at the tasks, consider who will be responsible and set a target date for completion of the individual tasks. Some tasks might be very quick to accomplish others might take some time. As you put your plan together remember to consider resource needs and priorities. Are there certain EHR features that need to be added? Do you need additional head count? Establishing priorities will help determine the timeline.
Utilize an Action Plan Template
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PARTICIPANTS TEMPLATE
ACTION PLAN TASK/
MILESTONE TASK LEAD
TARGET DATE
COMPLETION DATE
STATUS SMART GOAL
COMMENTS (include challenges
or facilitators) Choose a milestone or enter your own.
Enter name.
Click to enter a date.
Click to enter a date.
Choose or add one.
Click here to enter a goal.
Click to enter comments.
Choose a milestone or enter your own.
Enter name.
Click to enter a date.
Click to enter a date.
Choose or add one.
Click here to enter a goal.
Click to enter comments.
Presenter
Presentation Notes
Here is an action plan template that will be provided to each Partner Hospital team. It has drop down menus and free text boxes to help you fill in the table. As a team you will need to figure out what you need to do to develop automatic referral? Break down each task and assign someone to oversee the task. If tasks take more or less time than planned, you can adjust the action plan. Under tasks, we also included milestones. Milestones are high level tasks successful hospitals took to improve their patients’ access to, and participation in CR. TAKEheart recommends that hospitals include the milestones in their action plans. These milestones were culled from the CRCP and recommended by national CR experts who have successfully implemented ARCC in their own hospitals. The milestones were identified as critically important to success and achieving them will help you make progress in implementing automatic referral with care coordination. Some hospitals may have achieved certain milestones before starting the intervention, some milestones may not be relevant to a hospital. However, the milestones might help you define additional tasks required for your organization to successfully implement automatic referral with care coordination. Establish realistic timeframes and goals to complete the work.
Tasks Need SMART Goals Too
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PARTICIPANTS TASK: DEFINE AUTOMATIC REFERRAL
Beginning 2/4/2020, the CR QI team will meet with IT representatives each Tuesday and Thursday at noon for a half hour to define the changes necessary for automatic referral and will complete the task by 2/28/2020 .
Presenter
Presentation Notes
Don’t forget that tasks need SMART goals too. Here is an example of incorporating a SMART goal for a task. This level of specificity will help the team truly get the work done. Some tasks may be carried out by the entire team, or committees can be formed and others will be individual tasks.
Example of Action Plan
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PARTICIPANTS TEMPLATE
ACTION PLAN TASK/
MILESTONE TASK LEAD
TARGET DATE
COMPLETION DATE
STATUS SMART GOAL
COMMENTS (include challenges
or facilitators) Schedule meetings with IT representatives and leaders to discuss automatic referral
Luna Patel 2/28/2020 Click to enter a date.
In progress Beginning 2/4/2020, the CR QI team will meet with IT representatives each Tuesday and Thursday at noon for a half hour to define the changes necessary for automatic referral and will complete the task by 2/28/2020.
Lots of conflicting IT projects within the hospital
Presenter
Presentation Notes
Here is an example of the template partially filled in.. Tasks can be overlapping and interdependent. You will have multiple tasks occurring in parallel. You may also have tasks that are dependent others being completed. Agreeing on realistic goals helps everyone get their work done and provides a visual to motivate continued progress.
What’s Next?
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PARTICIPANTS PARTNER HOSPITAL PEER ACTION GROUP MEETINGS
Continue working with your CR Team on your Action Plan
Discuss how you are progressing Exchange your Action Plan with
another hospital and provide feedback
Presenter
Presentation Notes
The purpose of the Partner Hospital Peer Action Groups (PAG) is to support the TAKEheart Partner Hospitals through the planning and implementation of automatic referral with care coordination. The PAG enables staff from the TAKEheart Partner Hospitals to interact with one another in reviewing and discussing each monthly module, share their experiences, and obtain support and suggestions from their peers. At your next PH Peer Action Group meeting you will discuss how you are proceeding on developing an Action Plan. You will exchange your Action Plan with another hospital and give each other feedback. Your coaches will be available to help you. Therese, I turn it back to you
Next Up: Module 3
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PARTICIPANTS WORKFLOW, DATA & IMPLEMENTATION We will continue our discussion of
systems change by looking at the cardiac rehabilitation process with a discussion of workflow mapping, data collection and using data for implementation. “Automating bad processes does not improve anything…our experience is that it is best to fix the process, then automate the fixed process.” Dr. John Halamka, CIO BIDMC, Boston, MA
Presenter
Presentation Notes
Thank you Kim and Kate for sharing great information with us today. Before we open the room up to questions for our speakers, I want to provide a preview of Module 3. Next month, we will continue to focus on building the foundation for systems change by examining workflows, data capture and analysis. We will dive into the details of the cardiac rehabilitation process: referrals, enrollment and participation. We will discuss what data you will want to capture and use for implementation. Please join us next month as we continue to support you on the journey to automatic referral with care coordination.
Q&A
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PARTICIPANTS HOW TO ASK QUESTIONS
To ask a question open the chat box
Set the TO: field to All Panelists so that we can all see your question
Presenter
Presentation Notes
Now we would like to hear from you. At the bottom of your screen, you will see a conversation bubble similar to the one pictured here on the slide. Clicking that bubble will open a chat box. Please set the TO: field to all panelists. This ensures that we can all see your question. We ask that you keep questions general in nature, not hospital specific, so that the entire audience can benefit. We may not get to all of your questions today but we will respond to unanswered questions after today’s event. Feel free to type in your questions in the chat box. Our panelists are ready. Ok we have our first question: This one is for Kate: Can you tell us about a hurdle you faced in the transition to automatic referral and how you overcame it?
