Hello and welcome to Learning Team C’s presentation on Guidelines for the Management and Prevention of Osteoporosis. Our presenters today are: Susan Vitus RNC, BSN, Carol Taylor RN, RuthAnne Skinner RN, Dorothy Alford RN, BSMT, and Debra Austin RN.
The guidelines used for this presentation are based from National Guidelines Clearinghouse™ (NGC). The definition and mission as described in www.guideline.gov is as follows; The National Guidelines Clearinghouse™ is a comprehensive database of evidence-based clinical practice guidelines and related documents. The NGC mission is to provide physicians, nurses, and other health providers, health plans, integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use.
According to the NGC website; The National Guideline Clearinghouse™ (NGC) is an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. NGS was originally created by AHRQ in partnership with the American Medical Association and the American Association of Health Plans (now America’s Health Insurance Plans [AHIP]).
According to NGC’s guidelines for management and prevention of osteoporosis, the objectives for the guidelines are: aims to achieve significant, measurable improvements in the management and prevention of osteoporosis through development and implementation of common evidence-based clinical practice guidelines, and to design concise guidelines that are focused on key management and prevention components of osteoporosis to improve outcomes.
Osteoporosis is distinguished by a thinning and weakening of normal bone resulting in a decreased bone mass density and increased risk for bone fractures. There are two types of osteoporosis: Type I and Type II. Type I occurs in post-menopausal women and is the result in a decrease of estrogen. Although most commonly found in women, Type II occurs in both men and women. This type is due to aging and the loss of calcium over many years. (William, 2007)
Osteoporosis “affects one in every two women over the age of 50” (Cody, 2005, p. 1). It is foremost as a source of fractures in older adults which results in long-term impairment, disability, or death. In spite of this, many at risk women are undiagnosed and untreated. As a result, there are increased health-care costs and an ongoing need to distribute information on its causes and prevention. (Cody)
Osteoporosis can be a debilitating disease but if caught early enough, can be preventable. There are many risk factors associated with osteoporosis: being female, menopausal, over 50 years of age, health conditions, smokers, family history, Asian or white, sedentary lifestyle, vitamin D deficiency, never having children, excessive alcohol and caffeine consumption, even men with low testosterone levels are at risk. (Drug Digest, 2008) There are treatments to help prevent or lesson the effects that osteoporosis has on one’s body. Early detection is so important because the early one starts their treatment for this disease, the better the outcome.
Managing osteoporosis is not as hard to prevent or correct as people believe. There are many new medications on the market today, some that only have to be taken once per month. Taking bone-active agents that inhibit bone loss will help make bones stronger. Calcium with vitamin D is a wonderful source that helps build strong bones. Early detection and treatment makes a big difference in the final results. Exercise on a regular basis helps build strong bones and muscles that surround those bones, making the person much stronger. Using good body mechanics is essential for ones back and legs. Preventing fractures is the first line of defense for osteoporosis.
Prevention of osteoporosis is a healthy lifestyle away. There are many supplements on the market that offer an easy solution to adding calcium to ones diet. Eating food such as fish, greens, soy, onions, broccoli, and many more wonderful foods out there will help in the prevention of osteoporosis. Lifestyle changes such as quitting smoking, adding regular exercise to ones life, taking supplements and eating right will all help in the prevention or slowing down of this disease.
The scenario was decided on, because some of us are in the at risk group, with at least one team member with a concerning screening value. There are many risk factors, including women who are perimenopausal or menopausal. Other risk factors include chronic glucocorticoid therapy, as seen in asthmatics and arthritic diseases, organ transplantation, gonadal dysfunction in men and women, increased fall risk, underweight, deficient calcium and vitamin D in one’s diet, and family history of fractures. (NGC, 2007), along with other risk factors mentioned on a previous slide. Blacks have lower risk, as they enter menopause with a higher bone mass density . The statistics of the National Osteoporosis Foundation reveal 50% women and 25% men over age 50 will break a bone due to osteoporosis. (2008) Accessible screening is a problem in our time strapped society, to complete the necessary screenings which include mammograms, well woman exams, physical exams, colorectal screenings, and lipid profiles. It is difficult to fit in so many appointments into days off work and family commitments. Costs for all the co-pays are also a negative factor. Medicare has drastically cut reimbursement in 2006 for the DEXA scan, the gold standard for diagnosing osteoporosis. Legislation is being introduced to reverse this decision for two reasons. One, less people will seek screening in a very risky elderly population. The second reason is the cost savings of over $18 billion in direct care. Nursing home placements, social isolation, pain, and immobility would be decreased by better reimbursements for bone density testing. (National Osteoporosis Foundation, 2008) Preventative information is lacking for the general population. Seldom do we read or hear about osteoporosis. It is a screening test that needs to be advertised, so patients can be proactive when discussing their needs with their physician. Discussions with physicians should assess diet, exercise, risk factors and initial bone density screening. If osteoporosis or osteopenia is diagnosed, treatment modalities and regular screening tests need to be discussed, along with side effects of the various drugs recommended by the NGC guideline (2007). Alternative therapies should be explored and incorporated if feasible.
Lewin (1947), as discussed by Pellettiere (2006) in his Force Field Analysis Model, points out the importance of assessing the positive forces or drivers along with the negative forces. Knowing an organization’s strengths and weaknesses, up front, will make way for discovering novel ways to implement the osteoporosis guideline strategies in a positive manner, limiting conflict and resistance throughout the organization. No organization is completely ready for change. Senior management must be visible and supportive. Stakeholders need to be communicated to as to impending change and employees need to know their expectations and role in the guideline adoption. Mutual cooperation will stimulate success. (Susniene & Vanagas, 2006)
A conscious approach to change is proactive, driven by an awareness , choice and decision to adopt the NGC guideline into the organization. It is the foundation of the organization’ change culture. With the conscious approach in an organization, there is a greater probability of successful implementation of the guideline, because the organization’s members are psychologically ready for the change. Unconscious handling of change is reactive, driven by organizational crisis, fear and chance. Little thought goes into preparing the organization, with members going through the motions with implementation, dooming the adoption of the guideline to failure. (By, 2007)
The humanistic side of readiness for change begins with assessing a need for change and the likeliness of an organization’s personnel using the guideline to develop and utilize services. Policies and procedures within the organization need to be able to absorb the guideline. Management needs the philosophy that technology is available and useful in keeping their employees healthy and available to do their work. The organization’s mission and value statements should be supportive of the guideline implementation.
A need for change arises from available technology, market forces, competition between and within organizations for improved osteoporosis screening and treatment. The costs must be analyzed and monies found for need assessment and equipment purchases. The initial costs of improving insurance, benefits for employees, and equipment to perform bone density will be expensive. The return on investment will be realized by market analysis of costs prevented by implementing the guideline. Costs prevented most likely will outweigh the startup cost. Examples of major cost prevention are less sick pay, lost man hours and overtime reduced, benefit costs decreased because prevention is less expensive than short or long term disability cost effects on future insurance costs, and happier personnel and community, affecting competition and the bottom line. (Weber,2005)
Organizational readiness can not be hurried, as you can see. Done properly and thoroughly, the successful stage for implementation and evaluation can take place. We’ve prepared the organizational field, now it is time to reap the benefits by digging in with our implementation. .
Whitehead et al. (2004) recommends creating a preventative plan and a reform activity plan in order to prevent osteoporosis and decrease side effects of the disease and the disease process. The steps to implement are also based upon Whitehead et al. guidelines. By creating and organizing a Participatory Action Research (PAR) group, one creates means for evaluation and progress in the future. Create client information packets. These packets can contain information focused on lifestyle changes such as diet, exercise, and fall prevention. It is also important to have contact phone numbers for the National Osteoporosis Society (NOS) as well as self-referral information. The organization will provide these information packets in the women’s health, orthopedic, and elderly ward settings. Display osteoporosis awareness-raising display boards in prominent areas of each chosen clinical area. It is also recommended to develop in-house posters for placing around the hospital with contact details of osteoporosis services centers. (Whitehead et al., 2004) It is important to set up a formal health information referral process for at risk clients and their relatives with local osteoporosis specialists. By reaching at risk populations, care can be brought to where it is needed. Because most nurses and medical staff require continuing education classes to keep their license current, it is recommended to provided continuing education classes about osteoporosis.
Reform activities should be implemented along side of the preventative program. Preventative program activities will actually complement the reform activities. The organization should hire an osteoporosis nurse specialist. Major drug companies have provided short-term funding for the employment of osteoporosis nurse specialist for the initial set up until funding can be established for long-term funding. (Whitehead et al., 2004) Research has shown that implementation of a fall reduction program has decreased side effects of the osteoporosis disease process. (Whitehead et al., 2004) The organization is encouraged to implement a fall reduction program for all in-house patients. A new osteoporosis scanner will help create awareness to the medical community. It is recommended to set up a formal fund-raising group for a new osteoporosis scanner and involve members of research teams and local support groups. There is a need to set up a continuous program of osteoporosis awareness days at the organization with local physiotherapists. Finally, the organization should provided preventative exercise classes. “An ongoing and increasing level of preventative exercise classes linked to referred osteoporosis service clients” (Whitehead et al., 2004, p. 353). These classes can be run by a volunteer in the PAR group.
The Participatory Action Research group implemented allows for the organization group members to improve the performance quality of the changes. “Essentially Participatory Action Research (PAR) is research which involves all relevant parties in actively examining together current action (which they experience as problematic) in order to change and improve it” (Wadworth, 1998,¶10). PAR continues through repeated cycles to verify the effectiveness of the changes made. The success of the implementation of the osteoporosis guidelines depends on the continuous cycle of assessing, planning, implementing, and evaluating patient and staff satisfaction, as well as a evaluating the decrease in signs and symptoms of the osteoporosis disease process in at risk clients.
“ Typically, quantity measures are numerical descriptions of program activities and achievements, while quality measures often portray program activities and achievements through narrative descriptions (Gajda & Jewiss, 2004, ¶17). The organization’s program leaders will be concerned with determining if they decrease the patient population complications of osteoporosis, for quantitative evaluation, and documenting the personal perspectives of staff and patients receptiveness to the changes, for qualitative evaluation. “ Quantity measures are used to evaluate both process and outcome indicators. Very early on in the first stage of program implementation it will be important to establish and document what tools and strategies will be used to collect data that corresponds with each process and outcome indicator” (Gajda & Jewiss, ¶22). Quantity measures may examine how many people are being served and how often. “ Quality measures determine and document the effectiveness of the program’s activities and services. Evidence of a program’s quality can be gathered and reported through the use of narrative and/or numerical approaches. Mechanisms for gathering narrative information include individual or focus group interviews, open-ended survey questions, and observations of the program in action” (Gajda & Jewiss, ¶20). The perspectives of program participants, program staff, and other stakeholders can be obtained through interviews, surveys, or observations about the program’s quality through close-ended survey questions, such as those that ask participants to rate their level of satisfaction with the services and information provided. More powerful evidence is often generated when survey participants are asked to rate the degree to which they have gained new skills or information, or changed their behavior as a result of their involvement in the program (Gaida & Jewiss). As is the case with most initiatives and implementations, quality measure are important. Specifically for these osteoporosis guidelines, the project leaders anticipate that providers will report through written surveys and in interviews that activities will continue without problem and assist in tackling osteoporosis issues before they become a serious health concern.
Promoting a health awareness program to educate employees and patients regarding the prevention, diagnosis, and treatment of osteoporosis is important for early identification of osteoporosis. Education is the key for developing strategies for increasing knowledge of osteoporosis, health beliefs, and prevention behaviors.
Team C: Susan Vitus RNC, BSN Carol Taylor RN RuthAnne Skinner RNDorothy Alford RN, BSMT Debra Austin RN BSN University of Phoenix Creating Change Within Organizations HCS587 Terresa Randolph MSN, MA Psy March 30, 2008
National Guidelines Clearinghouse ™ (NGC) Evidence-based clinical practice guidelines and related documents Mission: provide detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.
Decreased bone massBone fracturesType IType II
Affects women over the age of 50Long-term impairment, disability, ordeathUndiagnosed, untreatedIncreased health-care costs
Being female Menopausal Over 50 years of age Health conditions Smokers Family history Asian or white Inactivity
Taking bone-active agents that inhibit bone loss Calcium Vitamin D Exercise Fall Prevention Techniques Diet Prevent fractures
Healthy Diet Regular exercise regime Calcium supplements Bone density tests Quit smoking Avoid alcohol and caffeine Get regular check-ups that include being measured
Importance: Women over 50 at higher risk Men also at risk Need for more accessible screening Need for better insurance reimbursement Need for more preventative information Preventative activities Need for recommended interventional modalities Pros and cons Alternative therapies
ORGANIZATIONAL READINESS Organizational assessment: Logical precursor to planning and implementing large scale change External environmental analysis Internal environment analysis
ORGANIZATIONAL READINESS Change readiness “Cognitive precursor to the behaviors of either resistance to, or support for, a change effort” (Armenakis, et al., as cited in By, 2007, p3) Conscious vs. unconscious Must be change ready before implementing change Organizational culture Beliefs, attitudes, intentions regarding need for change
ORGANIZATIONAL READINESS Internal analysis Management philosophy Worker satisfaction and perceived support Policies and procedures Mission and values Mindset of personnel Need for guideline adoption Willingness to utilize guideline as part of preventative care
ORGANIZATIONAL READINESS External analysis Financially feasible Market analysis Financial resources Return on investment is positive Incorporate into benefit packages Competitive benefits in community Adequate insurance reimbursement Perceived community need for preventative screening and treatment
IMPLEMENTATION Preventative Plan Organize a Participatory Action Research group Create client information packs Display osteoporosis awareness-raising display boards Set up formal health information referral process Provide osteoporosis continuing education classes for staff
IMPLEMENTATION Reform Activity Hire an osteoporosis nurse specialist Implement a fall reduction program Organize fund-raising for new osteoporosis scanner Set up osteoporosis education days Provide preventative exercise classes
By, R. T. (2007). Ready or not.... Journal of Change Management, 7(1), 3-11. Retrieved March 27, 2008, from EBSCOhost database. Cody, M. C. (2005). Creating a national osteoporosis awareness campaign. Business Briefing: North American Pharmacotherapy. Retrieved March 26, 2008, from http://www.touchbriefings.com/pdf/1442/ACF199.pdf Gajda, R. & Jewiss, J. (2004). Thinking about how to evaluate your program? These strategies will get you started. Practical Assessment, Research & Evaluation, 9(8). Retrieved March 30, 2008 from http://PAREonline.net/getvn.asp?v=9&n=8 Health Conditions .(2008). Osteoporosis, what are the risk factors. Drug Digest. Retrieved March 25, 2008 ,from http://www.drugdigest.org/DD/HC/RiskFactors John Muir Health. (2008). Managing osteoporosis. Health Reference Library. Retrieved March 27, 2008, from http://johnmuirhealth.com/index.php The National Guidelines Clearinghouse. (n.d.). About NGC. Retrieved March 24, 2008, from http://www.guideline.gov. The National Guidelines Clearinghouse. (n.d.). Management and prevention of osteoporosis. Retrieved March 10, 2008, from http://www.guideline.gov. National Osteoporosis Foundation. (2008). Proposed bill to protect patient access to osteoporosis testing by reversing cuts in medicare reimbursement . Retrieved March 28, 2008, from www.nof.org
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