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Evaluating Innovation:
Moving Toward the New Paradigm
of Care Delivery

Jeffrey M. Adams, PhD, RN
Director, Center for Innovations in Care Delivery
Connell Nursing Research Scholar
October 2013

1
EVALUATION STEERING COMMITTEE

 Gaurdia Banister

 Annie Kingsley

 Marianne Ditomassi

 Linda Lacke

 Rick Evans

 Bret O’Flaherty

 Brian French

 Robin Lipkis-Orlando

 Amy Giuliano

 Colleen Snydeman

 Dorothy Jones

 Jeff Adams

2
Innovation is…?????

Haircuts

Soda

Airlines

Garden Utensils
Hardwood Flooring

Automobiles
Laundry Detergent

Source: Adams JM. (in press) Guest Editorial: How do we know if we’re innovating? A strategy for
innovation evaluation in a practice setting. Journal of Nursing Administration.
3
“History of Healthcare Innovating”
•

4

Add photos of Healthcare
Innovation Products
A New Context for Innovation

•

5

CMS
“Patient Journey” Framework

Before

Preadmission
Care

During
Admission
Process: ED,
Direct Admits,
Transfers

Patient Stay;
Direct Patient Care, Tests,
Treatments, Procedures,
Clinical Support,
Operational Support

Post

Discharge
Process

Support Functions: Finance, Information Systems, HR

Goal: High-performing interdisciplinary teams that deliver safe, effective, timely,
efficient and equitable care that is patient and family centered.

Where Are There Opportunities to Reduce Costs Across These Processes of Care?
6

Post
Discharge
Care
INNOVATION UNIT EXPERIENCES SURVEY

“The MGH Innovation Units Program was developed as a frontline
initiative to address the gaps in the continuum of care and utilize the
expertise of all clinical disciplines to improve the patient experience,
quality of care, staff satisfaction and empowerment while decreasing
redundancy, costs, length of stay and readmission rates.”

Source: Ives Erickson J, Ditomassi M, Adams JM. (2012) Innovations in Care Delivery: A Blueprint for
the Future. Nursing Economic$ 30(5): 282-287.

7
MGH PCS’s Approach

Innovation Cluster
Focus Areas *

Interventions **

Evaluation
(Pre, During, Post)

Throughout Admission
Relationship-Based Care
Attending Nurse
Handover Rounding Checklist

Patient Engagement

Quantitative
•HCAHPS

Pre-Admission

•Leadership Influence
over Professional
Practice Environments
(LIPPES)

Pre-Admit Data Collection
Welcome Packet

During Admission

Roles & Structures

Education

Communication

Domains of Practice
Interdisciplinary Rounds
Business Cards
Quiet Hours
Hourly Rounding
Electronic White Boards
In Room White Boards
Smart Phones
Hand Held/ Tablets

Post-Discharge
Discharge Follow-up Phone Calls
Others as identified

•Quality Indicators
•Patients Perceptions
of Feeling Known
(PPFKN)
•Readmissions

•Focus Groups
(Staff, Patients,
Families, etc)
•Observations
•Survey of the
Innovation Unit
Expectations
(SIUE-pre)
•Survey of the
Innovation Unit
Experiences
(SIUE-post)

•Revised Perceptions
of Practice
Environment Scale
(RPPE)
•Cost per Case Mix

* The clusters are a lens
with which we gain
perspective on any
particular intervention.
8

•LOS

Qualitative

•Staff Retention
Other measures as identified
** May apply to any or all 3 of the cluster focus areas

June 2013
It is in there

9
Data, Data, Everywhere

6
10
Why is this Innovation Unit Evaluation complex?

•

Aimed at understanding successes & challenges of structures
processes and outcomes of care delivery AND the evaluation process
itself.

•

Telling the story in context of the immediate, while tracking
longitudinally to optimize sustainability.

•

All while the ship is sailing…

•

Different than research

11
The Process
Innovation Evaluation (90-Day Cycle)

Day 1-30

Day 31-60

Day 61-90

Source: Institute for Healthcare Improvement (2013)

12
So what are we finding?

•

Three examples of how and what we’re finding…
– Idea Books
– Innovation Unit Experiences Survey
– Innovation Unit Interventions Sustainability Checklist

13
Idea Books

14
INNOVATION UNIT EXPERIENCES SURVEY

What is it like
to work on an innovation unit?

15
Analysis of the data yielded five interrelated themes:
1. Feeling prepared: “There was ample support and pre-education.”
2. Innovation: “A complete change of culture.”
3. Managing Challenges and Concerns: “It has been very challenging.”
4. The Attending RN: “The glue for nursing care.”
5. Benefits to patients and families: “The impact on patient care is worth it all.”

16
INNOVATION UNIT EXPERIENCES SURVEY

Are the efforts being sustained?

17
Innovation Unit Observation
Checklist Phase 1 & 2

18
PATIENT/ FAMILY INTERVIEW

 

Do you have an Attending Nurse?

Phase I Only

Phase II Only

Phase I & II

Yes

59%

57%

58%

 

No

41%

43%

42%

If YES, was patient/family able to provide a name?

Yes

85%

57%

66%

 

No

15%

43%

34%

Did you receive an ARN Business Card?

Yes

36%

47%

 

No

64%

53%

57%

Do the nurses, doctors, and other staff make you feel like you
are part of the team?

Yes

100%

94%

96%

 

No

0%

6%

4%

Do you have a Discharge Envelope/Checklist?

Yes

47%

49%

48%

 

No

53%

51%

52%

If YES, is there a discharge date noted in the space provided?

Yes

0%

21%

14%

 

No

100%

79%

86%

Do you have a copy of the Patient & Family Notebook?

Yes

55%

53%

54%

 

No

45%

47%

46%

If YES, has it been helpful to you?

Yes

27%

73%

58%

*

 

No

73%

27%

42%

*

*

43%

*

*
Phase I Only

PATIENT/ FAMILY INTERVIEW

Phase II Only

Phase I & II

When someone comes in to check on you: Do they ask
about your pain?

Yes

96%

92%

93%

 

No

4%

8%

7%

When someone comes in to check on you: Do they ask you
whether you need to go to the bathroom?

Yes

54%

58%

57%

 

No

46%

42%

43%

When someone comes in to check on you: Do they ask you if
you need to change position and if you are comfortable?

Yes

71%

84%

80%

 

No

29%

16%

20%

When someone comes in to check on you: Do they ask you if
you need anything else before they leave the room?

Yes

96%

96%

96%

 

No

4%

4%

4%

Has your call bell been answered promptly?

Yes

92%

86%

88%

 

No

8%

14%

12%

*

*

*

*
Phase I Only

STAFF INTERVIEW OR OBSERVATION

Phase II Only

Phase I & II

Can you tell me the purpose of the Attending Nurse role?

Yes

100%

100%

100%

 

No

0%

0%

0%

Can you share an example of Relationship-based Care
that has occurred on the unit?

Yes

96%

90%

92%

 

No

4%

10%

8%

Do Interdisciplinary Rounds occur at a regular scheduled
time on your unit?

Yes

83%

98%

93%

 

No

17%

2%

7%

The Electronic White Board is utilized on the unit.
(Phase I and Lunder only).

Yes

92%

93%

92%

 

No

8%

7%

8%

Voaltés are utilized on the unit.

Yes

100%

100%

100%

 

No

0%

0%

0%

Hourly Rounding (Safety Rounds) occur on the unit.

Yes

100%

90%

93%

 

No

0%

10%

7%

*

*

*

*
*
*
Phase I
Only

OBSERVATION - IN-ROOM WHITE BOARD

Phase II
Only

Phase
I & II

100%

89%

93%

Patient Name

Complete & Accurate

 

Complete / Not Accurate

0%

0%

0%

 

Not Complete

0%

11%

7%

Date

Complete & Accurate

92%

79%

83%

 

Complete / Not Accurate

4%

19%

14%

 

Not Complete

4%

2%

3%

Nurse Name

Complete & Accurate

92%

82%

85%

 

Complete / Not Accurate

4%

16%

12%

 

Not Complete

4%

2%

3%

Physician Name

Complete & Accurate

65%

30%

43%

 

Complete / Not Accurate

4%

2%

3%

 

Not Complete

31%

68%

54%

Other Members of the Care Team (s)

Complete & Accurate

50%

76%

68%

 

Complete / Not Accurate

0%

0%

0%

 

Not Complete

50%

24%

32%

Estimated Discharge Date

Complete & Accurate

17%

13%

14%

 

Complete / Not Accurate

0%

2%

2%

 

Not Complete

83%

85%

84%

Goals for the Day

Complete & Accurate

68%

48%

54%

 

Complete / Not Accurate

0%

2%

2%

 

Not Complete

32%

50%

44%

*

*

*

*

*

*

*
OBSERVATION - PATIENT FACE SHEET

Phase I Only

Phase II Only

Phase I & II

Pre-Admission Estimated Length of Stay was identified

Yes

20%

26%

24%

 

No

80%

74%

76%

Estimated Discharge Date was identified

Yes

15%

0%

4% err

 

No

85%

100%

96%

Discharge Disposition was identified

Yes

9%

0%

3%

 

No

91%

100%

*

97%

OBSERVATION/STAFF REPORT –
QUIET HOURS

Phase I Only

Phase II Only

*

*

Phase I & II

Do Quiet Hours occur on the unit?

Yes

97%

92%

100%

 

No

3%

8%

0%

Quiet Hours signage is visible on the unit?

Yes

89%

92%

88%

 

No

11%

8%

12%

*

*
Positive:

Patient
 Do nurse, doctors and others make you feel part of the team?
 When someone comes in to check on you do they ask about – your pain?
 When someone comes in to check on you do they ask if your are
comfortable and want to change position?
 When someone comes in to check on you do they ask if you need anything
else before they leave the room?
 Has your call bell been answered promptly?
Staff
 Can you tell me the purpose of ARN role?
 Can you share an example of Relationship Based Care?
 Do interdisciplinary rounds occur at a regularly scheduled time?
Observation
 Electronic White Boards utilized on unit (Phase 1 and Lunder only)?
 Voaltés are utilized on the unit?
 In Room White Board – Patient Name Complete?
 Quiet Hours signage is visible?

24

Observed or Reported
 Quiet Hours occur on the unit?
 Hourly Rounding occurs on the unit?
Opportunities: Observation
 D/C Envelope – if yes is a D/C date noted?
 In Room White Board – Physician Name?
 In Room White Board – Care Team Members Names?
 In Room White Board – Estimated Discharge Date?
 In Room White Board – Goals for the Day?
 Face Sheet – Pre-admit expected LOS?
 Face Sheet – EDD?
 Face Sheet – Discharge disposition?
Aggregate data for Phase 1 and Phase 2

25
What is our evaluation telling us?

26
Next Steps for Evaluation
Continued evaluation in the 90-Day Cycle
Inclusion of Phase 3 and Phase 4 Units
Adjustment of measures based on Evaluation Steering Committee
Recommendations (i.e., deep dive: Estimated D/C Date, White Boards, Face Sheet)
Increased evaluation of ARN role
Increased transdisciplinary team input (regular meetings/groups soliciting insights)
Coordinate longitudinal data management (research)
Developing an Innovation Evaluation Manual
Publish, present, publish, present, repeat

27
MASSACHUSETTS GENERAL HOSPITAL
PATIENT CARE SERVICES

Including
Mechanisms of Evaluations
Data Elements
Instruments
Questions
Timelines
Dashboard examples
Observation Checklist
Number of Resources Needed

28
To identify the new paradigm
• Evaluate trends
• Build for research
• Utilize evidence to make

decisions
• Adopt, Adapt & Abandon
• Disseminate work

29
Nursing Director Survey Quote:
“Managing the new [innovation] processes is
time consuming. Communication to other staff
is ongoing. I feel I’ve answered the question,
‘What is this all about?’ too many times.
But…the impact on patient care is worth it all.”

30

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Evaluating Change and Tracking Improvement

  • 1. Evaluating Innovation: Moving Toward the New Paradigm of Care Delivery Jeffrey M. Adams, PhD, RN Director, Center for Innovations in Care Delivery Connell Nursing Research Scholar October 2013 1
  • 2. EVALUATION STEERING COMMITTEE  Gaurdia Banister  Annie Kingsley  Marianne Ditomassi  Linda Lacke  Rick Evans  Bret O’Flaherty  Brian French  Robin Lipkis-Orlando  Amy Giuliano  Colleen Snydeman  Dorothy Jones  Jeff Adams 2
  • 3. Innovation is…????? Haircuts Soda Airlines Garden Utensils Hardwood Flooring Automobiles Laundry Detergent Source: Adams JM. (in press) Guest Editorial: How do we know if we’re innovating? A strategy for innovation evaluation in a practice setting. Journal of Nursing Administration. 3
  • 4. “History of Healthcare Innovating” • 4 Add photos of Healthcare Innovation Products
  • 5. A New Context for Innovation • 5 CMS
  • 6. “Patient Journey” Framework Before Preadmission Care During Admission Process: ED, Direct Admits, Transfers Patient Stay; Direct Patient Care, Tests, Treatments, Procedures, Clinical Support, Operational Support Post Discharge Process Support Functions: Finance, Information Systems, HR Goal: High-performing interdisciplinary teams that deliver safe, effective, timely, efficient and equitable care that is patient and family centered. Where Are There Opportunities to Reduce Costs Across These Processes of Care? 6 Post Discharge Care
  • 7. INNOVATION UNIT EXPERIENCES SURVEY “The MGH Innovation Units Program was developed as a frontline initiative to address the gaps in the continuum of care and utilize the expertise of all clinical disciplines to improve the patient experience, quality of care, staff satisfaction and empowerment while decreasing redundancy, costs, length of stay and readmission rates.” Source: Ives Erickson J, Ditomassi M, Adams JM. (2012) Innovations in Care Delivery: A Blueprint for the Future. Nursing Economic$ 30(5): 282-287. 7
  • 8. MGH PCS’s Approach Innovation Cluster Focus Areas * Interventions ** Evaluation (Pre, During, Post) Throughout Admission Relationship-Based Care Attending Nurse Handover Rounding Checklist Patient Engagement Quantitative •HCAHPS Pre-Admission •Leadership Influence over Professional Practice Environments (LIPPES) Pre-Admit Data Collection Welcome Packet During Admission Roles & Structures Education Communication Domains of Practice Interdisciplinary Rounds Business Cards Quiet Hours Hourly Rounding Electronic White Boards In Room White Boards Smart Phones Hand Held/ Tablets Post-Discharge Discharge Follow-up Phone Calls Others as identified •Quality Indicators •Patients Perceptions of Feeling Known (PPFKN) •Readmissions •Focus Groups (Staff, Patients, Families, etc) •Observations •Survey of the Innovation Unit Expectations (SIUE-pre) •Survey of the Innovation Unit Experiences (SIUE-post) •Revised Perceptions of Practice Environment Scale (RPPE) •Cost per Case Mix * The clusters are a lens with which we gain perspective on any particular intervention. 8 •LOS Qualitative •Staff Retention Other measures as identified ** May apply to any or all 3 of the cluster focus areas June 2013
  • 9. It is in there 9
  • 11. Why is this Innovation Unit Evaluation complex? • Aimed at understanding successes & challenges of structures processes and outcomes of care delivery AND the evaluation process itself. • Telling the story in context of the immediate, while tracking longitudinally to optimize sustainability. • All while the ship is sailing… • Different than research 11
  • 12. The Process Innovation Evaluation (90-Day Cycle) Day 1-30 Day 31-60 Day 61-90 Source: Institute for Healthcare Improvement (2013) 12
  • 13. So what are we finding? • Three examples of how and what we’re finding… – Idea Books – Innovation Unit Experiences Survey – Innovation Unit Interventions Sustainability Checklist 13
  • 15. INNOVATION UNIT EXPERIENCES SURVEY What is it like to work on an innovation unit? 15
  • 16. Analysis of the data yielded five interrelated themes: 1. Feeling prepared: “There was ample support and pre-education.” 2. Innovation: “A complete change of culture.” 3. Managing Challenges and Concerns: “It has been very challenging.” 4. The Attending RN: “The glue for nursing care.” 5. Benefits to patients and families: “The impact on patient care is worth it all.” 16
  • 17. INNOVATION UNIT EXPERIENCES SURVEY Are the efforts being sustained? 17
  • 19. PATIENT/ FAMILY INTERVIEW   Do you have an Attending Nurse? Phase I Only Phase II Only Phase I & II Yes 59% 57% 58%   No 41% 43% 42% If YES, was patient/family able to provide a name? Yes 85% 57% 66%   No 15% 43% 34% Did you receive an ARN Business Card? Yes 36% 47%   No 64% 53% 57% Do the nurses, doctors, and other staff make you feel like you are part of the team? Yes 100% 94% 96%   No 0% 6% 4% Do you have a Discharge Envelope/Checklist? Yes 47% 49% 48%   No 53% 51% 52% If YES, is there a discharge date noted in the space provided? Yes 0% 21% 14%   No 100% 79% 86% Do you have a copy of the Patient & Family Notebook? Yes 55% 53% 54%   No 45% 47% 46% If YES, has it been helpful to you? Yes 27% 73% 58% *   No 73% 27% 42% * * 43% * *
  • 20. Phase I Only PATIENT/ FAMILY INTERVIEW Phase II Only Phase I & II When someone comes in to check on you: Do they ask about your pain? Yes 96% 92% 93%   No 4% 8% 7% When someone comes in to check on you: Do they ask you whether you need to go to the bathroom? Yes 54% 58% 57%   No 46% 42% 43% When someone comes in to check on you: Do they ask you if you need to change position and if you are comfortable? Yes 71% 84% 80%   No 29% 16% 20% When someone comes in to check on you: Do they ask you if you need anything else before they leave the room? Yes 96% 96% 96%   No 4% 4% 4% Has your call bell been answered promptly? Yes 92% 86% 88%   No 8% 14% 12% * * * *
  • 21. Phase I Only STAFF INTERVIEW OR OBSERVATION Phase II Only Phase I & II Can you tell me the purpose of the Attending Nurse role? Yes 100% 100% 100%   No 0% 0% 0% Can you share an example of Relationship-based Care that has occurred on the unit? Yes 96% 90% 92%   No 4% 10% 8% Do Interdisciplinary Rounds occur at a regular scheduled time on your unit? Yes 83% 98% 93%   No 17% 2% 7% The Electronic White Board is utilized on the unit. (Phase I and Lunder only). Yes 92% 93% 92%   No 8% 7% 8% Voaltés are utilized on the unit. Yes 100% 100% 100%   No 0% 0% 0% Hourly Rounding (Safety Rounds) occur on the unit. Yes 100% 90% 93%   No 0% 10% 7% * * * * * *
  • 22. Phase I Only OBSERVATION - IN-ROOM WHITE BOARD Phase II Only Phase I & II 100% 89% 93% Patient Name Complete & Accurate   Complete / Not Accurate 0% 0% 0%   Not Complete 0% 11% 7% Date Complete & Accurate 92% 79% 83%   Complete / Not Accurate 4% 19% 14%   Not Complete 4% 2% 3% Nurse Name Complete & Accurate 92% 82% 85%   Complete / Not Accurate 4% 16% 12%   Not Complete 4% 2% 3% Physician Name Complete & Accurate 65% 30% 43%   Complete / Not Accurate 4% 2% 3%   Not Complete 31% 68% 54% Other Members of the Care Team (s) Complete & Accurate 50% 76% 68%   Complete / Not Accurate 0% 0% 0%   Not Complete 50% 24% 32% Estimated Discharge Date Complete & Accurate 17% 13% 14%   Complete / Not Accurate 0% 2% 2%   Not Complete 83% 85% 84% Goals for the Day Complete & Accurate 68% 48% 54%   Complete / Not Accurate 0% 2% 2%   Not Complete 32% 50% 44% * * * * * * *
  • 23. OBSERVATION - PATIENT FACE SHEET Phase I Only Phase II Only Phase I & II Pre-Admission Estimated Length of Stay was identified Yes 20% 26% 24%   No 80% 74% 76% Estimated Discharge Date was identified Yes 15% 0% 4% err   No 85% 100% 96% Discharge Disposition was identified Yes 9% 0% 3%   No 91% 100% * 97% OBSERVATION/STAFF REPORT – QUIET HOURS Phase I Only Phase II Only * * Phase I & II Do Quiet Hours occur on the unit? Yes 97% 92% 100%   No 3% 8% 0% Quiet Hours signage is visible on the unit? Yes 89% 92% 88%   No 11% 8% 12% * *
  • 24. Positive: Patient  Do nurse, doctors and others make you feel part of the team?  When someone comes in to check on you do they ask about – your pain?  When someone comes in to check on you do they ask if your are comfortable and want to change position?  When someone comes in to check on you do they ask if you need anything else before they leave the room?  Has your call bell been answered promptly? Staff  Can you tell me the purpose of ARN role?  Can you share an example of Relationship Based Care?  Do interdisciplinary rounds occur at a regularly scheduled time? Observation  Electronic White Boards utilized on unit (Phase 1 and Lunder only)?  Voaltés are utilized on the unit?  In Room White Board – Patient Name Complete?  Quiet Hours signage is visible? 24 Observed or Reported  Quiet Hours occur on the unit?  Hourly Rounding occurs on the unit?
  • 25. Opportunities: Observation  D/C Envelope – if yes is a D/C date noted?  In Room White Board – Physician Name?  In Room White Board – Care Team Members Names?  In Room White Board – Estimated Discharge Date?  In Room White Board – Goals for the Day?  Face Sheet – Pre-admit expected LOS?  Face Sheet – EDD?  Face Sheet – Discharge disposition? Aggregate data for Phase 1 and Phase 2 25
  • 26. What is our evaluation telling us? 26
  • 27. Next Steps for Evaluation Continued evaluation in the 90-Day Cycle Inclusion of Phase 3 and Phase 4 Units Adjustment of measures based on Evaluation Steering Committee Recommendations (i.e., deep dive: Estimated D/C Date, White Boards, Face Sheet) Increased evaluation of ARN role Increased transdisciplinary team input (regular meetings/groups soliciting insights) Coordinate longitudinal data management (research) Developing an Innovation Evaluation Manual Publish, present, publish, present, repeat 27
  • 28. MASSACHUSETTS GENERAL HOSPITAL PATIENT CARE SERVICES Including Mechanisms of Evaluations Data Elements Instruments Questions Timelines Dashboard examples Observation Checklist Number of Resources Needed 28
  • 29. To identify the new paradigm • Evaluate trends • Build for research • Utilize evidence to make decisions • Adopt, Adapt & Abandon • Disseminate work 29
  • 30. Nursing Director Survey Quote: “Managing the new [innovation] processes is time consuming. Communication to other staff is ongoing. I feel I’ve answered the question, ‘What is this all about?’ too many times. But…the impact on patient care is worth it all.” 30

Editor's Notes

  1. I