Lucy Savitz, Ph.D., M.B.A.
The Need for Sepsis Care Training
Problem: Sepsis is a leading cause of death in U.S. hospitals. Early identification and treatment have been shown to be effective in saving lives. However, there is a changing evidence base as more research is done and the Centers for Medicare & Medicaid Services (CMS) changes the performance measure, creating misalignment.
Special considerations include the following:
- Direct and indirect costs and benefits
- Turning intangibles into tangible benefits/costs
- External influencers (state regulations, government monitoring)
- Dynamic evidence base
Business Objective: Implementation of the 3-hour sepsis bundle reliably across patient care settings (emergency department, inpatient units, intensive care units)
|Decreased in-hospital mortality||Developing and testing training materials|
|Decreased length of stay||Maintaining training materials|
|Decreased ICU days||Staff time in training|
|Increased discharge disposition to home||Analytic time to produce reports**|
|Increased staff morale*||Chart abstraction time|
|Increased positive patient experience||Dedicated staff time|
|(Future) avoided payment penalty||Decision support tool development|
|Increased bundle compliance (process)||EHR programming—CDS|
|Decreased time to treat (process)||Refresher training/reinforcement|
NOTE: CDS = clinical decision support; EHR = electronic health record; ICU = intensive care unit.
* “Lipstick Lady” example and decreased turnover.
** Value of measurable feedback.
Mark Bowden, P.T., Ph.D.
Medical University of South Carolina
The Division of Physical Therapy at the Medical University of South Carolina (MUSC) has developed a clinical residency program for physical therapists to meet the mission of improving clinical excellence through postprofessional education. A physical therapy residency is an optional postprofessional program designed to substantially advance the individual’s expertise in examination evaluation, diagnosis, prognosis, intervention, and management of patients within a specialty. Residency participation often results in a clinical specialization designation from the American Board of Physical Therapy Residency and Fellowship Education. In 2012, the physical therapy division partnered with a team of MUSC M.B.A. students to develop a business plan for the residency program. Important factors that shaped the direction of the residency program were identified, highlighted by the two largest factors preventing licensed therapists from pursuing residency education: relocating to a new location (56 percent of respondents), and tuition costs of the residency combined with opportunity costs associated with reduced salary (94 percent of respondents). The program set out to develop a business model in which MUSC was responsible for primary didactic education but developed a network of clinical partners to invest in their staff and serve as sites to translate education into practical clinical skills.
The Division of Physical Therapy developed a neurologic residency program (and later added an orthopedic residency program) with the following features:
- The program would minimize cost to the individual therapist in the development of clinical partners who would pay tuition ($8,000–$9,000 per year) in exchange for an extended service contract with the therapist.
- The program would be a blended model to minimize costs, combining on-site education in Charleston, South Carolina, with weekly
virtual classroom meetings and site visits from the academic faculty to the clinical sites.
- The program would maximize the expertise within the MUSC community and minimize outside instruction to help control costs.
- An experienced therapist (more than 3 years of specialty physical therapy experience) at the facility would agree to mentor the resident for 160 hours of one-on-one time over the course of the residency in exchange for sitting in on any didactic classes at no cost.
- The program could be completed within 12 months.
Initial partners included individual branches of the HealthSouth Corporation, but the model has recently expanded to include Roper St. Francis Healthcare System and Wake Forest Baptist Healthcare System.
The education model includes four onsite, intensive weekends in Charleston, and the clinical partners provide transportation to and from Charleston. In exchange, the residency program provides 64 hours of didactic content that includes live patient sessions and the opportunity to treat patients with residency faculty. In addition to the intensive weekends, the residents meet with faculty weekly for a 2-hour session within a virtual classroom. All of these sessions are built on an Internet-based platform maintained by the MUSC College of Health Professions IT Department. Importantly, each resident is given an MUSC username and password, which not only allows all content to be secure behind a firewall but also provides access to all MUSC protected sites, including the library and all of the electronic journals and resources. In addition, residency faculty go to each clinical site three times per year not only to observe the resident in practice but also to observe mentor–resident interactions. This “mentor the mentor” program has proven critical to the success of a multisite residency to assure that the program mentors are extensions of the centralized faculty.
Quantitatively, pilot data indicate that patients treated by residents or residency graduates have shorter lengths of stay, improved Functional Independence Measure (FIM) and FIM efficiency scores, a higher discharge percentage into the community (and lower to skilled nursing facilities), and overall Program Evaluation Model scores. Clinical partners report much greater success recruiting and retaining therapists, spending a fraction of historical costs for search and startup packages. Feedback from clinical partners indicates an enormous value for the per-resident tuition, and the program has grown each year with a steady expansion of clinical partners.
From the MUSC perspective, the university has noted several high-
value outcomes as well. The residency program clinical partners are also sites for clinical education for MUSC’s entry-level Doctor of Physical Therapy students, and improving the overall performance and culture within these sites vastly improves the clinical training experience. Revenue from the residency program is targeted for use for strategic planning, including use as seed money for additional residency programs and other academic entrepreneurial endeavors. The partnership with residency clinical sites has thus far yielded one pilot therapy project by HealthSouth, which is currently being leveraged into an application for a large, multisite pragmatic clinical trial.
To date, 21 residents have enrolled in this program from 11 clinical sites across seven states. Importantly, most of these individuals would not have been able to pursue residency education if not for this financial model. In 3 years, it has become one of the largest neurologic residencies in the nation. Ten of the 11 individuals who took the Neurologic Clinical Specialist (NCS) examination passed on the first effort. The program learned a great deal from the one who did not, as this clinical experience and workload did not allow a translation from the didactic classroom to the clinic. As a result, all applications are currently reviewed not only for the resident but for the clinic and mentor as well to assure the potential of success for the resident and facility. Subjective data indicate that the program has generated substantial benefits for the clinical partners, including improved recruitment and retention of staff, increased marketing opportunities via residency site location and an increase of NCS-certified therapists (see directory of specialists available at http://www.abpts.org/FindaSpecialist), and a cultural shift in the direction of improved evidence-based practice within the facility as evidenced by increased peer-review activities, journal club leadership, and neurologic program development.
The Virginia Commonwealth University (VCU) Medical Center is an 865-bed academic medical center and is a part of VCU Health in Richmond, Virginia. VCU comprises many health-related schools, including, but
not limited to, schools of medicine, nursing, dentistry, allied health, health administration, physical therapy, and pharmacy. In 2016, the Langston Quality Scholars Program (LQSP) was founded through a collaboration between VCU Medical Center and the Schools of Medicine, Health Administration, and Nursing through the Langston Center for Quality, Safety and Innovation.
The LQSP is an experiential learning program designed to deliver continuing professional development focused on the science of improvement and leadership. The hybrid program curriculum focuses on the science of improvement methods and tools, change management, and leadership. The 8-month program consists of didactic workshops and online modules as well as biweekly project coaching sessions with a science of improvement expert. Each of the eight dyads selected a project based on mutual interests with support from their leadership.
The medical respiratory intensive care unit (MRICU) at the VCU Medical Center is a 28-bed intensive care unit caring for critically ill adults who often require specialized therapies, such as mechanical ventilation, continuous renal replacement therapy, titratable continuous infusions of sedating agents and vasoactive medications, and intensive monitoring of vital signs and hemodynamics. The patients are cared for by two multiprofessional teams (red and blue) that are composed of nurses, physicians (attending, fellow, resident, intern), advanced practice providers, dieticians, physical and occupational therapists, critical care pharmacists, and respiratory therapists. Patients are admitted to either the blue or the red MRICU teams on an alternating (every other day) rotation schedule.
The Society of Critical Care Medicine (SCCM) and the American Association of Critical Care Nurses (AACN) recommend a “bundled” approach to the care of the critically ill (Balas et al., 2012; Ely, 2017). As part of the ABCDEF bundle (see iculiberation.org), each letter represents one component of best practice in critical care. Collectively, the ABCDEF bundle is an initiative to assist in implementing the 2013 SCCM Pain, Agitation, and Sedation Guidelines (Barr et al., 2013). Research has shown that when these best practices are incorporated as a bundle the patient has better outcomes, including decreased ventilator days, decreased incidence of delirium, and shortened hospital length of stay.
Each individual aspect of the ABCDEF Bundle was introduced in the MRICU prior to the LQSP; however, thorough understanding of the bundles by the team and the compliance rates of the separate aspects of the bundle were low. Secondary to the poor compliance and limited understanding of a best practice initiative, the MRICU dyad chose to focus on three components of the ABCDEF bundle during the LQSP: “B” (Both Spontaneous Awakening Trial [SAT] and Spontaneous Breathing Trial [SBT]), “C” (Choice of analgesia and sedation), and “E” (Early Mobility and Exercise).
With coaching from the science of improvement specialists, the dyad formed a small interdisciplinary team representative of MRICU clinicians. Using the science of improvement tools such as process mapping and fish bone diagrams, the team was able to understand and dissect the problem of ABCDEF bundle compliance. The problem was stemming from multiple factors, but the key deficiency was the lack of communication and coordination about the plan of care from the team. It was clear they could improve upon their interprofessional collaborative practice. The aim statement for the project stated that by October 2016 the team would achieve daily interprofessional communication and coordination of care relevant to patient sedation level, liberation potential, and mobility plan for all MRICU blue team Critical Care Hospital-4th Floor (CCH 4) intubated or trached patients as evidenced by increased compliance with SAT/SBT, adherence to Richmond Agitation and Sedation Scale (RASS) goals, and discussion and implementation of a daily mobility plan.
Plan-Do-Study-Act (PDSA) cycles were performed to find a solution for the project. After five major revisions, the solution developed by the group involved a daily morning interprofessional team huddle. The huddle would occur at the patient’s bedside using a 2-minute scripted dialogue that focused on three components of the ABCDEF bundle (B, C, and E). The interdisciplinary team included a provider (M.D. or advanced practice providers), bedside RN, RN clinical coordinator, physical therapist, occupational therapist, pharmacist, and respiratory therapist. The night RN caring for the patient would complete the questions listed on the rounding tool, which was read to the team by the morning shift RN. Following the scripted presentation, a brief interprofessional discussion followed, outlining the daily plan of care relevant to liberation potential, sedation choice, and mobility plan.
Baseline (preintervention) data were obtained from both teams and included choice of sedating infusions, compliance with SAT/SBT, percentage of time at RASS goal in a 24-hour time frame, and discussion and implementation of an individualized mobility plan. Following implementation of the project, similar data were obtained on the intervention team (MRICU blue team patients that were intubated or trached). Huddles were completed on each patient in the intervention group until the patient was discharged from the intensive care unit (ICU). The intervention data encompasses the time frame from July 12, 2016, through October 31, 2016. Currently, the huddle is still being implemented, and the team is focusing on continued educational efforts to fully implement all components of the ABCDEF bundles and methods to guarantee sustainability. In addition, future PDSA cycles will emphasize methods to expand, engrain, and implement the huddle to include all MRICU patients (MRICU blue and red team patients).
From July 12 through October 31, 2016, 269 huddles were completed on MRICU blue team patients. These blue team patients included all intubated or trached patients, and the team huddled on these patients even after they were liberated from the ventilator and until they were discharged from the ICU. Data collected revealed four major findings (when compared to preintervention data): increased percentage of time at sedation target (RASS) goal, decreased use of benzodiazepine infusions, increased compliance with Spontaneous Awakening and Breathing Trials, and increased numbers of patients with a mobility plan.
Length of stay analysis showed a clear reduction in both ICU and hospital length of stay when the intervention team (blue team) was compared to the nonintervention team (red team). There was a 1.14 day reduction in average ICU length of stay for MRICU blue team patients compared to MRICU red team patients. Furthermore, the difference in length of stay held even when taking patient acuity into account as both teams had similarly observed expected length of stay ratios by diagnostic related grouping.
Other unmeasured outcomes that were noted from this project include better understanding of other disciplines’ roles and perspectives; perceived improved staff morale, camaraderie, and job satisfaction; increased education among multiple providers, and overall improved communication across multiple disciplines. In addition, being introduced to key principles in the science of quality improvement allows members to implement these tools toward other quality improvement projects throughout the hospital and community.
The cost of the continuing professional development (CPD) LQSP was $97,494, which equates to $12,127 per M.D./RN dyad. This cost estimate includes faculty salaries, coaching, continuing medical education, Institute for Healthcare Improvement online modules, speakers, center staff, and educational supplies. The average cost of one 20-minute huddle (with full attendance of staff: attending physician, fellow, advanced practice provider, clinical coordinator RN, bedside RN, occupational and physical therapist, and pharmacist) is $120.50.
Regarding length of stay, a reduction of 1.14 ICU days among the intervention (MRICU blue team) equates to an estimated annual cost reduction of $2.26 million. This calculation is based on an average daily ICU cost of $3,184.00 as outlined by Dasta et al. (2005).
When VCU Health specific ICU charges were analyzed, there was a reduction in both average MRICU accommodation and respiratory therapy charges in the intervention group (MRICU blue team) compared to the nonintervention group (MRICU red team).
In summary, the LQSP is a high-value continuing development project that provided the VCU Health MRICU team with the tools needed for a successful quality improvement initiative. This project has the propensity for a substantial return on investment.
Marilyn DeLuca, Ph.D., R.N.
New York University
Working to Achieve the 90-90-90 Targets in Namibia
The 90-90-90 targets aim to end the AIDS epidemic by 2030 (UNAIDS, 2014). Developed in consultation with national and regional stakeholders, the targets call for countries to implement strategies that, by 2020, will allow
- 90 percent of persons living with HIV to know their HIV status.
- 90 percent of HIV-positive individuals to have access to antiretroviral treatment (ART).
- 90 percent of those receiving ART to achieve viral suppression.
The goals of ART are to suppress viral load, reduce associated morbidities and increase longevity among HIV-positive individuals, and reduce the spread of HIV infection among noninfected individuals.
Namibia is a high- to middle-income country with a population of 2.5 million people, and it has a high HIV-positive prevalence rate of 14 percent (Wessong et al., 2015). In 2014, Namibia’s minister of health projected a near doubling of the number of those requiring ART in 2015 to 220,000 individuals. To expand access to ART, the government is seeking strategies to increase ART services in government-supported health centers. Among the major constraints to expanding services is the limited number of physicians (282) and nurses (4,251) employed in the public sector. Retention of qualified staff, maldistribution of clinicians, and low physician salaries in the public sector constrict access to health services.
In Namibia, as in other settings, physicians are the designated clinicians who enroll patients into and prescribe antiretroviral treatment. To increase access to ART, several countries are expanding policies and practices through the use of the nurse-initiated antiretroviral treatment model (NIMART) (Callaghan et al., 2010). Following training in ART and associated changes in policy, practice, and certification, nurses can prescribe and manage HIV-positive patients. Evaluations of these programs indicate that patients are as well managed as in physician-initiated and managed ART settings; in some instances, NIMART settings report higher patient retention in ART (Kredo et al., 2014).
The case described focuses on one Namibian region referred to as Region A. In 2014 (base year), Region A enrolled 1,715 new patients in ART and provided a total of 213,358 patient visits. Given past trends in HIV prevalence and recent population growth in Namibia, it is projected that by 2018 an additional 146,120 newly HIV-positive individuals will require ART treatment in Namibia. With 10 percent of the country’s population, estimates indicate that 10 percent of HIV-positive individuals live in Region A (Wesson et al., 2015).
Using a staffing projection model, Workload Indicators of Staffing Need or WISN (WHO, 2010) staffing requirements were calculated with and without NIMART for Region A.
Adoption of NIMART and interventions that allow professional nurses to competently practice at the full scope of their preparation have implications across settings. Such practice and policy changes have the potential to reduce demand for physician time, promote interprofessional patient-centered care management, and, most significantly, increase access to care.
The purpose of the project is to evaluate the cost utility of implementing NIMART in Region A in Namibia’s government-supported health centers.
Business Case Objectives
To compare the value of ART care and treatment in Region A with and without NIMART to inform decision making by the ministry of health, considering monetary and other costs and desired outcomes, which include an increase in the number of individuals enrolled in ART, their viral suppression, and improved health status.
Value = (Quality + Outcome)/Costs
Short-term outcomes (by end of year 1) include
- increased number of HIV-positive individuals enrolled in ART.
- increased number of HIV individuals managed on ART.
- increased number of HIV individuals with suppressed viral load.
Middle to long-term outcomes (by end of year 5 and beyond) include
- reduced morbidity among HIV-positive individuals.
- increased life expectancy among HIV-positive individuals.
- decreased prevalence of HIV positivity among individuals in Namibia.
- decreased transmission of HIV among individuals in Namibia.
AMERICAN NURSES CREDENTIALING CENTER ACCREDITATION INNOVATION PILOT: AWARDING OUTCOME-BASED CONTINUING EDUCATION (CE) CREDIT
Kathy Chappell, Ph.D., R.N., FNAP, FAAN
Accreditation and Institute for Credentialing Research
The American Nurses Credentialing Center (ANCC), as the leader in accreditation of continuing nursing education, is piloting an innovative method of awarding CE credit to nurses using an outcome-based model. This model is designed to integrate a learner/team-directed educational approach that incorporates performance/quality improvement expectations into learning experiences to positively impact nursing practice, patient, and/ or systems outcomes.
The outcome-based model has five levels, beginning with articulation of knowledge and skills and progressing through application of knowledge and skills, demonstration of knowledge and skills in an educational setting, integration of knowledge and skills into practice, and impact on practice, patient, and/or system outcomes. Professional practice gaps serve as the guide for determining desired outcomes of each learning experience.
The pilot was launched in October 2016 and will be evaluated over the next 12 months. Five ANCC accredited providers are participating:
- American Nurses Association Center for Continuing Education and Professional Development
- Dartmouth-Hitchcock Nursing Continuing Education Council
- Montana Nurses Association
- OnCourse Learning
Each pilot organization will be developing its own educational activities and recruiting registered nurses to provide qualitative and quantitative evaluation feedback. Feedback will be used to better understand how awarding outcome-based CE credit may affect the educational experience. ANCC-certified nurses will be able to use credit awarded toward ANCC certification renewal requirements. Credit may also be accepted by individual boards of nursing and health care organizations that require documentation of continuing professional development activities, though nurses are encouraged to contact their respective boards and organizations to confirm.
David C. Benton, R.G.N., Ph.D., FFNF, FRCN, FAAN
National Council of State Boards of Nursing
This panel contribution focuses on a radically different approach to the provision of continuing professional development (CPD). Instead of focusing on the individual learner, the exemplar describes how a systemic approach was taken to addressing a real organization-wide problem—workforce shortages—through focusing on identifying best practices in flexible working practices and getting frontline managers to own and implement these solutions.
The work drew on the systematic review of Francke et al. (1995) that identified the determinants of behavior change associated with successful CPD. By using an initial social network analysis of nursing leadership in a fully integrated health care delivery system in northeast Scotland, the structure of existing communication pathways and commonly experienced problems was identified (Benton, 2015).
A 1-day event was built on the work of Spencer Johnson’s Who Moved My Cheese? (Johnson, 1998) and created a parable on the original story with a focus on introducing flexible working practices. After some initial presentation the remainder of the day focused on an action learning model. Opportunities to implement the learning were engineered ahead of time; as a result, flexible working practices were introduced, with several of
these being written up and published. Multiple added-value consequences occurred—a reduction in vacancies; reduced costs associated with the use of agency staff; the creation of an in-house staffing bank; and the identification of a wide range of innovative experiences and practices that radically improved patient care, increased efficiency of services, and saved money.
Reflecting on this work, it is possible to suggest that a number of paradigm shifts are required if high-value CPD is to be designed, implemented, evaluated, and accredited. A new model of accreditation of CPD is needed to fully recognize the learning that can take place as a result of an initial well-designed kickoff event that then delivers continuing professional development over a prolonged period.
EXPLORING A BUSINESS CASE FOR HIGH-VALUE CONTINUING PROFESSIONAL DEVELOPMENT: AN ACCREDITOR’S PERSPECTIVE ON LEVERAGING THE POWER OF LEARNING
Kate Regnier, M.A., M.B.A.
Accreditation Council for Continuing Medical Education
The Accreditation Council for Continuing Medical Education (ACCME) dedicates its efforts to leveraging the power of learning for the benefit of individuals, institutions, and the patients they serve. ACCME manages a geographically distributed educational system comprising about 2,000 accredited organizations that plan and present 150,000 educational activities annually. These accredited organizations are located throughout the country; in addition, ACCME has recently begun accrediting international organizations. Accredited organizations engage in interactions with more than 14 million physician learners and 11 million other health care professionals each year. That means each clinician interacts multiple times with educators every year.
Informed in part by the Institute of Medicine report Health Professions Education: A Bridge to Quality, ACCME changed the focus of accredited CME from knowledge acquisition to knowledge in action—teaching clinicians how to apply education to practice. Since 2006, ACCME has required educators to design interventions to change learners’ competence, performance, and/or patient outcomes, and to measure those changes. Activities are based on practice-relevant, valid content that is independent of commercial interests.
Recently, after 2 years of engagement with the CME community, ACCME instituted a new menu of criteria for Accreditation with Com-
mendation. These criteria provide an incentive—a 6-year rather than 4-year term of accreditation—for organizations to implement best practices. The criteria address five themes:
- Promotes team-based education
- Addresses public health priorities
- Enhances skills
- Demonstrates educational leadership
- Achieves outcomes
ACCME believes there is a strong business case for accredited CME and CPD, as described in the article “The Leadership Case for Investing in Continuing Professional Development,” by Graham McMahon, M.D., M.M.Sc., published in Academic Medicine.
According to McMahon, accredited professional education
- is a cost-effective, powerful catalyst for change;
- creates and supports teams;
- improves well-being by building empowered teams that take care of each other;
- engages clinicians with institutional priorities where they work and learn;
- facilitates processes to empower clinician participation in quality improvement initiatives that are bottom up, rather than top down;
- improves referrals to appropriate, necessary treatment options; and
- engages patients in team and care decision-making improvements to quality and safety.
It is important to demonstrate the business case with data. There are numerous examples of accredited CME making a meaningful and measurable difference in safety, quality, and patient care. Here are a few examples of outcomes that resulted from CME initiatives:
- An increase in patient satisfaction and involvement in care decisions
- Improved care coordination for the mentally ill
- Improved outcomes for sepsis patients
- Significantly lowered rate of complications and improved outcomes for both maternal and neonatal patients
- Lower rates of deaths from accidental opioid overdose
To further leverage the power of education, ACCME coordinates with colleague accreditors across the health professions, licensing, and credentialing bodies. For example, ACCME collaborated with accreditors in nurs-
ing and pharmacy to develop Joint Accreditation for Interprofessional Continuing Education, a shared system to promote team-based education.
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UNAIDS (Joint United Nations Programme on HIV/AIDS) 2014. Fast-Track: Ending the AIDS Epidemic by 2030. Geneva, Switzerland: UNAIDS.
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