UNC HEALTH CARE SYSTEM
TRANSLATING CARING THEORY ACROSS
THE CONTINUUM FROM INPATIENT TO
AMBULATORY CARE
Meghan McCann MSN, RN, NE-BC
Director Oncology Services
University of North Carolina Health Care
0
UNC HEALTH CARE SYSTEM
Across the Continuum to Ambulatory Care
• The Ambulatory Care Environment
• Translating Caring Theory to Ambulatory Care
• Translating Caring Theory to the
Emergency Department
• Sustaining the Carolina Care Culture at
UNC Health Care
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UNC HEALTH CARE SYSTEM
The Ambulatory Care Environment
• Times with patients are shorter
• Repetitive over time
• Span the length of treatment
• May be interrupted by inpatient stays
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UNC HEALTH CARE SYSTEM
Translating Caring Theory to
Outpatient Oncology
North Carolina Cancer Hospital
• Flagship site for UNC Cancer Care with 150,000 visits/year
• Clinical home of UNC Lineberger Comprehensive Cancer Center
• Multidisciplinary adult and pediatric space including 101 examination,
treatment, consultation, and procedure rooms
• 72 infusion stations for adults (48), children (14), and clinical trials (10)
• 3 Linear Accelerators for Radiation Therapy
• 50 inpatient beds for medical oncology and bone marrow transplant
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UNC HEALTH CARE SYSTEM
SCT and the Oncology Patient
Tenets resonate for patients treated for a chronic
illness over time
• Maintaining Belief in patients ability to come through illness with
meaningful life/dignified death
• Understanding what is most important to patients/families
• Supporting patients/families through difficulty
• Assisting patients who cannot do for themselves
• Enabling patients to progress to highest level during
• Treatment
• Survivorship
• End of life
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UNC HEALTH CARE SYSTEM
Dissemination in Outpatient Oncology
• Replication of Inpatient Success
• Effort led by Oncology Carolina Care Committee
• Multidisciplinary membership of staff and leaders
• Guidebook rewritten to accommodate ambulatory
arena
• New behavior each month
• High patient volume with different providers
across diagnoses and clinical environments
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
• Few minutes of uninterrupted time to
Moment of
Caring:
Knowing
and
connect and convey concern during visit
• Recognize feeling of patient
• Establish connection
• Convey concern
• Goal – Each team member spend 3
uninterrupted minutes with at least one
patient
Being With
• Registration
• Scheduling
• Waiting room
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
Nurse
Manager
Multi-level
Rounding:
Being With
and
Doing For
Schedulers
and
Registration
Interdisciplinary
Hourly
Patient
Rounding
Director
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
Hourly
R
ARe you comfortable?
Patient
O
Other/the care providers accompanying
Rounds:
U
Use the bathroom? Does patient need
Being With
N
Need anything?
and
D
Doing For
S
patients to their visits are acknowledged
assistance/directions?
Door/curtain open or closed for privacy
in clinic rooms?
Safety assessment/call bell in reach?
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
Patient/Family
Advisory Board
• Allows Board members to
Rounding:
connect with patient over
Being With
shared experiences
and
• Offer insight and ease fears
Doing For
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
Words
and
Ways
that Work:
Being With
and
• Patients become active participants
and decision makers in care
• Guide interactions to ensure caring and
concern are consistently communicated
• Helps set and manage expectations
• Greet patients
• Correctly identify patients
• Perform hand hygiene
• Transition patient to next caregiver
Enabling
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
• Entails careful listening to complaint, owning problem,
and working quickly to resolve issue
• Listen with care
• Provide blameless apology
• Thank patient/family for sharing concern
• Fix the problem
• Consider provision of service recovery item
• Follow up with patient/family to let them know how problem has
been addressed
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
•
By actively listening, showing empathy, apologizing
without blame, and fixing the problem, satisfaction
can be increased
•
Creates opportunity for follow-up to improve systems
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
• Team proactively discusses specific
patient needs, is attentive to safety, and
Clinic
Huddle:
Knowing
ensures needs are met during visit.
• Multidisciplinary daily team meeting in clinical
area to encourage information sharing
• Promotes care team partnership
• Enhances patient care
• Creates forum to address safety concerns
• Fosters teamwork
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UNC HEALTH CARE SYSTEM
Carolina Care and
Outpatient Oncology Patients
Clinic
Huddle:
Knowing
• During huddle
• Review of clinic schedule
• Discuss care needs that require focused
attention/support
• Identify opportunities to improve clinic flow
• Kudos are shared
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UNC HEALTH CARE SYSTEM
Evaluation and Sustainment in
Outpatient Oncology
• Sustained scores highest in clinics across system
• 19 percentile increase for overall
• 4 percentile increase for nursing
• Consistent Top 5 Clinics of eligible clinic locations (Meg’s
graph?)
• Review of PG data on monthly basis
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UNC HEALTH CARE SYSTEM
Evaluation and Sustainment in
Outpatient Oncology
• Coordination of improvement efforts with Oncology
Operations Team
• Participation of Oncology leadership in organization
wide CCIOC
• Repeat of roll out 2 years post initial implementation
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UNC HEALTH CARE SYSTEM
Translating Caring Theory to
the Emergency Department (ED)
UNCH Emergency Department
• Annual visit volumes of approximately 72,000 adults and
10,000 pediatric patients
• One of the largest referral centers in North Carolina
• Admit rate near 30%
• Certified Level I Trauma Center for adult and pediatrics
• State Burn Center
• Joint Commission Stroke Center
• Chest Pain Center
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UNC HEALTH CARE SYSTEM
Caring Theory and the ED Patient
Tenets resonate for patients treated in an ED
• Stressors compounded
• High Acuity
• Mixed patient population
• High patient volumes
• Entry point for 50% of inpatient admissions
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UNC HEALTH CARE SYSTEM
Dissemination in the ED
• Replication of Inpatient Success
• Effort led by CNO and ED Director
• Multidisciplinary membership of staff and leaders
• Multiple week roll out
• Each behavior introduced across shifts
• High patient volume with different providers
across diagnoses and clinical environments
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UNC HEALTH CARE SYSTEM
Carolina Care and ED Patients
Moment of
Caring:
Knowing
and
• Convey presence and empathy despite
pressures of busy/changing environment
• Pat on shoulder
• Kind words
• Talking with patient during assessment
• Sitting down to connect while starting an
Being With
intravenous line
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UNC HEALTH CARE SYSTEM
Carolina Care and ED Patients
Nurse
Manager
Multi-level
Rounding:
Being With
and
Doing For
Health Unit
Coordinator
(HUC)
Interdisciplinary
Hourly
Patient
Rounding
Director
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UNC HEALTH CARE SYSTEM
Carolina Care and ED Patients
Hourly
• Hourly Comfort Rounds by Nurses
Patient
and Nursing Assistants
Rounds:
• Focus on personal needs
Being With
and
Doing For
• Offers of food and drink when permissible
• Pain management
• Helping patient and family understand wait time
• Communication of Plan of Care
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UNC HEALTH CARE SYSTEM
Carolina Care and ED Patients
Words
and
Ways
that Work:
Being With
and
Enabling
• Time compression makes 1st
impression essential
• Wait times and the unexpected are key
drivers of dissatisfaction
• AIDET organizes all major components
into one tool
•
•
•
•
•
Acknowledge
Introduce
Duration
Explanation
Thank you
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UNC HEALTH CARE SYSTEM
Carolina Care and ED Patients
Words
and
Ways
• Other important Carolina Care
behaviors and messages
• Closing curtains for privacy
that Work:
Being With
and
• Washing hands for safety
• Stepping out to document care
• Posting important info on the white board
in each room
Enabling
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UNC HEALTH CARE SYSTEM
Carolina Care and ED Patients
• Entails careful listening to complaint, owning
Blameless
Apology:
Being With
the problem, and working quickly to resolve
issue
• Listen with care
• Provide blameless apology
• Thank patient/family for sharing concern
and
• Fix the problem
• Consider provision of service recovery item
Enabling
• Follow up with patient/family to let them know how
problem has been addressed
25
UNC HEALTH CARE SYSTEM
Evaluation and Sustainment in the ED
• Increase from 15th percentile and sustain at 65th despite
volume/capacity constraints
• Current focus
• Improving patient throughput
• Increasing survey returns through discharge calls
• Introduction of Bivaris
• Sends discharged patients text or email with link to electronic survey
• Has increased response rate from 5% to 30%
• Patients respond within 24 hours versus 30 days
• Provides more detailed comments yielding more actionable format
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UNC HEALTH CARE SYSTEM
Sustaining the Carolina Care Culture
at UNC Health Care
• Accountability
• Sustaining Carolina Care in Changing
Environment
• Carolina Care 2014
• Evaluation and Sustainment of Carolina Care 2014
• Sustaining Excellence – The New Frontier
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UNC HEALTH CARE SYSTEM
Accountability
• Multidisciplinary Monday Morning Carolina Care
• Carolina Care Implementation Oversight Committee
• Big 5
• Geriatrics
• Pulmonary/Infectious Disease
• Family Medicine/Nephrology
• General Medicine
• GI Surgery
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UNC HEALTH CARE SYSTEM
Accountability
• Inclusion in Performance Evaluation
• Inclusion in Nursing Professional Expectations
• Weekly Updates and High 5
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UNC HEALTH CARE SYSTEM
Accountability
Annual goals: mean goals for each unit
Unit
FY 15 Proposed Goal
3 AD
CTSU
5 AD
87.5
89.1
88.5
3 WST
6 BT
8 BT
6 WST
85
86
84
85
4 AD-N
5 BT
5 EST
5 WST
7 NSH
6 NSH
6 EST
89
88.2
91
91
91
87.5
87.5
6 WH
5 WH
3 WH
88.1
88.1
89
7 CH
6 CH
5 CH
91
87
89
4 ONC
BMTU
90
91
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UNC HEALTH CARE SYSTEM
Accountability
Key Outcomes from Big 5
• GI Prep with Gatorade
• Care of floors
• Temperature control
• Development of unit brochures
• HUC initiated rounding
• Warm afternoon washcloths
• EVS on Demand
• New food tray activators to keep food warm
• Nutrition Food Service leadership rounding
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UNC HEALTH CARE SYSTEM
Sustaining Carolina Care in
Changing Environment
New challenges
• Organization adopted integrated Press Ganey Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS) patient
satisfaction survey in July 2013
• Implementation of new Electronic Medical Record
Goal - Increase UNCH overall patient satisfaction scores
during implementation of new electronic medical record and
adjust focus to align with HCAHPS
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UNC HEALTH CARE SYSTEM
Carolina Care 2014
Created Carolina Care 2014 Interprofessional Taskforce
• Nursing
• Pharmacy
• Pastoral Care
• Nutrition and Food Services
• Environmental Services
• Supply Chain Services
• Patient and Family Advisors
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UNC HEALTH CARE SYSTEM
Carolina Care 2014
Taskforce divided into eight working groups, with each
group assigned an area of focus
• Patient engaged report
• Nurse-physician rounding
• Communication through care boards
• Narrating care
• Active listening
• Positivity
• Communication in an electronic environment
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UNC HEALTH CARE SYSTEM
Carolina Care 2014
Creating Carolina Care 2014
• Taskforce met for an all-day off-site work session
• During session, team members
• Reviewed goals of the initiative
• Created educational materials for staff
• Devised a rollout plan to ensure implementation prior to the
transition to the EMR
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UNC HEALTH CARE SYSTEM
Carolina Care 2014
Implementing Carolina Care 2014
• Carolina Care 2014 content was introduced in weekly segments
• Information was reviewed during weekly Carolina Care Huddles
• Managers utilized standardized template that included a weekly topic of
focus with
•
Set goals and tasks
•
Tools to educate staff members and weekly metrics to determine success
•
Electronic access Carolina Care tools on a shared network drive
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UNC HEALTH CARE SYSTEM
Carolina Care 2014
Carolina Care 2014 Implementation Tools
• Weekly Huddle Guides
• Words and Ways that Work
• Evidence-based literature to support interventions
• Pocket cards with key weekly topic information
Managers also shared information and tools with staff members during
monthly staff meetings and through weekly email messages
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UNC HEALTH CARE SYSTEM
Evaluation and Sustainment of
Carolina Care 2014
• Following implementation, scores improved to 76th percentile in March 2014 and
reached high of 95th percentile week of March 16, 2014
• Post-intervention metrics: outperformed FY14 organizational goal (75th percentile)
for patient satisfaction. These improvements were sustained in May 2014 (82nd
percentile) and June 2014 (83rd percentile)
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UNC HEALTH CARE SYSTEM
Sustaining Excellence – The New Frontier
• Ambulatory Improvements across Medical Center and
Physician led clinics
• Physician Engagement
• Carolina Care across affiliate hospitals within UNC Health
Care System
• Annual Competency for all Nursing staff
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UNC HEALTH CARE SYSTEM
Tonges Translational Model for
Theory-Driven Practice
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