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Optimizing the Roles of Nurses to Improve
Efficiencies
Gina Browne
Scott Robertson
Stephen Samis
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OPTIMIZING THE ROLES OF NURSES
TO IMPROVE EFFICIENCIES
Gina Browne
Professor of Nursing
McMaster University
Presentation Prepared for the CHSRF on Call Webinar Series
Optimizing the Roles of Nurses to Improve Efficiencies, June 27, 2012
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Transforming?
“… we must depart from
habits of mind that have
characterized our usual
thinking.”
- Clyde Hertzman
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WICKED PROBLEMS
Wicked questions are used to expose the assumptions held
about an issue or situation by members of a group
-Zimmerman
… to make the “undiscussable”, discussable
-Rusch
It is “wicked” if there is an embedded paradox or tension in
the question
Wicked questions do not have obvious answers “How to
control health costs and make the health care system
sustainable?”
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General Assumptions About Causation of Costs:
•
•
•
•
Aging?
Chronic Disease?
Baby Boomer?
Technological Advances?
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CONTEXT and Behaviour re-examined
Ontario population 13 million
• 1% of population 130,000 use 49% of
hospital/home care services
• 5% of population 650,000 use 84% of
hospital/home care services
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Winnipeg ED Frequent Use Category
(Doupe et al., 2012)
Less
Frequent
1-6
visits/year
Frequent
1-17
visits/year
Very
Frequent
> 18 +
visits
103,287
2,177
223
Primary Care Visits >7
33.2%
66.7%
71.3%
Primary Care Physicians
Visited >3
22.7%
46.8%
62.3%
Specialists Physician
Visits >3
22.3%
48.7%
38.1%
Hospital Admissions >2
1.7%
5.0%
3.6%
E.D. Visits Previous Year
>7
0.5%
17.8%
70%
Calls to Health Links >
2.7%
13.0%
20.2%
Number of People
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Less
Frequent
Frequent
Very
Frequent
27.0%
46.5%
57.9%
Arthritis
39.7%
60.1%
78.0%
Asthma
17.8%
37.6%
40.4%
Diabetes
12.7%
28.4%
25.1%
Heart Disease
14.5%
31.3%
14.8%
Ischemic Stroke
8.2%
17.4%
10.3%
Lowest Income
Quintile
Physical Disease
- Winnipeg, Doupe et al., 2012
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Less
Frequent
Frequent
Very
Frequent
Anxiety
12.6%
34.3%
57.0%
Depression
30.4%
60.3%
79.4%
Dementia
6.1%
21.6%
43.9%
Personality Disorder
2.2%
13.3%
31.4%
Schizophrenia
1.9%
8.0%
22.9%
Substance Abuse
9.9%
35.9%
67.3%
Mental Illness
- Winnipeg, Doupe et al., 2012
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Principles of causation in Social Epidemics “Tipping Point”
The “boiling” point of massive modern change”
by Malcolm Gladwell “Biographies of Mysterious change”
1. Contagious Behaviour or ideas:
… unexpected properties of things
… “sticks”, makes an impact
… because of reading , hearing, seeing, thinking
e.g… virus, fashion, crime, technologies, use of health resources
2. Law of the few:
… little causes having big effects
… geometric progression and out-of-proportion, not
… proportional or gradual
3. Both contagion and the few happens in a hurry! Dramatic change – “baby
boomers” - “The power of context”
Drummond Report
Deterioration of Ontario’s Financial Rating
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Different Ways of Tipping
• Growth (stimuli): aging, technology
• Growth (transformation) of disease: from
acute to chronic
• Growth and loss in context
– Health care consumes 50% of
provincial budgets
– Financial down grading
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How can we create positive social epidemics?
Arab
Spring?
• Contagious message of social
justice sticks
• Suddenly “man set himself on fire”
• Youth rebels
• Arab Spread
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New Contagious Messages About Patient
Needs and Health Care:
• A few people use most expensive health
resources
• Acute, episodic, on-demand medical care:
– A poor match for some chronically ill
– Does not prevent emergency hospital use
• Proactive nurses providing continuity needed for
better care of chronically ill and vulnerable 5%
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Transforming Models of Care
“Hi Access”
Recurrent Problem
Citizen
Resolved Problem
Citizen
Hi Vulnerability
Low Vulnerability
Resistant Problem or
Unreached
5%
No problem resourceful
citizen
“Low Access”
84% of hospital home care budget
95%
16% of hospital home care budget
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Comparative effects and costs of
models of care for chronic
disease
Expert Commission 2012
CHSRF/CNA
“Better Health, Better Care”
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Effects Produced
Effects Produced
Costs for Resources
Costs for
Consumed
Resources Consumed
Increased
Increased
Same
Same
Reduced
Reduced
Increased
Increased
More Effective/
More Costly
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Equally Effective/
More Costly
Same
Same
More Effective/
Equally Costly
4
Equally Effective/
Equally Costly
Reduced
Reduced
More Effective/
Less Costly
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Equally Effective/
Less Costly
2
Less Effective/
More Costly
3
5
Less Effective/
Equally Costly
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Less Effective/
Less Costly
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- Birch & Gafni, 1996
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Promising Models of Chronic Care?
•Nurse-led
•Natural settings-schools
•Primary Care
•Community
•Home Care
• Professionally-led
• Targeted
• Proactive (outreach and aimed at determinants of
health)
• For chronically ill or circumstances
• Supplement areas of vulnerability
• Comprehensive – Interdisciplinary Team
• Use of phone or alerts (case finding)
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Priority Chronically Ill?
•
•
•
•
•
Hospitalized past year recently discharged
ER use past year recently discharged
Lives alone
Cognitive impairment (Dementia)
Mental (Anxiety, Depression, Substance
Abuse)
• Living in a long-term care facility
• Poor
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Steps for Large Scale Transformations
-John Kotter
1.
2.
3.
4.
5.
6.
7.
8.
Increase the urgency for change
Build the powerful guiding team
Get the vision right
Communicate for buy-in e.g. MD Model okay
for 95% (remove fear), Nurse led model for 5%
Empower action
Create short term wins
Don’t let up
Make change stick… contagious messages
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Closing Comment:
Changing behaviour is less a matter of
giving people analysis to influence
their thoughts and more about helping
people see a truth to influence feelings
– The Heart of Change
- John Kotter
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The Northern reality of advanced
nursing practice
Scott Robertson
Chief Nursing Officer, Government of the Northwest Territories
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NURSING PROFESSION ACT
S.N.W.T. 2003,C.15
In force January 1, 2004;
SI-004-2003
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A Tale of Two Hospitals
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Now what?
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Questions?
Please submit your questions electronically
using the “Questions box” on the
bottom left of your screen.
Alternatively, English questions can be asked
verbally by pressing *1 on your telephone.
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Thank you!
To connect directly with our presenters….
browneg@mcmaster.ca
nursing@gov.nt.ca
For more information on past and future
sessions please visit us at www.chsrf.ca/oncall
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