Building Blocks: Protocols

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NICHE Building Blocks II: Clinical Protocols

John Jorgensen, RN, MPADirector, Informatics, Auxiliary ServicesFort Sanders Regional Medical CenterKnoxville, Tennessee

Deirdre Carolan Doerflinger, CRNP, Ph.D.Geriatrics Clinical Nurse SpecialistInova Fairfax HospitalFalls Church, Virginia

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Introduction

The purpose of this presentation is to provide information not only on what makes a good protocol but more over how to utilize protocols to drive improvements in the care of older adults.

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Objectives

Discuss factors that influence the selection, implementation and dissemination of evidenced based clinical best practice protocols

Describe implementation strategies for successful implementation of a protocol

List at least three methods of “hardwiring” protocols

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Objectives (continued)

Identify the importance of interdisciplinary collaboration for protocol implementation

Delineate strategies for addressing the challenges of measuring performance

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A Protocol by Any Other Name

Protocol – “Precise guidelines with a structures and logical approach to a closely specified clinical problem” (D. Jenkins, 1991)

Procedure – “Set of action steps describing how to complete a clinical function”

Algorithms- Set of steps that approximates the decision process of and expert clinician

Clinical Practice Guidelines – “Systematically developed statements to assist the practitioner and patient decisions about appropriate health care for specific clinical circumstances (S. Wolf, 1990)

Critical Paths – Multidisciplinary approach that guides the nurse in what to do and when

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NICHE Protocols Research based clinical practice protocols for

specific geriatric syndromes Help the nurse prevent, recognize and treat clinical

conditions seen frequently in elders Common Geriatric syndromes and/or other Clinical

Issues for hospitalized older adults are:

Pressure Ulcers

Advance Directives

Adverse Drug Events

Falls

Physical Restraint Use

Pain Nutrition-Weight Loss

Delirium

Sleep Disturbance

Dementia Discharge Planning

Functional Decline

Incontinence Depression

Capezuti, E., Zwicker, D., Mezey, M., Fulmer, T., Gray-Miceli, D., and Kluger, M. (Eds.). (2008). Evidence-based geriatric nursing protocols for best practice (3rd edition). New York: Springer Publishing Company

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Influential Factors For Protocol Adoption The high level view of the process

includes: Recognition Selection of appropriate

evidenced based practice (EBP) protocols

Adoption/Implementation Hardwiring the protocol

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Step One: Recognition

Takes many forms As simple as clinical area identifying

areas of practice concerns/patient outcomes Must be data driven

As robust as using an assessment tool such as the Geriatric Institutional Assessment Profile (GIAP) to identify areas for needed improvement

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Step Two: Selection of the EBP Protocol Many well researched protocols

are available Why are they not used even when

there is clear evidence of their effectiveness? Social influence theory Transtheoretical model Diffusion of innovation theory

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Social Influence Theory

Social influence theory posits that behavior of one person influences others as to how they respond, feel and think about change. (Zinbardo, Leippe, 1991)

– decisions and actions are strongly guided by prevailing practice, social norms, economic pressures and the habits, customs and values held by peers (Mittman, 1992)

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Transtheoretical Model Transtheoretical model – identifies 5

stages involving movement from knowledge and attitudinal change to action phrases where emotional and positive reinforcement need to occur and finally to practitioners adapting to the behavior enters a maintenance phase where the behavior is self sustaining as long a social support and reward systems are in place (Rogers, 1995).

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Diffusion of Innovation Theory

Diffusion of innovation theory posits that change occurs when a small group of innovators believe strongly that adoption of a protocol will improve patient care. This “change idea” then passes from the innovators to the “early adopters” and the idea takes off. (Rogers, 1995)

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Step Two: Selection of the EBP Protocol Involve end users from outset, enlist

ownership Involve key players

“Nay sayers” Champions

Be flexible - may need to incorporate EBP into own protocol

Lobby, lobby, lobby! Present opportunities individualized to

specific audience

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Step 3: Implementation Successful implementation

dependent upon recognition of factors which inhibit and encourage protocol adoption. Qualities

ProtocolHealthcare professionalPractice setting

Incentives for adoption Regulatory requirements

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Step 3: Implementation

Tips Place protocols in easily accessible

location Use pocket cards with bullet points

or checklists Computer prompts Use of trigger cards such as

SPICES mnemonics (Fulmer, 1991)

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Step 3: Implementation Considerations

Determine opinion leaders (nurse managers or credible staff person) – gain their support

Clinician factors such as age, training, knowledge base in protocol domain

Irrational forces – fear, anxiety and resistance to change all tied to beliefs about self-efficacy

Are the protocols too rigid

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Step 3: Implementation

Publicize in every possible forum: you never know where you will find

a new champion! No surprises, no matter how

insignificant Know your measurement

mechanism going in

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Step 4: Hardwiring

Continual review of outcomes Education

New staff Annual review

Competency Training Monitoring use of the protocol

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Strategies for Successful Protocol Implementation – Administrative Support 8 of the top 10 barriers to using research

findings in practice are related to the work environment and the organizational process Lack of authority Little support from other staff and

physicians Management refusal Insufficient time

These barriers are directly influenced by management

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Strategies for Successful Protocol Implementation – Committee/Council Prevailing organizational culture (customs,

attitudes, beliefs) must support protocol adoption and implementation

Teams are at the very root of this culture Utilize teams as the base units for change

Staff survey as to key geriatric syndromes

Manager conducts interviews to collect commentary to determine priorities

Annual goal setting Unit staff and manager work

collaboratively to establish goals, set action plans and assigned specific tasks to complete

Unit progress monitored – staff become experts

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Strategies for Successful Protocol Implementation – Social Influence Strategies

The most crucial factor for successful protocol implementation is the use of multifaceted strategies (Kaluzney et al., 1995; Oxman et al., 1995; Solberg et al., 2000.

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Strategies for Successful Protocol Implementation – Social Influence Strategies Catalogues of strategies to meet

specific to the situation seem most appropriate Must fit desired behavioral

change Practitioner type Technologies in use

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Strategies for Successful Protocol Implementation – Social Influence Strategies

Social influence strategies useful in healthcare setting Use of opinion leaders (excellent

staff clinicians, APRNs, nursing school faculty members, outside experts)

Performance improvement Study groups Patient care rounds Participatory guideline development

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Strategies for Successful Protocol Implementation - Consultants Wherever possible involve internal

consultations and involve them on patient care teams Pharmacy for poly pharmacy Therapies for skin care, mobility,

discharge planning SLPs for swallowing protocols Risk management for elopement

Involve outside consultants to assess, kick off your program and to evaluate progress GIAP services provide valuable

information on institutional attitudes, education and practice

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Strategies for Successful Protocol Implementation – Models of Care Fit strategies to the model of care being

used. Geriatric Resource Nurse (GRN) Model

Experts on each unit guide protocol development

Acute Care for Elderly (ACE) Protocol development for distinct unit

Social influence strategies remain in play regardless of care model

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Hardwiring Protocols – Sustaining Behaviors Promote compliance with creative

rewards and incentives Friendly competition between units Use of awards for unit with best

project – See NICE AWARD Reports at leadership on nursing unit

performance Falls rates Skin care stats Documentation screening on

admission, assessments and interventions for pain and patient discharge planning.

Regular study groups, sensitivity training, monthly rounds, Games that increase knowledge

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Hardwiring Protocols – Sustaining Behaviors Use of special training for opinion

leaders who become the role models when training of all staff is initiated

Case presentations Huddles where there is a short meeting

to identify patient issues and communicate to all team members

Consider educating consumers through public relations Knowledge of best practice empowers

consumers to make choices that are more informed

A way to evaluate appropriateness of care

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Hardwiring Protocols – Sustaining Behaviors

New employee education should include information on the protocol & its justification for use

Extends to floats & temporary employees Cover the critical protocols of fall

prevention, restraint use and management of difficult behaviors

Incorporate this training into annual competency training for all staff to reinforce and sustain the behavior change

Titler and colleagues suggest “reinfusion” of evidenced-based practice by developing a plan of systematically reintroducing the protocol and monitoring its use.

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Hardwiring Protocols – Sustaining Behaviors

Agreed upon documentation can be embedded into the electronic medical record Prompts & screen lay out are critical to success Education of staff on use of screens critical Constant monitoring via clinical electronic query

provide leadership with information on performance

A variety of EBP tools can be incorporated Alerts can be sent to various disciplines: for

abuse, frail elder consults, pharmacy consults for med reconciliation, functional assessment screening can trigger therapy involvement and fall event data tracked more efficiently to reduce incidence.

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Interprofessional Collaboration The goal of protocol implementation is to

ensure the actual use of the protocol. Involvement of disciplines requires a

common language and documentation that transcends petty fiefdoms within the traditional bureaucratic structure of health care organizations

Intra professional teams can be formed to work jointly on issues common to all

Clear examples include skin care, fall prevention, pain management, restraint reduction and preventing the hazards of immobility

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Approach Deployment Results

(1) Reacting To Problems (2) Early Systematic Approach

(3) Aligned Approach (4) Integrated Approach

Steps Toward a Mature Process Approach

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Measuring Performance (Quality is in the eye of the beholder) Different interests for multiple

users a key challenge Stakeholders

Internal• Administration• Clinical staff• Quality department

External• Regulatory agencies• Consumers – Health grades, CORE

Measure information

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Measuring Performance (Quality is in the eye of the beholder) (cont’d) Must use acceptable measurement tools

where care measures are identified and standardized with a common measurement language grounded in shared perspectives on quality across groups and disciplines.

Once systems are in place data must be collected: Logistical issues of collecting,

recording, reporting and managing data

Data must be analyzed in statistically appropriate ways

Health care environments are different and change frequently – finding common denominators is a major hurdle

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Measurement Tools Assessment phase findings - Data

allergies Collecting data without:

Knowing why Seeing results Developing findings and conclusions

Cataloging monitoring activities to Determine if they are truly needed What / where they get reported Are there actionables Who is the owner so that collection

can readily be accessed –important o these days of continuous readiness.

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Characteristics of Good Measurement Tools

Characteristics of good performance measures Usefulness

What do we need to know? How do we intend to use the performance

measure and can it be used this way? Targets improvement now, in the past and for

the future Precisely defined – clear operational definitions Validity – does the measure measure what it is

intended to measure? Sensitivity – ability to capture the “true” cases of

the event being measured (false positives) Specificity – The likelihood of a negative test

when the condition is actually present – indicates low specificity.

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Characteristics of Good Measurement Tools

Characteristics of good performance measures (cont’d) Reliability – Results that are reproducible and

consistent indicate high reliability. Interpretable – the degree to which it conveys

a result that can be linked to the quality of clinical care.

Risk-adjusted – Some patients are sicker than others some have co morbidities, some older and more frail. – create level playing field

Easy to collect – Easily retrievable data with little burden – goal quick and good rather than quick and dirty!

In control – must reflect the practice being observed and must be within the control of the practitioner

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Data Collection Methods Standard chart review Clinical Query in which the

documentation database can be queried for specific elements

Direct observation Interviews

Staff Patients Physicians

Tracers – essentially and interview and record review all in one

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Analysis / Interpretation /Reporting Results -Begins with taking data

and organizing it into categories Could be hierarchical Based on a structural taxonomy

Findings – Taking results to the next level that speak to the outcomes of the results

Conclusions – An overview of findings for use in future projects or as predictors for future activities.

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Healthcare Change / Differences / Considerations

Healthcare is dynamic and change occurs frequently

There is movement of care from one setting to another

Frequent introduction of new technology Even within supposed integrated health

care delivery systems there is often a lack of standardized processes between facilities

Also exists a new public awareness where there is a desire to see outcome data prior to undergoing procedures or being admitted to a particular facility

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Summary Elder focused practice protocols have the

potential to improve patient care by fostering clinical decision making based on best practice geriatric nursing standards

Administrative commitment and a comprehensive organizational strategy are pivotal.

Pay close attention to how and what protocols are developed

Recognize/publish small successes in winning additional support

Remember imagination, courage and love are positive drivers for change.