Goals for the session:

Have beginning understanding of next level of the Documentation Framework

Support introduction of Safety & Education documentation changes as next building block of Documentation Framework

Have begun a unit-specific implementation plan

Know proposed rollout schedule, especially go live date for your unit.

Knowledge of resources available to support this work

Falls/Safety Documentation Changes: Implementation Planning

◦ We began to implement changes to our Nursing Documentation Framework in October, 2010 with the rollout of Priority Problems.

◦ Based on feedback from nurses and from recent Magnet and JCAHO Surveys, this change has been the catalyst for dramatic improvements in documentation. “My documentation reflects how I impact patient

outcomes” (typical Staff Nurse comment when speaking about Priority Problems).

Intro

◦ We are now ready to begin the next phase of the Nursing Documentation Framework change with implementation of the Falls/Safety Section and changes to Education Tab.

◦ As with Priority Problems, this is less of a technical change, more of a practice change.

◦ This is a huge ongoing culture change

Intro. (cont.)

◦ CAPS will sit with participant(s) from their unit(s) the extent possible but we want to work in teams, even if it’s not your unit team.

◦ We will begin to craft a unit-specific Implementation Plans

◦ We ask that you honor timeframes

◦ Jot down questions and “ah-ha’s” as you go so you don’t lose them. If there are any issues we are not able to address today, we will put on Parking Lot for follow up after the session.

Logistics

Falls expert brought in to address high Falls rate said our emphasis was on screening for rather than preventing falls. Our old screen had been modified to the point that it was NOT evidence-based.

Historical approach to a new regulation or problem – ADD a NEW Documentation section◦ Increases documentation burden on nurses◦ Nurses spend time documenting about instead of preventing

problems◦ Our goal to help with increasing staff satisfaction – standardize and

simplify documentation. The hospital is a dangerous place for patients. “First do no harm” (Hippocrates). Organizational Goal --

Culture of Safety

Kotter’s 1st Step:

Increasing the Sense of Urgency

At your table, identify 3-5 common safety risks for patients on your unit. 1. _____2. _____3. _____4. _____5. _____

Kotter’s 1st Step:

Increasing the Sense of Urgency

Finding our way together….

Kotter’s Step Two: Form a Powerful

Coalition

As the Nursing Leaders of VUMC, we must actively LEAD this transformation of practice & documentation

Requires strong leadership & visible support

We cannot “manage” change from the sidelines

“Managing change isn’t enough – you have to lead it.” (Kotter, 1996)

Managers create order & predictability, while leaders establish direction, vision, motivate & inspire people. (Weber & Joshi, 2000)

◦ Nursing Leaders & Nursing Educators

◦ Staff Nurses (novice to expert)

◦ SuperUser Champions

◦ SSS CAPS

◦ HED Builders

◦ Key Stakeholders: Medical Director, Physicians, Nurse practitioners

◦ Engage Opinion Leaders early & engage as Champions

Building a Change Coalition

Work as a TEAM

Build ongoing urgency & momentum for the need for change

Change Coalition will…

Vision Statement Safety Documentation, including

assessment, interventions, teaching, and notification, will result in a safer environment for our patients and will prevent or minimize injury.

This will improve patient care and clearly define nursing’s contributions to patient care and the team.

Kotter’s Step 3: Create a Vision

If documentation is a reflection of our care – does it show that nurses make a difference?

Physiological◦ Cardiac◦ Bowel/Gastric◦ Life cycle (pregnancy)◦ Metabolic (glucose)◦ Physical Regulation (infection)◦ Respiratory◦ Skin Integrity◦ Tissue Perfusion◦ Urinary◦ Medication

Psych/Behavioral◦ Cognitive/Neuro◦ Coping◦ Health Behavior◦ Role Relationship◦ Self Care◦ Self Concept

Functional◦ Activity◦ Fluid Volume◦ Nutrition◦ Safety◦ Sensory/Pain

21 CCC Categories

Building an Outcomes Oriented

Documentation Framework

A Home for Evidence Based Nursing Care

Assess * Care * Teach * Manage Priority Problems

According to Albert Mehrabian’s research study in 1968 how much of the message is the actual words used?

◦ 38%◦ 7%◦ 55%

Kotter’s Step 4:

Communicating the message

Email Group meetings One-on-one communication Company publications High level and executive storytelling

delivered company-wide

Which of the following delivery methods is the most effective?

One-on-one face to face discussions that are honest and straight forward and that offer details of the change on a personal level

Cascading small group meetings to share information, brainstorm solutions and implement new processes

According to the 2005 Change Management Best Practice Report….

Communicating to Different Generations

Baby Boomers born 1945 – 60

Traditionalists born before 1945

Generation X – children of boomers

Millenials – grandchildren of boomers

Traditionalists

Baby Boomers

Generation X

Millenials

 Make decisions based on what has worked in the past

Consistency is important

Show Me generation--Body language is very important

Favor top-down decisions

Value respect

Will fight for a cause

Highly Collaborative

Optimistic

Prefer messages presented from positive standpoint

Value work and life balance

Shaped by a culture of instant results

Multi-taskers

Avoid unnecessary meetings

Baby Boomers

Blog

Face to Face communication

Email

PowerPoint Presentation

Styles of CommunicationMatch the Generation to a Style Preferred by that Generation

Generation X

Millenials

Traditionalists

Web Site E-mail updates Monthly updates for leadership to communicate

to staff Newsletters

You can expect to see some/all of the following strategies used to communicate additional Documentation Framework Changes:

For the next 5 minutes discuss:

Who should be included in your unit’s coalition for change? List names and/or titles

Begin to identify your unit-specific communication plan – be specific and include timeframes

Area Specific Coalition and Communication Plan

Obstacles are generally in 3 categoriesPeople

ProcessesStructure

Kotter’s Step 5:

Removing Obstacles & Empowering Action

1. Leadership: Commit to change & voice consistent message

2. Educators & Super Users: Communicate advantages of new process

3. Curmudgeons: Listen to their feedback but don’t leave true resisters in leadership positions

4. 5 positive encounters to overcome 1 negative

5. All Leaders demonstrate their belief that the change will improve patient care & continuity of care

People

o Can’t be too complicated o Must be fairly easy to learno Must fit into workflow o CQI: Looping process…education,

implementation, evaluation, reeducate or change, reevaluate, reeducate/change

Process

o Commit to overtime pay: for SuperUsers to be available during implementation

o Change takes time: hard-wiring to new processes can take up to 4 weeks

o Adequate Education: Educators, Superusers, Staff o Identify competing projects: other quality/safety

initiatives; policy/product changes… Anything that will require extra time

o Watch out for staff and Manager overload!

Structure

Take 5 minutes to:

Identify obstacles to success & develop action plans to address

Include prior commitments that might influence timelines for Priority Problem rollout on your unit

Removing Obstacles & Empowering Action

9 North experience

1. What were improvements experienced with use of modified Falls/Safety documentation approach?

2. How did you hard wire the change?

3. What were the challenges to adoption?

Kotter’s Step 6:

Create Short Term Wins

Identify 2-3 successful changes they have experienced in VUH over the past 2-3 years

◦ During any of these changes, did you identify short-term wins during the change process?

◦ How did you celebrate these wins?

◦ What techniques did you use to hardwire the change?

Kotter’s Steps 7 & 8:

Build on the Change & Anchor the Change in culture

Team completes Implementation Worksheet

Educator, Leadership Team member, CAPS partner to create unit-specific plan and begin training

Utilize your CAPS and watch for communication updates

NEXT STEPS