Transformation in Healthcare Transformation in Healthcare Delivery: Essential ComponentsDelivery: Essential Components

Marita G. Titler, PhD, RN, FAANMarita G. Titler, PhD, RN, FAANDirector of Research, Quality and Outcomes Management

Department of Nursing Services and PatientUniversity of Iowa Hospitals and Clinics

Clinical ProfessorUniversity of Iowa College of Nursing

Senior Scientist – CRIISP VA HSR Center

Iowa City, IA

TransformationTransformation

▼ Reform – process for trying to make the current pattern work.

▼ Transformation – developing a new and very different pattern.

▼ Revolution – new models of thought; paradigm shift.

Why the current system Why the current system cannot be reformedcannot be reformed

▼ Third party payer system

▼ Current system is profoundly misfocused in defining the doctor as the center of the system and acute care as its primary interest.

▼ Activities of healthcare are simply too complex to be reformed by a political process.

▼ The rejection of new ideas and new technologies are inherent in the current system

(Gingrich, 2003)

ComparisonsComparisonsCurrent System Transformed System

Provider centered Individual Centered

Price Driven Value Driven

Knowledge disconnected Knowledge intense

Slow diffusion of innovation Rapid innovation and speed of diffusion

Care is reactive, episodic, and disjointed Use genetic, outcomes-based knowledge to create a preventive, self-managed, and health-oriented system of continuous involvement using the nutrition-activity-attitude model

Paper based Electronic, information based

Triangular third-party-controlled market Binary, market mediated

ComparisonsComparisons

Current System Transformed System

Adversarial government manages by process

Collaborative government manages by outcomes

Limited choice Increased choice

Outcomes undermeasured and ignored Outcomes measured and improved

Expensive, predatory trial lawyer-enriching system of dispute resolution

Fair, affordable system of health justice that protects individuals and encourages access to quality care

Overall cost increase Overall cost decrease

(Gingrich, 2003)

Essential Elements to Transform Essential Elements to Transform HealthcareHealthcare

▼ Leadership

▼ Collaboration and Community Partnerships

▼ Balance between regulation and creativity

▼ Health care Information systems

▼ Research – Programs of Research – Considerations when planning clinical studies –

translation into practice

▼ Studying current transformations

Leadership Leadership ▼ Central function of leadership is to achieve

a collective purpose.

▼ Transaction-based– “you scratch my back, I’ll scratch yours”– Mutual purposes are advanced only as long as

both parties perceive their individual interests are furthered by the relationship

▼ Transformation-based – When leaders engage with followers in pursuit

of jointly held goals – Relationship based

Transformation-Based Transformation-Based Leadership: Essentials Leadership: Essentials

▼ Balancing the tension between efficiency and reliability – that is quality and safety with cost.

▼ Creating and sustaining trust

▼ Actively managing the process of change

▼ Involving workers in work design and work flow decision making

▼ Creating a learning organization

(IOM, 2004; A rapid learning health system/Health Affairs S, 2007)

Challenges in HCD: Challenges in HCD: LeadershipLeadership

▼ Role of CNE in organizational structures

▼ Development of nurse managers of micro-systems

▼ Education of CNE and NMs

▼ Dollars invested by healthcare systems in training of current and future nursing leaders

▼ Span of control and performance expectations of nurse managers

▼ Responsibility and accountability for staffing, quality and safety in patient care

Collaboration and Collaboration and Community PartnershipsCommunity Partnerships

▼ Nurse Physician collaboration

▼ Collaboration with consumers/individuals

▼ Creating acute care environments that promote self-care of individuals and their families (e.g. critical care; peri-op settings; medication management; patient/family education).

▼ Partnerships across acute care hospitals

▼ School settings – how are school nurses being utilized? Need to be engaged as interactive resources for wellness education

The National Nursing Practice The National Nursing Practice Network for EBP and Network for EBP and Translation ScienceTranslation Science

NNPN represents a commitment to the promotion and implementation of evidence-based practices through a

collaborative model designed to promote shared learning and participation.

Mission and Vision Mission and Vision StatementStatement

▼ The mission of the NNPN is to foster exceptional healthcare outcomes; advance professional nursing practice thru application of evidence; support nursing leadership development for EBP; increase understanding of mechanisms and strategies that fosters use of evidence.

▼ Vision – to be a national exemplar of nursing practice excellence, innovation, translation science, and promotion of EBPs

About Us: NNPN Represents 15 statesAbout Us: NNPN Represents 15 states

Regulation and Creativity: The Regulation and Creativity: The BalanceBalance

▼ CMS core metrics

▼ October 2008 – payment for adverse events

▼ Emphasis placed on meeting regulatory requirements

▼ May detract from creative innovative ways to meet health and healthcare needs– Self-care management for chronic illnesses– Health education and wellness.– Will/are health systems resourcing these federal

expectations

(Auerbach et al, 2007 NEJM; Shortell et al, 2007 JAMA)

Information Systems: Information Systems: ChallengesChallenges

▼ Need to be adequately piloted, tested and revised for usability in care prior to deployment

▼ Understand the work and workflow and then designed to support work

▼ Data warehouses and repositories – essential data elements

▼ Including nursing treatments – standardized language to capture the work of nursing

(Doebbeling et al, 2006; Titler et al, 2004)

PublicationsPublications

▼ Dochterman J., et al. (2005). Describing nursing care using standardized language. Journal of Nursing Scholarship, 37(1), 57-66.

▼ Titler, M., Dochterman, J., Pettit, D., Everett, L., Xie, X., Kanak, M., & Fei, Q. (2005). Cost of hospital care for elderly at risk of falling. Nursing Economics, 23 (6): 290-306.

▼ Titler, M., Dochterman, J., & Reed, D. (2004). Guideline for conducting effectiveness research in nursing and other healthcare services. Iowa City, IA: The University of Iowa, College of Nursing, Center for Nursing Classification & Clinical Effectiveness.

▼ Titler, M., Dochterman, J., Xie, X. J., Kanak, M., Fei, Q., Picone, D. M., et al. (2006). Nursing interventions and other factors associated with discharge disposition in older patients after hip fractures. Nursing Research, 55(4), 231-242.

PublicationsPublications▼ Shever, L., Titler, M., Dochterman, J., Fei, Q., & Picone,

D.M. (2007). Patterns of nursing intervention use across six days for three older patient populations. International Journal of Nursing Terminologies and Classifications, 18 (1), 18-29

▼ Titler, M., Dochterman, J., Kim, T., Kanak, M., Shever, L., Picone, D. M., et al. (2007). Cost of care for seniors hospitalized for hip fractures and related procedures. Nursing Outlook, 55, 5-14.

▼ Titler, M., Jensen, G. A., McCloskey-Dochterman, J., Xie, X., Kanak, M., & Reed, D. (in press). Cost of hospital care for older adults with heart failure: Medical, pharmaceutical, and nursing costs. Health Services Research .

PublicationsPublications▼ Picone, D. M., Titler, M., Dochterman, J., Shever, L.,

Kim, T., Abramowitz, P., & Kanak, M., (in press). Predictors of medication errors among elderly hospitalized patients. American Journal of Medical Quality

▼ Kanak, M., Titler, M., Shever, L., Fei, Q., Dochterman, J., & Picone, D. M. (in press). The effects of hospitalization on multiple units. Applied Nursing Research

▼ Reed, D., Titler, M., Dochterman, J., Shever, L., Kanak, M. & Picone, D. (in press). Measuring the dose of nursing interventions. International Journal of Nursing Terminologies and Classifications.

The wonder pill most frequently encountered currently is in fact the “wonder clinical information system,” despite the often glaring discrepancy between the promise of systems in showrooms and the way they perform in the real world.

Shojania & Grimshaw (2006). Health Affairs, 24(1), p 149

Warning

Essential Elements to Transform Essential Elements to Transform HealthcareHealthcare

▼ Leadership

▼ Collaboration and Community Partnerships

▼ Balance between regulation and creativity

▼ Health care Information systems

▼ Research – Programs of Research – Considerations when planning clinical studies –

translation into practice

▼ Studying current transformations

University of IowaIowa City, Iowa

Principal InvestigatorMarita G. Titler, PhD, RN, FAAN

Co-Principal InvestigatorKeela Herr, PhD, RN

Project DirectorGail Ardery, PhD, RN

InvestigatorsJohn Brooks, PhD

Kathleen C. Buckwalter, PhD, RN, FAAN William Clarke, PhD

Linda Everett, PhD, RNJ. Lawrence Marsh, MD

Margo Schilling, MDBernard Sorofman, PhD

Toni Tripp-Reimer, PhD, RN, FAANXianjin Xie, MS

Funded by AHRQ RO1 HS10482

TRIP Intervention Saves Healthcare TRIP Intervention Saves Healthcare Dollars and Improves Quality of CareDollars and Improves Quality of Care

Aim 1: To test the effect of the TRIP intervention on nurse and physician adoption of evidence-based acute pain management practices in elders.

Aim 2: To test the effect of the TRIP intervention on decreasing barriers to use of evidence-based acute pain management practices.

Aim 3: To determine the cost effectiveness of the TRIP intervention.

Follow-up – sustainability

Specific AimsSpecific Aims

RO1 HS10482

Cost FindingsCost Findings(Aim 3) (Aim 3)

▼ Total costs per patient were $1,495.89 less in the E group than the C group (p <0.0001)

▼ For each one-unit increase in the Summative Index, total costs decreased by $1,598.75 (p = 0.002)

▼ A net savings to the hospital of more than $131,000 per 100 patients, even after implementation costs are taken into account.

Cancer Pain in Elders: Cancer Pain in Elders: Promoting EBPs in HospicesPromoting EBPs in Hospices

▼ Keela Herr PhD, RN, FAAN (PI)

▼ Marita Titler PhD, RN, FAAN (Co-PI)

▼ Other investigators:– Perry Fine, M.D.– John Swegle Pharm D– Sara Sanders PhD– Mary Ersek, PhD

Study AimsStudy Aims

▼ To test the effect of a multifaceted TRIP-Cancer Pain Intervention on promoting adoption, by health care providers, of evidence-based cancer pain management practices for elder hospice patients

▼ To test the effect of a multifaceted TRIP-Cancer Pain Intervention on pain severity in elder hospice patients with cancer pain.

Improving Continence and Pain Control Improving Continence and Pain Control in Nursing Homes: M-TRAIN in Nursing Homes: M-TRAIN

▼ Multi-level Translation Research Application in Nursing Homes

▼ Janet Specht, PhD, RN (PI)

▼ Paula Mobiliy, PhD, RN, (Co-PI)

▼ Other investigators– Keela Herr– Sara Sanders– Gerald Jogerst

Study AimsStudy Aims▼ To test the effect of the M-TRAIN intervention on

urinary continence and pain outcomes for elderly NH residents.

▼ To test the effect of the M-TRAIN intervention on NH quality outcomes, state survey violation citations, and staff turnover.

▼ To describe the relationship of facility characteristics with high and low adoption among NHs that receive the intervention.

Use of Evidence-Based Use of Evidence-Based Practices in SchoolsPractices in Schools

▼ Susan Adams – doctoral dissertation

▼ Purpose – descriptive study to explore factors that promote use of evidence-based practices by school nurses.

▼ Instrument and conceptual model to guide further research

▼ Variables that promote or impede use of EBPs to guide implementation intervention research

Impact of System-Centered Factors, and Processes of Impact of System-Centered Factors, and Processes of Nursing Care on Fall Prevalence and Injuries from Nursing Care on Fall Prevalence and Injuries from

FallsFalls ▼ RWJ - INQRI (interdisciplinary quality research

initiative)

▼ Purpose - investigate linkages among 2 NQF patient outcomes of falls and injury from falls, NQF system-centered measures such as skill mix, nursing care hours per patient day (HPPDS), and professionalism, and processes of care to prevent falls.

▼ Sites are 190 adult medical-surgical units from 45 hospitals in the U.S. that are members of the NNPN.

Center GrantsCenter Grants

What factors should one consider What factors should one consider in designing a research study to in designing a research study to make it ready for translation, make it ready for translation,

assuming efficacy and assuming efficacy and effectiveness are found?effectiveness are found?

Nature of the intervention being tested

Population

Health care system

Public Policy

DisseminateKnowledge

GenerateNew

Knowledge

QualityClinicalPractice

ApplyFindings

in Practice

ConductResearch

IdentifyQuestions

Factor to Consider: Nature Factor to Consider: Nature of the interventionof the intervention

▼ Complexity of the intervention

▼ Intervention dose

▼ Frequency of delivery

▼ Who delivers the intervention

▼ How will this intervention get packaged for ease of use?

▼ How will you package the dependent variables from the study into metrics for use in busy HC settings

Factor to Consider: Nature Factor to Consider: Nature of the intervention of the intervention

▼ Clinically relevant alternative interventions

▼ Who delivers the intervention– RA– Knowledge and skills– Multiple care givers– Credentials – Educational level– Expertise (novice to expert)– Family caregivers– Lay persons– Health literacy – Training package

Factor to Consider: Sample, Factor to Consider: Sample, Patient population, ConsumerPatient population, Consumer

▼ Population of interest

▼ Severity of illness/health status

▼ Primary medical diagnoses

▼ Co morbidities

▼ Heterogeneity; inclusion criteria

▼ Age/developmental level

▼ Where does this population have the greatest opportunity to receive this intervention

Factor To Consider: Factor To Consider: Healthcare System Healthcare System

▼ Setting Type▼ Integration into work flow▼ IT implications▼ Population – high volume; high cost▼ Leadership▼ Data source in the HCS for effectiveness (process and

outcome metrics)▼ Packaging the intervention specific to the setting▼ “Context matters”

Healthcare SystemHealthcare System

▼ Will this intervention work in settings like ours with staff resources and competing demands similar to those we have?

▼ Community based research networks

Factor to Consider: Public Factor to Consider: Public Policy Policy

▼ If I do this study and the effect of the intervention is realized, what would the public policy headline look like?

▼ Why should policy makers care about your findings? (high volume issue; high cost?)

▼ Cost-effectiveness of the intervention

▼ What are the key messages for local, state and national public policy makers.

Institute for Healthcare ImprovementInstitute for Healthcare Improvement

This document is in the public domain and may be used and reprinted without permission provided appropriate reference is made to the Institute for Healthcare Improvement.

Studying Current Transformations

Propensity Scoring Propensity Scoring

▼ Statistical method for determining the unique effect of a treatment; reduces the bias in studies in which groups are not randomized to a treatment.

▼ Attempts to recreate circumstances comparable to randomization.

▼ Propensity score is defined as “the conditional probability of being treated given the individual covariates” (D’Agostino, 1998, p.2265)

MethodsMethods▼ Propensity Scores

– Propensity scores are a useful method in observational studies where the researcher had no control on what subjects received the treatment variable of interest.

– It reduces the bias between the group that received the treatment and the group that did not receive the treatment by controlling for a number of confounders.

– Alternative to case control design – matching on variables is limited

– Researcher must first decide what the treatment variable of interest is.• Propensity score analysis dictates that the

treatment variable be dichotomous

Qualitative Research Qualitative Research ▼ Example – Hysong et al 2006

▼ Understanding knowledge use in acute care settings needs to be further informed by qualitative research that uncovers the relative effectiveness of implementation strategies (ex- audit and feedback).

▼ Although RCTs may be the gold standard, qualitative methods may add to our understanding of implementation interventions, and mechanisms by which they work

▼ We should invest in more qualitative studies of ongoing national efforts to improve care (100,000 lives campaign; patient safety practices)

Closing thoughtsClosing thoughts▼ When will we see transformation of

healthcare?

▼ Acute care – who should be running hospitals or multi hospital systems?

▼ How will continuity of care and wellness be emphasized?

▼ Will we capture care delivered by nurses and other healthcare providers?