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Implementation of Joint Commission Measures Implementation of Joint Commission Measures for Alcohol- and Tobacco-related Inpatient Care at VA Pittsburgh Healthcare System g y Lauren M. Broyles, PhD, RN Lauren M. Broyles, PhD, RN Research

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Implementation of Joint Commission Measures Implementation of Joint Commission Measures for Alcohol- and Tobacco-related Inpatient Care at VA Pittsburgh Healthcare System g y

Lauren M. Broyles, PhD, RN Lauren M. Broyles, PhD, RN Research Health Scientist VA Pittsburgh Healthcare System Assistant Professor of Medicine Assistant Professor of Clinical and Translational Science University of Pittsburgh Lauren.Broyles@va.gov

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

y @ g

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SLIDE 2

Acknowledgments

  • Melissa Wieland, PhD; Monica DiNardo, PhD, CRNP; Andrea

Confer, BA; Karen Mancini, MHA, BSN

  • Ali Sonel MD & Ira Richmond DNP MS RN
  • Ali Sonel, MD & Ira Richmond, DNP, MS, RN
  • Career Development Award (CDA10-014) from the Health

Services Research & Development service of the U.S. Department f V t Aff i

  • f Veterans Affairs
  • VA Office of Nursing Services Pilot Program
  • This material is also the result of work supported with resources

This material is also the result of work supported with resources and the use of facilities at the VAPHS, Pittsburgh, PA

  • The views expressed in this presentation do not necessarily reflect

the position or policy of the Department of Veterans Affairs or the the position or policy of the Department of Veterans Affairs or the United States government

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SLIDE 3

Overview

  • Main components of the new SUB/TOB

measures from The Joint Commission (TJC) measures from The Joint Commission (TJC)

  • Five guiding principles
  • General implementation theory
  • Facilitators and barriers to implementation of the

SUB/TOB measures at VA Pittsburgh Healthcare System (VAPHS) y ( )

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  • Large academic medical center
  • Large academic medical center
  • 2 campuses, 661 beds
  • >10,000 admissions/year
  • ~5500 surgeries/year
  • ~1300 trainees/year across disciplines
  • $36.4 million in research

$

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SLIDE 5

External Peer Review Program (EPRP) (EPRP)

  • Official data source for monitoring VA

performance

  • Goal = improve quality of care
  • Data used primarily for quality improvement,

evaluation, and benchmarking with external

  • rganizations
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SLIDE 6

ORYX Program

  • Integrates outcomes and other

performance measurement data into performance measurement data into hospital accreditation process

  • Public availability of performance measure

d t ll i f h it l data allows comparisons of hospital performance

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ORYX Measures for Substance and Tobacco Use

  • Effective January 1, 2014

Tobacco Use

y

  • For all VA Medical Centers nationwide

– Optional for other healthcare systems – Optional for other healthcare systems

  • Similar to those in VA primary care

A l t ll h it li d ti t

  • Apply to all hospitalized patients
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SLIDE 8

Admitting provider

Alcohol screening within 3 days of admission

Social worker

Brief intervention counseling IF ALCOHOL OR SUBSTANCE USE DISORDER

Operationalizing Substance Use M

Psych consult

IF ALCOHOL OR SUBSTANCE USE DISORDER, ALSO: Referral to outpatient treatment

Social worker, based on Psych consult recs

Measures

FDA‐approved med for treatment

Psych consult recs Admitting provider, based on

Follow up contact 15 30 AUD/SUD

Psych consult recs

Follow up contact 15‐30 days after discharge

Primary care RNs? LPNs?

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SLIDE 9

RN

Tobacco screening within 3 days of admission

RN

Brief practical counseling Operationalizing Tobacco Use M

RN + Provider RN

Pharmacotherapy in hospital Referral for outpatient counseling/quit line Measures

Provider RN

Referral for outpatient counseling/quit line Pharmacotherapy at discharge

Primary Care RN? LPN?

Follow up 7‐30 days after discharge after discharge

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SLIDE 10

Timeline

  • Fall 2013
  • January to March 2014
  • January to March 2014
  • April to June 2014
  • July to October 2014
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SLIDE 11

How did I get here?

  • Clinical Background
  • Program of Research

Program of Research

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SLIDE 12

Fall 2013

“The Basics”

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

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SLIDE 13

Guiding Principles

  • Interdisciplinary
  • Participatory
  • Participatory
  • Patient-centered
  • Efficient for staff/congruent with practice
  • “Meaningful metrics”

Meaningful metrics

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SLIDE 14

Establishing the Team

  • Identifying and inviting stakeholders
  • Establishing a charter
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Initial Committee Representation

  • Nursing (inpatient medicine and psych + primary care)
  • Social Work (inpatient medicine + psych)

Social Work (inpatient medicine + psych)

  • Medicine (inpatient medicine + psych)

S b t S i lt

  • Substance Specialty (outpatient)
  • Quality & Performance
  • Research
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Literature Review

  • Inpatient SBIRT, tobacco cessation svcs
  • SBIRT implementation literature

SBIRT implementation literature

  • General implementation theory
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Supplemental Grant Funding

  • VA Office of Nursing Services
  • Formative evaluation

“E l ti I ti t Al h l/T b P f “Evaluating Inpatient Alcohol/Tobacco Performance Measure Implementation” (PI: Broyles)

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PRECEDE-PROCEED

  • Predisposing Factors

–

a person’s motivation to undertake a new behavior or activity; include knowledge attitudes beliefs personal preferences existing skills and knowledge, attitudes, beliefs, personal preferences, existing skills, and self-efficacy

  • Reinforcing Factors

– follow a behavior or activity that provide continuing reward or incentive for its persistence or repetition; include social or professional support, peer influence, recognition

  • Enabling Factors

– make it possible (or easier) for individuals or populations to change their behavior; includes programs resources and services in the social or professional includes programs, resources, and services in the social or professional environment

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SLIDE 19

Aims

1) To assess the antecedent and reinforcing factors required to initiate implementation of the TJC alcohol/tobacco measures on two inpatient units at

  • ur facility (PRECEDE)

2) To assess the factors associated with successful d t i d i l t ti f th TJC and sustained implementation of the TJC alcohol/tobacco measures on two inpatient units at

  • ur facility (PROCEED)
  • ur facility (PROCEED)
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Methods

  • 30 minute audio-recorded interviews with

clinicians/administrators (10) and patients clinicians/administrators (10), and patients (5) from each of 2 pilot units

  • 3 time points: before during after pilot
  • 3 time points: before, during, after pilot

implementation U it b ti

  • Unit observations
  • Rapid analysis of transcripts
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SLIDE 21

January to March 2014

“Getting the Lay of the Land”

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

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SLIDE 22

Initial Logistics

  • National VA call

C itt ti 2 4 k

  • Committee meetings every 2-4 weeks
  • Learning the measures
  • Understanding grant activities game plan
  • Understanding grant activities, game plan

Implementation The roll-out

Formative Evaluation of the

The roll out (QI)

Evaluation of the Roll-out (Research)

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SLIDE 23

Initial Brainstorming Existing Resources Existing Concerns and Barriers Existing Processes of Care

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SLIDE 24

Deciding on Structure & Roles

  • By Unit?

Medical / Behavioral Health Medical / Behavioral Health

  • By Measures?

Alcohol & Tobacco

  • By Activities?

S, BI, RT, Pharmacotx, F/U

  • Missing stakeholders/expertise?

Missing stakeholders/expertise?

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SLIDE 27

April to June 2014

“Cycling”

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

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SLIDE 28

Study Interviews

  • Patients
  • Clinicians

Clinicians

  • Administrators
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SLIDE 29

False Starts and Dead Ends

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SLIDE 30

Heating up

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SLIDE 31

Admitting provider

Alcohol screening within 3 days of admission

Social worker

Brief intervention counseling IF ALCOHOL OR SUBSTANCE USE DISORDER

Operationalizing Substance Use M

Psych consult

IF ALCOHOL OR SUBSTANCE USE DISORDER, ALSO: Referral to outpatient treatment

Social worker, based on Psych consult recs

Measures

FDA‐approved med for treatment

Psych consult recs Admitting provider, based on

Follow up contact 15 30 AUD/SUD

Psych consult recs

Follow up contact 15‐30 days after discharge

Primary care RNs? LPNs?

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SLIDE 32
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SLIDE 33
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SLIDE 34

July to October 2014

“Prioritizing and Plowing Forward”

Behavioral Health is Essential to Health Prevention Works | Treatment is Effective | People Recover

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Prioritizing

  • Stick to Pilot
  • Phase-in process
  • Phase I: process to address 85% of patients
  • Phase II: the “outliers”/unique issues

– Opioid dependent patients – Critical care transfer issues

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SLIDE 36

Piloting the CPRS templates

  • Providers: AUDIT-C and order sets
  • Issues of workflow intuitiveness training
  • Issues of workflow, intuitiveness, training
  • “Think-alouds”
  • VERC
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SLIDE 37

Training

  • Providers in AUDIT-C
  • Social Workers in BI
  • Social Workers in BI
  • Nurses in Tobacco Tactics
  • Developing & Ordering Materials
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SLIDE 38
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SLIDE 39

Tobacco Tactics

Sonia A. Duffy, PhD, RN VA Ann Arbor Healthcare System

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Summary Summary In this 15 minute video, smokers learn how to create their personal plan for quitting. The program examines why people smoke, why they may want to quit, how they can identify their personal triggers to smoke, and introduces nicotine replacement, as well as non-nicotine replacement therapies, to aid in quitting It encourages people to make a diary of their aid in quitting. It encourages people to make a diary of their smoking behavior and to set a quit date. Potential relapse situations are also covered.

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http://va-tobaccotactics.nursing.umich.edu/ username: test password: testpass

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TT Templates & Evaluation Plan

  • Developing CPRS templates and

evaluation with nurses & admins evaluation with nurses & admins

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SLIDE 52

F/U Contact

  • Who?
  • How?
  • How?
  • When?
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SLIDE 53

September to October 2014

  • Limiting the pilot by service
  • Finalizing training plans

Finalizing training plans

  • Tobacco training for nurses

H d t itt

  • Hand-over to committees
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SLIDE 54

Moving forward

  • Roll-out the SUB and TOB measures
  • n pilot units
  • n pilot units
  • Templates finalized but need to be built

at national center – unpredictable time at national center unpredictable time frame

  • Work through follow up contacts and
  • Work through follow-up contacts and

calls

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SLIDE 55

Thorns in our side

  • CPRS
  • Interpreting and clarifying measures

Interpreting and clarifying measures

  • Other clinical, research, admin

responsibilities responsibilities

  • Sporadic meeting attendance

S ti ill t

  • Summer vacations, illness, etc.
  • Approvals depended on monthly

meetings

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SLIDE 56

Hurdles

  • Unfunded mandate, limited guidance

and resources

  • Complex measures
  • Busy clinicians and researchers

Busy clinicians and researchers

  • # services, stakeholders, and disciplines
  • Layers and numbers of approvals
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SLIDE 57

Hurdles

  • General politics and personalities
  • Outsiders

T b t i

  • Taboo topic
  • Dual roll-out of SUB and TOB

Dual roll out of SUB and TOB

  • CPRS
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SLIDE 58

Facilitators

  • Outsiders
  • Prior research —> relationships
  • Prior research —> relationships
  • CPRS

D i t d d i Cli i l

  • Designated and responsive Clinical

Informatics staff

  • Dual roll-out of SUB and TOB

measures

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SLIDE 59

Facilitators

  • Administrative leadership support and buy-in
  • Chartered, interdisciplinary committee
  • Team dedicated to an effective roll out
  • Team dedicated to an effective roll out
  • Champions with special interests/skills/roles
  • Performance measurement partner
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SLIDE 60

Facilitators

  • Some existing POCs for spring board
  • Existing psych liaison service

g p y

  • Tobacco Tactics
  • CHERP’S in-house data experts

p

  • VISN-wide SharePoint and calls
  • Recent TJC visit
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SLIDE 61

6 Lessons Learned

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Patient-Centeredness Staff Efficiency Time Stakeholder Engagement g g “Meeting the Measures” Good Clinical Care Good Clinical Care

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Core Committee

  • Melissa Wieland, PhD
  • Monica DiNardo, PhD, CRNP

A d C f BA

  • Andrea Confer, BA
  • Barbara McQuaid, BSN, RN
  • Scott Golden MD
  • Scott Golden, MD
  • Leigh Gemmell, PhD
  • Adam Gordon, MD, MPH

Adam Gordon, MD, MPH

  • Lakya Amaranatha, MD
  • Pat Akerly, CRNP, CAC
  • Karen Mancini, MHA, BSN
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SLIDE 65

Core Committee

  • Melissa Dykstra, MSW
  • Meghan Booth, MSW
  • Renita Parker, MSN, RN
  • Adam Gordon, MD, MPH
  • Lawrence Gerber, MD
  • Erika Hoffman, MD

E ik Still BSN BC RN

  • Erika Still, BSN-BC,RN
  • Igor Tseyko, MD
  • Paul Bulgarelli MD
  • Paul Bulgarelli, MD