1. Implementing Nurse-driven protocols that leads to improved team-based care in a PCMH practice Mathew Devine, DO Michael Mendoza, MD Loron Oster, RN Nikki Vavrina, DO Highland Family Medicine December 6, 2014

2. Highland Family Medicine o Moved physical site June 2005 o Family Medicine Residency expanded from 10/10/10 to o 12/12/12 – June 2012 o Over 65,000 visits annually/ over 20,000 patients o Switched EMR to Epic from Allscripts 5/2012 o P4 site 2008-2012 o LEAP site 2013-present HFM Mission: “Provide improved access to patients to the highest quality, cost- effective, and innovative patient-centered care through interdisciplinary collaboration”

3. LEARNING OBJECTIVES On completion of this session, the participants should be able to: 1. Identify the processes that are needed to be taken to create a nurse-driven protocol. 2. Discuss the steps needed to implement a nurse driven protocol in their clinical setting. 3. To prepare a roadmap and action plan to measure and track the progress of implementing your own nurse driven protocol.

7. Steps for Creating a Nurse – Driven Protocol STEP I: Identify a problem that needs to be changed – create your AIM statement STEP II: Identify practice champions to promote the change process and to help make the idea become part of the practice STEP III: PLAN Create a Roadmap for the process. Communicate idea and discuss with practice at-large and leadership Implement a PILOT group to test the change Educating pilot group: Provide patient, clinician and RN education to the practice in regards to the policy Create a draft of the policy/protocol Budget analysis (if needed) STEP IV: DO/STUDY Implement the Pilot and create a roadmap to measure the effectiveness of the policy in practice Review and tweak the policy based on the pilot Then go-live for entire practice STEP V: ACT Provide patient, clinician and RN education to the practice in regards to the policy Implementation of practice wide process STEP VI: TRACK Tracking the METRICs over time to see if positive change is continually occurring Continue with education of new staff and patients

8. STEP I Identify a problem that needs to be changed This will eventually lead to what is your AIM statement for the project Example for process will be Anticoagulation management

9. RN Driven protocols New York State – Nurse practice act This act does allow for standing orders and protocols to be created How did our practice identify the AIM

11. STEP 1: Small group exercise Either individually or in a small group take the next 2-3 minutes to jot down your ideas for a process that needs to be changed at your practice Please use the RN Driven Protocol Worksheet to record this information

13. STEP 2: Identify practice champions to promote the process of change and to help make the idea become a practice policy Establishing BUY – IN ** This is one of the most important critical aspects of leading change** What were the concerns of the RN group and clinician group? Examples: of Practice stake holders from HFM Anticoagulation policy How did we get the practice excited about this change?

14. Step 2: Small group exercise Either individually or in a small group take the next 2-3 minutes to write down the practice members that you will need to touch base with for this process to be implemented Please use the RN Driven Protocol Worksheet to record this information

15. STEP 3: Identifying Practice needs for successful implementation To review how Anticoagulation nurse-driven protocol was approved to start the process of creating a policy Practice leadership and discussions at other meetings Review of patient data

16. STEP 3 – Practice Needs Does this create any issues that compliance needs to be aware of? How does this affect the finances of the practice? Are there any additional staffing that are needed Who is likely to benefit from this change?

17. STEP 3 – Getting the Green light Create a draft proposal

20. STEP 3 - continued Communicate ideas and discuss and solicit team/practice input on the proposed policy and protocol

21. STEP 3 Create a small pilot group to trial the change process prior to finalization of policy Provide clinician and RN education to the pilot study group on the policy

22. STEP 3 – Break out Either individually or in a small group take the next 2-3 minutes to: Identify which individuals in your practice would be good to solicit for pilot

23. Measuring where you are going Prior to implementing you want to make sure that you come up with METRICS to demonstrate that the policy/protocol is successful

24. STEP 4 Implement the Pilot Create a Roadmap to measure the effectiveness of the policy in practice Review and tweak the policy based on the pilot

25. Anticoagulation Pilot Project Approach To roll out Policy and provide education/handouts to providers Providers to sign “Pledge” that they have read the policy and agree with treatment protocol Providers to review a list of their current patients that are on anticoagulation medication and they will: Update problem list with necessary information Create Quickaction for Normal INR reporting (used Epic) Create Quickaction for protocol use for patient plan Handout to be given on policy/protocol Protocol to be placed in alcove and nursing area Email to practice to inform them of pilot and that this only is being performed on 200/400 over the next 6-8 weeks and then to be spread to the rest of the practice.

26. Preparation for Go-Live Erecord Identify workflow for INR and flowsheet Create policy & present to QI Review PILOT Policy on Suites 200/400 to Start 1/1/2013 ANTICOAGULATION PROJECT GOALS/PLANNING DecOctSepAugJulyJuneAprilMarchFebJanMayNov HIGHLAND FAMILY MEDICINE QI commitee in conjunction with Ops Core to create INR practice protocol using best evidence practices

27. Completion of PILOT Communicate POLICY to Practice and implement Check METRICS Orient new staff and residents ANTICOAGULATION PROJECT PLANNING DecOctSepAugJulyJuneAprilMarchFebJanMayNov HIGHLAND FAMILY MEDICINE QI commitee in conjunction with Ops Core to create INR practice protocol using best evidence practices

28. If time Step 4: Break out Either individually or in a small group take the next 2-3 minutes to: Work on the Roadmap for your project

29. STEP 5: Go-Live practice wide Provide patient, clinician and RN education to the practice in regards to the policy Implementation of practice wide process

31. Anticoagulation Protocol – What did we accomplished? -Competency developed for RNs/training for providers -Consistent template available for managing INR’s -Epic upgraded anticoagulation encounter-helpful if used correctly -Accurate lists of anticoagulation patients on all suites -Ongoing RN education for INR management, quarterly education by Lead RN Concerns - process is multistep and can be at times confusing, if handoffs are not done patients can be at risk, part time providers are challenging to keep in communication loop, difficult to find in epic “what dose is my patient on” Resident/staff turnover & need for ongoing education (interns)

32. STEP 6:Tracking the METRICs over time

33. Anticoagulation Tracking Cont Anticoagulation Tracking 7/1/2012 to 3/31/2013 4/1/2013 to 12/31/2013 N16001797 Average2.522.48 SD0.930.05 Median2.42.3

35. Conclusions and Lesson Learned Had positive patient, nurse, and provider satisfaction surveys Audits revealed that in comparison to prior to go-live practice has decreased the average amount of patients in therapeutic INR range by 7% Nurses are ordering more INRs The average INR is less with the nurses taking over the anticoagulation treatment management There is less variance in the INRs than when MD/DOs managed Need to further look at this data thinking about Are there variables in seasonality of INR testing Should patient admitted to hospital be excluded Have there been any bleeding events that have occurred during new policy? How many as compared to prior to policy

36. Discussion/Feedback Next steps: Implementation of your ideas into your residency programs and/or outpatient centers Common pitfalls and solutions for creating these processes Any other questions?