Connected Thinking Blog - NACHRI Conferences

Closing Plenary: BreakAway Results

To close out the NACHRI 2010 Annual Leadership Conference, champion triathlete and motivational speaker Tony Schiller shared his stories from the IronMan triathlon and other life experiences as inspiration for attendees. The session was a chance to be encouraged by the possibilities of human achievement, the value of perseverence and the importance of a winning mindset.

Schiller encouraged attendees to set themselves on a "breakaway" mindset, avoiding "quit," "chase," and "pack" mindsets. "All the quit needs is an excuse." In contrast, a breakaway mindset puts aside all the other voices and doesn't question the end in sight.

Schiller was inspired in his racing and in his life by medically fragile children who show bravery and perseverence in the face of enormous adversity. One of the breakaway stories of Schiller's life is not the races he has won, but the energy he has invested in helping start the MiracleKids Triathlon, inspired by a friend who's son died of cancer. The triathlon is run by children on behalf of medically fragile children who are unable to race.

Schiller's message is one of encouragement for everyone: the true breakaway moments don't come from winning, but from serving.

Looking to the Future

2010 was an amazing Annual Leadership Conference with exciting sessions, great collaboration, productive networking and lots of innovative ideas to take home to grow, implement and expand upon. Start planning now to to join your peers at next year's Annual Leadership Conference, to be held October 9 - 12, 2011, in Bellevue, WA.

Integrating a Quality Program Among Children's Hospitals and Medical Schools.

In a session with incredibly exciting content, a trio of presenters representing Children's Medical Center Dallas, The Children's Hospital in Aurora, CO, and Nationwide Children's Hospital in Columbus, OH, shared outcomes from a group that was brought together to look at how to integrate quality improvement as a central element of children's hospitals' relationship with medical schools.

There is a need for an integrated quality program in children's hospitals. Significant investment is being made to improve quality and safety of care. Yet there are still significant gaps in quality and safety outcomes in the care of pediatric patients in these same institutions. If so much effort is going into improvement, why are there still so many problems?

The approach of the presenting team was to recognize the lack of integration between the hospitals and the medical schools they work with and look for ways to bring the two into alignment. The two do not always integrate improvement strategies, priorities and resources. There is a lack of standardized approach to quality imrpovement education. And hospital improvement efforts can fail to consistently engage physicians who do not in turn see personal recognition for their work.

In 2009, executives and academic chairs from 15 NACHRI member children’s hospitals met to discuss the benefits and challenges of integrating their respective quality programs and to define implementable approaches for integration. A three-part integration framework was developed for adoption and testing at the participating institutions and dissemination to other children’s hospitals:

• Alignment, Prioritization, and Funding
• Quality/Performance Improvement Education
• Professional Development and Career Progression

The group found common ground and realistic approaches to integrating quality programs for improved patient outcomes and expanded quality improvement expertise. Some of the key steps toward alignment:

• Commtment starts with board of directors, medical board and medical staff leadership
• You need a defined position in the academic department with quality as a responsibility to help facilitat integration Physician participation is crucial. There is a tension between add-on commitments vs. a true dedication of time.
• To get physicians engaged and committed, there must be a tie to professional development for physicians for it to be worth their time. As with traditional clinical research areas, training physicians works best with mentors. These mentors may be sporadic within the institution, but it is possible to get external mentors to help team quality improvement strategies to physicians.
• It is not just the inside that needs change. Professional societies need to promote and recognize the legitimacy -- and urgency -- of quality improvement and safety work. Funding from government, foundations and other grantors needs to be directed to QI and safety work.

Long-term objectives of the work. The goal of this group is that participating organizations will use the integration framework as the basis for dialogue, planning and devleopment of an integrated quality program at their own institutions. A white paper has been submitted for publication, so the presenters are not permitted to post their slides on the NACHRI website until after publication of the piece. However, the group is excited about sharing their work in detail in the near future. The group plans for dissemination of the integration framework to a wider pediatric community. This is a beginning and a call to action.

For more information on the presenters and their work, the session description is available on the NACHRI Annual Leadership Conference website.

Efficient Patient Flow Through Technology

At Arkansas Children's Hospital, the last five years have seen a radical improvement in patient flow and they have the numbers to support their success. As just one small example, time for outpatient arrival to registration is down to less than three minutes through a self check-in process. The self check-in also eliminated need for translators in the check-in process and allowed 45 percent of admitting staff to be reassigned to other job roles.

The technology revamp of the patient flow process has been led by Carol Graham, MHSA, RD, vice president of ambulatory care services, and David Higginson, ACMA, chief information technology officer. Their mission has been to use technology and facts -- not anecdotes -- to track and improve every aspect of flow. Now they have support staff, nurses, physicians and administration all using the same system and have between 16 and 28 timestamps tracked for every single patient visit with all the data availble in real time.

Looking back on their process and continuing improvement efforts, they've mapped the transition down to five steps:

Step 1. Desire to change -- Self explanatory, but without a desire to change, there will never be the support and embrace of new systems.

Step 2. Inject technology

• Through a coordinated effort, touchscreens and badge scanners connected to an electronic dashboard, patient records, bed availabilty, scheduling, etc..., were used to replace paper systems and the emergency department patient whiteboard. 
• Touchscreens are outside of every room and used throughout the hospital.
• For registration, a Web-based dashboard was projected on the wall where the old whiteboard used to be to help streamline the change.
• Integrated into the system is an electronic "admissions scrubber" that helps the nurses focus on just what pieces of information they really need on the patient to update their accounts.
• State immunization database is integrated so nurses have shot records handy. Growth charts are integrated and automatic.
• These steps save several minutes per patient.
• Dashboard also keeps record of rooms available and doctors ready to see patients.
• Real bed reservations are visible everywhere in the hospital.

Step 3: Make change stick -- It took 18 months to convince the majority of the staff to transition to the dashboard. There are still a few laggards who are slowly being converted. The hospital has found that giving people funcationality in the system that makes their lives easier has been one of the best ways to entice people to use the system. For instance, the touchscreens are set up to allow staff to clock in and to reset their network passwords if they need to -- two functions that used to be more complicated; when reluctant staff engage the touchscreen system to clock in they also see some of the other funcations that are related to improving patient care, and eventually they make the move.

Step 4: Focus on facts, not anecdotes

• Data makes it possible to drill down and see where challenges remain or where there are anomalies.
• Adapt -- Several of the best ideas came during the implementation process.So data exists to debunk anecdotes and make data-driven decisions. This kind of information is available in real time during meetings.

Step 5: Move to micro-monitoring and micro-adjustments

• Samples are just that. There is no "typical" day in a hospital.
• Online appointment rescheduling is available to patients online.
• You have to look at data and continually look for places to make adjustments to improve flow.

For the future, one of Higginson's pet projects he would like to implement is to look at parking as part of the patient flow. In a perfect world, he'd like to see signage when patients arrive that shows them which lots have how many available spaces. Patients all can swipe some sort of electronic ID card to when they park so that the clinic then knows they are on campus and when they will be arriving. Having patients swipe into parking would provide one more timestamp. More timestamps help provide the data needed to make data-driven decisions on ways to improve patient flow.

Check out the slides and presentation overview, and also read about another patient flow process implemented at The Children's Hospital of Philadelphia.

Discuss:

• Where is your hospital in the process of using technology solutions to improve your patient flow?
• What area in your hospital has the greatest need for patient flow improvement?

Poster Winners Announced

Top poster finalists were recognized during the chairman's luncheon.

The 2010 Annual Leadership Conference was structured by NACHRI Council on Education as a forum for children’s hospital leaders to gain new ideas, strategies and practices that will allow them to breakaway and provide innovative best practices for children’s healthcare. Posters and sessions are accepted based on the themes for the meeting. The Education Council administers the top poster award program on behalf of the NACHRI Executive Committee of the Board of Trustees.

This year’s posters were evaluated on the following criteria:

• Demonstration of problem or challenge
• Relevance / Interest
• Results / Outcomes OR Potential for outcomes
• Innovation
• Design of the poster

The Council extends their appreciation to all poster presenters for making this a particularly difficult year. Four top posters were chosen:

Creation of a NANO (Nurse Administered Nitrous Oxide) Sedation Program
Mary Kay Farrell, RN-BC, Clinical Educator, Children’s Hospitals and Clinics of Minnesota, Minneapolis, MN

Impact of the CARES Psychiatric Assessment Unit on Patient Management in the Emergency Department
Sharon Smith, MD, Research Director, Associate Medical Director, Connecticut Children’s Medical Center, Hartford, CT

Integration of a Simulation Center into a Pediatric Intensive Care Unit
Megan Boone, RN, MSN, CCRN, Clinical Nurse Specialist, Kosair Children’s Hospital Norton Healthcare, Inc., Louisville, KY

While all top posters scored high in terms of the criteria, there was one top poster that presented such a strong example of innovation for children’s hospitals that the Council selected it as the overall poster winner:

Medication Therapy Management in a Pediatric Medical Home
James McCord, MD, Medical Director, Children’s Hospitals and Clinics – St. Paul, St. Paul, MN

Congratulations to the poster winners and thanks to all of the members that presented posters at the NACHRI 2010 Annual Leadership Conference. The posters are a rich resource of innovative ideas and best practices to help the community of children's hospitals improve and streamline care.

The 2010 Annual Leadership Conference was structured by NACHRI Council on Education as a forum for children’s hospital leaders to gain new ideas, strategies and practices that will allow them to breakaway and provide innovative best practices for children’s healthcare. Posters and sessions are accepted based on the themes for the meeting.  The Education Council administers the top poster award program on behalf of the NACHRI Executive Committee of the Board of Trustees.

 

This year’s posters were evaluated on the following criteria:

1.  Demonstration of problem or challenge

2.  Relevance / Interest

3.  Results / Outcomes OR Potential for outcomes

4.  Innovation

5.  Design of the poster

 

The Council extends their appreciation to all poster presenters for making this a particularly difficult year.  The Council has chosen four top posters.   

C.A.R.E. Award Winner Announced

The first ever NACHRI C.A.R.E. Award was presented by NACHRI President and CEO Lawrence McAndrews during the chairman's luncheon. The Champion of Analytics and Research Excellence (C.A.R.E.) Award was developed to:

• Recognize and reward commitment to the advancement of efficiency, safety, and effectiveness in health care through data and research
• Stimulate all children’s hospitals to share data and best practices
• Optimize the use of NACHRI Analytics data in member hospitals

The award was created by NACHRI Council on Management Information Services led by Jim Shmerling to recognize exceptional use of NACHRI Analytics programs. The MIS Council judged the entries, and looked for demonstrated improvement in efficiency, safety, timeliness and effectiveness of care in each competing hospital. The three C.A.R.E. Award finalists are:

• Kosair Children's Hospital, Justine O’Flynn, “Using VPS data outside the walls of the Pediatric Intensive Care Unit”
• Blythedale Children's Hospital, Linda Hurwitz, “NACHRI Specialty Hospital CLA-BSI Project: The Children’s Hospital Experience”
• Children's Hospital of Wisconsin, Dr. Tom Rice and Dr. Ramesh Sachdeva, “Combining NACHRI Analytics for Identifying National Best Practices and Accelerating Local Improvement”

The C.A.R.E. winner is Justine O'Flynn for her work using VPS data outside the walls of the PICU to transform child abuse evaluation and treatment response. O'Flynn has been a pediatric critical care nurse for almost 40 years. She is currently patient care data system analyst for the "Just for Kids" Critical Care Center at Kosair Children's Hospital in Louisville, KY. She has been the VPS site coordinator since August of 2001 and has participated as an alpha and a beta "tester" for many of the VPS upgrades. She developed a passion for child abuse prevention as a bedside nurse while caring for young babies with inflicted abusive head trauma. O'Flynn is currently the chairperson of the Child Abuse Task Force at Kosair Children's Hospital. Congratulations to Justine O'Flynn for her amazing work!

NACHRI Board Members

The chairman's luncheon was a chance to thank members who have finished their term serving on the NACHRI Board of Trustees, and to welcome new members to the board.

Members transitioning off the board served from October 2004 through October 2010. NACHRI is thankful to:

• Jay Berkelhamer, M.D.,    Children's Healthcare of Atlanta
• Chris Durovich, Children’s Medical Center Dallas
• Lee Fetter, St. Louis Children’s Hospital
• David Fisher, M.D., Seattle Children’s
• Alan Goldbloom, M.D., Children's Hospitals and Clinics of Minnesota
• Margaret Perryman, FACHE,  Gillette Children's Specialty Healthcare
• Kerri Ruppert Schiller, Children’s Hospital of Orange County, Orange, CA
• Stephen Stephenson, M.D., Iowa Health – Des Moines

New members joining the NACHRI Board of Trustees:

• Michael Farrell, Rainbow Babies & Children's Hospital, Cleveland, OH
• Thomas Kmetz, Kosair Children’s Hospital and Pediatric Services, Louisville, KY
• Joseph Laver, M.D., St. Jude Children’s Research Hospital, Memphis, TN
• James Mandell, M.D., Children’s Hospital Boston
• Joseph Mott, Primary Children’s Medical  Center, Salt Lake City, UT
• Paula Nobel, Children’s Memorial Hospital, Chicago, IL
• Sheldon Stein, FACHE, Mt. Washington Pediatric Hospital, Inc., Baltimore, MD
• Steven Worley, Children's Hospital New Orleans

The following members were re-elected as trustees:

• Meri Armour, Le Bonheur Children's Hospital, Memphis, TN
• Amy Mansue, Children's Specialized Hospital, New Brunswick, NJ
• James Stockman, M.D., American Board of Pediatrics, Chapel Hill, NC

The slate of officers for the upcoming term is:

• Chair - Christopher Dawes, Lucile Packard Children's Hospital at Stanford, Palo Alto, CA
• Chair Elect - James Mandell, M.D., Children’s Hospital Boston
• Treasurer - Rick Merrill, Cook Children’s Health Care System, Fort Worth, TX
• Secretary - Herman Gray, M.D., Children's Hospital of Michigan, Detroit, MI

The Assocation is grateful to all of these members for their dedication and support.

Welcome New Hospitals to NACHRI

The annual chairman's luncheon and meeting of the membership was a chance to welcome new members to the Association:

Institutional I-C member

• New York-Presbyterian, Phyllis and David Komansky Center for Children’s Health

Associate members

• Diamond Children’s Medical Center in Tucson
• Children’s Hospital of the University of Illinois in Chicago   
• Ronald McDonald Children’s Hospital in Maywood, IL
• Advocate Lutheran General Children’s Hospital in Park Ridge, IL
• Floating Hospital for Children at Tufts Medical Center in Boston
• Hurley Medical Center Children’s Services, Flint, Michigan
• Stony Brook Long Island Children’s Hospital, Stony Brook, NY
• Ochsner Medical Center for Children, New Orleans

Supporter

• Wesley Medical Center, Wichita, KS

Thanks to all of these hospitals who have joined NACHRI to help improve health care for all children.

titutional I-C member

I am happy to announce our new member hospitals

Institutional I-C

New York-Presbyterian, Phyllis and David Komansky Center for Children’s Health

Slide 5 : Associate members

Associates:

Diamond Children’s Medical Center in Tucson

Children’s Hospital of the University of Illinois in Chicago    

Ronald McDonald Children’s Hospital in Maywood, IL

Slide 6 : Associate members

Advocate Lutheran General Children’s Hospital in Park Ridge, IL

Floating Hospital for Children at Tufts Medical Center in Boston

Hurley Medical Center Children’s Services, Flint, Michigan

Slide 7 : Associate members

Stony Brook Long Island Children’s Hospital, Stony Brook, NY

Ochsner Medical Center for Children, New Orleans

 

Slide 8 : supporter

Supporter:

Wesley Medical Center, Wichita, KS

Simulation Programs to Improve Care

In a packed session, teams from The Children's Hospital of Philadelphia and Lucile Packard Children's Hospital at Stanford presented simulation initiatives that have worked at their hospitals to improve quality, patient satisfaction and return on investment. There is far too much detail to go into in a short blog, but the teams have been kind enough to provide detailed outlines of their work as well as making their PowerPoint presentations available.

A quick overview of the simulation training initiatives presented:

• Dress Rehearsals and Rolling Refreshers -- A team from The Children’s Hospital of Philadelphia used a cart equipped with a Central Venous Catheter (CVC) in a simulated chest, Clinical Nurse Educators traveled to patient care units throughout the hospital, conducting “CVC Dress Rehearsals.” Cognitive and psychomotor skills were assessed and individualized immediate feedback was provided. A certified Basic Life Support (BLS) instructor utilized a cart equipped with a monitor/defibrillator and a resuscitation manikin to provide opportunities for pediatric intensive care unit (PICU) staff to simulate CPR at the patient’s bedside. These “Rolling Refreshers” allowed physicians, nurses and respiratory therapists the opportunity to practice according to the AHA guidelines with real time automated directive and corrective feedback until skill success was attained. Over 16 months, 523 nurses participated in CVC Dress Rehearsals. Improvement in nurses’ confidence, knowledge and psychomotor performance on manikins was noted. Participants were more apt to correctly perform a dressing change on a real patient. Mean CLABSI rates decreased from 5.2 to 3.2 per1000 line, contributing to improved quality of care and a substantial cost savings.
  
  
• Improving Patient Satisfaction in Ambulatory Settings Through the Use of High-Fidelity Simulation Training, Lucile Packard Children’s Hospital at Stanford -- Principles of Family-Centered Care are widely recognized and increasingly incorporated into clinical practices within pediatric ambulatory settings to improve patient and family satisfaction. Concomitantly, good communication between clinic staff and parents is recognized as key to a family-centered clinic. Yet, limited research exists that identifies theoretically-based measures for healthcare communications or effective training methods. Moreover, it is difficult to replicate the parent experience in training so that staff have a “real-experience” training. Results of two pilot studies conducted at our hospital, using a cadre of well-trained “parent actors” in a simulation training aimed at improving communication in clinic will be presented: Study #1: Improving communication skills of outpatient staff; Study #2: Improving hand-off communication with an obstetric clinic team. The combination of simulation and parent actors results in a powerful training environment. Trainees are able to practice new communication skills with well-trained parent actors in simulated but challenging communicative situations.
  
  
• Optimizing the ROI in Simulation at Your Children’s Hospital, Lucile Packard Children’s Hospital at Stanford -- Simulation is a key component of the hospital's strategic plan. Rather than viewing simulation as simply a tool for training, Lucile Packard Children's Hospital sees it as a methodology for enhancing learning and a strategy for evaluating human performance and system function; therefore it is an integral part of the hospital patient safety program, and has been in use for more than a decade. The hospital uses simulation to identify and remediate human and system weaknesses; the training has had the effect of transforming the culture at the children’s hospital away from one of blame and shame into one where staff acknowledge mistakes and learn from them. Real world outcomes of the program include:
  • Creation of a hospital committee to identify and prioritize targets for simulation
  • Empowerment of multidisciplinary task forces to implement simulation
  • Re-allocation of resources from less effective training and safety efforts to simulation-based programs
  • Collaboration with professional organizations to create national models of care

DISCUSS:

• Where has your hospital used simulation to teach and/or transform care?
• What did you learn from simulation that you didn't anticipate at the outset?

Health Care Panel With TN Gov. Bredesen

Tuesday morning started with a presentation from Tennessee Governor Philip Bredesen (D) who recently released Fresh Medicine, a book with his ideas on how to reform the American health care system. After his presentation, Bredesen was joined by a panel of children's hospital CEOs who offered their own ideas and participated on an open dialogue on broad strategies for health care reform.

Steven Altschuler, MD, president and chief executive officer, The Children's Hospital of Philadelphia, gave his vision for a health care future that focuses on a robust primary care network with a medical home for every child, utilization of outpatient care as often as it is appropriate, and a transition where the children's hospitals of today become the pediatric regional intensive care units of the future.

Steve Allen, MD, chief executive officer, Nationwide Children's Hospital, shared about the Partners for Kids programs at Nationwide, a physician hospital organization that has helped expand access for children across the state, radically improve pediatric vaccination rates, decrease preterm births, decrease hospital length of stay and improved tracking of patient medical histories.

Craig Cordola, MBA, MHA, FACHE, chief executive officer, Children's Memorial Hermann Hospital, shared his perspective as a former children's hospital CEO and as the current CEO of a health care system on how the health care system he leads is preparing for health care reform, looking also at some of the state-specific challenges in Texas. The system is working through an extensive analysis of all parts of the organization -- all departments, all hospitals, all processes -- to find ways to streamline and improve care across the organization.

Bredesen offered his own ideas on the present health care reform legislation. He expects that the current laws will cause a dramatic decline in employer sponsored insurance. The financial case for a business to turn over the responsibility to the government is too good for many places to pass up.

The two big issues that must be solved in health care are: how to pay for it and how to structure it. In brief, Bredesen wants to model health care payments after the Social Security program, accessible to every American and maintaining a personal dignity not seen under the Medicaid/Medicare system. For structures, Bredesen promoted a "systems of care" model that pays more attention to coordination of care in an integrated faction.

Bredesen says we must quantify what health care needs to be and agree how to measure it. Checks need to be put into place at every step along the way from the outset. His solution is to publish an annual "red book," a single place where a best practice approach to each disease or procedure is codified for universal use, and implement a way of measuing the outcomes and compliance with the standard.

The biggest challenge he sees is that "health care has become such a narrow party line vote that a lot of dynamics have nothing to do with the policy and everything to do with party line."

DISCUSS:

• What is your hospital doing to prepare for health care reform implementation?
• How would you change health care if you could?

Raising Up Leaders

First instruction:
A green sign with these words: "Select a picture that reflect's your organization's leadership intentions."

Folding tables are covered by hundreds of glossy 8x10" pictures, reflecting a diversity of styles and subject matter. A close up of Fruit Loops swimming in milk; divers feeding a manatee; Impressionist lanscapes; a vista of Machu Picchu; blurred whisps of cyclists flying across the French landscape; a blurry black and white of a naked woman on a horse; a placid sea turtle backlit into silhouette by the sun  a grainy sepia-tone group of miners, huddled against the cold, grizzled and worn, eyes boring into the camera.

Each attendee selects a picture to answer the opening question. No two pictures are alike. We'll find out later what the pictures are for.

Gillette Children's Specialty Healthcare in Minnesota has established their Leadership Academy on a combination of externally and internally developed curricular elements to encourage leadership growth at all levels of the organization. The program is open to all employees, regardless of title.

Gilette is a over 100 years old as an organization, but in the last decade, has gone from 450 to 1,100 employees, making intentional leadership growth a priorty for health growth. Even in the midst of expansion, Gilette is a very flat organization without director positions -- managers are the highest level for the leadership academy.

The program is based on engaging learners in three ways:

1. Allow participants to choose what they take and when (courses are not in lockstep; learners can choose what is most pertinent to them and take it when it fits their schedule)
2. Engage learners through intentional, relevant work;  courses must have prework, homework and follow up activities. Sustaining learning is both a goal and a challenge.
3. Continuing evaluation of the progress of the leadership program through a 360 process.

The training in the Annual Leadership Conference session is based around a "World Cafe" model, modified for the time and logistic constraints of the room. Attendees took sticky notes and pasted answers on the wall to the following six questions:

1. What about your organization's culture program development informs your leadership?
2. How might you assess your leaders' needs for formal skill and knowledge development?
3. What constraints unique to your organization would influence your planning process?
4. Are there rhythms or initiatives present in your organization that would dictate your program implementation?
5. What evaluation perameters and methods would provide feedback to enhance future programming?
6. What short and long term goals/outcomes might you examine as part of your leadership program success?

Attendee responses and other wrap-up from the session will be available soon on the NACHRI Web site in the notes and overviews for Monday sessions.

The pictures, it turns out, are meant to help people visualize how they internally think about their organizations. Last instruction: As you reflect on picture, think about these four questions:

• Does it reflect your organization's historic place in the health care community?
• Does it reflect your organization's present leadership stance?
• Does it reflect your organization's clear direction for the future?
• Does it reflect your organization in the midst of change?

What kind of image would you use to think about your organization's leadership? How does that image reflect how you think about what direction your organization is going?