Urgent Matters Application Overview Demonstration Project

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Urgent Matters Application Overview Demonstration Project

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1. 1 University Health System’s own goals and objectives included: reducing diversion time (times when the EC is closed to certain or all categories of patients arriving by ambulance), improving patient throughput time to increase capacity and the overall volume of patients seen by a physician, and to improve patient outcomes and satisfaction by reducing EC waiting times.University Health System’s own goals and objectives included: reducing diversion time (times when the EC is closed to certain or all categories of patients arriving by ambulance), improving patient throughput time to increase capacity and the overall volume of patients seen by a physician, and to improve patient outcomes and satisfaction by reducing EC waiting times.

2. 2 Population of Bexar county = 1,409,834. San Antonio’s population is growing faster than the general population of the United States. Between 1990 and 2000, the U.S. population increased 13 %, compared to San Antonio’s increase of 22 % and the county’s increase of 17.5 %. During this same time period, two of the fastest growing groups were the Hispanic population, and the 45-64 age group. Besides providing care for the uninsured population of Bexar county, UHS serves as a teaching facility for physicians, nurses and allied health professionals at the University of Texas Health Science Center at San Antonio (UTHSCSA). Only civilian Level One trauma center for a 22-county area.Population of Bexar county = 1,409,834. San Antonio’s population is growing faster than the general population of the United States. Between 1990 and 2000, the U.S. population increased 13 %, compared to San Antonio’s increase of 22 % and the county’s increase of 17.5 %. During this same time period, two of the fastest growing groups were the Hispanic population, and the 45-64 age group. Besides providing care for the uninsured population of Bexar county, UHS serves as a teaching facility for physicians, nurses and allied health professionals at the University of Texas Health Science Center at San Antonio (UTHSCSA). Only civilian Level One trauma center for a 22-county area.

3. 3 EC sees > 70,000 people annually. 25% admitted 33% to ICU or OR UHS consists of University Hospital and 5 clinics in separate locations. We have a multi-organ transplant program for heart, liver, kidney, lung and pancreas. This means we get a large population of patients in need of transplants. The Health System routinely operates 484 beds, and sees more than 70,000 emergency patients annually. About 25 % are admitted from the EC and 33% of these go to the ICU or OR. UHS consists of University Hospital and 5 clinics in separate locations. We have a multi-organ transplant program for heart, liver, kidney, lung and pancreas. This means we get a large population of patients in need of transplants. The Health System routinely operates 484 beds, and sees more than 70,000 emergency patients annually. About 25 % are admitted from the EC and 33% of these go to the ICU or OR.

4. 4 Hospital Bed Mix OB 37 Med-Surg 264 ICU 73 Pedi 17 NICU 40 Psyc 28 Rehab 25 The typical patient population at UH is similar to many hospital of its size, with the majority of patients being Medical – Surgical. For our hospital, many of these are intermediate care patients with many pre-existing conditions and co-morbidities. There is a Surgical Trauma ICU, a medical ICU, a pediatric ICU, and a neonatal ICU on separate floors.The typical patient population at UH is similar to many hospital of its size, with the majority of patients being Medical – Surgical. For our hospital, many of these are intermediate care patients with many pre-existing conditions and co-morbidities. There is a Surgical Trauma ICU, a medical ICU, a pediatric ICU, and a neonatal ICU on separate floors.

5. 5 PRIMARY PROBLEM Approaches described Improvements in Environmental Services (EVS) response time. Admission Discharge Nurse Push Pull Protocol. OR Posting Notification. Improving Output from the EC back door and Inpatient bed turnover time. We chose to focus this presentation on those RCTs that helped most with getting patients out the back door of the EC, which was most affected by inpatient bed turnover and admission & discharge processes. These included improvements in Environments Services (EVS) response time, the Admission-Discharge Pull system, and the OR posting changes.We chose to focus this presentation on those RCTs that helped most with getting patients out the back door of the EC, which was most affected by inpatient bed turnover and admission & discharge processes. These included improvements in Environments Services (EVS) response time, the Admission-Discharge Pull system, and the OR posting changes.

6. 6 EVS Support Proactive team – early adopters. Slaying “sacred cows.” EVS personnel remove sheets, not nurses. Paradigm shift from bed “released” to bed “available.” Improved data collection processes. Dual notification and sign-off processes. When it comes to process improvement and changing behavior, Alex Lamela, UHS EVS Director, is proactive and not reactive. These were the early adopters to RCTs. Slaying sacred cows - In the past, EVS did not clean some beds until the nursing staff removed bed linen once the patient was discharged. EVS now removes linen after patient discharge, instead of nursing staff. This protocol came out of the quality check process of observing staff during the discharge process. By setting up an improved data collection system between his Housekeepers (HK) and the Hospital Unit Secretaries (HUS), along with a dual notification and sign-off process, EVS cut approximately 109 minutes off the IP Bed Turnaround Time. There was also a paradigm shift from bed “released” to bed “available” which has resulted in a heightened awareness of clean and empty beds actually being available beds. Instead of beds being held after the patient has departed and the room has been cleaned, EVS has set up an immediate notification process between the Housekeeper and the UC and they are capturing this time as the bed available time. When it comes to process improvement and changing behavior, Alex Lamela, UHS EVS Director, is proactive and not reactive. These were the early adopters to RCTs. Slaying sacred cows - In the past, EVS did not clean some beds until the nursing staff removed bed linen once the patient was discharged. EVS now removes linen after patient discharge, instead of nursing staff. This protocol came out of the quality check process of observing staff during the discharge process. By setting up an improved data collection system between his Housekeepers (HK) and the Hospital Unit Secretaries (HUS), along with a dual notification and sign-off process, EVS cut approximately 109 minutes off the IP Bed Turnaround Time. There was also a paradigm shift from bed “released” to bed “available” which has resulted in a heightened awareness of clean and empty beds actually being available beds. Instead of beds being held after the patient has departed and the room has been cleaned, EVS has set up an immediate notification process between the Housekeeper and the UC and they are capturing this time as the bed available time.

7. 7 EVS Initiatives Rounded on their designated floors 1 hour prior to the end of their shift. Decreased and sustained IP bed TAT from 167 min. to current = 35 min. Bed tracking system implemented. Resulted in quicker notification & response time, which improves on the “pull” system. EVS also rounds on their designated floors 1 hour prior to the end of their shift to do a visual check to validate the number of rooms that actually need to be cleaned vs. the number of discharge cleans that are reported in the system. If time allows, these rooms are added to the day shift “to be cleaned list” and cleaned before the end of the day shift. This practice has had a tremendous impact on decreasing the number of rooms that are “batched” or “dumped” at the change of shift. This practice has also added value to depicting the number of beds that are actually available for patient placement. UHS has decreased and sustained their IP Bed TAT (DC Order/Bed Empty to Bed Available) from 167 minutes to current = 35 minutes. We now have a new bed tracking system, which is improving EVS notification of beds needing to be cleaned as patients depart. EVS also rounds on their designated floors 1 hour prior to the end of their shift to do a visual check to validate the number of rooms that actually need to be cleaned vs. the number of discharge cleans that are reported in the system. If time allows, these rooms are added to the day shift “to be cleaned list” and cleaned before the end of the day shift. This practice has had a tremendous impact on decreasing the number of rooms that are “batched” or “dumped” at the change of shift. This practice has also added value to depicting the number of beds that are actually available for patient placement. UHS has decreased and sustained their IP Bed TAT (DC Order/Bed Empty to Bed Available) from 167 minutes to current = 35 minutes. We now have a new bed tracking system, which is improving EVS notification of beds needing to be cleaned as patients depart.

8. 8 TeleTracking BedTracking® System Impacts productivity and accountability Automated one call dispatch to EVS personnel. Provides realistic bed availability expectations. Summary reports help manage personnel & bottlenecks. This is just a brief overview of the bed tracking system we selected. TeleTracking Bedtracking system … Impacts productivity and accountability by automating functions. Improves communication - provides realistic bed availability and employs real-time data and eliminates work flow steps and delays. Provides summary reports to help manage personnel & bottlenecks. This is just a brief overview of the bed tracking system we selected. TeleTracking Bedtracking system … Impacts productivity and accountability by automating functions. Improves communication - provides realistic bed availability and employs real-time data and eliminates work flow steps and delays. Provides summary reports to help manage personnel & bottlenecks.

9. 9 Average Inpatient Bed TAT What about that big drop early on? That is the no cost effect of using simple strategies for change. The project goal of 6.9 hours for average total throughput time was not achieved, although some progress was made on the baseline measure of 9.2 hours with a 12-month average of 8.2 hours. With a goal of 125 minutes turnaround time, and a baseline of 167 minutes, IP bed TAT dropped in the first month to 56 minutes and remained at a mean of 46 for the duration of the project. We implemented Bed Tracking (Environmental Services Department) on April 26, 2004 (Phase One)....We implemented Pre-Admit Tracking (Phase Two) on June 15, 2004.What about that big drop early on? That is the no cost effect of using simple strategies for change. The project goal of 6.9 hours for average total throughput time was not achieved, although some progress was made on the baseline measure of 9.2 hours with a 12-month average of 8.2 hours. With a goal of 125 minutes turnaround time, and a baseline of 167 minutes, IP bed TAT dropped in the first month to 56 minutes and remained at a mean of 46 for the duration of the project. We implemented Bed Tracking (Environmental Services Department) on April 26, 2004 (Phase One)....We implemented Pre-Admit Tracking (Phase Two) on June 15, 2004.

10. 10 Communication Implemented lime green paper RCT. Discharge rack. Weekly & bi-weekly meetings. Flowed processes. Guidelines developed. Work plan maintained & distributed regularly to team via email. Previous to the Urgent Matters project, there was a lack of communication between departments about bed needs. Improvements came through small techniques… Placing a lime-green paper in a clear container for the unit clerk with the date and time EVS completed the cleaning of a room resulted in a 13 % improvement in bed turn around time. A discharge rack for hospitalists and NPs to leave DC orders, which are then made a priority by the unit clerk, resulted in a 44 % improvement in order written to departure time. Weekly & bi-weekly meetings encouraged face-to-face collaboration. Flowed processes during meetings to find loopholes or problem areas. Guidelines were developed once new processes were identified. Work plan was maintained & distributed regularly to team via email. Previous to the Urgent Matters project, there was a lack of communication between departments about bed needs. Improvements came through small techniques… Placing a lime-green paper in a clear container for the unit clerk with the date and time EVS completed the cleaning of a room resulted in a 13 % improvement in bed turn around time. A discharge rack for hospitalists and NPs to leave DC orders, which are then made a priority by the unit clerk, resulted in a 44 % improvement in order written to departure time. Weekly & bi-weekly meetings encouraged face-to-face collaboration. Flowed processes during meetings to find loopholes or problem areas. Guidelines were developed once new processes were identified. Work plan was maintained & distributed regularly to team via email.

11. 11 Admission - Discharge Process Emptying beds Focused on discharge checklist. Proactive Case Manager role. Encouraged early rounding. Nurse told pts of D/C before chart is completed. Clothes closet. Discharge lobby. Discharge signs placed in pt rooms. The Admission discharge process changed from a push to a pull process. The admission-discharge RN is to “search out” dismissals by researching anticipated discharges and assess their needs prior to discharge. The RN then functions in an assertive manner in obtaining the final discharge order for the patient. Case managers have been very successful in working with physicians to promote patient discharges by 10:00 a.m. For all floors, over a 5 week period, from early December through mid-January, the average number of orders written before 10:00 a.m. increased from 17 % to 31 %. Case managers have a weekly meeting to review long stay patient records. A discharge check list is given to the primary care nurse upon patient admission. Teaching & medical equipment needs are identified and resolved prior to discharge. Prizes were awarded to nurses who kept up with discharge preparations. A-D nurse tell pts of D/C before chart is completed so they can begin to call family members and arrange transportation. There is also a “clothes closet” that house supervisors and social workers have access to for patients who do not have anything to wear to be discharged home with. The efforts at increased discharges resulted in a need for discharge holding area for patients waiting for transportation. Discharge signage was placed in patient rooms to encourage leaving when discharged. The Admission discharge process changed from a push to a pull process. The admission-discharge RN is to “search out” dismissals by researching anticipated discharges and assess their needs prior to discharge. The RN then functions in an assertive manner in obtaining the final discharge order for the patient. Case managers have been very successful in working with physicians to promote patient discharges by 10:00 a.m. For all floors, over a 5 week period, from early December through mid-January, the average number of orders written before 10:00 a.m. increased from 17 % to 31 %. Case managers have a weekly meeting to review long stay patient records. A discharge check list is given to the primary care nurse upon patient admission. Teaching & medical equipment needs are identified and resolved prior to discharge. Prizes were awarded to nurses who kept up with discharge preparations. A-D nurse tell pts of D/C before chart is completed so they can begin to call family members and arrange transportation. There is also a “clothes closet” that house supervisors and social workers have access to for patients who do not have anything to wear to be discharged home with. The efforts at increased discharges resulted in a need for discharge holding area for patients waiting for transportation. Discharge signage was placed in patient rooms to encourage leaving when discharged.

12. 12 Admission - Discharge Process Pull strategies Admission/Discharge nurse actively pulling patients. Once room assigned, nurse calls EC for report within 15 minutes. Implement discharge checklist when patient admitted. CNO emphasized to nurse managers about effect of pulling patients to maintain staff levels. TCU also helped decompress EC. The creation of an Admission/Discharge nurse dedicated to actively pulling patients from the EC and facilitating discharges was well received by nursing staff who were freed to concentrate on patient care. Changed hours of A & D nurse on Hartmen from 11-7 to 9-5 to move average discharge time earlier in day. Once pt room assigned, nurse calls EC for report within 15 minutes. If no call to EC from unit nurses in 15 minutes, EC PCC calls them to give report. The admission discharge nurse initiates the discharge checklist when patient admitted. The primary nurse is expected to follow up on the patient’s discharge needs daily. CNO emphasized to nurse managers about effect of pulling patients to maintain staffing levels so nurses are not sent home due to low census.The creation of an Admission/Discharge nurse dedicated to actively pulling patients from the EC and facilitating discharges was well received by nursing staff who were freed to concentrate on patient care. Changed hours of A & D nurse on Hartmen from 11-7 to 9-5 to move average discharge time earlier in day. Once pt room assigned, nurse calls EC for report within 15 minutes. If no call to EC from unit nurses in 15 minutes, EC PCC calls them to give report. The admission discharge nurse initiates the discharge checklist when patient admitted. The primary nurse is expected to follow up on the patient’s discharge needs daily. CNO emphasized to nurse managers about effect of pulling patients to maintain staffing levels so nurses are not sent home due to low census.

13. 13 Average Time Decision to Being Admitted This graph shows the time period from the when the physician makes a decision to admit the patient until the patient gets to a bed. Showed notable improvement from its baseline measure of 6 hrs to an average time of 4 hrs (32% improvement), and exceeded the project goal of 4.5 hrs by 10 %. The goal line has been changed from 250 minutes to 120 minutes.This graph shows the time period from the when the physician makes a decision to admit the patient until the patient gets to a bed. Showed notable improvement from its baseline measure of 6 hrs to an average time of 4 hrs (32% improvement), and exceeded the project goal of 4.5 hrs by 10 %. The goal line has been changed from 250 minutes to 120 minutes.

14. 14 OR Posting Notification Special physician’s EC to OR order sheet improved patient flow. Form for posting cases. If more than an hour wait for OR - pt moved to alternate area. Reduced EC wait time from 6 hrs to 1.9 hrs (68%). Adds 40 hrs of bed space/ day. See 5 more pts/ day. Adopted as a best practice. A special Physician's order sheet will be used for EC patients on call to OR. Once completed the form is faxed to adm. who collaborates with HS & EC PCC to take pt to OPS, Gyn EC, TCU or PTU. Alternate places for EC pts waiting OR procedure. Codes were set up in IDX so pts who wait in TCU, OPS, GYN, or PTU areas can be located when the need arises. IDX Codes are TOP8, OPEC, GOP6, and POP9. For EC patients who are on call to OR, a call is placed to the OR "runner" via cell phone. If OR area cannot take pt in 1 hour, the patient is transported to TCU, Gyn EC, PTU, or OPS to wait. Data showed a decrease in average EC wait time from 6 hour wait to 1.9 hours (68%). This equates to an additional 40 hours of bed availability per day, or the ability to see an additional 5 patients per day. The new process will be adopted as a best practice. A special Physician's order sheet will be used for EC patients on call to OR. Once completed the form is faxed to adm. who collaborates with HS & EC PCC to take pt to OPS, Gyn EC, TCU or PTU. Alternate places for EC pts waiting OR procedure. Codes were set up in IDX so pts who wait in TCU, OPS, GYN, or PTU areas can be located when the need arises. IDX Codes are TOP8, OPEC, GOP6, and POP9. For EC patients who are on call to OR, a call is placed to the OR "runner" via cell phone. If OR area cannot take pt in 1 hour, the patient is transported to TCU, Gyn EC, PTU, or OPS to wait. Data showed a decrease in average EC wait time from 6 hour wait to 1.9 hours (68%). This equates to an additional 40 hours of bed availability per day, or the ability to see an additional 5 patients per day. The new process will be adopted as a best practice.

15. 15 Teams with 1st case starting on time win cafeteria meal tickets (random selection). Showed 9.4% improvement in OR start times over four month period. Another RCT trial for surgery teams involved teams that started their first case on time. OR charge nurses began randomly giving the tickets to the team who has the first case started on time. Jeanne and James now have OR teams asking if they're the winners in the mornings. See next slide for data.Another RCT trial for surgery teams involved teams that started their first case on time. OR charge nurses began randomly giving the tickets to the team who has the first case started on time. Jeanne and James now have OR teams asking if they're the winners in the mornings. See next slide for data.

16. 16 Meal Ticket Effect on 1st Cases Starting on Time Graph depicting 1st start case on time by day of week averaged from 10.6% before the meal tickets (blue line) to 20% after meal tickets. From Jan 04 thru April 04 the percent of first OR cases starting on time before the RCT averaged 10.6%. After the RCT the percent of first OR cases starting on time was 20% for an 9.4% improvement. Graph depicting 1st start case on time by day of week averaged from 10.6% before the meal tickets (blue line) to 20% after meal tickets. From Jan 04 thru April 04 the percent of first OR cases starting on time before the RCT averaged 10.6%. After the RCT the percent of first OR cases starting on time was 20% for an 9.4% improvement.

17. 17 Sharing the Lessons (1) Process gaps were revealed. Managing by numbers more important. Effective Communication between departments is essential. Improve existing data collection methods. Mine current data better. Standardizing work processes increases efficiency & reduces chance for errors. There were numerous lessons learned during the course of the project, many having to do with internal processes and organizational effectiveness. As with any effective learning experience in the workplace, process gaps were revealed that translate to lost efficiency and productivity. The importance of managing by numbers was underscored as the need to track the raw data elements of the project’s key process indicators on a daily basis became apparent to the units. It soon became apparent that while UHS captured highly accurate data in some areas, in others it was data poor. The project also emphasized the need for clearly-defined, non-fragmented communication pathways between the emergency department, the clinical units, and administrative centers. The need to fine tune existing data collection systems, add new systems and mine current data, and audit data for quality were all highlighted at the project’s beginning. There is a need for standardization of work processes from unit to unit to achieve greater efficiency and reduce chance of errors. There were numerous lessons learned during the course of the project, many having to do with internal processes and organizational effectiveness. As with any effective learning experience in the workplace, process gaps were revealed that translate to lost efficiency and productivity. The importance of managing by numbers was underscored as the need to track the raw data elements of the project’s key process indicators on a daily basis became apparent to the units. It soon became apparent that while UHS captured highly accurate data in some areas, in others it was data poor. The project also emphasized the need for clearly-defined, non-fragmented communication pathways between the emergency department, the clinical units, and administrative centers. The need to fine tune existing data collection systems, add new systems and mine current data, and audit data for quality were all highlighted at the project’s beginning. There is a need for standardization of work processes from unit to unit to achieve greater efficiency and reduce chance of errors.

18. 18 Sharing the Lessons (2) Simple ideas can bring vast returns Staff realized they could tolerate small short changes. A success in one area can yield results or solutions other than expected. Increased compliance with documentation. Social Workers and Case Managers developed closer working relationship with nurses and providers. Simple ideas can bring vast returns at little to no cost. Team members learned that they could tolerate a certain amount of ambiguity, which could actually lead to the development of unexpected efficiencies. They could tolerate small changes over a short amount of time. Successes in one area lead to improvements in other areas. There was increased compliance with admission documentation because the admission discharge nurse completed the form the same way each time. The case management team began spending more time talking with nurses and physicians about patient throughput.Simple ideas can bring vast returns at little to no cost. Team members learned that they could tolerate a certain amount of ambiguity, which could actually lead to the development of unexpected efficiencies. They could tolerate small changes over a short amount of time. Successes in one area lead to improvements in other areas. There was increased compliance with admission documentation because the admission discharge nurse completed the form the same way each time. The case management team began spending more time talking with nurses and physicians about patient throughput.

19. 19 Sharing the Lessons (3) Greatest Barriers & Challenges Sustaining new practices once project ends. Keeping employee attitudes to continual change positive, without backsliding or “burn-out.” Greatest Barriers & Challenges Sustaining new practices once project ends. Keeping employee attitudes to continual change positive, without backsliding or “burn-out.”Greatest Barriers & Challenges Sustaining new practices once project ends. Keeping employee attitudes to continual change positive, without backsliding or “burn-out.”

20. 20 Team-focused culture of change developed Acceptance of RCT concept. DMAIC (Duh-May-ick) and RCTs adopted house-wide Real world simple techniques are used. Front line people (the workers) are involved. Sense of ownership in the process. Probably the greatest team-focused culture of change it has generated within the System overall success attributable to the project has been the acceptance of the RCT concept among staff as a process improvement tool far surpassing any previously implemented. This appears to be based on the great level of autonomy inherent in the RCT process. While this is not to say there has not been those that have grumbled or withheld their commitment, the majority of employees appear to have been won over by the high level of ownership and relative ease of RCTs lasting only a few days. Maintaining momentum to keep improving other processes is key. We have also used the DMAIC model and RCTs with a Fall Prevention PI team. Key differences in DMAIC and other improvement processes are that simple techniques from the “real world” are used; front line people (the workers) are involved in plans and decision-making; sense of ownership in the process, and controlling gains is very important.Probably the greatest team-focused culture of change it has generated within the System overall success attributable to the project has been the acceptance of the RCT concept among staff as a process improvement tool far surpassing any previously implemented. This appears to be based on the great level of autonomy inherent in the RCT process. While this is not to say there has not been those that have grumbled or withheld their commitment, the majority of employees appear to have been won over by the high level of ownership and relative ease of RCTs lasting only a few days. Maintaining momentum to keep improving other processes is key. We have also used the DMAIC model and RCTs with a Fall Prevention PI team. Key differences in DMAIC and other improvement processes are that simple techniques from the “real world” are used; front line people (the workers) are involved in plans and decision-making; sense of ownership in the process, and controlling gains is very important.

21. 21 System Impact Double-edged sword More efficient - able to treat 500 more patients per month (6,000 annually). Increased utilization of hospital resources. Need for more nursing staff, but not budgeted. Significant strain on bed capacity. As a result of the overall effect of these successful measures, the UHS emergency center continues to see an average of 500 more patients per month. For the year, this equates to an average of 6,000 additional patients being see who otherwise might have gone without medical care. Because of the increased patient load, there has a need for increased staff in various areas, but this was not considered in the previous year’s budget. There was also a significant strain on the already tight bed capacity of the hospital.As a result of the overall effect of these successful measures, the UHS emergency center continues to see an average of 500 more patients per month. For the year, this equates to an average of 6,000 additional patients being see who otherwise might have gone without medical care. Because of the increased patient load, there has a need for increased staff in various areas, but this was not considered in the previous year’s budget. There was also a significant strain on the already tight bed capacity of the hospital.

22. 22 Rewinding the Clock Free Advice Standardize data collection methods. Establish effective team Allow brainstorming, Avoid blaming. Assign duties for RCTs Someone to keep up the Work plan and Issues/Solutions sheet. Make sure KPIs reflect intended measures. Keep lines of communication open. Plan for resistance to change Celebrate successes ! If we could have done things differently, we would have developed a database sooner. Identify team - Assign a small diverse team of people who are interested being a part of the solution, not a part of the problem. Avoid blaming past ways of doing things, or pointing fingers at people or positions. Allow brainstorming during meetings, which may cause some delays in meeting goals, but is a valuable part of the process. Assign responsibility and maintain Workplan & Issues/solutions sheet Keep lines of communication open It is critical to identify a process for data collection, retrieval & analysis & who will be the people responsible. If you don’t have good documentation, things will fall apart quickly. Everyone needs to agree on what is to be measured. You must detail the thing or event in wording terms with written operational definitions (inclusion and exclusion criteria). What was the baseline or pre-intervention measurement before anything was done? 6. Plan for resistance to change, and “burn out,” and methods to overcome them. 7. Celebrating successes helps prevent disillusionment with change efforts. If we could have done things differently, we would have developed a database sooner. Identify team - Assign a small diverse team of people who are interested being a part of the solution, not a part of the problem. Avoid blaming past ways of doing things, or pointing fingers at people or positions. Allow brainstorming during meetings, which may cause some delays in meeting goals, but is a valuable part of the process. Assign responsibility and maintain Workplan & Issues/solutions sheet Keep lines of communication open It is critical to identify a process for data collection, retrieval & analysis & who will be the people responsible. If you don’t have good documentation, things will fall apart quickly. Everyone needs to agree on what is to be measured. You must detail the thing or event in wording terms with written operational definitions (inclusion and exclusion criteria). What was the baseline or pre-intervention measurement before anything was done? 6. Plan for resistance to change, and “burn out,” and methods to overcome them. 7. Celebrating successes helps prevent disillusionment with change efforts.

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