Walden University
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Walden Dissertations and Doctoral Studies
Walden Dissertations and Doctoral Studies
Collection
2017
Evidence-Based Practice Project Proposal:
Reducing CHFRR &rough the Get Well
Networks CHF Prevention Education Materials
Susan Kay Richmond
Walden University
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Walden University
College of Health Sciences
This is to certify that the doctoral study by
Susan Richmond
has been found to be complete and satisfactory in all respects,
and that any and all revisions required by
the review committee have been made.
Review Committee
Dr. Oscar Lee, Committee Chairperson, Health Services Faculty
Dr. Dorothy Hawthorne-Burdine, Committee Member, Health Services Faculty
Dr. Diane Whitehead, University Reviewer, Health Services Faculty
Chief Academic Officer
Eric Riedel, Ph.D.
Walden University
2016
Abstract
Evidence-Based Practice Project Proposal: Reducing CHFRR Through the Get Well
Networks CHF Prevention Education Materials
by
Susan Richmond
MSN, Walden, 2008
Project Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
Walden University
November 2016
Abstract
In the United States, congestive heart failure (CHF) impacts 6.5 million adults and costs
about $39 billion year with a projected incidence increasing by 25% by 2030. CHF can
be addressed by advancing patient self-care knowledge through interactive patient
education. For this project, the Health Beliefs Model guided a strategy to stimulate
behavior modification based on perceived benefits of self-care. The purpose of this
quality improvement project was to implement an interactive patient education video
system, called the Get Well Network, to encourage patient self-care to reduce CHF
readmission rates at a veteran’s administration hospital. Four evidence-based CHF video
order sets were developed with interactive multidisciplinary patient-provider teach back
strategies and questions. The topics included: medication adherence, dietary restrictions,
smoking cessation, and exercise. During the period of project implementation, all
veterans admitted with a diagnosis of CHF were given the opportunity to view the
educational videos; the completed viewing rate increased from 3% to 30% during the
initial 6 weeks. An attempt was made to retrieve quarterly data on congestive heart
failure patient readmission rates from the Veteran’s Administration’s computerized
system. However, recent changes in the ICD coding system have slowed the data
gathering process and it continues to be ongoing. This project has the potential for
positive social change by increasing veteran knowledge of self-care, thereby reducing the
likelihood of CHF readmission.
Evidence-Based Practice Project: Reducing CHFRR Through the Use of the Get Well
Networks CHF Prevention Education Materials
by
Susan Richmond
MSN, Walden, 2008
Project Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
Walden University
November 2016
Dedication
I would like to dedicate this project to my brother, Howard Richmond. He taught
me to reach for the stars and that I could accomplish anything if I worked hard enough.
His interest in health care spurred mine. Through behavioral health modification
strategies, he has successfully managed heart failure for a number of years and is the
inspiration for this project.
i
Table of Contents
List of Tables……………………………………………...……………………………….ii
List of Figures………………………………………………………………………….….iii
Section 1: Overview of the Evidence-Based Practice Project…………………...………...1
Preliminary Project Question……………..…………………………………….….2
Overview of the Scholarly Project………………………………………………....3
Project Design and Methods…………………………………………………….…7
Limitations…………………………………………………………………...….…7
Section 2: Review of scholarly evidence……………………………………………….….7
Literature Review…………………………………………………………………….……8
Theoretical/ConceptualFrameworks…...……………………………………………….….9
Section 3: Approach/Methods to Accomplish Purpose & Meet Project Goals………......14
Approach/Methods…………………………………………………………………….….15
Stakeholder Involvement in Developing Goals, and Objectives………………..…….….17
Plan to Gain Nursing Buy In ..............................................................................................19
Human Subjects Protection…...……………………………………………………….….24
Study Timeline and Plan for Data Analysis…………………………….………………...24
Section 4: Approach and Methods…………………………………………………….….24
Summary and evaluation of findings………………………...……………………….…..24
Implications……………………………………………………...…………………….….25
Strengths…………………………………………………………………………...….….25
Limitations ......................................................................................................................... 26
ii
Opportunities for Improvement .........................................................................................27
Analysis of Self ..................................................................................................................28
Professional ........................................................................................................................29
Summary and Conclusion ..................................................................................................29
Section 5: Scholarly Product for Dissemination ...............................................................30
References ..........................................................................................................................31
Appendix A: Heart Failure PPT for Dissemination ...........................................................37
Appendix B: CHF Poster for Dissemination .....................................................................38
Appendix D: BPVAMC Institutional Review Board Approval: .......................................39
iii
List of Tables
Table 1. Objectives, Approach and Retrospective Data Review……………………22
iv
List of Figures
Figure 1. Fishbone.....................................................................................................106
Figure 2. Diagram Timeline for project........... .........................................................107
1
Section 1: Overview of the Evidence-Based Practice Project
According to the American Heart Association (AHA, 2014) in heart failure, the
heart is unable to circulate an adequate supply of blood to the cells. The result is fatigue,
shortness of breath and is often associated with excess fluid retention, though fluid
redistribution is often at the root of the problem (Dunlap and Sobotka, 2013).
Congestive heart failure (HF) currently affects 6.5 million adults in the United
States (Roger, et al., 2012) with a projected increase in incidence of 25% by 2030
(Heidenreich, 2011). CHF approximate cost is $39 billion annually in the US (Gerdes, et
al., 2013). The 2009 data shows that the mean cost per CHF readmission was $13,000
with a 25.1 percent readmission rate (Rizzo, 2013). Rizzo (2011) goes on to add that this
is equivalent to 118% the cost of an initial admission for CHF, which averaged $11,000
in 2009.
The purpose of this capstone project is to utilize evidence based clinical practice
education toward the goal of decreasing congestive heart failure (CHF) readmission rates
at Bay Pines VA Medical Center. Part one of this paper will include the project mission
statement with an overview of the evidence-based scholarly project. This will include the
complications associated with CHF, project goals and objectives. Part two will be a
review of scholarly evidence. Part three will cover the approach and methods to be used
in accomplishing the purpose and goal of this CHF readmission reduction project. The
conclusion will cover a recap of project purpose and project outcomes to date.
2
Preliminary Project Question.
Project question: What is the relationship between the rise in incidence of CHF
and lifestyle and can this relationship be altered through patient education?
Overview of the Evidence-Based Scholarly Project
Mission Statement
According to Zaccagnini & White (2011) a mission statement’s purpose is to
provide direction in a given project. The mission statement for project is: The
purpose of this project will be to decrease complications associated with CHF
patient's through behavior modification education and improving and patient
education programs toward the end goal of improving the CHF patient’s quality
of life, in addition to, decreasing the RSSR for CHF at Bay Pines Veterans
Medical Center.
The intervention to be implemented will address the health problem of
CHF and will be based in a quality improvement intiative. The risk factors of
smoking, diet, sedentary lifestyle, cholesterol level, elevated blood pressure and
weight are modifiable CHF risk factors. The fishbone diagram in Figure 1
represents the cause and effect of CHF readmissions. According to Kelly (2011)
the head of the fish represents the problem and the causal categories are the
bones. It is hoped that by teaching the benefit of healthy lifestyle and adhering to
the prescribed medication regime and understanding when to contact their health
care providers, better CHF symptom management can be obtained.
CHF program Patients
3
Lab Value Monitoring Smoking
Coordination of Services Regular weigh ins
Physician buy in Med Compliance
Staff buy in Pt Behavior Modification Barriers
_____________________________________________________________ Problem: CHF
Readmissions
Outpatient classroom location Physician education
Lack of sustainable D/C goals Nurse education
Under-utilization of
Electronic learning Pt Ed program limitations
Environment Education
Figure 1. Fishbone diagram showing CHF cause and effect created by author.
Project Design and Methods
The program design will be 2 pronged. One prong will be to gain nursing buy in; the
second prong will be to reduce CHF readmission rates. The objectives, approach and
retrospective data review plan are included in Table 1. The initial aim will be to gain
nursing buy in and support toward the goal of increasing the use of the Get Well Network
patient education video system. The project goal is through increased utilization of the
CHF patient education video, in conjunction with the inpatient programs currently in
place (cardiology team, CHF nurse and dietician) the intervention will impact CHF
readmission rates. The education will be delivered through the Get well Network, an
Objectives
Approach
Retrospective Data Review Pre
& post data to be examined with the
following questions in mind:
4
Track patients admitted with
CHF over 6 month period.
Monitor patients ad-
mitted with CHF for a
period of 6 months
When teaching patient’s the value of
CHF education videos, will viewer
rate increase?
Increase Use of the Get Well
Network.
Teach each Veteran
how to use the
electronic key pad
Can CHFRR be impacted through
increase use of the Get Well Network
CHF education videos?
Decrease CHF readmission
rates. Provide education on how
to manage symptoms of CHF to
decrease CHF exacerbation.
Load CHF videos into
the interactive
viewers/educate each
Veteran about the
pertinence of this
information in regard
to their CHF diagnosis.
Can nursing utilization rates be
increased through showing outcome
improvements?
Increase nursing buy in of the
Get Well Network.
Educate nurses on the
importance of
encouraging the
patients to view the
education videos and
the use of the key pad.
Has nursing buy in been achieved?
Table 1. Objectives, Approach and Retrospective Data Review.
interactive patient education program. The targeted intervention group will be the
inpatient CHF patient population at Bay Pines Medical Center. The timeline for the
program will run over six months with visits to the unit occurring two times per week
(See Figure 2).
The initial approach to nursing will be one to one. The union prohibits formal
surveys except in rare instances. Therefore, an informal semi-structured interview will be
conducted with each nurse. The tool used will be the following three questions have been
approved by the Chief Nurse of Education and will be asked of each nurse:
1. Do you see value in the Get Well Network?
2. What, if any, are the barriers to using the Get Well Network?
5
3. If shown the value of the Get Well Network, can you see yourself using the
interactive patient education videos in patient education?
The reliability and validity of qualitative interviews can be preserved in so long as
neutrality, consistency and truth value are maintained (Appleton, 1995). The author plans
to memorize the questions so that consistency can be maintained in asking each question.
The author will maintain a neutral stance when interviewing. Nursing responses will be
taken at face value to maintain truth value. If a nurse chooses not to participate, it is her
right to decline and this right to decline will be respected. If the nurse provides a no
answer then further education will need to be developed for the CHF nursing staff to
show the value of the Get Well Network.
Once this process has been completed, the cardiac rounding team plan to begin
rounds and will encourage the use of the Get Well Network. The cardiac dietary team
contacted this author and requested a meeting with herself and then the Section Head of
Cardiology. Once the cardiac rounding team and cardiac dietician learned of the project
details they showed great interest and readily agreed to participate in the project. The
section chief felt that since CHF nurses on the cardiology units are members of the
rounding team, they are ideal to load the patient education videos.
6
Figure 2. Timeline for project
The plan will be to track patients admitted with CHF for a period of six months.
According to Zaccagnini & White (2011) data can be analyzed in a number of ways, the
data needs to be specific to the indicator. The data review will be of the Get Well
Network use rates and the CHFRR. Data collection methods for CHFRR and Get Well
Network use rates are already in place. This data will be compared with the same time
period of the previous year. The video viewing rate will be tracked through the Get Well.
The CHF readmission rates are tracked through the practicum site. Viewer rates will be
tracked to observe for number of videos loaded and number of videos viewed. The CHF
readmission rates will be compared with the same time period the previous year. It is
7
hoped that through providing education and strategies for managing exacerbation of
CHF, that the CHF readmission rate will be reduced.
Limitations
The limitations of this project include the small sample size and the fact that this
project relies upon nursing buy in and willingness of patient participation. As stated by
Kelly (2011) when designing a project improvement team, consideration needs to be the
knowledge required to understand the process and project design. She adds that the team
should be designed so that it supports the goal of the group while circumventing
limitations. Since this study will be conducted on an inpatient unit with a specific
demographic, gaining buy in of, both, patient’s and nursing staff is essential in
overcoming this limitation.
II. Section 2: Review of scholarly evidence
In 2008 the Centers for Medicare & Medicaid Services (CMS, 2014)
issued a letter to State Medicaid directors stating they would no longer reimburse
the extra cost associated with certain hospital acquired infections. According to
the Centers for Disease Control & Prevention (CMS, 2014) common medical
errors account for in excess of $4.5 billion in preventable health care spending
annually. The CMS now requires monitoring of CHF readmission rates within 30
days of discharge.
As stated by Lefevre (2014) cardiovascular risk factors are common in
adults, these include: diabetes, obesity, hyperlipidemia and hypertension. The
8
U.S. Preventive Services Task Force (USPSTF) recommends that in order to
improve CHF outcomes (LeFevre, 2014) smoking cessation, exercise and dietary
behavior modification programs are required to aid the traditional healthcare
approach. These programs should be inclusive of education and counseling
programs for all adults diagnosed with or who present with risk factors associated
with cardiovascular disease (LeFevre, 2014).
The Veteran’s Administration (VA) has 153 hospitals. Therefore, the VA
benchmarks against itself. Nationally the VA sets their 30-day Risk Standardized
Readmission Rate (RSRR) benchmark at the 10th percentile. For 2013 the rate
was 18.792. At Bay Pines VA Hospital, the 2013 CHF RSSR was 19.478. In
order to meet bench, the metric will need to improve by 0.686 percentile points.
Literature Review
A literature search revealed that behavior modification has been shown to
be effective in reduction of CHF and associated symptomology. As stated by
Nielson (as cited in Hines & Randall, 2010) the Institute for Healthcare
Improvement developed a transition focused project that reduced HF 30-day
readmission rates from 15% to 6% over a one year and one month period, July of
2006 through August 2007. This was accomplished through a comprehensive
model redesign which included enhanced staff and patient education initiatives.
(Nielsen et al., 2008). If the principles of this project were applied to a program at
Bay Pines, since they were successful in attaining a 9% reduction over a one year
9
and one month period, it would be hoped that a 0.686 reduction could be
achieved.
The Get Well Network is a comprehensive education program already a
component of the Veteran’s Health Administration (VHA) patient education
program. The Get Well Network (GWN, 2015) delivers wellness programs to
motivate patients toward adapting healthy lifestyle changes to inpatients in
hospitals across the U.S. At the author’s practicum site, policies are in place for
its use, though due to a lack of nursing buy in, at Bay Pines, the use rate is one of
the lowest in the region of VISN 8. Less than 25% of the nurses use this learning
tool. Hopefully, through showing the nurses how this tool can benefit patient
outcomes, the author would be able to gain buy in and see a rise in use. The VHA
collects data locally, as well as, at the national level, so processes are already in
place for the collection of the Get Well Network data.
Theoretical/Conceptual Frameworks
Dorothy Orem’s Self Care Theory
Dorothy Orem viewed nursing as a human health service. Her Self-Care
Deficit Theory has its roots in the fundamental idea that certain factors need to be
met for optimal health is to occur in an individual. Orem’s theory stresses the
need for nurses to provide the activities of daily living a patient may not be able to
accomplish on their own by assessing and accommodating patient self-care
deficits. She goes further to state that not only is it nursling’s responsibility to
provide these needs, but to teach the family to provide care as well.
10
Orem's theory, based in three concepts: self-care, self-care deficit, and
nursing systems. “The power of nurses to design and produce nursing care for
others is the critical power that is operative in nursing. This human power with its
constituent capabilities and disposition is named “nursing agency”. (Parker, p
143.) Improving self-care is at the root of this projects purpose making Dorothy
Orem’s theory appropriate for this project.
Health Belief Model (HBM)
A well founded theory that would seem appropriate to address this
problem is Health Belief Model (HBM). As stated by Croyle (cited by Nursing
Theories, 2013) the HBM is a suitable model to address behavioral problems
which create health concerns. The HBM is relevant to this project because heart
failure is the end result of all diseases affecting the heart. Causative factors
include smoking, alcoholism, obesity, cholesterol level, and a sedentary life style
are lifestyle choices which are behavioral in nature. These lifestyle choices create
the circumstance which makes the HBM appropriate for this project.
This model proposes that the likelihood of a behavior modification is
based upon the individual’s perception of the benefit of making the change
(Kettner, Moroney & Martin, 2008). In the HBM model the person’s perception
of “the severity of a potential illness, the person's susceptibility to that illness, the
benefits of taking a preventive action, and the barriers to taking that action”
(Nursing Theories, 2013) are what determines an individual’s health associated
actions.
11
The recommended strategies are: conducting a health risk appraisal to
determine who is at risk, communicating the risk of associated unhealthy
behaviors, communicating recommended actions to nullify or diminish risk and
clarifying benefits, aid in identifying barriers and ways to decrease barrier
influence and provide incentives and, reducing anxiety, demonstration of new
skills, role modeling and reinforce benefits of improved self-efficacy (Nursing
Theories, 2013). The diagnosis of CHF identifies the risk, the Get Well Network
education videos are designed to communicate the risk and clarify the benefit.
The Health Belief Model (HBM) has been widely used in the field of
nursing. According to Baghianimoghadam (2013) the HBM “is one of the most
widely used models in public health theoretical framework” (p. 52) and is used by
nurses worldwide. A pertinent example would the heart failure (HF) study
conducted in Iran of patient’s self-reported perception of heart disease. This study
was conducted to gain a better understanding of the patient’s attitudes, behaviors
and educational needs of the HF population (Baghianimoghadam et al., 2013).
These authors went on to add that the HBM can be utilized to develop effective
intervention strategies and has the potential to be used to develop educational for
programs for individuals and communities (Baghianimoghadam et al., 2013).
Since this model has been used successfully in the past for heart failure education
programs, it should be a good choice for this project as well.
12
Formulation of Evidence-Based Practices and Action Plan
The diagnostic model that will be used to determine the primary cause of CHF
readmission and possible ways to reduce them is the Root Cause Analysis (RCA). As
stated by Wald and Shojania (cited by Nicolini et al., 2011) RCA is a retrospective
structured investigative process for examining events. It can also be utilized to
understand why a process is not working the way it should. The steps, as stated by Amo
(cited by Nicolini et al., 2011) include: identifying the incident, team organization, study
of the work process, fact collecting, analysis of data and search for causative factors,
corrective action and evaluation of action outcomes.
Data can be used to determine trends, develop procedures to improve quality and
set standards. “Evidence ultimately must be used to create evidence-based practice
protocols based on best care as defined by those care processes that routinely produce
safe, effective care, and are validated in real-world settings” (Asher et, al., 2014, p. 137).
According to (Nicolini et al., 2011) collecting data, is a time-consuming, labor intensive
process, care must be given to this process to ensure the accuracy. An efficient way to
organize data is through charts and graphs. The fishbone diagram in Figure 1 represents
the cause and effect of CHF readmissions. According to Kelly (2011) the head of the fish
represents the problem and the causal categories are the bones.
An understanding of data analysis and the power of literature review is essential
when conducting an RCA. Review of literature and data analysis will provide a baseline
and direction to find the tools we need to improve best practices. This knowledge will aid
13
in understanding underlying causative factors. This understanding can facilitate change
and improve the management of chronic disease.
The U.S. Preventive Services Task Force (USPSTF) reviewed 74 CVD behavioral
health intervention trials of preventive services designed to aid patients in engaging
patient in healthy behaviors while limiting unhealthy behaviors. The behavioral health
education/counseling focused upon combined approaches to healthier lifestyle
development. The USPSTF study found that a substantial number of participants were
obese or overweight and that these interventions proved beneficial.
The evidentiary review showed that in adults with cardiovascular risk factors the
interventions made small but important changes in health behavior outcomes. The
USPSTF report, according to by Lefevre (2014) showed that cholesterol levels were
reduced by approximately 0.08 to 0.16 mmol/liter and low density lipid levels were
reduced from 1.5 to 5 mg/dL. Blood pressures decreased by 1 to 3 mm Hg and 1 to 2 mm
Hg, systolic and diastolic, respectively (Lefevre, 2014). Diabetes incidence decreased by
as much as 42% in trials reporting outcomes after 3 years (Lefevre, 2014). Weight
decreased by an amount equal to a BMI reduction 3 kg” (Lefevre, 2014). Of the 74 trials
only 6 reported adverse events and these were minor. Additional qualitative information
which would aid in the project is a review of current process of the work process,
policies, and current patient and staff education.
In reviewing the fishbone diagram (Figure 1.) and the data presented above, it
becomes clearer that the focus of the project should be two pronged. One prong or sub-
group should concentrate on behavior modification education and the other prong or sub-
14
group will focus upon staff and patient education. In reviewing the literature above,
targeted patient education areas should include: Smoking Cessation, Nutritional
Management, Lipid-lowering Drug Therapy and Exercise Training.
III. Section 3: Approach/methods to accomplish purpose and meet goals of
the project
The project goal will be to reduce CHFRR through use of the Get Well
Networks CHF prevention education materials. The process/approach will be:
1. Cardiac rounding team will see patients admitted with a CHF diagnosis for
a period of 6 months,
2. Rounding will occur Monday-Friday.
3. Cardiac dietary staff will ensure that each Veteran understands how to use
the electronic key pad.
4. CHF nursing staff will load the CHF videos into the interactive viewers
and educate each Veteran about the pertinence of this information in
regard to their CHF diagnosis; with cardiac rounding team reinforcement
Monday-Friday.
5. Data review and analysis.
6. Post data review and follow up with nurses. Topic will be program
outcomes and the importance of continuing to encouraging the patients to
view the education videos and the use of the key pad.
The work will be accomplished by an interdisciplinary team. The cardiologist
has agreed to encourage the nurse to load the patient education videos during the
15
cardiac team patient rounds. The cardiac dietician has agreed to teach the patients
how to use the soft key pad. These rounds will be conducted Monday-Friday.
The data review will be of the Get Well Network use rates and the CHFRR.
This data will be compared with the same time period of the previous year. Data
collection methods for CHFRR and Get Well Network use rates is already in
place. Pre and post data will be examined with the following questions in mind:
1. With patient education on the value of the education videos, will viewer
rate increase?
2. Can CHFRR be impacted through increase use of the Get Well Network
CHF education videos?
3. Can nursing utilization rates be increased through showing outcome
improvements?
Approach/Methods
Preliminary Project Question or Hypothesis.
My Project question: What is the relationship between the rise in
incidence of CHF and lifestyle and can this relationship be altered through patient
education aimed toward behavior modification in the CHF population?
Project Method
The study design the author plans to use to address the health problem of
CHF is a quality improvement initiative with retrospective data analysis. A
quality improvement project utilizes current evidence-based knowledge and best
patient practices which apply to a given patient population to address
16
opportunities to improve outcomes or deficiencies (Stausmire & Ulrich, 2015).
Since it is the author’s intent to examine the relationship between patient
education aimed toward adopting healthy behaviors and the effect on CHF
readmissions in a limited practice environment through the use of an existing
process, the quality improvement project design is a good fit for this project.
The tenets and assumptions that support the use of this design is the
limitation of a single inpatient environment (the project site) and the short term
duration of the project necessitating inclusion of all patients admitted with CHF
so that an adequate number of project subjects may be obtained. Since, the initial
plan will be that during the 5 month project period, all inpatient Veterans with,
either, a primary or secondary diagnosis of CHF will be offered the opportunity to
watch the Get Well Network CHF education videos. Therefore, regardless of
participation status, all Veterans will be offered the opportunity to participate in
the Wellness Network education videos. Written educational materials regarding
the adoption of healthy behaviors will be offered to study participants for home
use will be provided the CHF nurse educator and discharge pharmacist. The
participants will then be followed outpatient for a period of six months.
According to Friis & Sellars (2014) factors that can contribute to error include
poor precision, sampling error, variability in measurement and systematic errors.
Since this is a targeted study of all participants who enter the hospital,
randomization will not be a factor, though their voluntary status is recognized as a
potential for bias. Another potential for bias in this study will be due the
17
limitation of it begin offered only to those ill enough to be hospitalized. Though,
these variables have the potential to introduce bias into the study, it is hoped
through precise interpretation of the data collected that the error potential will be
reduced. Confounding variables that will be reviewed are extraneous factors
which can affect the participant’s ability to adopt healthy behaviors and their
willingness to participate in the study.
This project will include a retrospective review of data. Since it is the
author’s intent to examine the variable between increased use of the inpatient
learning videos, patient outcomes and the impact on gaining nurse buy in this
method would seem appropriate.
Stakeholder Involvement in Developing Mission Statement, Goals, and Objectives
It is important to have representatives from the target population when developing
program objectives and goals because these stakeholders possess culturally sensitive
knowledge which may be crucial to the success of the program. According to Hodges &
Videto (2011) stake holder’s input regarding existing health problems, health concerns
and quality of life can provide valuable insight when determining the goals and
objectives for a program. Through involving the target population in the development of
goals and objectives, the cultural needs and health concerns of a given population can be
more easily met.
One way to involve target population in program design is through providing the
fundamental training necessary so that a basic understanding of the program design
18
theory chosen for the project can be achieved. The AHA’s Essential Elements of Project
guide their projects. One project principle they adhere to is: “ensure that all stakeholders
are involved, as appropriate, in project activities” AHA (2015).
Target population members are subject knowledge expert that can provide
invaluable advice regarding the culture. According to Donna Shambley-Ebron (Laureate,
2011) two types of knowledge are important in program planning: expert of knowledge
and the holder of the local knowledge. As first hand holders of knowledge, the holder of
local knowledge can aide in the identification of barriers, strengths and opportunities.
Strategies to navigate a lack of interest or disagreements include a good
understanding of team/group team dynamics and team building skills include developing
a leadership style which engages the growth a change environment. A transformational
leader can help to gain buy in because it they foster a positive growth environment
through the enculturation of trust and inspired vision (Schwartz et al., 2011). This is
accomplished through personalized team member recognition and empowering team
members to challenge the status quo. Challenging the team members to embrace and
engage change can help to dispel a lack of interest. Lewin’s Theory of Planned Change
can be used to gain buy in. According to Zaccagnini & White (2011) the DNP prepared
nurse leader will be able to integrate concepts of change theory with leadership theory.
Plan to Gain Nursing Buy In
19
A transformational leader can help to gain buy in because it they foster a positive
growth environment through the enculturation of trust and inspired vision (Schwartz et
al., 2011). This is accomplished through personalized staff recognition and empowering
staff to challenge the status quo.
An understanding of team dynamics and management of systems is essential to
gaining buy in. Additionally, by instilling a vision into staff so they understand why the
change is necessary aids in gaining buy in (Mitchell, 2013). The leaders of this project
will need to have insight into potential problems that will arise so that they may forestall
them before they start. Potential problems that could arise include allocation of resources,
scheduling conflicts, staffing challenges and a lack of educational resource tools. These
types of problems can deter buy in and hamper the group process.
As stated by Cecelia Wooden (Laureate, 2011) the effective manager will have a
good understanding the stages of team development, which are forming, storming,
performing. She adds that the successful team leader will know what the goals are of the
group and have a timeline in mind prior to arriving at the first meeting. This will aid in
giving the team a vision of what is to be accomplished and enable them to seed into the
end result.
According to Zaccagnini & White (2011) the DNP prepared nurse leader will be
able to integrate concepts of change theory with leadership theory. Giving the team a
sense of how this project can improve patient outcomes will help keep team members
vested. Helping the team members to see the value in the project will encourage members
to become actively involved. As the caregivers will be the end users, including them into
20
the planning process will not only provide valuable input, it gives a sense of ownership
toward the end goal. Involvement of direct the care nurse is an effective way to gain buy
in (Smith, Laureate, 2011) as this process gives direct care staff a sense that it was their
project and their design. That is how incorporating the nurses into the change, vests, both,
them and their work into the project and engages buy in.
Lewin’s Theory of Planned Change can be used to gain buy in. This model can
aid in achieving meaningful and successful organizational change through the stages of
unfreezing, moving, and refreezing. The unfreezing phase, could be utilized to gain an
understanding of the current process, how it works and to provide education to the nurses
about why change is necessary. As stated by Radtke (2013) a good way to engage nurses
in the change process is though showing how the change in practice can improve patient
outcomes.
In the moving or transitional stage, change agents (Shirey, 2013) look at change
as a process with the understanding that a component of transitioning is the stance or
inner motivation that individuals take in reaction to a proposed change. As stated by
Shirey (2013) during this stage a detailed plan of action will be developed and as the staff
may be plagued with uncertainty, they will require mentoring and coaching to help them
to keep on track and not lose sight of the goal. Showing the nurses how to this change can
improve outcomes in their patient population, will encourage them to try out the proposed
change.
According to Shirey (2013) the refreezing stage requires incorporating the change
so that it becomes entrenched into existing systems, policies and the organizational
21
culture. She adds that the refreezing stage is crucial as this phase locks in the process
over time. After about 5 or 6 weeks people have a tendency to revert to old ways of doing
things so during the refreezing, reinforcement and any additional education will help lock
in the new process.
As with changing any ingrained pattern, resistance is natural. There are ways to
effectively manage through resistance. During the needs assessment, opposing and
motivating factors can be identified. As stated by (Zaccagnini, & White, 2011) while
there will always be driving and resistive factors, Lewin’s change theory of unfreezing,
moving, and refreezing can be used to unfreeze an opposing situation and aid in
implementing change.
Systematic Evaluation
It is essential to quantify and evaluate any scientific intervention (Friis & Sellars,
2014). To accomplish this a systematic evaluation must be conducted. The primary
purpose of the evaluation will be to examine if there is a causal effect between the
intervention and outcome. The outcome data must be measured and then evaluated with
scientific methodology. As stated by Friis & Sellars (2014) the Four Stages of Evaluation
are Formative Evaluation, Process Evaluation, Impact Evaluation and Outcome
Evaluation.
The Formative Evaluation begins as soon as the program idea is conceived (Friis
& Sellars, 2014). An element of the Formative Evaluation is to determine project
feasibility (Tudor-Locke et al., 2002). In this project, it was hypothesized that the
22
intervention of the Get Well Network as an education tool could lead to the adoption of
healthy behaviors (smoking cessation, adoption of healthy eating habits, and developing
an exercise program) which in turn could lead to lower CHF readmission rates in the
T2D. The use of increased physical activity levels and manipulation of dietary intake has
been shown to be effective in reducing CHF risk factors (Thomas et al., 2010). Since
previous project has shown behavior modification education as beneficial, this project
should meet the qualifier of feasibility.
As stated by Friis & Sellars (2014) the Process Evaluation is used to determine if
the program will serve the target population as intended; this evaluation process should
go into effect as soon as the program begins. This purpose of this project is to aid in the
reduction of the CHF readmissions and to improve usage rates of the Wellness Network
in the inpatient population. This Process Evaluation plan will include an assessment of
whether the number of the target population being served is as expected (Friis & Sellars,
2014). In this instance the target population is the CHF inpatient population.
The Impact Evaluation measures the change in knowledge, attitudes, beliefs and
behaviors of the target population. A similar project to the one proposed was conducted
in Thailand. This group conducted a quasi-experimental study of 30 elders with
uncontrolled T2D against a control group (Ounnapiruk et al., 2014). They examined
effectiveness of educational empowerment, and the topics of diet and exercise education
on blood sugar levels. The program ran for 12 weeks. While fasting blood sugars did not
improve significantly, the education initiative had improved the patient’s knowledge of
23
diabetes, as well as, their perceived self-efficacy and adherence to a proper diet and
medication regime than the control group (Ounnapiruk et al., 2014). It is hoped that this
project will perform at the same level or better.
Another function of the Impact Evaluation includes collecting baseline data (Friis
& Sellars, 2014). This data collection will help to inform the project developers about
whether or not they are making progress toward their goals (Friis & Sellars, 2014). The
nurse’s pre and post surveys and the CHF readmission rates will aid in determining the
program’s impact on the target population.
The Outcome Evaluation process includes data review at selected intervals (Friis
& Sellars, 2014) and will be two pronged. One arm will be the evaluation of the nursing
staff and whether or not there was increased use of the Get Well Network. The second
arm will examine the CHF readmission rates to determine if the educational intervention
may have had impact. The goal of the Outcome Evaluation is to see how well the
program met its goals (Friis & Sellars, 2014). It is hoped at program completion, the
program goals will have been met.
Human Subjects Protection
The study has been approved by the Institutional Review Board Project and
Development (R&D) Service at Bay Pines VA Healthcare System.
Study Timeline and Plan for Data Analysis
January 2015-June 2016
24
During this time period patients admitted with CHF will be education on how to
use the Get Well Network’s soft key pad. The CHF education videos will be loaded into
the viewers. Data will be tracked to compare the number of videos loaded with the
number of videos viewed. The number of CHF readmissions will be tracked each month
as well.
May-June 2015
Data analysis will be conducted and completed. A report of the project findings
will be written at the projects conclusion. Once written, upon receipt of approval from the
project site, final paper which outlines the project, overall goals and outcomes will be
submitted for publication in a peer reviewed nursing journal.
IV. Section Four: Discussion and Implications
Summary and evaluation of findings
I am in the implementation phase of my project, which is the DO step of
the PDCA cycle. The CHF readmission rate is 20.481 for the fourth quarter of
2015 (VA SAIL Report, 2016). I will need to wait until the 2016 1
st
quarter
reports come out to compare the CHF readmission rate pre and post intervention.
The ICD codes changed from ICD 9 to ICD 10 (CMS, 2016). ICD 9 had 7
diagnostic categories for CHF and ICD 10 has 13. The ICD 10 coding at my
practicum site is still being built by the data warehouse information technology
staff. Completion is not expected for at least 3 months. The initial completion rate
for viewing of the GWN patient education videos was 3%. The first month of the
project showed an increase to 26% of videos viewed.
25
Implications (for practice/action, for future research, for social change)
The initial findings suggest that there has been an increase in the
completed patient education videos viewed of 26%. It will be interesting to watch
this trend over the next 2 months. At the completion of the project, the CHF
Readmission Rate will be examined to see if they have decreased. If so, it may be
possible to show an association between the viewing rates and the current CHF
rate.
Future implications for this project if shown to be successful include an
expansion of this project to other diagnostic groups within the practicum site. A
change in process utilizing emerging technologies, according to Dunlap and
Sobotka (2013) could improve follow up care through an enhanced staff and
patient education process. Additionally, if these outcomes are sustainable, it is
possible to expand this project to other VA hospitals.
Strengths
Since this project is being conducted on a single inpatient diagnostic
group, patients admitted with CHF, this adds strength to the choice of the PDCA
design. An additional strength of this project includes the use of an
interdisciplinary team. Through collaborative brainstorming, additional benefits
are gained through an interdisciplinary team that might not otherwise be attained
through a single discipline (Zaccagnini & White, 2011). The interdisciplinary
team greatly assisted in the development of this project.
26
Strength of the project includes the chosen data collection method. The
data collection systems for the interactive patient education videos and the CHF
readmission rates are already in place. Therefore, data points exist which can be
used to compare outcomes from the year previous. I am using aggregate data to
compare an increase in Get Well Network Use Rates against CHF Readmission
Rates. Aggregate data is information that is compiled into percentages or rates
and is tracked over time often to compare benchmarks (Ryan & Thompson,
2002). The CHF Readmission Rates are already being collected by the VA for
distribution at the national level. Additionally, the pre-tested reliability of the
interactive patient education videos adds rigor as well.
The patient education documentation template which was built for the
electronic medical record makes it easier for the nurses to document the patient
education. Ease of use increases nursing engagement which adds to the strength
of the project design.
Limitations
The limitations include a relatively small sample size when compared with
the number of individuals with CHF. Heart failure (HF) currently affects (Roger,
et al., 2012) 6.5 million adults in the United States. However, minor projects can
lead to larger initiatives if they prove to be effective. Another limitation includes
the limitation of a single inpatient environment (the research site) and the short
term duration of the project necessitating inclusion of all patients admitted with
CHF so that an adequate number of research subjects may be obtained.
27
Additionally, the project success is dependent upon behaviors of the CHF patient.
As stated by Dr. Kristen Mauk people have to be willing to change or to listen to
what you've discovered" (Laureate, 2012). In order for the project to be
successful, the patient must engage in medication and symptom management as
well as elimination of unhealthy behaviors.
The project is being conducted within the VA systems which provide
Veterans with a comprehensive health care system. This limits the ability to
duplicate the project in the private sector. Duplication of results is an important
aspect of any project.
Opportunity for improvement
An opportunity for improvement for future a project includes further
investigation of data collection methods. If I had looked into the ICD coding prior
to project initiation, I might have started the project earlier or postponed the
implementation date so that I would have congruent data. Another opportunity for
improvement is the limitation of being a student. As such, I am not always
available to meet with the team, the team members as cardiology staff members
are able to make decisions and make changes to the project without my input. If I
were a full-time staff member of the hospital, it could make the communication
process easier and I might have more influence as the project leader.
Analysis of self
Self-analysis is a necessary task to undertake if growth is to occur. A key
component of self-analysis is an assessment of strengths and weaknesses
28
(Roberts, 2014). As a DNP student, I feel that I have experienced a great deal of
growth. Not only from the practicum project, but through the opportunities
offered in the practicum experience. I have gained expertise in critiquing articles
for their scholarly value and am now the facilitator for the Nursing Journal Club
and the secretary for the Nursing Research Committee. I work with other nurses
to critique articles for presentation and assist them with honing their presentation
skills.
My expertise as a project developer has grown through this experience
secondary to the learning opportunity afforded me though the insights offered
through an interdisciplinary team and the opportunity to work with the Chief
Nurse of Research and the Chief Nurse of Education. Overcoming barriers and
moving through the IRB process has afforded a great learning experience. When
one encounters delays and barriers that need to be worked through, a greater
learning opportunity can become available than if the project went smoothly from
start to finish.
Professional
One component of professional growth where I have observed growth is
through the development of an interdisciplinary team. As stated by Zaccagnini
and White (2012) gaining an ability to appreciate the similar and dissimilar
perspectives of other interprofessional team members is necessary function of the
professional nurse. Through working with an interdisciplinary team with members
29
from different areas of the world has allowed me to gain a greater understanding
of the value that a differing perspective can add to the team.
Another area of professional growth has been in the area of systems
management. According to Roberts (2014) systems thinking is a leadership
expectation of the nurse executive. Through the learning opportunities afforded
me through this program, I feel more confident in systems management.
Summary and Conclusion
As previously stated the Bay Pines VA, the 2013 CMS 30-day Risk
Standardized Readmission Rate (RSRR) was 19.478 (VHHC, 2015). The 2015
fourth quarter showed it to be 20.481. The VA national benchmark is set at the
10th percentile (17.792). The mission of this project will be to decrease the RSSR
for CHF to the national benchmark toward the aim of improving quality of life for
CHF patients. The outcome of this project is yet to be seen, however, I am
hopeful that we can establish a positive association between the CHF readmission
rate and an increase of viewer rates. As stated by Beth Houser (Canter, 2001) to
be effective, nursing leaders must be “agents of change”. Hopefully, this change
initiative will be accomplished through a nursing and patient education project
which will be focused upon a patient education initiative to enhance and promote
healthy behaviors.
V Section Five: Scholarly Product for Dissemination
The scholarly product for dissemination includes a PowerPoint
Presentation for dissemination of project to staff (see Figure 1) , a poster
30
presentation for Nurse’s Day 2016 (see Figure 2) and a manuscript for publication
(see Figure 3). Secondary to the change in the ICD 9 codes to ICD 10, there will
be a delay in obtaining the CHFRR data. This data will be added to the
manuscript prior to submission for publication consideration.
31
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Appendix A: Heart Failure PPT for Dissemination
Susan Richmond, RN-BC, MSN
Kelsey Baizan, Registered Dietician/Nutritionist
in conjunction with Cardiology Outpatient Clinic and Dr. Paszczuk
38
Appendix B: CHFRR Poster for Dissemination
39
Appendix C: Bay Pines IRB Approval Letter
