AHRQ’s Safety Program for Nursing Homes: On-Time Facilitator Training
Implementation of the Preventable Hospital and ED Visits Reports
Note: This part of the training consists of interactive exercises and does not have any associated slides.
Introduction
Say:
Yesterday you were introduced to the components of On-Time Preventable Hospital and ED Visits, including the electronic reports and implementation materials. Today we will focus on the role of the Facilitator in implementing the program using these materials.
You will participate in two scripted exercises to help illustrate how the Change Team and Facilitator would interact during the implementation of the hospital transfer prevention program. After each exercise, we will debrief regarding what was learned.
In these exercises you will play the parts of the Facilitator and Change Team members. You will simulate the interaction of the Facilitator and the team as they assess their facility’s current hospital transfer prevention program and choose the On-Time Preventable Hospital and ED Visits reports to use in daily practice. In these exercises you will choose the meetings and huddles into which the team will incorporate the reports. Finally, you will decide how to begin to pilot the reports on at least one unit.
Although these exercises compress a number of decisions that the nursing home Change Team will make, the exercises should stimulate discussion about implementation issues that may arise in actual practice that are specific to On-Time and the Facilitator’s role. We understand that to be in this training you already have experience with quality improvement programs in nursing homes and are familiar with nursing home operations and practices. So the goal is to help you understand how your skills can be applied to helping implement On-Time Preventable Hospital and ED Visits materials.
Review of the Nursing Home’s Program for Preventable Hospital and ED Visits Prevention Program
Say:
The Self-Assessment Worksheet is the first tool to help integrate the On-Time reports into the nursing home’s workflow. The Self-Assessment Worksheet guides the review of the nursing home’s prevention practices, identifies meetings and huddles already used by staff to discuss the management of residents’ health, and reviews how staff evaluate the potential causes of hospitalizations and ED visits that do occur. This review helps the team identify ways they can use the On-Time reports to improve their ability to prevent hospitalizations.
We include a scripted exercise in which each of you will be assigned roles of the Facilitator and members of the interdisciplinary team with actual lines that present what a team discussion of a nursing home’s prevention practices may be and illustrate how a Facilitator may interact with the team. After the scripted exercise, we’ll discuss the exercise and the Facilitators’ approach to working with the team.
Do:
Ensure that each participant has the following materials available:
- A blank copy of the Self-Assessment
- The scripted exercise “Change Team Meeting for Self-Assessment”
Assign a role to each participant, including:
- Facilitator [Tom]
- Program Champion (Quality Assessment and Assurance [QAA] Coordinator) [Beth]
- Director of Nursing (DON) [Mary]
- Nurse Manager Unit A [Jill]
- Nurse Manager Unit B [Frank]
- Minimum Data Set (MDS) Coordinator [Caroline]
- Staff Development Coordinator (SDC) [Susan]
- Evening Shift Nursing Supervisor [Henry]
- Administrator [Betty]
- Social Worker [Laura]
Ask:
Do you have any questions before we begin the scripted exercise?
Note to Trainer:
If there are fewer than 10 participants, some participants should be asked to take on two roles. If there are more than 10 participants, assign “extras” to take turns playing the Facilitator; or ask some participants to provide feedback to the group when the exercise is completed.
Role names may be changed to better fit a participant’s gender if he or she would feel more comfortable using a different name.
Do:
Instruct the “actors” to begin.
When participants have finished reading the scripted exercise:
Say:
Great job! Thanks for participating in the role play. Let’s talk a bit about how the meeting went and how a facilitator can help to ensure that the Self-Assessment process is valuable.
Debrief:
When the role play exercise is over, choose from the following questions to engage the group in a debrief. Potential responses are included below as points for discussion. Clearly, these are not all the possible answers.
- How would you describe the strategies the Facilitator used during the Self-Assessment discussion?
- The Facilitator allowed the Team Champion to lead the change team meeting.
- The Facilitator tried to keep the pace of the discussion moving so all sections of the Self-Assessment were covered.
- The Facilitator emphasized the importance of research that suggests that improved prevention care can prevent unnecessary hospital transfers.
- The Facilitator indicated that a facility’s gaps in prevention practices related to hospitalizations are not that unusual and a focus on preventing hospitalizations is a new area for quality improvement. It is important for the team to think that this effort is doable and builds on their strengths.
- The Facilitator pointed out that policies and procedures related to risk factors for hospitalizations are more likely to already exist. The strategy is to identify which are the most important risk factors and work to prevent declines in these risk factors to encourage earlier interventions so that the overall risk of hospitalization will not increase. This is in contrast to waiting for hospitalizations to occur before intervening.
- The Facilitator identified ways the On-Time reports can save staff time when discussion allows these insights.
- The Facilitator helped guide discussion by asking probing questions.
- The Facilitator asked questions to help the team see the value of On-Time reports.
- The Facilitator helped the team think about risk factors for hospitalizations.
- The Facilitator helped the team see how reports could help introduce prevention during existing meetings or huddles.
- The Facilitator reassured the team that he will work with them to help them integrate the reports into their existing meetings and help them with new meetings, if needed. The facilitator needs to help them plan the meeting to keep the new discussions focused so they do not add too much time to the meeting. The Facilitator clarified that discussing residents who were hospitalized is different from identifying changes in risk and intervening before hospitalization occurs. The latter is about prevention and early intervention.
- The Facilitator helped discussion of root cause analysis and showed how On-Time reports may help with their investigations.
- How could you as a Facilitator use the script to help an actual change team identify ways the reports could help the team prevent hospitalizations?
Have them fill out the Self-Assessment and discuss how their nursing home differs from the illustrated nursing home.
Have them discuss the areas they need to improve to help them intervene earlier and prevent hospitalizations. Have them talk about the reports that might help them.
Note to Trainer: Additional question that may be asked:
Do you think the Facilitator missed some opportunities or made some mistakes interacting with the team? If yes, provide some examples.
Review of the Change Team’s Process for Choosing On-Time Reports, Incorporating Reports Into Meetings, and Piloting Those Meetings
Say:
We have a role-playing exercise similar to the exercise we used for the Self-Assessment to illustrate the role of the Facilitator and Change Team in determining which On-Time Reports and meetings the Change Team will decide to pilot. The handouts we will use include a filled in Menu of Implementation Strategies, the Communication Practice grid from the Self-Assessment Worksheet, and a Meetings Description document.
Since nursing home staff may call meetings by different names, the Meetings Description document was created to help clarify the content of meetings and huddles listed in the Menu. It also includes suggested attendees and Preventable Hospital and ED Visits reports that may be used in those meetings. These handouts are intended to help the Change Team make their implementation decisions. As before, we will have a debriefing after the exercise.
The intent of this meeting is to give the Change Team an opportunity to decide which On-Time Preventable Hospital and ED Visits electronic reports they will use and at which clinical team or quality improvement meetings they will use those reports. Once they decide, the team will determine if they have existing meetings that meet their needs or if a new meeting is needed.
The Change Team then decides how to pilot the use of the reports. They may opt to trial one or more of the reports on one unit and then gradually roll the use of the reports out to the entire facility, as is commonly done, or implement across the facility at one time. It is important to focus on the strategies the Facilitator takes in working with the team during this discussion.
In reality, a change team may make these decisions over a number of change team meetings. But for purposes of familiarizing the Facilitator with his or her role, the exercise treats this as one session.
If multiple meetings occur without progress by the team toward making decisions about implementing the reports, the Facilitator should offer strategies to hasten the decisionmaking process (e.g., assist the team to set timeline goals for decisions, attempt to determine what barriers may be impeding progress toward implementation). Before we begin the scripted exercise, let’s spend 10 minutes reviewing the materials provided as handouts.
Do:
Ensure that each participant has the following materials available:
- Completed Menu of Implementation Strategies Worksheet
- Completed Communication Practice Grid from Self-Assessment Worksheet
- Meeting Descriptions Document
- Role play script
Implementation Scripted Exercise
Say:
In our previous exercise the facilitator helped the team to use the Self-Assessment to identify how the nursing home staff t currently try to prevent hospital transfers.. The Facilitator also assist the team in selecting reports that they want to use and determining how and in which meetings or other venues they will use them. In addition to making these decisions, considerations for the change team at this point of the implementation process include whether the reports will be trialed on all units or certain units and, if trialed on certain units, how and when they will be rolled out to others.
For this scripted exercise, you’ll play the same part(s) as in the Self-Assessment exercise and, as before, after the scripted exercise, we’ll have some questions for discussion following completion of the role play.
Ask:
Do you have any questions before we begin the scripted exercise?
Do:
Instruct the “actors” to begin.
When participants have finished reading the scripted exercise:
Say:
That was another super job with the role play – thank you all for participating. Let’s examine this part of implementation and let’s discuss the strategies the Facilitator used and your thoughts about them.
Debrief:
When the role play exercise is over, choose from the following questions to engage the group in a debrief. We include appropriate responses below in case these points are not made. Clearly, these are not all the possible answers.
- How would you describe the strategies the Facilitator used during the Self-Assessment discussion?
- He began with a question about why the team chose Unit A.
- He summarized the team’s decisions from the Self-Assessment discussion, reminding them about their interest in adding discussions of high-risk residents and not just recent discharges to the hospital during Medical Director rounds. The Facilitator can help the team keep track of their prior discussions and decisions made. Several times during the meeting, the Facilitator recaps the group’s findings from the Self-Assessment exercise, reminding the team which meetings the team has expressed interest in enhancing and helped them think about which reports would be useful.
- The Facilitator helps the team think through how they would add discussions of the patients included on the reports to the Medical Director rounds.
- The Facilitator helps the team think about who on the staff would find the information on the reports valuable.
- During our scenario the members of the Change Team were generally very excited about the information that could be made available to them by using the On-Time reports. As a Facilitator, you can expect Change Team members to express concern about adding time during existing meetings to review the content of the On-Time reports or adding a meeting to discuss the On-Time reports. How would you address these concerns? What strategies could you use to overcome facility staff concerns regarding the potential burden on the staff of attending new or longer meetings in which On-Time reports are discussed?
- A Facilitator can explain that the Menu of Implementation Strategies displays many ways On-Time reports can be used and suggests what meetings reports may work well in. The list is intended to give facility staff ideas about how they might use On-Time, not to require new or longer meetings.
- A Facilitator should always acknowledge the team’s concerns but also reassure the team that they control what meetings On-Time reports will be used in.
- A Facilitator can reassure the team that On-Time helps to more efficiently use time by directing discussion toward residents most at risk for preventable transfers.
- A Facilitator can highlight how the reports may reduce the time it takes to assemble the information needed to make care plan changes.
- Directing attention back to the residents and focusing on the value of the team coming together to plan care could also be an effective strategy to overcome resistance.
- Reflecting on a previously successful change that felt overwhelming at the time of implementation can also help with resistance to new processes.
- Facilitators may find it helpful to ask about a particular meeting or process the team feels is especially successful and ask them about how the initial implementation of it went and encourage the staff to reflect on the hurdles they faced and how they, as a team, overcame them.
- How is the On-Time implementation approach of piloting in one unit prior to rolling it out to the facility at large consistent with a true quality improvement or QAPI cycle. How can that information motivate a team to continue to work on implementation of On-Time if they face hurdles during such a trial?
- When referring to a quality improvement or QAPI cycle, the Plan-Do-Study-Act (PDSA) model for improvement may be the cycle that comes to mind. This cycle allows you to test a change and refine it to ensure that it can be carried out and will actually result in improvement. By planning a small test of change before rolling it out facilitywide, you can address problems and unexpected findings before the larger rollout. The Change Team should be reassured that process improvement cycles such as PDSA are successful means to test a change and allow for examination and refinement of it. They should be encouraged to view hurdles that they find in that examination as potential opportunities to make the process the best it can be before rolling it out to the facility at large.
- It is worth understanding that initial implementation of reports in a meeting may be inefficient, but with practice the discussion can be made more focused so it does not add too much time to the meeting. The Facilitator should help them understand realistic expectations during the implementation period.
Note to Trainer: Additional question that may be asked:
Do you think the Facilitator missed some opportunities or made some mistakes interacting with the team? If yes, provide some examples.
