I also want to share although may not be relevant to your question directly but some of the processes related to Medicare and Medicaid related to Hospice (End of Life) are unethically misused for the financial gains. The true example is not too far from our own hometown. In NORTH TEXAS – A federal grand jury had indicted 16 Texans for their part in a health care fraud scheme. The indictment alleges that over a four-year period, the company Novus Health Services billed Medicare and Medicaid $60 million for fraudulent hospice services, of which some $35 million was paid to the company. It is very painful to read the extent of the unethical issues. The link below regarding this issue can be accessed via the link below: https://www.justice.gov/usao-ndtx/pr/sixteen-individuals-charged-60-million-medicare-fraud-scheme.
It is good to have a structured curriculum like you mentioned train the trainer model. It is good practice to have your physician facilitators to teach the course, as you mentioned consisted of seven full days of training, and you are ready to roll out the course to your physicians.
How do we create the greatest buy-in from the physicians?
Greatest “buy in” comes if your physicians were included in this from the beginning of the initiation of this project and had their voice in planning to its implementation phase. If we can prove the value to our physicians in taking this seven days’ course in terms of quality as well as quantity. If we can add CMEs (Continuing Medical Education hours) to the modules will help.
Which physicians should we introduce the course to first?
The value of this program should be introduced to physicians who are willing to attend and have the commitment to stay longer in that organization. I think in the beginning Hospitalist will be a good to consider.
How do we engage our next group of facilitators, given the amount of work it takes to become a facilitator?
Need to have some incentive programs for them in terms of bonuses or a recognition by organizational leadership periodically. It is also important to share with these facilitators your patient care data in terms of Press Ganey scores, fewer errors and more collaboration in quality as well as quantity etc.
How do we create a sustainability model? In other words, we expect improvement in metrics initially, but what creates the sustained improvements?
Sustainability is a challenge but if this program needs to survive and to be sustained, it needs to be periodically revisited and revised in terms of its impact. This impact needs to be shared and filtered through the entire organization and become a part of an organization culture among physicians. This program needs an ownership, monitoring, periodic reevaluation in terms of metrics followed by processes to meet the required targets to make this as a living and breathing process.
The issue is a very common challenge. Currently, I took an administrative role and some of the basic tools and resources related to the strategies and revisiting the role clarification for each leader focusing on organizational chart definitely helped. Some of the areas we reinforced might help you too:
1.Understanding Manager versus Leader
•Links vision and activities to people so right things get done correctly at right time to realize goals of organization
•Converts employee talent into performance and shows competence in a professional area
•Describes where team is going
•Has a vision for a future
•Clears path toward destination communicates a vision, and naturally, generates enthusiasm and confidence in those they lead
2.Reinforcing the department Vision
•Vision motivates and directs the team
•Vision and goals help a team stay focused and on track
3.Empowering through: Mutual Respect and build trust
Functional Trust – believing that the team or an individual will do a job well
-“I believe and trust you know your job”
-Interpersonal Trust – believing in the trustworthiness of another
-Virtue of their character
-Open and honest communication
4.Empowering through: Consistent, Visible Support
•Publicly affirming others
•Showing confidence in one another
•Showing support through outward declaration
•Standing by someone during difficulties
•Responding to others with compassion – not criticism
•Giving someone the ‘benefit of the doubt’
•Respecting teammates not present
6.Team Member Development
•Build and foster skills in the individuals
7.Understanding and Collaboration
•Team ability to collaborate with each other
•Cohesive, moving in the same direction, work for the same purpose
•Provide information about individual & team performance
•Feedback should be positive and growth-inspiring
B.E.E.R. Feedback Method:
B: behavior – what is the employee doing that is unacceptable?
E: effect – why is the behavior unacceptable? How does it hurt productivity, bother
E: expectations – what do you expect the employee to do or not to do to change?
R: results – what will happen if the employee changes (positive tone) or this behavior
continues (negative tone)?
9.Effective Decision-Making Competencies
•Decisions are data-driven using fact-based information and utilization of EBP
•Demonstrates understanding of levels of authority for decision making for charge nurse and for staff
•Incorporates patient/family perspectives into decisions about patient care
•Utilizes rounding with purpose for determining patient needs
•Sets realistic mutually negotiated goals and priorities
•Evaluates outcomes of decisions
At our Organization, we implemented a PI (Performance Improvement) project using PDCA Cycle. This project helped with our Fall rate significantly.
•Using the Performance Improvement method “Plan-Do-Check –Act (PDCA), the Fall Prevention campaign was implemented focusing on preventing patient’s falls and its related injuries
•Posey vests discontinued
•Voice-activated bed alarms promoted
•Soft belt restraints added to inventory
•Staff educated on minimizing restraint product use
•Policy on falls and safety revised
•Patients and family members were educated
•Hourly Rounding with purpose implemented
•“Call Don’t Fall” signs posted in different languages in patient’s rooms
•Reduced use of agency staff
•Confused patients assigned rooms closer to nurse’s station
•Night staff assigned temporary work stations closer to patient rooms
•Improved Nurse-Patient ratio for night shift
•Measures of success evaluated through monthly unit-based patient fall reports, direct observation, post-fall investigation forms review and comparison with NDNQI benchmarks
•Post-fall investigation form revised to include post-fall “huddle”
•Exploration of additional product resources such as chair alarms, etc.
•Patient Safety education sheet related to fall prevention.
•An observable decrease in patient fall rate from initial 12.8 % to the set benchmark provided by National Database on Nursing Quality Indicators (NDNQI) of below 3.5 falls /1000 patient’s days after implementing Performance Improvement method “Plan-Do-Check –Act (PDCA) process. This is seen in our present practice as shown below.
Though most Americans (71 percent in a recent survey (Harvard School of Public Health, 1999) say that their home is their preferred place of death, only 25 percent of U.S. deaths occur at home (IOM, 1997). Most of the 2.5 million deaths each year in the United States occur in institutional settings (45 percent in hospitals and 22 percent in nursing homes), and over 25 percent of Medicare expenditures go to beneficiaries’ final year of life (Riley and Lubitz, 2010). Although the above data is a bit old but the issue is similar since the evidence above support this still as an existing challenge for the health care organizations and health care teams.
I recently came across the excellent publication and this article, “England’s Approach to Improving End-of-Life Care: A Strategy for Honoring Patients’ Choices.” This article shared the objectives of England’s end of life care strategy as below:
Objectives of England’s End of Life Care Strategy
•Increasing public awareness of death and dying to facilitate people’s discussion of their preferences and help drive improvements in service quality.
•Ensuring that people are treated with dignity and respect at the end of their lives.
•Ensuring that pain and suffering are kept to an absolute minimum by providing access to skillful symptom management.
•Ensuring access to physical, psychological, social, and spiritual care.
•Ensuring that people’s individual needs, priorities, and preferences for end of life care are identified, documented, reviewed, respected, and acted upon.
•Ensuring coordination of services so that patients receive seamless care.
•Ensuring that high-quality care is provided in the last days of life and after death in all care settings.
•Ensuring that caregivers are appropriately supported.
•Ensuring that health and social care professionals receive the education and training necessary for providing high-quality care.
•Ensuring that services provide good value for the money to the taxpayer.
Source: Department of Health, End of Life Care Strategy: Promoting High-Quality Care for All Adults at the End of Life (London: Department of Health, 2008).
Although my posting will not give you a direct answer to your concern but definitely give you direction on how to approach this issue. In my reference list, the very first link will take you to the strategy used by England to help with almost similar concerns.
Bradford, G, “England’s Approach to Improving End-of-Life Care: A Strategy for Honoring Patients’ Choices” 2010. Retrieved from http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jul/1527_Gray_Englands_approach_endoflife_care_intl_brief_v2.pdf
Harvard School of Public Health/Robert Wood Johnson Foundation poll, April 22–May 15, 1999.
IOM, Approaching Death, 1997, 2.
G. F. Riley and J. D. Lubitz, “Long-Term Trends in Medicare Payments in the Last Year of Life,” Health Services Research, 2010, 45(2):565–76.