Hello, I'm Michelle Wood and I'd like to welcome you to the session, The Key to Changing Culture with ACC Accreditation and NCDR. Our speaker today will be Lisa Wright. Lisa is the Cardiovascular Outreach Coordinator for Methodist University in Memphis, Tennessee. Methodist University is associated with the Methodist Healthcare System, which is a six hospital system that serves the cities of Memphis and surrounding areas in Arkansas and Mississippi. Lisa's position as Cardiovascular Outreach Coordinator has allowed her to work with referral centers and EMS providers to participate in community outreach, the development of pathways and power plans, data and quality management, and the development of multidisciplinary teams to create a culture of collaboration and excellence. Please welcome Lisa Wright. Good morning. My name is Lisa Wright. I'm a CV Outreach Coordinator at Methodist University Hospital in Memphis. And I'd like to thank you for the opportunity to share our journey to challenging culture with ACC Accreditation and NCDR. I have no disclosures. And what we'd like for you to take away from our journey was our development of an organizational structure that resulted in both integration and consolidation to achieve CV service line program potential quality and efficiency goals, and to recognize that the key to success is changing your culture through engagement, education, feedback, and consistency. Our challenge was to develop and manage an evidence-based quality-driven program. And we currently, as are all of you, working in conditions that have challenging physician and nursing resource issues, as well as capacity within our facilities. So we felt like that our struggles were very similar to all, and that our lessons learned would be equally valuable to you. Our goals involved integrating our organizational structure. We found that we had many gaps within our organizational structure, which actually created barriers to being able to successfully implement certain processes and achieve our goals. So we made a commitment also through the utilization of evidence-based practices to develop our clinical and operational and financial strategies. We recognized that we could not just connect clinical and not approach the operational and financial needs also. So we actually incorporated the clinical, operational, and financial strategies into one. Our ultimate goal was to achieve optimal potential, quality, efficiency, financial goals, and ultimately improve our outcomes. Our strategy was to develop a multidisciplinary approach, and this involved an adaptive leadership team within our stakeholder team, as well as a belief that there's always room for improvement. We were going to utilize the process-based data approach to improve the quality of the care and the service that we provided to our patients. This did involve, as we mentioned in our goals, that we would integrate our clinical, operational, and financial strategies with shared goals and objectives. The tactics that we used were primarily focused around the utilization of the ACC accreditation products, as well as the NCDR chest pain in my registry. We were focused on the utilization of indicated CV power plans, order sets, protocols, and pathways, as well as taking and transitioning very complex data into meaningful analytics through balanced scorecards and dashboards, hoping that we would be able to translate our strategic goals into process goals and metrics. So, what did our journey look like? In the beginning, it felt like we were finding our way through a very, very complex and disorganized maze. Through the utilization of the ACC accreditation model using essential components, we were able to integrate and consolidate our program, which was one of our primary strategic goals. We were able to accomplish this through the essential components of governance, which afforded us a functional structure to be able to accomplish both our clinical, financial, and operational goals. It provided us a method to ensure that we not only measured our quality appropriately, but we were able to utilize it to actually drive our care. It provided us a more effective relationship with our community outreach to both better assess the needs in our community, as well as to educate our community. Another important relationship or stakeholder that became a part of our team was our pre-hospital team. The relationship and importance of our EMS providers in the care of our patients and how we serve our community is essential, as is the relationship. The early stabilization component required that we organize our ED methodology in the way in which we brought these patients into our facility and managed their care from the moment of arrival throughout their stay. The acute component worked with our inpatient stakeholder team to ensure that we were able to accomplish in a timely manner the clinical care that we were committed to provide. The transition of care component was a very, very important essential component in our program, that being that we were able to successfully transition these patients from our hospitalization environment into their own home environment and community environment where the resources there could appropriately care for them. One of the key components of the accreditation that led to the integration and consolidation of our team was the requirement that there be a charter, and this was somewhat like a contract that existed between all the stakeholders on our team that clearly defined that we had a shared purpose, vision, that our goals were shared, that we were clear on our scope, as well as to ensure that we did have the appropriate membership and engagement of the appropriate team members. We actually mapped what this charter looked like to make it a more user-friendly document for our team, and then we began the journey to develop a clinical structure. The foundation of the structure was related around stakeholder engagement. What we recognized was that our team would have more knowledge of what was included in the content of the pathways and the protocols, but this would also enhance compliance and understanding and the ability to actually drive the care. We included anyone that was involved in the care of the patient population and developed an actual integrated care team and involved that care team in the actual design of what the processes and protocols would look like. As you can see here, sometimes a visual is worth a thousand words. This was our nursing team working hand-in-hand with our cardiology team to actually develop and design what the protocols would look like. This team worked on the development and the utilization of the evidence-based power plans and protocols. This included order sets and protocols that would be utilized across the care team spectrum and throughout the stay of the patient. We also, and this is one of the gifts that was afforded us by American College of Cardiology, was the value of pathways and flowcharts. That tended to make those pathways, those protocols, actual living, breathing methods and pathways to care for the patient. We also had clearly defined roles so that everyone on the team was able to have collaborative care and shared goals. Ultimately, our accomplishment was that we had taken very complex guidelines as well as data that was abstracted and vetted with complexity and put together structured protocols, pathways, and order sets that would drive our team. Another important component in the development of a culture of excellence was recognition of the value of education. Historically, much of our education was perceived to be a necessary evil that checked a lot of boxes. What we realized was that education is actually a gift of knowledge and that as we approached our stakeholder teams in the development of the education and competency for each of our teams, that we would change this to be perceived as an actual value in their personal development as well as their professional development. Another component of our education plan was that it would require knowledge and respect of all of the different stakeholder roles on our team. And last but not least, was the development of our quality plan and understanding that most people see the world as they are, not as it really is. We had to work on changing the characteristics of the basic quality and construct of our QAPI plan. That would be based on the fact that quality should be credible and true. We were able to accomplish this knowing that vetted registries afford you a method to ensure that you're looking at the right things in the right way through consistent definitions and consistent abstraction processes, as well as it allows you to benchmark with other like institutions and that affords you knowledge outside the confines of the walls of your own facility. We were able to accomplish this through the utilization of the NCDR chest pain MR registries. One of the benefits also included the fact that this is a product of American College of Cardiology, which did afford recognition from our physician team as it was a college of their peers. Another change that we made related to stakeholder engagement was the role of the abstractor. Historically, the abstractor abstracted retrospectively and we transitioned her role to the point that she was actually a member of our daily care team. She was engaged in the actual oversight and review of the care as it actually occurred. And this made a tremendous difference as far as the perception, even of our care team and the role of the abstractor and the advantages of having a registry to guide our care. It also required an understanding that you have data that is retrospective, you have data that can be concurrent, and you also have prospective use of your data. That being said, we knew that we had to understand that our vetted reports are received retrospectively. Many times it was going to be four to six months before we actually were able to see what that looks like. We also had to recognize that these results would be reflective of four rolling quarters. So you would be able to look at your performance over time. Also, it meant that you can never take a coffee break. You could not have a bad day or a bad quarter that the expectation would be that you would have sustainable quality of care. Most importantly, you had to recognize your opportunity to change was now. So we had to incorporate the utilization of retrospective, concurrent, and prospective utilization for data. One of the key components in our quality plan was the importance of taking complex data and transitioning it into meaningful analytics, recognizing that the most concentrated time that one can spend on a task without becoming distracted is about eight minutes. We had to transition how we presented data. The data was usually presented in meetings in which there were going to be multiple agenda items that were going to be presented. And we wanted to use our time with the most value added perspective. Another component was recognizing that many times the way in which you present the data can be very complex. It can look like the package insert in a foreign language, and we can make it very difficult for you to retrieve where it actually looks like it is a scavenger hunt. So, in order to engage our team, we wanted to develop our balance scorecards and dashboards using the visual management rule. That being that anybody on the team at any time should be able to know exactly how they're performing if you're standing within ten feet of that visual management and have only three seconds to look at it. We were able to accomplish that from transitioning the standard format in which we presented our data into a heat map where you can literally, based on the color in the visual map, be able to determine how you were performing. We also recognized that in our efforts to both integrate and consolidate our team, that we would need to expand the inclusion of our quality metrics, not only in quality meetings, but also expand that to our staff meetings, our marketing meetings, our budget meetings, and our resource meetings. And it was also important to recognize both our successes, as well as our opportunities with our team. We then felt we had met the five aspects of quality, that being that we had a product, that we had our evidence-based protocols and pathways that allowed us to check and monitor and control our processes, as well as manage both our opportunities and successes with an assurance that our patient outcomes would be optimal. At the end of our journey, what we found was that we were able to take very complex guidelines and data in a very fragmented team and a bunch of pieces of paper and transition those to characteristics of our everyday existence. We've gone from a very complex, confusing maze to clear pathways for success. We now had that multidisciplinary team that utilized the evidence-based processes to develop care and provide care, as well as vetted quality metrics, reflecting the results of that care. Again, I'd like to thank you for the opportunity to share our journey, and I wanted to ask if there were any questions. Thank you for the wonderful presentation, Lisa. I have a few questions for you. Could you describe the aha moment that represented the physician engagement when you really felt like they were on board versus pushing back? Absolutely. I think that it was actually twofold. I think the first being when they realized that this actually was a method of caring for patients that provided them an assurance that the patients would receive all of the care based on the protocols and pathways through the utilization of an organized care team. I think their initial perspective was that it would be harder, and they found that it was much easier. And then secondly, I think the transition from their perspective of quality metrics, going from something that they dreaded and viewed as punitive to something that they looked forward to and actually perceived as an opportunity to improve care. Thank you, Lisa. I'd like to expand upon that a little bit. How did you overcome the challenges of current practice versus what the accreditation requirements were? For example, those physicians that have always done it this way that wanted to continue doing that, but your multidisciplinary team recommended a different process. Sure. Well, I think it's innate in all of us to want to succeed and to do things well, but I think it's also innate in all of us to have a fear of what change will entail. And I think the advantage of utilizing the accreditation tool was that it's modeled in a way in which change is actually perceived as an opportunity. And it takes away your fears of failure, and the ACC team provides you a tremendous amount of support. And that makes actually those challenges actually opportunities. I see. So you utilize the support of the people that you were working with through your accreditation process to help answer any reasons of why the change was necessary. Without a doubt. And not only that, they allowed us and provided us the support to accomplish and succeed versus any intimation of failure. Awesome. How does your leadership continue to support the use of accreditation in the NCDR? Well, actually, if you were to look at our strategic plan now, the ACC accreditation and the utilization of the NCDR chest pain and my registry is included in all of our annual strategic plans. ACC is actually considered one of our stakeholders. Thank you very much. And finally, I noticed during your presentation that you relied heavily on a broad education scope to multi team members within the hospital and some community education. Do you know, is there any plan to broaden your education scope to include, say, urgent care centers, other physician types? Absolutely. I think one of the key components in the current version seven for the chest pain center accreditation relies heavily on transition of care. And that extends to the hospital. Because our goal is actually that the patient succeeds in the outpatient setting, that they actually rely less and less on us, and that they are successfully transitioned from the hospital to the outpatient setting. So, Lisa, I understand that the accreditation requirements help specify who should be on your team as far as titles. But can you describe how you selected individuals to fill those roles from the emergency team? What what type of individuals did you select for that team? Absolutely. I'll share. Are few of the individual we had adjustable and mobile providers. I had had students, they had been online for about four months, and the most important thing about the optimization of our programs is support from ourgnational support groups. Absolutely. I'll share our philosophy in the development of our teams, and it was actually one of utilizing the good Samaritan rule, and one of the things that we found was that there were actually members within our stakeholder areas that came to the forefront and wanted to be a part of our program. And they ended up being our leaders. They ended up being key leaders within our stakeholder group. We found that this was actually more effective than the leaders being appointed. Very good. Thank you. When you started presenting your data to the group, how did you address the common theme that we hear? That's bad data or my patients are sicker. How did you you or your position leaders address those type of comments? I think that's a great point. That was one of the reasons that we actually brought our physician team into the actual foundational team in the development of our processes as well as our quality plan. Once they understood the things that we were looking at and how we looked at them, that we utilized standard definitions that were outlined for us within the accreditation tool, and as I referred to earlier, they had a lot of respect for that tool as it came from the college of their peers and their colleagues. And I think that that was key to their understanding as they were actually a part of the team that developed what that visual management would look like. Then I think that they actually had a true understanding and we were able to transition as we covered in the presentation, the perspective that now the data was both credible and true. Thank you very much, Lisa. I have one final question, which I don't know that you'll be able to give a clear answer on that yet, but I think it's important that we do kind of address COVID and the impact that's had. As you guys are moving through your processes, rather it's continuing accreditation or continuing your culture of excellence in the processes that you developed, how are you doing the things that you were doing considering the impact that COVID has had? I think that's also a great question and a great challenge that is shared by all. Actually, the accreditation process has been beneficial to us in times that are very, very stressful and very, very difficult on a day to day basis to be able to conduct the care that you want to do. The care that you want to provide. It is beneficial to have a focus that is based on a foundation of processes and a team that is very sure of their defined role. I think it gives them direction and stability in a time of turmoil and chaos. So, it's actually, I think, been one of the things that has sustained us throughout very difficult times. Well, thank you very much, Lisa, and thank you for presenting to us the process that you've used to change the culture in your organization. Thank you, Michelle, and thank you to ACC for all of the support they afford our team.

ACC Accreditation

NCDR

multidisciplinary approach

quality of care

balanced scorecards

COVID-19 pandemic