TAKEheart Implementation Guide Module 2
Implementation Guide - Module 2System Change: Laying the Foundation and LeadershipModule PurposeFollowing the call to action in Module 1, the purpose of this module is to lay the foundation forsystems change. Topics include how to: 1) identify a CR champion, 2) form a multidisciplinary CRQuality Improvement (QI) team (composition of the team, and why), and 3) develop an Action Plan.The module provides a brief introduction to the Institute for Healthcare Improvement’s (IHI) Modelfor Improvement.Target AudiencePrimary audience: CR QI Team implementing automatic referral with care coordinationSecondary audience: Non-team cardiac clinicians, discharge planners, care coordinators, hospitalleadershipLearning ObjectivesUpon completion of this module attendees will be able to: Select a CR champion to lead the CR QI Team and advocate for automatic referral with carecoordination. Identify key members of a multidisciplinary CR QI team with representatives from key departmentsand patient advisors. Create an Action Plan for implementing automatic referral with care coordination.Key Takeaways from the Module Ensure the champion has the skills to engage and collaborate with hospital leadership to setthe course for automatic referral with care coordination.Start with a few key members for the multidisciplinary team, then as you build momentum youcan add team members.Break each change that you want to make (to implement automatic referral with carecoordination) into specific tasks with discrete responsibilities and timeframes.o Keep the process flexible, don’t be afraid to make adjustmentso Start small and build upon the successes
Steps and Guidance for Getting StartedSTEP 1: Choose a ChampionIdentify a CR champion to work with key members of the hospital leadership and other stakeholderswho will need to buy-in to the effort and help marshal resources. The champion needs to be a credible and trusted member of the cardiac care group at thehospital.He or she will work to persuade key stakeholders of the value of increasing CR specificallythrough automatic referral with care coordination.The CR champion may be the team leader although in some hospitals the implementationteam may be led by someone else.The Champion will help to manage challenges such as conflicting interests and scarceresources to move the project forward.In many cases the Champion will be a clinician, although there may be other hospital staff whocan assume the role.STEP 2: Create a Multidisciplinary Cardiac Rehabilitation Implementation TeamForm a multidisciplinary team to serve as the foundation for system change. Select action oriented individuals who have credibility with peers and possess goodcommunication skills. Include individuals who “touch” all parts of the process. Crucial members are likely to include:o IT representatives with the expertise needed to set up an automatic or “opt-out”electronic referral of all eligible patients to CR.o Physicians and nurses who can advocate for automatic referral with peers and otherclinicians.o Hospital QI staff and managers who can bring expertise in leading organizational changeo Patients (including CR graduates) who, as end users, can bring valuable insights aboutthe process. If the hospital has patient family advisory committee, consider asking themto participate.o CR staff (if applicable) Set up designated meeting time for the team. Develop meeting agendas and materials. Set up daily/weekly/monthly huddles and check-ins with different members of the team forstatus updates on the Action Plan tasks, sharing information and data about the project,celebrating successes and generating of new ideas. Determine what is needed in terms of infrastructure, cost, and technical expertise toimplement automatic referral with care coordination.STEP 3: Create an Action Plan: Develop a summary of what the team hopes to achieve: create an aim /Aim-Statement-Worksheet.aspxEstablish SMART (Specific, Measureable, Achievable, Relevant, and Time bound) goals.Complete the Action Plan Template, see attached Action Plan templatePH ACTION PLANTEMPLATE.docx
o Determine the tasks required to accomplish automatic referral with care coordination.o The Action Plan template includes project milestones under the tasks column. Milestones are high level tasks that are critical for achieving a goal. TAKEheartrecommends that hospitals include the following milestones in their ActionPlans. These milestones were culled from the Million Hearts/AACVPR CardiacRehabilitation Change Package (CRCP) and recommended by national CRexperts who have successfully implemented automatic referral with carecoordination in their own hospitals. The five milestones in bold and underlined below have been deemedespecially important by the experts. The TAKEheart Project Team will trackeach hospital’s progress towards achieving these five milestones as part of theevaluation of the TAKEheart initiative.1. Plan to advertise benefits of CR to relevant hospital staff.2. Plan to engage cardiologists in TAKEheart.3. Finalize an Action Plan & select milestones.4. Map out the hospitals current CR process from time ofreferral/discharge to appointment and identify patient, program,and system barriers.5. Create new workflow incorporating automatic referral.6. Develop a protocol for clinician to clinician hand-off toinpatient/rehabilitation CR programs to clarify CR plan of care,improve transitions, and reduce readmissions.7. Develop a protocol for outpatient CR programs to follow when apatient attends their first CR session.8. Plan to engage staff (e.g., cardiologists, staff currently involved inCR) in developing the specifications for an automatic prompt.9. Develop specifications for EMR10. Launch of tested EMR with functionality desired by the hospital11. Assess the hospitals CR baseline referral rate.12. Implement a system to monitor CR after participation in TAKEheartcohort is completed, if monitoring is not embedded into EMR.13. Create a care coordinator position with written role/jobdescription14. Develop training materials for the care coordinator15. Care coordinator identified/hired and starts work16. Develop a list of CR programs available to hospital's patients.17. Plan to advertise the benefits of CR to patients & their families. As noted above, each hospital will have its own, individual Action Plan withmany tasks and subtasks, in addition to these recommended milestones.Some hospitals may have achieved certain milestones before starting theintervention, and some milestones may not be relevant to a particularhospital.o Identify the individual responsible for each tasko Determine a target date for completing each task.o Establish SMART goals for each tasko Consider resource needs and priorities Additional features might need to be added to the EHR system. Data labor hours for data management and analysis Additional headcount
Hold a Meeting to create an Aim statement for the project; see attached Sample MeetingAgendaSAMPLE AGENDA.docxKey Resources:1.Institute for Healthcare Improvement (IHI). “Quality Improvement Essentials Toolkit.” 2020. Available y-Improvement-Essentials-Toolkit.aspxIHI’s QI Essentials Toolkit includes the tools and templates to launch a successful quality improvement project andmanage performance improvement. These tools include a short description, instructions, an example, and a blanktemplate.2.Institute for Healthcare Improvement (IHI). “Aim Statement Worksheet.” 2020. Available atement-Worksheet.aspxIHI’s Aim Statement Worksheet provides guidance around writing an effective aim statement, which delineatesclear and specific plans for upcoming improvement work.3.Institute for Healthcare Improvement (IHI). “Project Planning Form.” 2020. Available tPlanningForm.aspxThe Project Planning Form is a useful tool to help teams think systematically about their improvement project,including a listing of the changes that the team is testing, the person responsible for each test of change, and thetimeframe for each test. The form allows a team to see at a glance the overall of the project.4.McNeil, Patrick. “Clinical Champtions.” LiverPool Hospital. Available 3-clinical-champions-mcneil.pdfThis PowerPoint, created by Liverpool Hospital, suggests the roles, responsibilities, and recruitment of clinicalchampions.5.Centers for Disease Control and Prevention. “Million Hearts: Getting to 70% Cardiac Rehabilitation Participation:Action Steps for Hospitals.” Available MHActions%20for%20Hospitals.pptxThis PowerPoint, created by CDC’s Million Hearts, outlines both clinical and community-based steps for hospitalsto optimize their cardiac rehabilitation programs.6.Centers for Disease Control and Prevention. “Million Hearts: Tools and Protocols.” Available ndex.htmlThis webpage, developed by the CDC’s Million Hearts, provides tools, protocols, and action guides to improvepatients’ cardiovascular health.7.Centers for Disease Control and Prevention: Million Hearts. Cardiac Rehabilitation: Saving Lives, Restoring Health,Preventing Disease.” 2018. Available at: https://millionhearts.hhs.gov/files/Cardiac Rehab Infographic-508.pdfThe CDC’s Million Hearts “Saving Lives, Restoring Health, Preventing Disease” infographic provides an overview ofthe individual and systemic benefits of cardiac rehabilitation, the common barriers to referral and enrollment, andsome potential interventions for reducing this gap.
8.Health Information Technology, Evaluation, and Quality Center. “Guide to Improving Care Processes andOutcomes in Health Centers: An Approach to Quality Improvement.” 2016. Available in-healthcentersThis quality improvement approach can be used to augment current QI approaches used in your health center, orcan serve as a placeholder QI methodology when there isn’t already a robust QI process in place.9.TMIT Consulting, LLC. “Clinical Decision Support Quality Improvement Worksheet.” 2016. Available T%20QI%20Guide%20CDS%20QI%20Worksheet Essential.docxThis tool can help users document and analyze current approaches to specific quality improvement targets andplan enhancements.*This activity has been planned and implemented in accordance with the accreditation requirements and policies of theAccreditation Council for Continuing Medical education through the joint providership of the American Board of QualityAssurance and Utilization Review Physicians, Inc. (ABQAURP) and the American Hospital Association (AHA). ABQAURP isaccredited by the ACCME to provide continuing medical education for physicians.The American Board of Quality Assurance and Utilization Review Physicians, Inc. designates this live activity for amaximum of 1.0 AMA PRA Category 1 Credits . Physicians should claim only the credit commensurate with the extentof their participation in the activity.ABQAURP is an approved provider of continuing education for nurses. This activity is designated for 1.0 contact hoursthrough the Florida Board of Nursing, Provider # 50-94.
Instructions: The template below is designed to assist you with the creation of your action plan. The Task/Milestone column allowsyou to click on a prepopulated milestone or type a task your organization needs to undertake to implement automatic referral (AR) andcare coordination (CC). The milestones are high level tasks identified in the Cardiac Rehabilitation Change Package (CRCP) asimportant for successful implementation of AR and CC. Each one is covered in a specific training curriculum module. Although themilestones are important, the expectation is each organization will identify many additional tasks as part of their action plan. In theTask Lead column, type in the name of the person responsible for the task. A calendar drop down will appear when you click on theDate columns. The Status column allows you to click on a prepopulated option or type in your own. The Smart Goal and Commentcolumns allow for free text typing.The template provides an initial table with four rows. Additional rows can be added by hovering over and clicking the single rowbelow the table. A blue ( ) sign will appear and an additional row will be added. You can add as many rows as you need.ACTION PLANTASK/MILESTONETASKLEADTARGET COMPLETION STATUSDATEDATESMARTGOALCOMMENTSChoose a milestone orenter your own.Choose a milestone orenter your own.Entername.Entername.Click toenter a date.Click toenter a date.Click to enter adate.Click to enter adate.Choose oradd one.Choose oradd one.Click here toenter a goal.Click here toenter a goal.(include challengesor facilitators)Click to entercomments.Click to entercomments.Choose a milestone orenter your own.Entername.Click toClick to enter aenter a date. date.Choose oradd one.Click here toenter a goal.Click to entercomments.
AGENDAAutomatic Referral with Care CoordinationKick-offDate January 20201:00PM – 2:00PMMeeting called by Cardiac Rehabilitation ChampionAttendees:Please read:Members of the Multidisciplinary CR QI TeamCenters for Disease Control and Prevention: Million Hearts. Cardiac Rehabilitation: SavingLives, Restoring Health, Preventing Disease” 2018. Available at:https://millionhearts.hhs.gov/files/Cardiac Rehab Infographic-508.pdfAdes PA, Keteyian SJ, Wright JS, et al. Increasing cardiac rehabilitation participation from20% to 70%: a road map from the Million Hearts Cardiac Rehabilitation Collaborative. MayoClin Proc. 2017;92(2):234–42.1:00 – 1:15IntroductionTopic Call to actionMeeting Rm. A1:15 – 1:45Item #1Topic Develop Aim statementMeeting Rm. A1:45 – 2:00Item #2Topic Assignments for next meetingMeeting Rm. ANotes:
o The Action Plan template includes project milestones under the tasks column. Milestones are high level tasks that are critical for achieving a goal. TAKEheart recommends that hospitals include the following milestones in their Action Plans. These milestones
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