Project Charter
PLEASE NOTE. THIS PROJECT:
Part 1 |
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| Project Charter Information | |||||||||||||||
| Project Name | Implementing Evidenced Based Palliative Focused CHF Protocol for Advance
Practice Clinicians in Long Term Care |
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| Project Site | Optum-United Health Group | ||||||||||||||
| Contact at site | Name with credentials: Adrienne Peart APRN, NPC, Clinical Service Manager.
Organizational Email: Phone Number: |
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| Preceptor | Name with credentials: Lora Crowe, PHD, Senior Clinical Service Manager.
Email: Phone Number: |
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| Executive Sponsor | The executive sponsor is Adrienne Peart APRN, NPC, a Clinical Service Manager at Optum. The reason for selecting the sponsor is the extensive experience in handling patients with complex health needs. The manager also coordinates efforts by advance practice clinicians and monitors outcomes to ensure that services provided match patients’ needs and expectations. | ||||||||||||||
| Gap Analysis | Optum Health is a subsidiary of the United Healthcare Group responsible for providing healthcare services to those who are insured by United healthcare insurance products. Therefore, the strategic priorities of Optum health reflect the corporate mission and core values that align with the broader United Health Group (UHG) vision of improving customer experience by making healthcare work better for everyone by helping people live healthy lives. The strategic priorities of UGH-Optum health for 2021 includes expanding access to preventative care services to 85% of its customers by year 2030, shifting 55% of outpatient surgeries to a high-quality, cost-effective setting by year 2030 and closing 600 million gaps in care for customers by the 2025 (UHG, 2020). Undoubtedly providing affordable, quality, safe, and effective patient care set precedence and is the number one priority of UHG. Achieving high-quality outcomes, lower costs, and improved consumer and physician satisfaction, driven by our high-performing local care practices. UHG have the focus of efficient and profitability of the services provided by the organization, low-cost services is a priority.
The problem at the practice site is the lack of use of an evidenced-based protocol for APCs to proactively manage members with CHF with reduced ejection fraction in long-term care. Even though some patients are managed by a cardiologist and have echocardiograms, they are not readily available to the APC at the skilled nursing facilities. However, the skilled nursing facilities become the patient’s medical home under the management of Optum APC. Therefore, the Optum APC can manage the polypharmacy and CHF regimen per AHA guideline. |
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| Evidence to Support the Need | Ten patients with heart failure with reduced ejection fraction diagnoses were selected, reviewed, and compared with AHA guidelines. None of the charts audited had ARNI (angiotensin receptor-neprilysin inhibitor) known as Entresto is part of the AHA recommendation for management of heart failure with reduced ejection fraction. Four patients with African American (AA) heritage are not on Hydralazine and only one patient was one SGLT2i as indicated by the guideline (Heidenreich et al., 2022). All ten charts reviewed had full code status indicating a lack of understanding of disease trajectory and recommendations (Mechler & Liantonio, 2019). | ||||||||||||||
| PICOT | In advanced practice clinicians in complex care management at Optum (P) implementation of CHF palliative care protocol (I) compared to No heart failure protocol (c) to measure APC compliance with CHF protocol for patients in long -term care (O) within 10 weeks(T) | ||||||||||||||
| Project Aim | The aim is to streamline Advanced Practice Clinicians use of palliative care protocols for CHF patients at Optum. The project seeks to enhance the implementation of AHA guidelines for Advanced Practice Clinicians (APC) handling members with NYHA class IV heart failure in the long-term care. The anticipated impact is that the guidelines with enhance compliance with guidelines established to safeguard patients from severe complications and premature death. The intervention will address gaps in using evidenced-based protocols for APCs to proactively manage members with CHF with reduced ejection fraction in long-term care. | ||||||||||||||
Part II |
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| Stakeholders | |||||||||||||||
| Stakeholder | Identify the key stakeholders for your project. Think of key stakeholders (internal and external). This might include patients/clients, families, community leaders and organizations, health agencies, systems within the organization etc. List between 3-4 potential stakeholder members | ||||||||||||||
| Initials or ficitious name | Title, Role or Affiliation. | Connection to the project. | Potential impact (how affected). | Contribution to the project. | Barriers or anticipated challenges if any | ||||||||||
| L.C | Senior clinical service manager | An internal stakeholders with knowledge of compliance gaps in advanced care setting. | The manager gets the opportunity to share ideas and experiences on the problem and the relevance of evidence-based palliative focused CHF protocol on quality and safety of patient care. | The manager will highlight instances of non-compliance with CHF protocols and the specific areas that undermine the care team’s response to patients’ demands. | A busy schedule may limit the manager from actively participating from the start to the completition of the project. | ||||||||||
| A.P | Clinical service manager | Oversees the functions of advanced practice clinicians in a long-term care setting. | Opportunity to work with a compliant workforce that is response to guides and protocols for managing patients with reduced ejection fraction in long-term care. | Share experiences about successes and failures associated with handling patients with heart failure and reduced ejection fraction | A busy work schedule would limit A.P from being available throughout the project. | ||||||||||
| V.S | Advance practice nurse | The nurse is part of the workforce in long-term care setting tasked with the responsibility of handling patients with complex and sensitive health needs. | The nurse will acquire knowledge and skills necessary for enhancing compliance with guidelines and protocols for delivering evidence-based palliative care | Share experiences on reasons for non-compliance with guidelines and procedures and the implications of the project on quality and safety of care. | The nurse may be reluctant to provide adequate and correct information on events within long-term care setting that trigger non-compliance with vital policies and procedures. | ||||||||||
| Team Leader | The lead leader is D.A. The leader is an advanced practice nurse and oversee nurses activities in a long-term care setting. The reason for selecting the leader include experience working in the unit and engaging patients with complex health needs. The leader also understand aspects such as staff compliance and their implications and safety of care. Useful qualities the leader leverages for success include emotional intelligence, effective communication, and collaboration. Notably, the leader is an active listener and encourages collaborative and well-collaborated practices to optimize care outcomes. Emotional regulation and intelligence enable the leader to interact with different healthcare professionals and patients. The team leader embraces diversity, equity, and inclusion in leading the workforce and improvement efforts. Compassion and cultural intelligence makes the leader responsive to values and preferences of the care team and patients.
One leadership approach utilized to lead the team is transformational stye. The approach allows leaders to inspire a shared vision characterized by efforts to take ownership of nurses roles and perform beyond expectations (Specchia et al., 2021). Additionally, the transformational approach encourages nurses to demonstrate higher moral values and integrity across the care continuum. Servant leadership is another consideration that allows a leader to encourage the workforce through empowering and uplifting everyone within the advanced care setting (Alam et al., 2019). The servant leader understands the needs of the team and identifies new and better ways of helping workers to solve problems. The rationale for selecting transformational and servant leadership is because of the need for leaders to encourage diversity of thoughts, create a culture of trust, and foster personal and professional development in others. Listening to team members and understanding the workplace demands make transformational and servant leaders accountable for their actions and words (Alam et al., 2019). A leader might utilize servant leadership by allowing team members to express their ideas and expectations when implementing a new procedure, structure, or process. Leaders can utilize a transformational approach when there is greater uncertainty when adopting new protocols. The leader clarifies the purpose of the change and encourages shared vision towards improving the quality and safety of patient care. |
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| Team Members | |||||||||||||||
| Title | Department or Affiliation | Credentials or Qualifications | Rationale for selection/Contribution to the project | ||||||||||||
| V.S | Nurse manager | Nursing | Doctor of Nursing Practice | Has over 10 years experience working in a critical care setting. The knowledge and skills make the member crucial for sharing knowledge and skills on strengthening compliance with practice standards and procedures. | |||||||||||
| R.S | Advanced care nurse | Nursing | Advanced Practice Nurse and Doctor of Nursing Practice | The member will share experiences on events in palliative care setting and the need for strict compliance with nurse practice standards. The member will help design collaborative and coordinated efforts necessary to optimize care outcomes. | |||||||||||
| R.A | Nurse educator | Nursing | Doctorate in Nursing Administration | The nurse educator facilitates training programs designed to enable nurses to understand compliance gaps within the advanced care setting. The member will coordinate with nurse leaders and the workforce to share insights into the impact of evidence-based palliative focused CHF protocol in long-term care. | |||||||||||
| D.A | Primary investigator | Nursing | Doctoral student | The primary investigator will provide the oversight to ensure everything runs within the scope and deliberables. | |||||||||||
| Communication Plan | |||||||||||||||
| Team Member/Stakeholder. | Purpose of communication (Inform, share, engage, solicit information?). | Frequency and timing of communication. (How often, specific stages of project?) | Method of communication (consider audience, method, culture, language, inclusion). | Who is responsible for the communication to this member? (Why is it important who delivers the message?) | Potential challenges/ barriers or assets with communication (barriers, language, culture, different disciplines, best practices (cite the literature 1-2 sources as needed). | ||||||||||
| Nurse manager | Seek information on compliance issue and improvements necessary to improve quality of life in palliative care. | Weekly meetings to share progress and identify areas of improvement | Face-to-face conversations | Primary investigator to access details on effectiveness of the intervention and adjustments necessary to produce the best outcomes. | A busy schedule may undermine the timing and consistency in face-to-face interactions. | ||||||||||
| Advanced care nurse | Share details of the proposed intervention and engage the nurse on implications on the quality and safety of patient care. | Bi-weekly discussions of the progress | e-mail and face-to-face conversations | The primary investigator will engage the nurse to identify effectiveness of the intervention and improvements necessary to achieve the intended outcomes. | The busy nature of palliative care may interfere with the frequency and timing engagements | ||||||||||
| Nurse educator | Inform the nursing team on the implications of implementing evidenced based palliative focused CHF protocol for advance practice clinicians in long term care | Weekly interactions to raise awareness about the progress and interventions necessary to achieve the intended outcomes. | Face-to-face and emails | The advanced care nurse, primary investigator,and nurse manager will collaborate with the nurse educator to make everyone responsive to the intervention | The external stakeholder may re-schedule meetings due to commitment outside Optum. | ||||||||||
| Executive sponsor | Solicit information on progress and implications on the organization | Bi-weekly reports | E-mails | The primary investigator will submit a report on progress made and improvements necessary to optimize outcomes | The busy work schedule may delay responses from the executive sponsor | ||||||||||
Intervention and Measurement |
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| Evidenced Based Palliative Focused CHF Protocol
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One intervention is an evidence-based palliative focused CHF protocol. The aim is to remind the care team about standards and practices that enable them to maintain the best possible quality of life. The protocol includes efforts necessary for nurses to support patients, relieve symptoms, and protect patients from discomfort (Heidenreich et al., 2022). Compliance with CHF protocols enhances cooperation of all advance practice clinicians to provide the best care in all stages in palliative care. A second intervention is adopting the American Heart Association guidelines on effective long-term care (Mechler & Liatonio, 2019). Consistent utilization of the guidelines makes nurses more responsive to patients needs. The interventions encourage high quality communication, clarity of goals, and shared decision-making to offer adequate support to patients and families. | ||||||||||||||
Improvement Model / Framework |
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| The Plan-Do-Study-Act is the preferred improvement model. The framework provides insights into the intended accomplishments, the approach for determining an improvement, and changes necessary to produce better outcomes. The initial step is assembling a team with knowledge of issues in palliative care and opportunities for enhancing compliance with guidelines for optimizing care outcomes. The forward-thinking team designs an aim statement and describes the problem in detail (Ryann et al., 2021). Evidence from members of the nursing team is crucial to understand issues in the workplace that undermine compliance with CHF for patients in long-term care. The PDSA model also guides the team to identify causes of non-compliance and alternatives available to mitigate non-compliance with quality and safety guidelines. The second step is implementing the action plan by documenting issues, unexpected outcomes, observations necessary to produce the best outcomes. The third step of the PDSA model is studying, which allows them team to ascertain the relevance of the intervention and viability of compliance protocols (Knudsen et al., 2019). The final step is acting, where the nursing team begins to apply CHF protocols consistently. The rationale for choosing the model is because of the systematic approach that allows the care team to understand the implications of the interventions. The framework guides nurses to develop a viable and sustainable plan for improving the quality and safety of patient care. PDSA is a good fit for the project considering the ongoing nature and ability to make Optum more efficient in handling patients in advanced care setting. | |||||||||||||||
Proposed Outcomes |
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| Metric (What is being measured to determine success): | Outcome Measure (What is the desired outcome in measurable terms): | Process Measure (Are you doing the right things to get to the outcome? Are the steps in the process leading to the planned outcome?): | Balancing Measure (Are the changes being made causing problems in other areas?): | ||||||||||||
| Compliance with guideline-directed medical therapy (GDMT) | Reduced morbidity and mortality by 20% | Consistent use of guidelines including verification and oversight of practices associated with GDMT | N/A | ||||||||||||
| Compliance with titrating practices for ensuring target dose | Reduce drug tritation errors by 30% | Nurses play close attention to medication guidelines, including effective use of checklists to reduce titration errors | N/A | ||||||||||||
| Ensure patients have hydralazine | 100% compliance with requirement for ensuring patients have hydralazine | Team-based functions to enhance oversight and vigilance in ensuring that patients have hydralazine | N/A | ||||||||||||
| Ejection fraction of >35 | 100% compliance with requirement for maintaining ejection fraction of >35 | · Errors intercepted on time.
· Careful assessment of patients’ medical condition and demographics to prevent the risk of heart failure
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N/A | ||||||||||||
Part III |
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| Data Collection & Management | |||||||||||||||
| Develop a plan for the collection, management, and stewardship of the data you will collect for your Project Charter. | |||||||||||||||
| The data to be collected is on compliance rates with CHF protocols. The details include compliance with guideline-directed medical therapy, dosage titration, ejection fraction, and the need to ensure that patients have hydrazaline, | Nurse manager in advanced care setting | The data will be collected on the fourth week after implementing the intervention | Data stored is secured computers within the advanced care setting | The data will be protected using log-on credentials to prevent unauthorized access. The primary investigator, executive sponsors, and nurse manager will have access to protected information.
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Demograhic aspects such as age and disabilities are crucial. The information makes the care team responsive to patients’ needs based on adequate knowledge of health complexities and best practices for reducing the risk of heart failure (Riahi & Khajehei, 2019). | ||||||||||
| Data Anaylsis | |||||||||||||||
| The project is a quality improvement process that seeks to Implement palliative approach heart failure management protocol for APCs in senior community settings. The method of analysis for initiated GDMT is descriptive statistics, which describes data by generating summaries. A similar analysis method applies for outcome measure associated with ensuring patient have hydrazaline. Descriptive qualities will apply for provcess data about compliance with titrating to target dose and ejection fraction. The method entails using narration to describe visual information. | |||||||||||||||
| SWOT Analysis and Business for Project | |||||||||||||||
| Strengths | |||||||||||||||
| · The team has immense knowledge, skills and experiences that enhance awareness about the value of incraesed compliance with CHF protocols in long-term care.
· Optum’s leadership support is crucial to empower the nursing team respond positively to the intervention. · Compliance with CHF protocols helps strengthen Optum’s brand credibility. · Optum has adequate financial resources to support initiatives meant to improve quality and safety of patient care. |
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| Weaknesses | |||||||||||||||
| · Incomplete compliance records may limit the project team from making informed decisions on improvements necessary to improve employees’ attitudes, behaviors, and values.
· There is no guarantee that the nursing team will adhere to new compliance measures due to other factors such as incentives and employee engagement practices associated with a dedicated workforce. · The project team may overlook aspects such as the physical environment and patient characteristics that make individuals vulnerable to heart failure. |
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| Opportunities | |||||||||||||||
| · Increased compliance will make the nursing team responsive to the needs and expectations of patients in a long-term care setting.
· The intervention provides a sustainable approach for overcoming issues such as medication errors and medical negligence observed in palliative care. · The intervention encourages patients to share experiences about their encounter with nurses. · Succesful outcomes reinforce Optum’s safety and quality culture, which boosts consumer confidence and trust. |
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| Threats | |||||||||||||||
| · Increased patient traffic may undermine advanced care nurses and nurse manager from contributing actively to the project.
· Ineffective employee engagement may undermine the workforce’s willingness to embrace recommended compliance protocols. · The facility may have to spend more on training existing and new staff to cope with the CHF protocols. |
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References
Alam, H. V., Miharja, M., Astarina, I., & Dewi, P. (2019). Servant leadership: Its impact and relationship on organizational performance & organizational learning in physicians. International Journal of Innovation, Creativity and Change, 9(5), 338-360. https://www.ijicc.net/images/vol9iss5/9503_Alam_2019_E_R.pdf
Heidenreich, P., Bozkurt, B., Aguilar D., Allen, L., Byun, J., Colvin, M., …..& Yancy, C. (2022). AHA/ACC/HFSA guideline for the management of heart failure. Journal of the American College of Cardiology, 79 (17), 895-1032. https://doi.org/10.1016/j.jacc.2021.12.012
Knudsen, S. V., Laursen, H.V., Johnson, S., Bartels, P.D., Ehlers, L. H., & Mainz, J. (2019). Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects. BMC Health Services Research,19(683), 1-9. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-019-4482-6
Mechler, K., & Liatonio, J. (2019). Palliative care approach to chronic diseases: End stages heart failure, chronic obstructive pulmonary disease, liver failure and renal failure. Primary Care, 46(3), 415-432. https://doi.org/10.1016/j.pop.2019.05.008
Riahi, S., & Khajehei, M. (2019). Palliative care: A systematic review of evidence-based interventions. Critical Care Nursing Quarterly, 42(3), 315-328. https://www.researchgate.net/publication/333375860_Palliative_Care_A_Systematic_Review_of_Evidence-Based_Interventions
Ryann, E., David, M., Sally, H., Nealon, M., Melissa, A., Jennifer, L., & Mark, M. (2021). Evidence-based practice and patient-centered care: Doing both well. Health Care Management Review, 46(3), 174-184. https://journals.lww.com/hcmrjournal/Fulltext/2021/07000/Evidence_based_practice_and_patient_centered_care_.2.aspx
Specchia, M.L.; Cozzolino, M.R.; Carini, E.; Di Pilla, A.; Galletti, C.; Ricciardi, W.; Damiani, G. (2021). Leadership styles and nurses’ job satisfaction. Results of a systematic review. International Journal of Environmental Research and Public Health, 18(1552), 1-10. https://doi.org/10.3390/ ijerph18041552
Appendices
Appendix I: Proposed Evidence-based Intervention
Appendix II: Outcome Measures and Analysis
| Measure | Measure Type | Type of Data Collected | Analysis Method | Results Reporting-Data Type |
| Step 1 Initiated GDMT | Process | Ordinal | Descriptive Statistics | Rate |
| Step 2 Titrating to target dose | Process | Ordinal | Descriptional qualities | Rate |
| Step 3. AA Patients have Hydralazine | Process | Ordinal | Descriptive statistics | Rate |
| Step 4 Ejection fraction of<35
Initiated Palliative Care discussion |
Process | Ordinal | Descriptional qualities | Rate |