Diana Choma and Kelly Chrunik: The Right Care at the Right Time
(Access show transcript) Diana Choma and Kelly Chrunik from Alberta Health Services share how they are leveraging the value of early warning systems used in healthcare organizations.
Summary
Alberta Health Services’ Diana Choma, Clinical Safety Leader and Kelly Chrunik, Clinical Informatics Lead, Child Health, wanted to ensure patients were getting the right care, at the right time, in the right place. They took a deep dive into why they were seeing a delayed reaction in patient deterioration events as a trend provincially.
This deep dive led to the inception of their project, which was to analyze the metrics in early warning systems to improve patient outcomes. The project received support from HIROC’s Safety Grants Program.
On the third episode of Share Scale Repeat, Kelly and Diana walk us through the actions they took in the four education cycles, the results from their project, and share advice for healthcare organizations on actioning a new early warning system.
Mentioned in this Episode
Transcript
Even the smallest idea can spark big change. At HIROC, we see it every day with organizations across Canada finding new ways to create the safest health care system. On Share Scale Repeat, we talk through some complex topics in healthcare, interviewing the brains behind the projects that are keeping Canadians safe. We're doing this so you can find ways to scale the information where you work, because safety can't happen in silos.
Trevor: Welcome to Share Scale and Repeat podcast. I'm Trevor and I'm here with my brilliant co host Abi. We have the absolute pleasure today to speak to Kelly Chrunik, who is the Clinical Informatics lead of Child Health, as well as Diana Choma, who is the clinical safety leader for Alberta Health Services. This is a really exciting Share Scale Repeat podcast that's going to focus on a conversation about hearing about surveillance and how we go about ensuring the most optimal maternal and neonatal care. I will welcome you both again and so many thanks. Thanks for being here. We know that mom and baby harm is one of the significant risks that we experience within our health healthcare systems and about how do we ensure that we're providing optimal care and how as a system can we learn about the Share Scale Repeat podcast really is about that discovery. It's about understanding and seeking that understanding and approach through experiences. So thank you so much Kelly and Diana for being here. Perhaps I can kick it off today and ask you Kelly and Diana, would you be open to telling us about yourselves and again perhaps expand about maybe where you work and your roles?
Diana: Sure. Thanks Trevor and Abi for inviting us today to the podcast. By background, I am a registered nurse with a baccalaureate degree and have over 20 years of diverse experience spanning acute care in Alberta. I'm passionate about advancing patient outcomes and fostering collaboration with those high performing teams in a complex healthcare environment. And I've really built my career on a foundation of evidence-based practice, quality improvement and a deep commitment to patient safety. And so for the past two years I have transitioned from the bedside to more of a consultant role with Alberta Health Services as a clinical safety leader. So what I do on a day-to-day basis is supporting leadership teams with quality assurance activities.
Kelly: And I'm Kelly Chrunik. I'm a clinical informatics lead supporting the EMR system of EPIC that we have provincially rolled out in our province of Alberta. I am also a nurse by background. I have experience from all different areas from long term care to rural inpatient and my last adventure was in a level one trauma center emergency room. I began my nursing career in Saskatchewan but have called Alberta home for the last 10 years. So I've got to have experience in two different health organizations and I also transitioned from the bedside about four maybe five years ago now into this role, had a few different roles now supporting the provincial rollout of EPIC. And for the past three years I've been working as this clinical informatic supporting the child health as well as our inpatient areas in adoption usage and optimization of our EMR.
Trevor: Wow, that's amazing. First and to all our listeners, thanks for being our frontline and thank you as always for sharing your experiences. I'm always humbled to hear about the passion and the purpose of going from bedside to sharing that at a higher governance level, but most importantly making sure that we stay connected as close to healthcare front lines as possible and again supporting that. So again huge, huge thank you for being a frontline. I'm wondering a brilliant project that really did seek to understand on a very important topic where we may not always talk about and we may not always share about. Would you mind telling us about your project and really from the beginning what really motivated the investigation and the understanding around this?
Diana: Yeah, I think to start with the motivation piece, the project stemmed from previous work around early warning systems and how they assist those healthcare providers providing care at the bedside and flagging patients at risk for deterioration based on, in our system anyways, vital sign parameters. So we decided to take a deeper dive into why we were seeing a delayed reaction to patient deterioration events as a trend provincially and wanted to analyze some of the metrics in an early warning system to improve patient outcomes, ensuring that the patients were getting the right care at the right time and of course in the right place.
Kelly: I think for me the motivation that came was it was something that I saw as such a valuable tool. We were still in like the implementation phases of the EMR and just as we progressed through our acute care launches just really getting to emphasize this tool. But once we did launch and looked at it on a provincial level, I just could not quite figure out why it was not really being utilized to its fullest potential. So that's where I entered this “who, what, why, when, where, how?” thought process. Why are users not seeing the value in this tool? What can we do to better integrate this tool and how do we get individuals to understand the value and potential of this? And then the final question was where do we go from here? So I went knocking on doors or email inboxes. Welcome to our digital world. And with that I was connected with very like-minded folks and who also wanted to know the answers to those same questions I was asking and what initially felt like it was just an idea that may or may never take flight. We began analyzing the data and really saw the desire for this work. And this wasn't really a rollout or a change management, it was more of a learning journey. So we looked at a way that we could do this as an educational cycle. So each cycle built on the last with the feedback shaping every next step that we took. So the project initially started out again just us hoping and the desire of wanting to do something great with this. So the request was to have a project that could be replicated and easily repeated. So we looked at doing a PDSA, so a Plan Do Study Act type model by using cycles of education and then measuring the in system metrics and comparing to pre pilot data.
Diana: So what Kelly and I found was that the data did tell a really good story, but so did the people using the tool that we were using. And sometimes those stories didn't match. So we had leveraged those four education cycles that Kelly had mentioned. And we kind of began with in cycle one, an awareness of the early warning system and how to escalate care according to any site-based protocols. And we reached out to a lot of frontline providers and surveyed their awareness and how they're using the tool. And then we focused on the gaps identified by frontline users. In cycle two, we kind of looked at it from role specific functionality and patient engagement. So we did engage a patient family advisor to our team to kind of roll this out again. And we focused on education and resources to support the understanding of the purpose of the tool, the value and then the functionality of the tool as well. In cycle three, we kind of did a deeper dive into the scoring system of an early warning system and some of the alerts or acknowledgments that we were seeing. So here we leverage some existing resources to reinforce education and support for their clinical workflow. And then in cycle four, this is where we kind of put it all together, we did a full workflow and suggested some simulation. So we had encouraged, just in time discussions at those shift huddles that nurses were having looking at early warning system scores and then how that relates to the patient plan of care. And we provided resources for a really neat tabletop exercises as a low fidelity SIM for consideration into orientation and planning. Kelly, what else did we have planned for them? We did some also introduced dashboard training for metric monitoring at that manager level, I guess and some visual cue management as well. As leveraging those Qi boards throughout the cycles. And our results really showed that every participating unit saw positive trends in their metrics and maintained above their baseline. And all pilot units also had exceeded other units within the same site. So that was something really positive that we saw and had taken back to our project sponsor, which he reinforced that the metrics were improved and it was successful.
Trevor: Fantastic work. And I really like the iterative human centered piece to this and I really do like going knocking on doors in the virtual environment. Which is emails, I think, putting it in perspective, maybe you can comment a little bit more on what we mean when we say escalation. And really in my mind, the concept of how do we create that roadway or to ensure that we're able to, hey, notice that something's happening and to action that and all of the features and considerations that come around it. But maybe you could just speak a little bit more around what do you actually mean when you're thinking about that escalation tool.
Kelly: One of the initiatives that came with the implementation of our EMR was also the implementation of the early warning system. And one of the leadership tools that needed to be completed with this was a escalation of care protocol. And that was driven by the patient's status that we would see. So based on our early warning system, patients have three different statuses. They have a stable, a watcher, and then a unstable status. So based on that scoring and that status that they have, there's an algorithm that would be followed should the patient require escalation. And that escalation is definitely part of the critical thinking that comes into does my patient match this score? What are my next steps? If they do, where am I going to go with this? Where am I escalating? What are my next steps? If they don't, I need to stop and consider and then continue my monitoring. So there is a lot that goes into it in the early stages, but also that reinforcement of the escalation of care and how that works with early detection of clinical deterioration.
Trevor: Yeah, thank you. No, I think that's really well said. And the idea that there's so much demands on attention, let alone making sure that we're communicating in a timely fashion and working as a team saves lives. Right. So this is extremely critical and important and something that's not simple to address or to implement. So congratulations again. I'm wondering, with the complexity around this, do you have, you've mentioned lots of pieces of advices, but do you have one key thing or one piece of advice that you'd give other healthcare organizations when they're considering or actioning implementing a new early warning system?
Diana: Yeah, I think that first and foremost you have to earn the trust of any frontline staff that you're working with, especially nurses. We want to work with systems that are actionable and accurate, of course, and really align with their workflow. So you need their buy in. And we can't just drop in a shiny new tech tool and a system update. There's data that supports with namely co designing it with the people that use it every day, it will be successful. So that's how you turn alerts into action and then that data into potential lives saved. So at one, I think trust is everything. Nurses often report that alerts either feel like there's false positives coming their way or they're redundant. And if they already sense intuitively that their patient is deteriorating, if alerts aren't timely or meaningful, then they're just going to be ignored. So we want our frontline staff to be supported, supported and not to experience that alert fatigue that we see so frequently in systems. And I think secondly, talking about actionability, it matters. So alerts should come with those clear next steps. And as Kelly had mentioned around the escalation of care protocols, kind of our guidance on how we escalate care. So if staff don't know what to do when let's say an alert fires, the system just becomes noise instead of a safety net. So I think it's really important for institutions to have a protocol in place and to socialize these and ensuring they are accessible and ingrained really into their everyday safety culture.
Kelly: And just to go off that from Diana, I'd like to just not only take the time to design it, but also take the time to implement it. So when we're implementing it, making sure that those staff who are going to be using the tool understand the functionality and the expectations of it. When it comes to a tool like this, it's not taking away your ability to critical think and it's not telling you what you can and can't do. It's just there to be a decision support tool for you. It enhances, doesn't replace. So I think that's also really important because individuals may feel that this is going to undermine them or override their abilities to do their jobs. And that's not it at all. It is just there is that, that safety net, that safety feature and if it's better understood, it's going to be better utilized.
Trevor: That's fantastic practical advice. I love the concept of alerts into action again, early warning systems and deterioration. As we all have been at the front line, our critical right say “hey, is something happening?” And part one and part two is, “did I do something about it?” So alerts into action. Absolutely. And I love what you're mentioning around it's a support, it's a support to human judgment, decision making and it's about enhancing our experience, our performance, our capability as humans and not meant to replace. Fantastic. And absolutely would love to hear more. Abi, are you open to continuing the conversations around the next questions?
Abi: Yeah, for sure. It's great to meet you both. And one of the things I took away from listening in so far is that working collaboratively really helped lift the project. You know, you just mentioned the importance of trust, for example. So tell listeners why team dynamics is so crucial.
Diana: Yeah, I think foremost, Kelly and I really had a shared passion for early warning systems. And so we were very lucky that we were able to work together on this project. And personally, I'm driven by the belief that every interaction is an opportunity to make a positive impact, whether that's on patients, on our colleagues and on the healthcare system as a whole. I think it matters to problem solve together with different professionals, even perhaps looking outside of our usual hospital care spaces. So we need to get creative sometimes. We know that we can't be the expert in everything and that's why shared learning is so important. And I think coming to the table, you have to be open. You can't come with a solution in mind and just know that there are so many opportunities to connect with other professionals outside of healthcare to learn about their approach to patient safety that in turn can inform our practices in healthcare.
Kelly: I think Diana really, really nailed that one on the head. I think the other part I would just add is that we, especially in this project, had very strong support from our project sponsor. And some days when this task felt like it was unreachable, we weren't the goal of what we were trying to do and just the day to day, the frontline burden that was happening and just we didn't quite feel like we may reach the finish line. We would then check in with our sponsor and just have that fire reignited and just that reminder of what we were doing is to support our frontline staff, to support our patient safeties and to hopefully improve patient outcomes. So I think that was one of our major parts of also working outside of our groups and getting to collaborative work with different individuals.
Abi: Yeah, coming to the table with an open mind and having that support from others is so important. And speaking of lifting the project, when we last chatted you shared one of the factors that attributed to the project's success, which is strong leadership support. Tell us more about that and how to best leverage when implementing a tool.
Kelly: I think that really segues from my last comment. Strong leadership support comes from all different phases of the project. It started for us with our sponsor who really mentored us and believed in us, who then, like, we believed in ourselves. So we were able to then share that with the groups that were participating in our pilot project. We were seeing a lot of success on those units with the strong leadership support. The ones who were prioritizing the work, who were coming to our debrief sessions and asking the questions to better understand, they were actively supporting efforts in the process improvement that we were trying to achieve through their communication techniques, through their training and resource sharing. And we were also their sideline cheerleaders. We were acknowledging their team efforts and celebrating their milestones that they were reaching and I think that really kept them motivated throughout the project.
Abi: Yeah, that's so important and I'm glad we touched on the value of two different but equally important contributors to success, team dynamics and strong leadership support. And lastly, what's next for your teams when it comes to innovation?
Diana: I think we're going to continuing to lead and inspire teams through change, utilizing frameworks and leaning on methodologies such as PROSCI and AIW, and continue to build relationships to foster that cultural safety. I think that's really important.
Abi: Amazing. And we'll be keeping an eye on what's next for sure. Well, thank you so much for joining us, Kelly and Diana and telling us about your amazing project.
Kelly: Thank you very much for having us.
Thanks for listening. For more interviews, be sure to follow our show wherever you get your podcasts. If you like what you hear, please rate and review the show. If healthcare innovation is your thing, check out HIROC’s award winning leadership podcast Healthcare Change Makers. And don't forget to follow us on LinkedIn to see the latest news in risk, safety, insurance and more. Share Scale Repeat is recorded by HIROC's communications and marketing team and produced by Podfly Productions. Have a question? Email us at [email protected].