1. 0 U N C H E A L T H C A R E S Y S T E M T RANSLATING C ARING T HEORY I NTO P RACTICE: The Carolina Care™ Model Mary Tonges PhD, RN, NEA-BC, FAAN Chief Nursing Officer, UNC Hospitals October 17, 2014 Virginia Organization of Nurse Leaders

2. 1 U N C H E A L T H C A R E S Y S T E M Across the Continuum to Ambulatory Care Carolina Care TM Tonges Translational Model Swanson Caring Theory T RANSLATING C ARING T HEORY I NTO P RACTICE

3. 2 U N C H E A L T H C A R E S Y S T E M Across the Continuum to Ambulatory Care Carolina Care TM Tonges Translational Model Swanson Caring Theory T RANSLATING C ARING T HEORY I NTO P RACTICE

4. 3 U N C H E A L T H C A R E S Y S T E M “Caring is a nurturing way of relating to a valued other to whom one feels a personal sense of commitment and responsibility.” K. Swanson, 1993 Swanson Caring Theory Swanson, KM 1991, Empirical development of a middle range-theory of nursing, Nursing Research, 40(3) 161-6. Knowing Being With Doing For Enabling Maintaining Belief

5. 4 U N C H E A L T H C A R E S Y S T E M avoiding assumptions assessing thoroughly seeking cues centering on the other engaging the self of both Knowing: Being With Doing For Enabling Maintaining Belief striving to understand an event as it has meaning in the life of the other Swanson Caring Theory

6. 5 U N C H E A L T H C A R E S Y S T E M being there conveying availability enduring with sharing feelings not burdening being emotionally present to the other Knowing Being With: Doing For Enabling Maintaining Belief Swanson Caring Theory

7. 6 U N C H E A L T H C A R E S Y S T E M performing competently/skillfully comforting anticipating protecting preserving dignity doing for the other as they would do for their self if it were at all possible Knowing Being with Doing For: Enabling Maintaining Belief Swanson Caring Theory

8. 7 U N C H E A L T H C A R E S Y S T E M informing/explaining validating/giving feedback supporting/allowing focusing generating alternatives/ thinking it through facilitating the other’s passage through life events and transitions Knowing Being with Doing For Enabling: Maintaining Belief Swanson Caring Theory

9. 8 U N C H E A L T H C A R E S Y S T E M sustaining faith in the other’s capacity to get through an event or transition and face a future with meaning Knowing Being with Doing For Enabling Maintaining Belief: believing in/holding in esteem offering a hope-filled attitude ‘going the distance’ offering realistic optimism helping find meaning Swanson Caring Theory

10. 9 U N C H E A L T H C A R E S Y S T E M Across the Continuum to Ambulatory Care Carolina Care TM Swanson Caring Theory Tonges Translational Model T RANSLATING C ARING T HEORY I NTO P RACTICE

11. 10 U N C H E A L T H C A R E S Y S T E M 1.Theory 2.Innovation 3.Application 4.Testing 5.Dissemination 6.Evaluation 7.Sustainment Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice

12. 11 U N C H E A L T H C A R E S Y S T E M Dr. Kristen Swanson 1.Theory: Swanson Caring Theory (SCT) Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice

13. 12 U N C H E A L T H C A R E S Y S T E M 2.Innovation: creating value through new ideas Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice

14. 13 U N C H E A L T H C A R E S Y S T E M 3.Application: putting ideas to a specific purpose/use Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice Moment of Caring Multi-level Rounding Hourly Patient Rounds No Passing Zone Words and Ways That Work Blameless Apology Proposed Links between Carolina Care and SCT Framing the Culture of Carolina Care

15. 14 U N C H E A L T H C A R E S Y S T E M Across the Continuum to Ambulatory Care Carolina Care TM Swanson Caring Theory Tonges Translational Model T RANSLATING C ARING T HEORY I NTO P RACTICE

16. 15 U N C H E A L T H C A R E S Y S T E M Carolina Care TM

17. 16 U N C H E A L T H C A R E S Y S T E M Each patient each shift Nurse sits with patient 3-5 minutes of touch and therapeutic listening Moment of Caring: Knowing and Being With Carolina Care TM

18. 17 U N C H E A L T H C A R E S Y S T E M Multi-level Rounding Hourly Patient Rounding Health Unit Coordinator (HUC) Director Interdisciplinary Nurse Manager Carolina Care TM

19. 18 U N C H E A L T H C A R E S Y S T E M Hourly Patient Rounds A r e you comfortable? O ther side? (Does patient need to turn?) U se the bathroom (Does patient need assistance?) N eed anything D oor /curtain open or closed for privacy S afety (Call bell will reach and no tripping hazards) RR OO UU NN DD SS Associated Swanson Caring Theory Component: Being With and Doing For Carolina Care TM

20. 19 U N C H E A L T H C A R E S Y S T E M Answer call light regardless of assignment “Road Signs” posted in hallways No Passing Zone: Being With and Doing For Carolina Care TM

21. 20 U N C H E A L T H C A R E S Y S T E M Alternative to “scripting” Key points to cover in interactions Words and Ways that Work: Being With and Enabling Carolina Care TM

22. 21 U N C H E A L T H C A R E S Y S T E M Listen to patient Apologize without placing blame Take action to address problem Follow-up with patient Blameless Apology: Being With and Enabling Carolina Care TM

23. 22 U N C H E A L T H C A R E S Y S T E M Proposed Links Between Carolina Care and SCT Carolina Care TM

24. 23 U N C H E A L T H C A R E S Y S T E M SCT: Framing the Culture of Carolina Care Carolina Care TM

25. 24 U N C H E A L T H C A R E S Y S T E M Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice making a preliminary evaluation before embarking on a course of action Model Units Medicine Service Surgery Service 4.Testing:

26. 25 U N C H E A L T H C A R E S Y S T E M Model Units: Medicine & Surgery Service Less than 20 bedsLess than 20 beds Combination of private/semi-private roomsCombination of private/semi-private rooms Model Units: Medicine & Surgery Service Less than 20 bedsLess than 20 beds Combination of private/semi-private roomsCombination of private/semi-private rooms CNO chaired Carolina Care Steering Committee to provide high level direction, integration and support Voice of the Patient Rapid Cycle Improvement: Design & Implement Nursing & Interdepartmental Unit-Based Teams Data Driven Action Plans/Performance Tracking 4. Testing: Preliminary Evaluation

27. 26 U N C H E A L T H C A R E S Y S T E M 4. Testing: Model Unit Results

28. 27 U N C H E A L T H C A R E S Y S T E M 4. Testing: Model Unit Results

29. 28 U N C H E A L T H C A R E S Y S T E M Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice spreading information and/or practices Carolina Care Guidebook Pre-Work Unit Assessment Pre-Work Teams Roll Out Recognition for Outstanding Performance 5.Dissemination:

30. 29 U N C H E A L T H C A R E S Y S T E M 5. Dissemination: Carolina Care Guidebook – CNO charge – Lessons learned from Model Units – Defined key staff roles and responsibilities – Pre-Work – Implementation sequence – Defined Carolina Care TM Interventions Moment of Caring Hourly Rounds No Passing Zone Words and Ways that Work Blameless Apology (Service Recovery) ‒ Discharge calls

31. 30 U N C H E A L T H C A R E S Y S T E M Patient satisfaction interview Patient satisfaction interview Part I Self assessment Self assessment Part II Call bell activity Call bell activity Part IV Environmental assessment Environmental assessment Part V Part III 5. Dissemination: Pre-Work Unit Assessment Analyze one year of unit performance on Press Ganey data Analyze one year of unit performance on Press Ganey data

32. 31 U N C H E A L T H C A R E S Y S T E M 5. Dissemination: Pre-Work Teams Carolina Care TM Implementation Oversight Committee CNO Nursing Directors Nurse Managers Director, Environmental Services Director, Food and Nutrition Data Analyst Nursing Teams Nurses Nursing Assistants Health Unit Coordinators Interdepart- mental Teams Nurses Housekeeping Nutrition & Food Service Plant Engineering Other Support Services Action Plans Assign process owners accountability for specific items Team approves action plan Unit Implementation Led by Nurse Mangers Nurse Manager held accountable for improving inpatient satisfaction at the unit level

33. 32 U N C H E A L T H C A R E S Y S T E M 5. Dissemination: Roll Out Simultaneous roll out on all acute care units 8 Week Implementation Sequence Monday morning Nurse Managers’ meeting Weekly focus areas Rounding Words & Ways that Work Bi-weekly nursing & Interdepartmental team meetings Building Action Plans Tracking performance measures Discharge calls Daily huddles Bright ideas Implementation Oversight Committee

34. 33 U N C H E A L T H C A R E S Y S T E M 5. Dissemination: Recognizing Outstanding Performance “Carolina Care TM Dollars” Unit recognition for Press Ganey goals achievement Unit Celebrations

35. 34 U N C H E A L T H C A R E S Y S T E M Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice 6.Evaluation: ascertaining value or worth Press Ganey Scores HCAHPS Scores Effect on Pressure Ulcer Prevalence

36. 35 U N C H E A L T H C A R E S Y S T E M 6. Evaluation: Results - Annual Mean PG Scores Overall Inpatient Satisfaction and Satisfaction with Nursing Carolina Care TM implemented in July

37. 36 U N C H E A L T H C A R E S Y S T E M 6. Evaluation: Results - Mean PG Scores Concern with Privacy, Meeting Emotional Needs and Attention to Special/Personal Needs Carolina Care TM implemented in July

38. 37 U N C H E A L T H C A R E S Y S T E M 6. Evaluation: Results - Annual Mean PG Scores Satisfaction with Pain Control and Prompt Response to Call Carolina Care TM implemented in July

39. 38 U N C H E A L T H C A R E S Y S T E M 6. Evaluation: Results - HCAHPS Scores March, 2011 – March, 2012 #1 Communication about Medications #2 Discharge Information

40. 39 U N C H E A L T H C A R E S Y S T E M 6. Evaluation: Effect on Pressure Ulcer Prevalence

41. 40 U N C H E A L T H C A R E S Y S T E M 7.Sustainment: Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice keeping in existence, maintaining Sustainment Efforts HCAHPS Scores

42. 41 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: Efforts Expansion Outpatient Carolina Care at Home Infrastructure Commitment to Caring Steering Committee Big 5 & Big 6 Service Framework New Interventions Semi-Private Rooms Family Meals VP Partners Happy Healing Days Heart of Carolina Care

43. 42 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: Expansion

44. 43 U N C H E A L T H C A R E S Y S T E M Inpatient 7. Sustainment: Infrastructure Change Management Resources D. Kaye, S. Herman, L. Mandelkher, G. Spivak Patient Experience Steering Committee Co-Chairs K. McCall W. Rotella Focus Team Inpatient Experience Team EmployeeOutpatient EngagementCommunication Co-Chairs D. Olmos T. Garner Executive Sponsors C. Donohue W. Rotella Co-Chairs D. Bass W. Arey Executive Sponsor J. Hirneisen Admitting Room Meals Nursing Tests – Txs Visitors& Families Discharge Personal Issues Co-Chairs L. Daniels L. Kapps Executive Sponsor M. Tonges JJ. Campbell J Strickler L. Osborne A. Mojica J. Ray C. Rege T. Smiley M. McCann L. Muss M. Bossert R. Daniels S. Rogers S. Crenshaw K. Mc Call J Pomerantz J. Hadar D. Lehman M. Tonges M. Rifkin K. McCall Co-Chair D. Bauer Executive Sponsors D. Spencer R. Lafrenaye

45. 44 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: Infrastructure

46. 45 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: New Interventions

47. 46 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: New Interventions

48. 47 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: HCAHPS – Rate The Hospital Highly FYTD Percentage – 77.6 (84 th Percentile)

49. 48 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: HCAHPS – Recommend Hospital FYTD Percentage – 83.0 (89 th Percentile)

50. 49 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: HCAHPS – Communication w/ Nurses FYTD Percentage – 80.8 (69 th Percentile)

51. 50 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: Press Ganey – Inpatient Overall FYTD Mean Score – 87.7 (79 th Percentile)

52. 51 U N C H E A L T H C A R E S Y S T E M 7. Sustainment: Press Ganey – Meals FYTD Mean Score – 84.8 (96 th Percentile)

53. 52 U N C H E A L T H C A R E S Y S T E M Tonges Translational Model for Theory-Driven Practice Tonges Translational Model for Theory-Driven Practice

54. 53 U N C H E A L T H C A R E S Y S T E M Across the Continuum to Ambulatory Care Carolina Care TM Swanson Caring Theory Tonges Translational Model T RANSLATING C ARING T HEORY I NTO P RACTICE